Somatic Symptom Disorder

Somatic Symptom Disorder is a psychiatric condition that includes physical symptoms. Someone with this disorder has a genuine medical condition but has developed psychological symptoms that are not part of the normal course of the illness.

Somatic symptom disorder is a psychiatric condition that includes physical symptoms. The nature and origin of the physical symptoms vary, but their significant psychological elements and impacts are the primary focus of diagnosis and treatment for somatic symptom disorder.

What is Somatic Symptom Disorder?

Somatic symptom disorder is a new mental health condition that was first included in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) published in 2013. It is defined by the presence of physical symptoms that cause significant psychological distress.

In previous DSM editions, the condition was called somatization disorder and defined differently. To be diagnosed with somatization disorder, a person had to have precise physical symptoms in each of four categories: pain, sexual, gastrointestinal and “pseudoneurological.” Diagnosing somatization disorder required ruling out or disproving a medical cause of these symptoms.

Somatization disorder required symptoms to be psychosomatic or to have a psychological rather than a medical origin. This reflects a traditional perspective. Stories from the early psychoanalytic period, when Freud and Jung were active, feature patients with mysterious physical ailments that analysts determined were caused by repressed emotion or by mental illness. These psychosomatic symptoms included blindness, loss of voice, spasms and paralysis.

The somatic symptom disorder definition is more straightforward than the definition of somatization disorder and focuses more on the psychological aspects and impact of somatic symptoms. The physical symptoms are not required to have a psychological cause, just a disproportionate psychological impact. Other somatic disorders, particularly conversion disorder, remain rooted in the concept of psychosomatic illnesses.

For a person to be diagnosed with somatic symptom disorder, the following DSM-5 criteria must be met:

• There are somatic symptoms that significantly disrupt daily life or cause severe distress
• The thoughts, feelings or behaviors focused on these symptoms are excessive in nature
• Both physical and psychological symptoms persist, usually for six months or more

The thoughts, feelings and behaviors related to the symptoms are not only excessive but must also include at least one of the following:

• Disproportionate and persistent thoughts about the seriousness of the symptoms
• Persistently high anxiety about somatic symptoms or related health concerns
• Excessive time and energy spent on behavior devoted to the symptoms

In other words, somatic symptom disorder is a condition in which a person spends excess energy worrying about or acting to address symptoms that would not typically require this level of response. It does not matter whether the symptoms are psychosomatic or medical in origin, only that the distress they cause is out of proportion with their actual health impact.

Conditions Related to Somatic Symptom Disorder

Somatic symptom disorder is one of five specific somatic disorders listed in the DSM-5. The relationship between physical symptoms and psychological symptoms differs among somatic disorders. Understanding these differences can help people understand how these symptoms generally affect one another.

In some somatic disorders, symptoms are rooted in a medical condition. In others, symptoms have a psychosomatic origin or an unspecified origin that is not considered for the diagnosis. In all of them, physical symptoms cause significant psychological distress.

Illness Anxiety Disorder

Illness anxiety disorder is similar to somatic symptom disorder in that it requires a person to have a high level of anxiety about physical symptoms and to take disproportionate action in response to them. However, it is different from somatic symptom disorder in that it has more to do with how a person perceives an illness than with their actual symptoms. It is also more explicitly psychological in nature.

To be diagnosed with illness anxiety disorder, a person must exhibit the following symptoms:

• Preoccupation with having or developing a serious illness
• A lack of somatic symptoms or only mild symptoms and a disproportionate fear of their significance
• High levels of anxiety about health and alarmed reactions to perceived physical changes
• Excessive checking for symptoms or avoidance of any medical examination whatsoever
• Persistent preoccupation with these concerns that lasts at least six months

Illness anxiety disorder has two subtypes: care-seeking and care-avoiding. These subtypes are assigned based on whether a person makes excessive efforts to be seen frequently by medical professionals or avoids them altogether.

Factitious Disorder

Factitious disorder is not a psychosomatic or medical condition but is a psychological condition in which a person claims to have physical or psychological symptoms they do not have. For a person to be diagnosed with the disorder, they must demonstrate all of the following:

• Falsification of physical or psychological symptoms
• Self-presentation as having an illness, impairment or injury
• Persistent deceptive behavior even in the absence of obvious external rewards

These symptoms cannot be better explained by another psychological condition, such as a psychotic or delusional disorder. The initial reason for the deception can vary, but the false symptoms persist even in the absence of financial gain or other external rewards. This clinical judgment distinguishes this disorder from malingering, the term used by providers to indicate that someone is intentionally falsifying an illness for an external reward.

People with factitious disorders are often motivated by a wish that they had another disorder. They want to be seen as having a particular medical or mental health condition and frequently have a history of child abuse or trauma. They may have genuine pain they want to heal but don’t know how to express it directly. Sometimes people with factitious disorder induce symptoms of illness or injuries. They are often unaware that they are doing this.

Conversion Disorder

Conversion disorder, also known as functional neurological symptom disorder, is the classic diagnosis for psychosomatic conditions. Many of Freud’s early patients were diagnosed with conversion disorder. To be diagnosed with this condition, a person must:

• Have one or more symptoms of altered voluntary motor or sensory functions
• Have been examined by physicians who found that these physical symptoms were not compatible with any existing neurological or medical conditions
• Have symptoms that are not better explained by another medical or psychiatric condition

These symptoms must cause significant functional impairment or distress. Conversion disorder has several subtypes based on the nature of psychosomatic symptoms. Different categories of conversion disorder symptoms include the following:

• Weakness or paralysis
• Abnormal movement (such as tremor or altered gait)
• Swallowing symptoms
• Speech symptoms
• Attacks or seizures
• Anesthesia or sensory loss
• Special sensory symptoms (such as visual or hearing disturbance)
• Mixed symptoms

Psychological stressors can precipitate the condition or these symptoms can arise independently of any stressors.

Psychological Factors Affecting a Medical Condition

Psychological factors affecting a medical condition is the DSM-5 diagnosis for people who have symptoms with a known medical cause and an abnormal or maladaptive psychological reaction to them. To be diagnosed with this disorder, a person must have psychological symptoms that negatively affect their medical condition in one of the following ways:

• They exacerbate or delay recovery from the medical condition
• They interfere with the treatment of the medical condition
• They constitute significant additional health risks
• They cause adverse physiological reactions or symptoms to develop

In other words, someone with this disorder has a genuine medical condition but has developed psychological symptoms that are not part of the normal course of the illness. Their reactions to the illness make it worse and lead to additional health risks.

Signs of Somatic Symptom Disorder

Somatic symptom disorders can be tricky to diagnose as they require a careful process of differential diagnosis to determine that they are not medical conditions or normal reactions to them. However, there are a few common signs that indicate the presence of a somatic disorder.

Persistent Pain or Fatigue

Most medical conditions have specific symptoms that can be detected by blood analysis, x-rays or other medical tests. Many of these medical disorders also cause pain and fatigue. However, when lethargy and physical discomfort are present when no other medical symptoms are detected or when all other physical symptoms are actively improving, they are more likely to indicate a somatic disorder.

Persistently High Level of Anxiety About Your Health

Two features of all somatic disorders are a preoccupation with somatic symptoms and anxiety about what they mean. This anxiety and the reactions to it can have a negative impact on the treatment of and recovery from an underlying medical condition when one is present.

This makes diagnosing somatic disorders tricky because anxiety is a natural response to medical conditions even when they are not associated with somatic disorders or symptoms. One sign that anxiety indicates a somatic condition is that it persists despite feedback from medical professionals that it is unwarranted or excessive.

Causes of Somatic Symptom Disorder

Causes of somatic symptom and related disorders are as varied as the conditions themselves. Somatic symptom examples include exaggerated psychological reactions to medical conditions, psychosomatic symptoms and self-induced injury. The causes of these symptoms and disorders are different but share certain factors in common.

Genetic Causes

Somatic symptom disorder symptoms may be particularly linked to family influence. Genetic factors affect how people perceive physical sensations, and family environments shape how people respond to these perceptions. A person is much more likely to develop a somatic disorder if they grew up with family members who had serious medical conditions or symptoms.

Similarly, the factitious disorder has been linked with having family members who are frequently hospitalized or are chronically ill. People learn from family members how much to fear illness and if medical symptoms are rewarded with special attention and care. Families who are unduly demonstrative of illness may inadvertently encourage members to view being ill as desirable.

Biological Causes

Somatic symptom disorder with predominant pain is an example of a somatic condition driven by biological causes. Differences in brain chemistry and nervous system sensitivity can cause some people to have a heightened perception of pain. People with a heightened awareness of physical sensations may be more likely to interpret them as signs of a medical illness.

Research by Clifford Woolf of Harvard shows that BH₄, a chemical produced by the nervous system, causes people to experience pain more intensely. People whose bodies produce more of this chemical have heightened reactions to pain because they experience it more acutely than others. Such sensitivities may especially influence the development of somatic symptom disorder and illness anxiety disorder.

Psychological Causes (Hypochondriasis)

Somatic symptom disorder signs and symptoms can also come from purely psychological causes. Psychosomatic symptoms can develop in response to trauma or abuse. Some people convert psychological pain into physical symptoms through an unconscious process that helped them survive in a home in which emotional expression was discouraged or repressed. Factitious and conversion disorders can follow from frequent childhood experiences of being unable to receive psychological comfort or help.

Co-occurring psychiatric conditions can also contribute to the development of somatic symptom disorders. The anxiety that particular symptoms are worse than they are or fears they are harbingers of doom may be driven by comorbid anxiety disorders. Factitious and conversion disorders are sometimes linked to comorbid dissociative or personality disorders. Many trauma-related disorders, especially dissociative disorders, involve altered perceptions of bodily sensations and diminished or heightened reactions to them.

How is Somatic Symptom Disorder Diagnosed?

Like most other psychiatric conditions, somatic symptom disorders are diagnosed through clinical interviews that confirm whether a person meets the relevant diagnostic criteria. Unlike other psychiatric conditions, these disorders often involve careful screening tests to determine whether physical symptoms have a medical origin.

Somatic symptom disorder tests are clinical instruments that may be used to determine whether reported physical symptoms arise from a medical condition or somatic disorder. Many clinicians use specific diagnostic instruments as part of an evaluation. These might include open-ended questions, multiple-choice questions or rating scales. The eight-item Somatic Symptom Scale (SSS-8) is a shortened form of the patient health questionnaire (PHQ) that was found to be a valid assessment tool in clinical research.

Who is at Risk for Somatic Symptom Disorder?

Shared risk factors for somatic symptom disorder and related disorders include the following:

• A history of child abuse
• A history of traumatic experiences
• A history of childhood illness or of having a seriously ill parent
• Heightened sensitivity to physical sensations, especially pain
• Difficulty processing emotions or decreased awareness of them
• Comorbid anxiety, depression or dissociative disorders
• A prolonged period of heightened or acute stress

In general, people are at risk for somatic symptom disorders when they are more sensitive to physical sensations, grow up in families significantly affected by medical conditions and have histories of trauma or anxiety.

Somatic Symptom Disorder Statistics

• Around 5 to 7 percent of the general population has a somatic symptom disorder.
• Approximately 20 to 25 percent of people who develop acute somatic symptoms later develop a chronic somatic disorder.
• Anywhere from 50 to 75 percent of patients with somatic symptoms experience improvement in their condition, while 10 to 30 percent experience a worsening of their condition.
• Most people with somatic symptom disorder develop the condition by the age of 30.

Physical discomfort and anxiety can be an overwhelming combination. People who are in pain and are afraid of what that pain means may start using substances to feel better or to relieve their anxiety. This can lead to addiction.

Many rehab facilities offer tailored treatment plans that address the complexities of co-occurring conditions. The Recovery Village has rehab centers across the United States that provide integrated treatment for people with a wide range of dually diagnosed disorders. To learn more about how treatment can help you learn how to manage anxiety, feel mentally and physically better and control cravings to use substances, contact a representative at The Recovery Village today.

Related Topic: Somatic symptom disorder treatment

Editor – Thomas Christiansen

With over a decade of content experience, Tom produces and edits research articles, news and blog posts produced for Advanced Recovery Systems. Read more

Medically Reviewed By – Stephanie Hairston, MSW

Stephanie Hairston received her Bachelor of Arts degree in Psychology and English from Pomona College and her Master of Social Work degree from New York University. Read more