Somatic Symptom and Related Disorders: Overview
Somatic symptom and related disorders are indicated by the presence of somatic and/or physical concerns, unpleasant thoughts, distress and impairment. People who experience these symptoms usually present to medical professionals for what they believe to be real, distressing physical symptoms. Sharma and Manjula (2013) have concluded that as many as one third to one half of all medical complaints cannot be explained.
Frequently individuals experiencing symptoms that can be defined within the category of somatic symptoms and related disorders are referred by physicians after exhaustive attempts to identify and diagnose the source of physical symptoms. Due to the significant comorbidity between these physical manifestations and depression and anxiety disorders, mental health professionals often find that they are dealing with significant physical distress along with mental health issues.
Changes from DSM-4-TR to DSM-5:
The DSM-4-TR category of Somatoform Disorders was changed to Somatic Symptom and Related Disorders in the DSM-V. Psychologists and other mental health professionals will now find two new diagnostic categories in this section including somatic symptom disorder and illness anxiety disorder. Individuals experiencing somatic concerns with or without current medical conditions can be diagnosed with the new category of somatic symptom disorder if they have both unexplained somatic symptoms and inappropriate or maladaptive reactions to those symptoms (APA, 2013).
The previous diagnosis of hypochondriasis was eliminated by the APA Somatic Symptoms Disorders work group because they believed that it was unnecessarily stigmatizing to patients. Also, they discontinued pain disorder as it was too difficult to determine whether pain was actually due to psychological or physical causes. (APA, 2013).
Diagnosis of Somatic Symptom and Related Disorders:
Because the signs and symptoms of somatic disorders are primarily physical, the initial focus needs to be on completing a comprehensive medical examination to determine the specific apparent cause of the concern. The DSM-5 allows for the consideration of diagnosable health issues along with the distressing reactions to those issues. Therefore, the initial diagnosis may include (a) if there are medical conditions present and (b) whether the individual’s reaction will be in excess to what would be expected in relation to those medical concerns.
The coexistence or comorbidity between somatic symptoms and mental health symptoms such as depression and anxiety is enormous. Frequently there seems to be significant cultural aspects to expressing depression and anxiety related symptoms somatically. Also, somatic and anxiety symptoms are often seen among individuals with substance use issues and patients who have experienced trauma making it imperative to also consider the possibility of PTSD in the differential diagnosis.
Cause and Treatment:
Somatoform disorders were initially considered to be psychodynamic reactions to stressors in which the patient was believed to be converting psychological issues into physical symptoms in attempting to cope with the stress. There are currently several models for potentially explaining the cause of somatic symptoms and related disorders. The APA (2013) have identified early traumatic experiences, social learning and social and cultural norms as well as biological and genetic vulnerability. So (2008) has concluded:
Ethnographic fieldwork has long indicated the presence of a specific type of culturally mediated illness where the individual suffering from psychological issues expresses distress in the form of physical symptoms and somatic complaints, with no known organic cause. In Western psychiatry this phenomenon is commonly labeled somatization disorder (p.68)
Most researchers have found a paucity of research into somatic symptom and related disorders due to their rarity. Sharma and Manjula (2013) have stated:
The basic premise of any psychological intervention in disorders with somatic symptoms is that somatization is a universal phenomenon and is a direct consequence of common psychological disorders such as anxiety or depression resulting in autonomic arousal symptoms or somatic complaints; it may be an idiom for help-seeking for severe social adversities such as poverty, domestic violence, stigma, associated with mental illness (p.117).
Referral for treatment usually occurs within the primary care setting and includes psychiatric or psychological consultation and intervention, reattribution therapy, cognitive behavioral therapy and/or a problem-solving approach (Sharma & Manjula (2013). In most cases, cognitive behavioral therapy has been found to be the most effective. Treatments for what was previously referred to as hypochondriasis in the DSM-4-TR and now defined as somatic symptom disorder or illness anxiety disorder frequently involves cognitive behavioral therapy, medication and psychoeducation.
Psychoeducation may be most appropriate when used for milder concerns and seems to concentrate on facilitating increased coping strategies and recognizing the role of stress in physical manifestations, as well as training in relaxation instead of attempts to convince individuals that their symptoms are unreal or “only in their heads”. Among the antidepressants, fluoxetine seems to be most helpful especially for symptoms that were formally referred to as hypochondriasis.
As with all counseling related therapeutic interventions, the therapeutic relationship is absolutely essential when working with people with somatic symptom and related disorders, especially given the fact that individuals may have experienced significant frustration from the medical conditions and healthcare providers who have a lack of understanding of the etiology of their symptoms. Because of the lack of understanding by both patients and clinicians, individuals experiencing these somatic symptoms can become very frustrated, feeling misunderstood, and will be quick to discontinue treatment if they feel that they are not being taken seriously.
Please see the following pages for specific symptoms and treatment information related to each diagnosis within the category of somatic symptom and related disorders.
Somatic Symptom and Related Disorders: DSM-5 Diagnostic Codes
300.82 (F45.1) Somatic Symptom Disorder
Specify if: With predominant pain
Specify if: Persistent
Specify current severity: Mild, Moderate, Severe
300.7 (F45.21) Illness Anxiety Disorder
Specify whether: Care seeking type, Care avoidant type
300.11 (___.__) Conversion Disorder (Functional Neurological Symptom Disorder)
(F44.4) With weakness or paralysis
(F44.4) With abnormal movement
(F44.4) With swallowing symptoms
(F44.4) With speech symptom
(F44.5) With attacks or seizures
(F44.6) With anesthesia or sensory loss
(F44.6) With special sensory symptom
(F44.7) With mixed symptoms
Specify if: Acute episode, persistent
Specify if: With psychological stressor (specify stressor), Without psychological stressor
316 (F54) Psychological Factors Affecting Other Medical Conditions
Specify current severity: Mild, Moderate, Severe, Extreme
300.19 (F68.10) Factitious Disorder (includes Factitious Disorder Imposed on Self, Factitious Disorder Imposed on Another)
Specify Single episode, Recurrent episodes
300.89 (F45.8) Other Specified Somatic Symptom and Related Disorder
300.82 (F45.9) Unspecified Somatic Symptom and Related Disorder
Some information adapted by Paul Susic Ph.D. Licensed Psychologist from the following sources.
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
Sharma, M.P., & Manjula, M. (2013). Behavioral and psychological management of somatic symptom disorders: An overview. International Review of Psychiatry, 25, 116-124. doi:10.3109/09540261.2012.746649
So, J.K. (2008). Somatization as cultural idiom of distress: Rethinking mind and body in a multicultural society. Counseling Psychology Quarterly, 21, 167-174. doi:10.1080/09515070802066854