Somatic symptom disorder — criteria, assessment and stepped care (MEQ)

(i) Definition and DSM-5 pivot. SSD: one or more distressing somatic symptoms disrupting daily life plus excessive thoughts, feelings, or behaviours related to symptoms (disproportionate seriousness beliefs, high health anxiety, excessive time/energy), typically a symptomatic state over months (usually more than 6 months). Key change: diagnosis does not require medically unexplained symptoms; concurrent disease can coexist if B-criteria met. Here multi-system symptoms, checking, high utilisation, and functional drop-out fit the construct pending full assessment.^[1]

(ii) Differentials. IAD: high illness fear with absent/mild somatic symptoms (this case has prominent symptoms → SSD more than pure IAD). FND: voluntary motor/sensory symptoms with positive incompatibility signs — not the primary pattern here. Factitious: intentional production for sick role — do not diagnose without evidence. Malingering: intentional production for external incentive — high-threshold language; not supported by stem alone. Also screen depression (PHQ-9 elevated), panic, OCD illness obsessions, evolving medical disease on red flags.^[1][3]

(iii) Assessment and risk. Alliance-first history; symptom and function map; prior work-ups and what would change management if repeated; health beliefs and checking; substances. PHQ-15 for somatic severity; PHQ-9/anxiety screens. Suicide risk: passive death wishes require full assessment (ideation, intent, plan, means, protective factors). Collateral from GP; identify coordinating clinician.^[2][3]

(iv) Stepped care and anti-iatrogenesis. Validate symptoms (both–and). Step 1: scheduled GP reviews (not only PRN ED), shared re-investigation thresholds, functional goals. Step 2: CBT for health anxiety/multi-symptom presentations (Barsky; Tyrer CHAMP in medical settings); Cochrane non-pharmacological benefits are modest — set realistic goals. High-utilising models support structured psychosocial care over endless scans. Explicitly avoid “all in your head,” unfocused investigation cascades, and specialist shopping without coordination.^{[3][4][5][7][8]}

(v) Medication limits. Drugs are not a magic anti-somatic cure; Cochrane pharmacological evidence is limited. Treat comorbid depression/anxiety. Example: sertraline 25–50 mg oral daily, titrate as tolerated toward antidepressant range with early review for activation, sexual side effects, and suicide risk; combine with CBT and collaborative care. Avoid long-term benzodiazepines as default. If pain-dominant phenotype later emerges, consider SNRI/TCA pathways with monitoring rather than polypharmacy.^[6]