# Somatic symptom disorder

Somatic symptom disorder, also known as somatoform disorder or somatization disorder, is defined by one or more chronic physical symptoms that coincide with excessive and maladaptive thoughts, emotions, and behaviors connected to those symptoms. The symptoms are not deliberately produced or feigned, and they may or may not coexist with a known medical ailment.
Manifestations of somatic symptom disorder are variable; symptoms can be widespread, specific, and often fluctuate. Somatic symptom disorder corresponds to the way an individual views and reacts to symptoms rather than the symptoms themselves. Somatic symptom disorder may develop in those who suffer from an existing chronic illness or medical condition.
Several studies have found a high rate of comorbidity with major depressive disorder, generalized anxiety disorder, and phobias. Somatic symptom disorder is frequently associated with functional pain syndromes like fibromyalgia and irritable bowel syndrome (IBS). Somatic symptom disorder typically leads to poor functioning, interpersonal issues, unemployment or problems at work, and financial strain as a result of excessive healthcare visits.
The cause of somatic symptom disorder is unknown. Symptoms may result from a heightened awareness of specific physical sensations paired with a tendency to interpret these experiences as signs of a medical ailment. The diagnosis is controversial, as people with a physical illness can be misdiagnosed with it. This is especially true for girls and women, who are more often dismissed when they present with physical symptoms.

## Signs and symptoms

Somatic symptom disorder can be detected by an ambiguous and often inconsistent history of symptoms that are rarely relieved by medical treatments. Additional signs of somatic symptom disorder include interpreting normal sensations for medical ailments, avoiding physical activity, being disproportionately sensitive to medication side effects, and seeking medical care from several physicians for the same concerns.
Manifestations of somatic symptom disorder are highly variable. Recurrent ailments usually begin before the age of 30; most patients have many somatic symptoms, while others only experience one. The severity may fluctuate, but symptoms rarely go away completely for long periods of time. Symptoms might be specific, such as regional pain and localized sensations, or general, such as fatigue, muscle aches, and malaise.
Those suffering from somatic symptom disorder experience recurring and obsessive feelings and thoughts concerning their well-being. Common examples include severe anxiety regarding potential ailments, misinterpreting normal sensations as indications of severe illness, believing that symptoms are dangerous and serious despite lacking medical basis, claiming that medical evaluations and treatment have been inadequate, fearing that engaging in physical activity will harm the body, and spending a disproportionate amount of time thinking about symptoms.
Somatic symptom disorder pertains to how an individual interprets and responds to symptoms as opposed to the symptoms themselves. Somatic symptom disorder can occur even in those who have an underlying chronic illness or medical condition. When a somatic symptom disorder coexists with another medical ailment, people overreact to the ailment's adverse effects. They may be unresponsive toward treatment or unusually sensitive to drug side effects. Those with somatic symptom disorder who also have another physical ailment may experience significant impairment that is not expected from the condition.

### Comorbidities

Most research that looked at additional mental disorders or self-reported psychopathological symptoms among those with somatic symptom disorder identified significant rates of comorbidity with depression and anxiety, but other psychiatric comorbidities were not usually looked at. Major depressive disorder, generalized anxiety disorder, and phobias were the most common concurrent conditions.
In studies evaluating different physical ailments, 41.5% of people with semantic dementia, 11.2% of subjects with Alzheimer's disease, 25% of female patients suffering from non-HIV lipodystrophy, and 18.5% of patients with congestive heart failure fulfilled somatic symptom disorder criteria. 25.6% of fibromyalgia patients met the somatic symptom disorder criteria exhibited higher depression rates than those who did not. In one study, 28.8% of those with somatic symptom disorder had asthma, 23.1% had a heart condition, and 13.5% had gout, rheumatoid arthritis, or osteoarthritis.

### Complications

Alcohol and drug abuse are frequently observed, and sometimes used to alleviate symptoms, increasing the risk of dependence on controlled substances. Other complications include poor functioning, problems with relationships, unemployment or difficulties at work, and financial stress due to excessive hospital visits.

## Causes

Somatic symptoms can stem from a heightened awareness of sensations in the body, alongside the tendency to interpret those sensations as ailments. Studies suggest that risk factors of somatic symptoms include childhood neglect, sexual abuse, a chaotic lifestyle, and a history of substance and alcohol abuse. Psychosocial stressors, such as unemployment and reduced job performance, may also be risk factors. There could also be a genetic element. A study of monozygotic and dizygotic twins found that genetic components contributed 7% to 21% of somatic symptoms, with the remainder related to environmental factors. In another study, various single nucleotide polymorphisms were linked to somatic symptoms.

### Psychological

Evidence suggests that along with more broad factors such as early childhood trauma or insecure attachment, negative psychological factors including catastrophizing, negative affectivity, rumination, avoidance, health anxiety, or a poor physical self-concept have a significant impact on the shift from unproblematic somatic symptoms to a severely debilitating somatic symptom disorder. Those who experience more negative psychological characteristics may regard medically unexplained symptoms to be more threatening and, therefore, exhibit stronger cognitive, emotional, and behavioral awareness of such symptoms. In addition, evidence suggests that negative psychological factors have a significant impact on the impairments and behaviors of people suffering from somatic symptom disorder, as well as the long-term stability of such symptoms.

### Psychosocial

Psychosocial stresses and cultural norms influence how patients present to their physicians. American and Koreans engaged in a study to measure somatization within the cultural context. It was discovered that Korean participants used more body-related phrases while discussing their connections with stressful events and experienced more sympathy when asked to read texts using somatic expressions when discussing their emotions.
Those raised in environments where expressing emotions during stages of development is discouraged face the highest risk of somatization. In primary care settings, studies indicated that somaticizing patients had much greater rates of unemployment and decreased occupational functioning than non-somaticizing patients.
Traumatic life events may cause the development of somatic symptom disorder. Most people with somatic symptom disorder originate from dysfunctional homes. A meta-analysis study revealed a connection between sexual abuse and functional gastrointestinal syndromes, chronic pain, non-epileptic seizures, and chronic pelvic pain.

### Physiological

The hypothalamo pituitary adrenal axis (HPA) has a crucial role in stress response. While the HPA axis may become more active with depression, there is evidence of hypocortisolism in somatization. In somatic disorder, there is a negative connection between elevated pain scores and 5-hydroxy indol acetic acid (5-HIAA) and tryptophan levels.
It has been suggested that proinflammatory processes may have a role in somatic symptom disorder, such as an increase of non-specific somatic symptoms and sensitivity to painful stimuli. Proinflammatory activation and anterior cingulate cortex activity have been shown to be linked in those who experienced stressful life events for an extended period of time. It is further claimed that increased activity of the anterior cingulate cortex, which acts as a bridge between attention and emotion, leads to increased sensitivity of unwanted stimuli and bodily sensations.
Pain is a multifaceted experience, not just a sensation. While nociception refers to afferent neural activity that transmits sensory information in response to stimuli that may cause tissue damage, pain is a conscious experience requiring cortical activity and can occur in the absence of nociception. Those with somatic symptom disorder are thought to exaggerate their symptoms through choice perception and perceive them in accordance with an ailment. This idea has been identified as a cognitive style known as "somatosensorial amplification". The term "central sensitization" has been created to describe the neurobiological notion that those predisposed to somatization have an overly sensitive neural network. Harmless and mild stimuli stimulate the nociceptive specific dorsal horn cells after central sensitization. As a result, pain is felt in response to stimuli that would not typically cause pain.

### Neuroimaging evidence

Some literature reviews of cognitive–affective neuroscience on somatic symptom disorder suggested that catastrophization in patients with somatic symptom disorders tends to present a greater vulnerability to pain. The relevant brain regions include the dorsolateral prefrontal, insular, rostral anterior cingulate, premotor, and parietal cortices.

### Genetic

Genetic investigations have suggested modifications connected to the monoaminergic system, in particular, may be relevant while a shared genetic source remains unknown. Researchers take into account the various processes involved in the development of somatic symptom disorder as well as the interactions between various biological and psychosocial factors. Given the high occurrence of trauma, particularly throughout childhood, it has been suggested that the epigenetic changes could be explanatory. Another study found that the glucocorticoid receptor gene (NR3C1) is hypomethylated in those with somatic symptom disorder and in those with depression.

## Diagnosis

Because those with somatic syndrome disorder typically have comprehensive previous workups, minimal laboratory testing is encouraged. Excessive testing increases the possibility of false positive results, which may result in further interventions, associated risks, and greater expenses. While some practitioners order tests to reassure patients, research shows that diagnostic testing fails to alleviate somatic symptoms.
Specific tests, such as thyroid function assessments, urine drug screens, restricted blood studies, and minimal radiological imaging, may be conducted to rule out somatization because of medical issues.

### Somatic Symptom Scale – 8

The Somatic Symptom Scale – 8 (SSS-8) is a short self-report questionnaire that is used to evaluate somatic symptoms. It examines the perceived severity of common somatic symptoms. The SSS-8 is a condensed version of the well-known Patient Health Questionnaire-15 (PHQ-15).
On a five-point scale, respondents rate how much stomach or digestive issues, back discomfort, pain in the legs, arms, or joints, headaches, chest pain or shortness of breath, dizziness, feeling tired or having low energy, and trouble sleeping impacted them in the preceding seven days. Ratings are added together to provide a sum score that ranges from 0 to 32 points.

### DSM-5

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) modified the entry titled "somatoform disorders" to "somatic symptom and related disorders", and modified other diagnostic labels and criteria.
The DSM-5 criteria for somatic symptom disorder includes "one or more somatic symptoms which are distressing or result in substantial impairment of daily life." Additional criteria, often known as B criteria, include "excessive thoughts, feelings, or behaviors regarding somatic symptoms or corresponding health concerns manifested by disproportionate and persistent thoughts about the severity of one's symptoms." It continues: "Although any one somatic symptom might not be consistently present, one's state of being symptomatic is continuous (typically lasting more than 6 months)."
The DSM-5 includes five distinct descriptions for somatic symptom disorder. These include somatic symptom disorder with predominant pain, formally referred to as pain disorder, as well as classifications for mild, moderate, and severe symptoms.

### International Classification of Diseases

The ICD-11 includes bodily distress disorder, which bears similarities to somatic symptom disorder. While both conditions involve somatic symptoms, bodily distress disorder appears to be more strongly associated with the experience of physical symptoms, whereas somatic symptom disorder is more closely linked to psychological distress. Patients meeting the criteria for both diagnoses tend to exhibit greater symptom severity across various psychosocial domains.
Bodily distress disorder is characterized by the presence of distressing bodily symptoms and excessive attention devoted to those symptoms. The ICD-11 further specifies that if another health condition is causing or contributing to the symptoms, the level of attention must be clearly excessive in relation to the nature and course of the condition.

### Differential diagnosis

Somatic symptom disorder's widespread, non-specific symptoms may obscure and mimic the manifestations of other medical disorders, making diagnosis and therapy challenging. For example, conditions such as adjustment disorder, body dysmorphic disorder, obsessive–compulsive disorder (OCD), hypochondriasis can also exhibit excessive and exaggerated emotional and behavioral responses. Other functional diseases with unknown etiology, such as fibromyalgia and irritable bowel syndrome (IBS), tend not to present with excessive thoughts, feelings, or maladaptive behavior.
Somatic symptom disorder overlaps with hypochondriasis and functional neurologic symptom disorder (FNsD), previously known as conversion disorder. Hypochondriasis is characterized by an obsession with having or developing a dangerous, undetected medical ailment, despite the absence of bodily symptoms. FNsD may present with one or more symptoms of various sorts: motor symptoms, which may involve weakness or paralysis; aberrant movements, including tremor or dystonic movements; abnormal gait patterns; and abnormal limb posture. The presenting symptoms in FNsD is loss of function, but in somatic symptom disorder, the emphasis is on the discomfort that specific symptoms produce. FNsD often lacks the overwhelming thoughts, feelings, and behaviors that characterize somatic symptom disorder.

## Treatment

Rather than focusing on treating the symptoms, the key objective is to support the patient in coping with symptoms, including both physical symptoms and psychological/behavioral (such as health anxiety and harmful behaviors).
Early psychiatric treatment is advised. Evidence suggests that SSRIs and SNRIs can lower pain perception. Because people with somatic symptom disorder may have a low threshold for adverse reactions, medication should be started at the lowest possible dose and gradually increased to produce a therapeutic effect.
Cognitive behavioral therapy (CBT) has been linked to significant improvements in patient-reported function and somatic symptoms, a reduction in healthcare expenses, and a reduction in symptoms of depression. CBT aims to help patients realize their ailments are not catastrophic and to enable them to gradually return to activities they previously engaged in, without fear of "worsening their symptoms". Consultation and collaboration with a primary care physician also demonstrated some effectiveness. Furthermore, brief psychodynamic interpersonal psychotherapy (PIT) for patients with somatic symptom disorder has been proven to improve the physical quality of life in patients with many difficult-to-treat and medically unexplained symptoms over time
CBT can help in some of the following ways:
* Learn to reduce stress
* Learn to cope with physical symptoms
* Learn to deal with depression and other psychological issues
* Improve quality of life
* Reduce preoccupation with symptom
Electroconvulsive therapy (ECT) has been used in treating somatic symptom disorder among the elderly; however, the results were still debatable with some concerns around the side effects of using ECT. Overall, psychologists recommend addressing a common difficulty in patients with somatic symptom disorder in the reading of their own emotions. This may be a central feature of treatment; as well as developing a close collaboration between the GP, the patient and the mental health practitioner.

## Prognosis

Somatic symptom disorder is typically persistent, with symptoms that wax and wane. Chronic limitations in general function, substantial psychological impairment, and a reduction in quality of life are all common. Some investigations suggest people can recover; the natural history of the illnesses implies that around 50% to 75% of patients with medically unexplained symptoms improve, whereas 10% to 30% deteriorate. Fewer physical symptoms and better baseline functioning are stronger prognostic indicators. A strong, positive relationship between the physician and the patient is crucial, and it should be accompanied by frequent, supportive visits to avoid the temptation to medicate or test when these interventions are not obviously necessary.

## Epidemiology

Somatic symptom disorder affects 5% to 7% of the general population, with a higher female representation, and can arise throughout childhood, adolescence, or adulthood. Evidence suggests that the emergence of prodromal symptoms often begins in childhood and that symptoms fitting the criteria for somatic symptom disorder are common during adolescence. A community study of adolescents found that 5% had persistent distressing physical symptoms paired with psychological concerns. In the primary care patient population, the rate rises to around 17%. Patients with functional illnesses such as fibromyalgia, irritable bowel syndrome, and chronic fatigue syndrome have a greater prevalence of somatic symptom disorder. The reported frequency of somatic symptom disorder, as defined by the DSM-5 criteria, ranges from 25 to 60% among these patients.
There are cultural differences in the prevalence of somatic symptom disorder. For example, somatic symptom disorder and symptoms were found to be significantly more common in Puerto Rico. In addition, the diagnosis is also more prevalent among African Americans and those with less than a high school education or lower socioeconomic status.
There is usually co-morbidity with other psychological disorders, particularly mood disorders or anxiety disorders. Research also showed comorbidity between somatic symptom disorder and personality disorders, especially antisocial, borderline, narcissistic, histrionic, avoidant, and dependent personality disorder.
About 10–20% of female first degree relatives also have somatic symptom disorder and male relatives have increased rates of alcoholism and sociopathy.

## History

Somatization is an idea that physicians have been attempting to comprehend since the dawn of time. The Egyptians and Sumerians were reported to have utilized the notions of melancholia and hysteria as early as 2600 BC. For many years, somatization was used in conjunction with the terms hysteria, melancholia, and hypochondriasis.
Wilhelm Stekel, a German psychoanalyst, was the first to introduce the term somatization, while Paul Briquet was the first to characterize what is now known as somatic symptom disorder. Briquet reported respondents who had been unwell for most of their lives and complained of a variety of symptoms from various organ systems. Despite many appointments, hospitalizations, and tests, symptoms continue. Somatic symptom disorder was later dubbed "Briquet Syndrome" in his honor.

## Controversy

Somatic symptom disorder has long been a contentious diagnosis because it was based solely on negative criteria, namely the absence of a medical explanation for the presenting physical problems. As a result, any person suffering from a poorly understood illness may meet the criteria for this psychological diagnosis, regardless of whether they exhibit psychiatric symptoms in the traditional sense.

### Misdiagnosis

Allen Frances, chair of the DSM-IV task force, claimed that the DSM-5's somatic symptom disorder brings with it a risk of mislabeling a sizable proportion of the population as mentally ill.
   Millions of people could be mislabeled, with the burden falling disproportionately on women, because they are more likely to be casually dismissed as 'catastrophizers' when presenting with physical symptoms.