Somatic Symptom Disorder

Somatic symptom disorder is one or more distressing somatic symptoms with excessive thoughts, feelings or behaviours related to them lasting over 6 months, irrespective of medical explanation.

• Prevalence 5 to 7% of adults; commoner in women, with high healthcare use.
• Associated factors: childhood adversity, anxiety, depression, alexithymia, medically unexplained symptoms.
• Comorbid medical illness may coexist; symptoms should not be dismissed.
• Chronic course with disability, and high costs from repeated investigation.

• Pain, fatigue, gastrointestinal, neurological symptoms; catastrophising, persistent high health anxiety, excessive time and energy devoted to symptoms.
• Doctor shopping, repeated investigations, avoidance of activity.
• Frequent comorbid depression and anxiety.

• DSM-5 criteria; Somatic Symptom Scale (SSS-8), PHQ-15.
• Appropriate but limited investigation to exclude organic disease; avoid unnecessary repeat testing.
• Assess depression, anxiety, trauma, substance misuse and suicide risk.
• Exclude illness anxiety disorder, functional neurological disorder, factitious disorder, panic disorder.

• Therapeutic relationship: regular scheduled appointments (every 4 to 6 weeks), single care coordinator, validate symptoms, avoid unnecessary tests and referrals.
• CBT for somatic symptoms (8 to 12 sessions), graded activity, mindfulness.
• Antidepressants for comorbid depression or anxiety, and sometimes for pain: sertraline 50 to 200 mg, duloxetine 60 mg, amitriptyline 10 to 50 mg at night, mirtazapine 15 to 30 mg.
• Avoid opioids and benzodiazepines.
• Collaborative care with primary care; treat concurrent medical conditions appropriately.