Somatic symptom disorder

Somatic symptom disorder is characterized by an extreme focus on physical symptoms — such as pain or fatigue — that causes major emotional distress and problems functioning. You may or may not have another diagnosed medical condition associated with these symptoms, but your reaction to the symptoms is not normal.

You often think the worst about your symptoms and frequently seek medical care, continuing to search for an explanation even when other serious conditions have been excluded. Health concerns may become such a central focus of your life that it's hard to function, sometimes leading to disability.

If you have somatic symptom disorder, you may experience significant emotional and physical distress. Treatment can help ease symptoms, help you cope and improve your quality of life.

Symptoms of somatic symptom disorder may be:

• Specific sensations, such as pain or shortness of breath, or more general symptoms, such as fatigue or weakness
• Unrelated to any medical cause that can be identified, or related to a medical condition such as cancer or heart disease, but more significant than what's usually expected
• A single symptom, multiple symptoms or varying symptoms
• Mild, moderate or severe

Pain is the most common symptom, but whatever your symptoms, you have excessive thoughts, feelings or behaviors related to those symptoms, which cause significant problems, make it difficult to function and sometimes can be disabling.

These thoughts, feelings and behaviors can include:

• Constant worry about potential illness
• Viewing normal physical sensations as a sign of severe physical illness
• Fearing that symptoms are serious, even when there is no evidence
• Thinking that physical sensations are threatening or harmful
• Feeling that medical evaluation and treatment have not been adequate
• Fearing that physical activity may cause damage to your body
• Repeatedly checking your body for abnormalities
• Frequent health care visits that don't relieve your concerns or that make them worse
• Being unresponsive to medical treatment or unusually sensitive to medication side effects
• Having a more severe impairment than is usually expected from a medical condition

For somatic symptom disorder, more important than the specific physical symptoms you experience is the way you interpret and react to the symptoms and how they impact your daily life.

When to see a doctor

Because physical symptoms can be related to medical problems, it's important to be evaluated by your primary care provider if you aren't sure what's causing your symptoms. If your primary care provider believes that you may have somatic symptom disorder, he or she can refer you to a mental health professional.

Caring for a loved one

When physical symptoms considered to be somatic symptom disorder occur, it can be difficult to accept that a life-threatening illness has been eliminated as the cause. Symptoms cause very real distress for the person and reassurance isn't always helpful. Encourage your loved one to consider the possibility of a mental health referral to learn ways to cope with the reaction to symptoms and any disability it causes.

Physical disability may cause the person to be dependent and need extra physical care and emotional support that can exhaust caregivers and cause stress on families and relationships. If you feel overwhelmed by your role as caregiver, you may want to talk to a mental health professional to address your own needs.

The exact cause of somatic symptom disorder isn't clear, but any of these factors may play a role:

• Genetic and biological factors, such as an increased sensitivity to pain
• Family influence, which may be genetic or environmental, or both
• Personality trait of negativity, which can impact how you identify and perceive illness and bodily symptoms
• Decreased awareness of or problems processing emotions, causing physical symptoms to become the focus rather than the emotional issues
• Learned behavior — for example, the attention or other benefits gained from having an illness; or "pain behaviors" in response to symptoms, such as excessive avoidance of activity, which can increase your level of disability

Risk factors for somatic symptom disorder include:

• Having anxiety or depression
• Having a medical condition or recovering from one
• Being at risk of developing a medical condition, such as having a strong family history of a disease
• Experiencing stressful life events, trauma or violence
• Having experienced past trauma, such as childhood sexual abuse
• Having a lower level of education and socio-economic status

Somatic symptom disorder can be associated with:

• Poor health
• Problems functioning in daily life, including physical disability
• Problems with relationships
• Problems at work or unemployment
• Other mental health disorders, such as anxiety, depression and personality disorders
• Increased suicide risk related to depression
• Financial problems due to excessive health care visits

Little is known about how to prevent somatic symptom disorder. However, these recommendations may help.

• If you have problems with anxiety or depression, seek professional help as soon as possible.
• Learn to recognize when you're stressed and how this affects your body — and regularly practice stress management and relaxation techniques.
• If you think you have somatic symptom disorder, get treatment early to help stop symptoms from getting worse and impairing your quality of life.
• Stick with your treatment plan to help prevent relapses or worsening of symptoms.

To determine a diagnosis, you'll likely have a physical exam and any tests your doctor recommends. Your doctor or other health care provider can help determine if you have any health conditions that need treatment.

Your medical care provider may also refer you to a mental health professional, who may:

• Conduct a psychological evaluation to talk about your symptoms, fears or concerns, stressful situations, relationship problems, situations you may be avoiding, and family history
• Have you fill out a psychological self-assessment or questionnaire
• Ask you about alcohol, drug or other substance use

Criteria for diagnosis

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association, emphasizes these points in the diagnosis of somatic symptom disorder:

• You have one or more somatic symptoms — for example, pain or fatigue — that are distressing or cause problems in your daily life
• You have excessive and persistent thoughts about the seriousness of your symptoms, you have a persistently high level of anxiety about your health or symptoms, or you devote too much time and energy to your symptoms or health concerns
• You continue to have symptoms that concern you, typically for more than six months, even though the symptoms may vary

The goal of treatment is to improve your symptoms and your ability to function in daily life. Psychotherapy, also called talk therapy, can be helpful for somatic symptom disorder. Sometimes medications may be added, especially if you're struggling with feeling depressed.

Psychotherapy

Because physical symptoms can be related to psychological distress and a high level of health anxiety, psychotherapy — specifically, cognitive behavioral therapy (CBT) — can help improve physical symptoms.

CBT can help you:

• Examine and adapt your beliefs and expectations about health and physical symptoms
• Learn how to reduce stress
• Learn how to cope with physical symptoms
• Reduce preoccupation with symptoms
• Reduce avoidance of situations and activities due to uncomfortable physical sensations
• Improve daily functioning at home, at work, in relationships and in social situations
• Address depression and other mental health disorders

Family therapy may also be helpful by examining family relationships and improving family support and functioning.

Medications

Antidepressant medication can help reduce symptoms associated with depression and pain that often occur with somatic symptom disorder.

If one medication doesn't work well for you, your doctor may recommend switching to another or combining certain medications to boost effectiveness. Keep in mind that it can take several weeks after first starting a medication to notice an improvement in symptoms.

Talk with your doctor about medication options and the possible side effects and risks.

While somatic symptom disorder benefits from professional treatment, you can take some lifestyle and self-care steps, including these:

• Work with your care providers. Work with your medical care provider and mental health professional to determine a regular schedule for visits to discuss your concerns and build a trusting relationship. Also discuss setting reasonable limits on tests, evaluations and specialist referrals. Avoid seeking advice from multiple doctors or emergency room visits that can make your care more difficult to coordinate and may subject you to duplicate testing.
• Practice stress management and relaxation techniques. Learning stress management and relaxation techniques, such as progressive muscle relaxation, may help improve symptoms.
• Get physically active. A graduated activity program may have a calming effect on your mood, improve your physical symptoms and help improve your physical function.
• Participate in activities. Stay involved in your work and in social and family activities. Don't wait until your symptoms are resolved to participate.
• Avoid alcohol and recreational drugs. Substance use can make your care more difficult. Talk to your health care provider if you need help quitting.

In addition to a medical evaluation, your primary care provider may refer you to a psychiatrist or psychologist for evaluation and treatment.

What you can do

Before your appointment, make a list of:

• Your symptoms, including when they first occurred and how they impact your daily life
• Key personal information, including traumatic events in your past and any stressful, major events
• Medical information, including other physical or mental health conditions that you have
• Medications, vitamins, herbs and other supplements, and the dosages
• Questions to ask your medical care provider or mental health professional

Ask a trusted family member or friend to go with you to your appointment, if possible, to lend support and help you remember information.

Questions to ask may include:

• Do I have somatic symptom disorder?
• What treatment approach do you recommend?
• Would therapy be helpful in my case?
• If you're recommending therapy, how often will I need it and for how long?
• If you're recommending medications, are there any possible side effects?
• For how long will I need to take medication?
• How will you monitor whether my treatment is working?
• Are there any self-care steps I can take to help manage my condition?
• Are there any brochures or other printed material that I can have?
• What websites do you recommend?

Don't hesitate to ask any other questions.

What to expect from your doctor

Your medical care provider or mental health professional may ask you questions, such as:

• What are your symptoms, and when did they first occur?
• How do your symptoms affect your life, such as at school, at work and in personal relationships?
• Have you or any of your close relatives been diagnosed with a mental health disorder?
• Have you been diagnosed with any medical conditions?
• Do you use alcohol or recreational drugs? How often?
• Do you get regular physical activity?

Your medical care provider or mental health professional will ask additional questions based on your responses, symptoms and needs. Preparing and anticipating questions will help you make the most of your appointment time.