What is somatic symptom disorder?

Somatic Symptom Disorder: Definition and Diagnostic Criteria

Somatic symptom disorder (SSD) is a psychiatric condition characterized by one or more distressing physical symptoms accompanied by excessive and disproportionate thoughts, feelings, or behaviors related to those symptoms, resulting in significant functional impairment that persists for at least 6 months. 1

Core Diagnostic Features

The diagnosis requires meeting three specific DSM-5 criteria 1:

Criterion A: Physical Symptoms

• One or more somatic symptoms that cause distress or significantly disrupt daily life 1
• These symptoms may or may not have an identifiable medical explanation 1, 2
• The presence or absence of a diagnosable medical condition does not exclude the diagnosis 3

Criterion B: Psychological Response (At Least One Required)

The defining feature is the excessive and disproportionate psychological response to the physical symptoms 1:

• Disproportionate and persistent thoughts about the seriousness of symptoms 1
• Persistently high anxiety about health or symptoms 1
• Excessive time and energy devoted to symptoms or health concerns 1

Criterion C: Duration

• The symptomatic state persists typically more than 6 months 1
• Individual symptoms may fluctuate, but the overall pattern of being symptomatic remains 1

Severity Classification

SSD is graded based on the number of Criterion B features present 1:

• Mild: One Criterion B symptom fulfilled 1
• Moderate: Two or more Criterion B symptoms fulfilled 1
• Severe: Two or more Criterion B symptoms plus multiple somatic complaints (or one very severe symptom) 1

Key Distinguishing Features

What SSD Is NOT:

• Not malingering: No intentional feigning for material or financial gain 1
• Not factitious disorder: Symptoms are not intentionally produced 1
• Not conversion disorder: Does not present as quasi-neurologic symptoms unexplained by neurologic disease 1

The American College of Chest Physicians emphasizes that the term "psychogenic" has been eliminated from modern psychiatric classification because functional imaging studies demonstrate cerebral correlates for these disorders 1.

Clinical Presentation

Common Manifestations

• Neurologic symptoms (weakness, numbness, abnormal movements) 1
• Pain syndromes (abdominal pain, headaches) 1, 4
• Autonomic symptoms 1
• Gastrointestinal complaints 1, 2

Typical Clinical Patterns

• Vague, poorly described complaints 1
• Symptoms that fluctuate with activity or stress 1
• Recent or current stressful life events 1
• Lack of physical findings despite extensive testing 1, 4, 2
• Multiple medical visits without resolution 4, 2

Epidemiology and Impact

• Affects 10-15% of adult primary care patients 1
• In pediatrics, recurrent abdominal pain accounts for 5% of office visits 1
• Headaches account for 20-55% of pediatric visits 1
• 10% of adolescents report frequent somatic symptoms 1
• Represents significant healthcare utilization and costs 1, 2

Diagnostic Approach

The diagnosis can only be made after extensive evaluation ruling out medical causes 1. The American Academy of Pediatrics notes that patients typically present to general practitioners and emergency departments rather than psychiatric settings, making recognition by non-psychiatric physicians critical 1, 4, 2.

Common Pitfall

Failure to recognize SSD may lead physicians to pursue unnecessary investigations or procedures, resulting in iatrogenic complications and significant financial burden on healthcare systems 2. The disorder often co-occurs with anxiety and depressive disorders, requiring assessment for these concurrent diagnoses 4.

Treatment Framework

First-Line Approaches

• Cognitive-behavioral therapy (CBT) is the primary treatment 4, 2
• Mindfulness-based therapy 4, 2
• Pharmacotherapy with SSRIs or tricyclic antidepressants for symptom management 4, 2

Critical Treatment Principle

The American College of Chest Physicians found that pharmacologic interventions are generally ineffective as monotherapy, whereas non-pharmacologic strategies including reassurance, counseling, and psychological referral show benefit 1.