Psych · Consultation-liaison psychiatry
Pain psychiatry and somatic symptom disorders
Also known as Somatic symptom disorder · Illness anxiety disorder · Hypochondriasis · Medically unexplained symptoms · Functional somatic syndromes · Chronic pain psychiatry · Bodily distress disorder
Exam-exhaustive fellowship topic on pain psychiatry and somatic symptom disorders for consultation-liaison practice — DSM-5-TR SSD and illness anxiety (vs ICD-11 framing), chronic pain–psych interface, PHQ-15 assessment, CBT and stepped care evidence, cautious SNRI/TCA analgesia, and opioid dual-diagnosis principles. FRANZCP-primary, globally tagged.
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Target exams
Red flags
- New or changing focal neurological, constitutional, or red-flag pain features — re-open the organic work-up even in known somatising patients
- Telling the patient 'it is all in your head' — destroys alliance and is nosologically wrong under DSM-5-TR SSD logic
- Long-term high-dose opioids for chronic non-cancer pain without functional goals — SPACE and CDC 2022 argue against routine superiority of opioids
- Opioid plus benzodiazepine (and often gabapentinoid) polypharmacy — overdose and dependence risk
- Care-avoidant illness anxiety missing real disease because the patient refuses examinations
- Factitious or malingering language without careful evidence — high medicolegal and alliance cost
- Suicidality, severe depression, or opioid use disorder untreated while focusing only on 'somatisation'
Meet the patient
A 52-year-old woman has been admitted under the physicians for the fourth time this year. Each admission: chest pain, abdominal pain, dizziness, normal scans, and a discharge letter that reads medically unexplained — consider psychiatry. She arrives angry, clutching a folder of results, and tells you the last registrar said it was "all in her head."[4][24]
She takes oxycodone 40 mg a day, diazepam 10 mg at night, and has stopped working. Her PHQ-15 is high, her mood is low, and she has not slept properly in months.[4][20]
Two questions decide whether she gets better or returns a fifth time. Has anyone given her a positive explanation that doesn't call her a liar? And what is the function she has lost — and could regain? Everything below serves those two questions at consultant depth.[6][24]
References24ShowHide
- [1]Dimsdale JE, Creed F, Escobar J, et al. Somatic symptom disorder: an important change in DSM J Psychosom Res, 2013.PMID 23972410
- [2]Dimsdale JE, Levenson J What's next for somatic symptom disorder? Am J Psychiatry, 2013.PMID 24306336
- [3]Mayou R Is the DSM-5 chapter on somatic symptom disorder any better than DSM-IV somatoform disorder? Br J Psychiatry, 2014.PMID 25029686
- [4]Kroenke K, Spitzer RL, Williams JB The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms Psychosom Med, 2002.PMID 11914441
- [5]Kroenke K, Spitzer RL, Williams JB, et al. The Patient Health Questionnaire Somatic, Anxiety, and Depressive Symptom Scales: a systematic review Gen Hosp Psychiatry, 2010.PMID 20633738
- [6]Henningsen P, Zipfel S, Herzog W Management of functional somatic syndromes Lancet, 2007.PMID 17368156
- [7]Fink P, Toft T, Hansen MS, et al. Symptoms and syndromes of bodily distress: an exploratory study of 978 internal medical, neurological, and primary care patients Psychosom Med, 2007.PMID 17244846
- [8]van Dessel N, den Boeft M, van der Wouden JC, et al. Non-pharmacological interventions for somatoform disorders and medically unexplained physical symptoms (MUPS) in adults Cochrane Database Syst Rev, 2014.PMID 25362239
- [9]Kleinstäuber M, Witthöft M, Steffanowski A, et al. Pharmacological interventions for somatoform disorders in adults Cochrane Database Syst Rev, 2014.PMID 25379990
- [10]Kleinstäuber M, Witthöft M, Hiller W Efficacy of short-term psychotherapy for multiple medically unexplained physical symptoms: a meta-analysis Clin Psychol Rev, 2011.PMID 20920834
- [11]Barsky AJ, Ahern DK Cognitive behavior therapy for hypochondriasis: a randomized controlled trial JAMA, 2004.PMID 15039413
- [12]Greeven A, van Balkom AJ, Visser S, et al. Cognitive behavior therapy and paroxetine in the treatment of hypochondriasis: a randomized controlled trial Am J Psychiatry, 2007.PMID 17202549
- [13]Tyrer P, Cooper S, Salkovskis P, et al. Clinical and cost-effectiveness of cognitive behaviour therapy for health anxiety in medical patients: a multicentre randomised controlled trial Lancet, 2014.PMID 24139977
- [14]Fallon BA, Ahern DK, Pavlicova M, et al. A Randomized Controlled Trial of Medication and Cognitive-Behavioral Therapy for Hypochondriasis Am J Psychiatry, 2017.PMID 28659038
- [15]Barsky AJ, Ahern DK, Bauer MR, et al. A randomized trial of treatments for high-utilizing somatizing patients J Gen Intern Med, 2013.PMID 23494213
- [16]Sumathipala A, Siribaddana S, Abeysingha MR, et al. Cognitive-behavioural therapy v. structured care for medically unexplained symptoms: randomised controlled trial Br J Psychiatry, 2008.PMID 18700219
- [17]Moore RA, Derry S, Aldington D, et al. Amitriptyline for neuropathic pain in adults Cochrane Database Syst Rev, 2015.PMID 26146793
- [18]Lunn MP, Hughes RA, Wiffen PJ Duloxetine for treating painful neuropathy, chronic pain or fibromyalgia Cochrane Database Syst Rev, 2014.PMID 24385423
- [19]Goldstein DJ, Lu Y, Detke MJ, et al. Duloxetine vs. placebo in patients with painful diabetic neuropathy Pain, 2005.PMID 15927394
- [20]Krebs EE, Gravely A, Nugent S, et al. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial JAMA, 2018.PMID 29509867
- [21]Dowell D, Ragan KR, Jones CM, et al. CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022 MMWR Recomm Rep, 2022.PMID 36327391
- [22]Williams ACC, Fisher E, Hearn L, et al. Psychological therapies for the management of chronic pain (excluding headache) in adults Cochrane Database Syst Rev, 2020.PMID 32794606
- [23]Kroenke K, Bair MJ, Damush TM, et al. Optimized antidepressant therapy and pain self-management in primary care patients with depression and musculoskeletal pain: a randomized controlled trial JAMA, 2009.PMID 19470987
- [24]Howe CQ, Sullivan MD The missing 'P' in pain management: how the current opioid epidemic highlights the need for psychiatric services in chronic pain care Gen Hosp Psychiatry, 2014.PMID 24211157