Psych · General adult psychiatry — somatic symptom and related disorders
Somatic symptom disorder
Also known as SSD · Somatisation · Somatization disorder · Somatoform disorder · Medically unexplained symptoms · Bodily distress disorder · Functional somatic syndromes · PHQ-15
Exam-exhaustive fellowship reference on somatic symptom disorder — DSM-5-TR criteria and the medically unexplained pivot, ICD-11 bodily distress framing, discriminators vs illness anxiety/FND/factitious/malingering, PHQ-15 assessment, collaborative stepped care, CBT evidence, pharmacotherapy humility, and avoiding iatrogenic harm. FRANZCP-primary, globally tagged.
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Red flags
- New or changing focal neurological, constitutional, night pain, or organ-failure signals — re-open the organic work-up even in known high-utilising patients
- Telling the patient 'it is all in your head' — destroys alliance and is nosologically wrong under DSM-5-TR SSD logic
- Endless unfocused investigations without a positive formulation — iatrogenic reinforcement of threat beliefs
- Opioid plus benzodiazepine (and often gabapentinoid) polypharmacy for chronic somatic distress without functional goals
- Active suicidality or severe depression untreated while the team argues only about 'somatisation'
- Factitious or malingering language without careful evidence — high medicolegal and alliance cost
- Care fragmentation / doctor shopping with no coordinating clinician and no re-investigation thresholds
Meet the patient
She is 44, and her file is thicker than her arm. Eleven years of abdominal pain, dizziness, palpitations and fatigue; four specialties; two normal endoscopies; one laparoscopy; and a folder of results she carries in a supermarket bag.[4][6][15]
She has been told there is nothing wrong four separate times, and each time she has come back with one more symptom. Today the emergency department has referred her to you with the single word "functional" in the referral box.[6][15]
The registrar asks whether the symptoms are real. That is the wrong question, and it is the reason she has been in the system for eleven years.[1][6]
References18ShowHide
- [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]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
- [18]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