Somatic Symptom Disorder

Welcome to PT 635 Pathophysiology of Complex Patient Problems This is a wiki created by and for the students in the School of Physical Therapy at Bellarmine University in Louisville KY. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Original Editors - Lauren Rouse & Laura Stigler from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - Lauren Rouse, Laura Stigler, Elaine Lonnemann, Admin, Wendy Walker, WikiSysop, Kim Jackson and Vidya Acharya  

Definition/Description

Somatic symptom disorder (SSD), as defined by the DSM-V code, occurs in individuals experiencing exaggerated and disrupted physical symptoms in multiple areas of the body, accompanied by exaggerated thoughts impairing activities of daily living. Diagnosis of SSD requires that the individual has experienced these symptoms for at least six months. This disorder has recently been updated from DSM-IV code of "somatization disorder" to the DSM-V code of "SSD". The prior diagnosis required patient complaints from four different symptom groups; however, this is no longer required with the DSM-V code. In addition, patients experiencing these symptoms associated with other comorbidities such as heart disease, osteoarthritis, or cancer were previously excluded from the DSM-IV diagnostic code. The DSM-V definition now includes these patients under the diagnostic code of SSD, even if the psychological symptoms were secondary to the primary diagnosis. These patients are considered appropriate for psychological treatment; however, a full psychological evaluation is needed to rule out other possible disorders.

The DSM-V code has been implemented for a variety of reasons:

1. The previous diagnosis of "somatoform disorders" is an ambiguous term and is not easily translatable between different languages, as it blends Latin and Greek roots. Somatic symptom disorder has made the diagnosis easily translatable.
2. The previous DSM-IV diagnostic code utilized Medically Unexplained Symptoms as the definining characteristic. This terminology is no longer acceptable. Patients may feel their complaints are deemed illegitimate in the medical community. Medical diagnosis should also never be made on the absence of symptoms. Finally, these symptoms are often unexamined rather than unexplained.
3. Overlap between somatization disorder, undifferentiated somatoform disorder, hypochondriasis, and pain disorder made the DSM-IV code confusing and disorganized. The new code sets a boundary between SSD and illness anxiety disorder.
4. Diagnostic criteria for previous DSM codes was confusing and unreliable, leading to strong specificity with weak sensitivity.
5. Previous inclusion of "Undifferentiated Somatoform Disorder" in the DSM-IV code loosely defined the diagnosis making proper diagnosis inaccurate.
6. Non-psychiatric physicians have rarely diagnosed the disorder due to the confusing nature of previous codes preventing accurate prevalence statistics of previous DSM codes. The new code has been implemented in attempt to improve communication between medical professionals of various backgrounds.
   

If you need additional clarification on the description of Somatic Symptom Disorder and the recent changes in DSM-V, you can check out the video below:

www.gmeded.com/dsm-5/somatic-symptoms-and-related-disorders-dsm-5

Prevalence

Information about the prevalence of SSD is lacking due to the recent changes in the DSM-V code in 2013. The prevalence of the DSM-IV code of somatization disorder is more widely known and the following data has been obtained: 

• For restrictive diagnoses, rates are low in community samples (0.1%) but this may be due to reporting bias
• The disorder may be as high as 2% in community dwelling women, whereas some cases are reported to be as high as 11.6% of the population
  
• The female-to-male ratio is 10:1 and may begin in childhood, adolescence, or early adulthood.
• Older adults diagnosed with somatization disorder is a rare finding. Older patients should be referred to a medical specialist for an underlying medical illness or consider depression as the primary cause of the individual’s perception of pain.
  
• 25% in neurology outpatient medical settings
  
• 27% in primary care

Statistical prevalence on the prior DSM-IV code is inaccurate do to the confusing description of the disoder; therefore, non-psychiatric physicians have rarely diagnosed somatoform disorders. In addition, psychiatric physicians used ambiguous terminology in diagnosis of patients with this disorder. Lack of consensus among the medical community has lead to inaccurate prevalence statistics. Despite the frequency encountered in clinics and studies in medical studies, prevalence among Anthem Blue Cross insured individuals was 0.00002 out of 28 million subscribers and appeared rarely in the medical databases of Medicare, Medicaid and Veteran's Administration. Creation of the new DSM-V code is attempting to provide a straightforward and simplified definition of the disorder so that medical professionals are able to effectively communicate the medical diagnosis of SSD.

Characteristics/Clinical Presentation

Diagnositic criteria for Somatic Symptom Disorder

A. Somatic symptoms:

    One or more somatic symptoms that result in disruption of daily life

B. Excessive thoughts, feelings and behaviors related to these somatic symptoms or associated health concerns: At least two of the following are needed to meet this criterion:

    1. High level of heath-related anxiety

    2. Disproportionate and persistant concerns about the medical seriousness of one's symptoms

    3. Excessive time and energy devoted to these symptoms or health concerns

C. Chronicity: the state of being somatic last > 6 months

Patients with SSD, with have one of the following as a dominate symptoms: somatic complaints, health anxiety, and pain.

Symptoms a patient may present with include:

• Muscle and joint pain
• Low back pain
• Tension headache
• Chronic fatique
• Non-cardiac chest pain
• Palpitation
• Non-ulcer dyspepsia
• Irritable bowel
• Dizziness
• Insomnia

Associated Co-morbidities

Currently, higher percentages of SSD has been found in persons with:

Irritable bowel syndrome
Fibromyalgia
Chronic pain
Post-traumatic stress disorder
Antisocial personality disorder
History if sexual or physical abuse

Medications

Pharmacological treatment for Somatic Symptom Disorder is not widely accepted and is not the preferred course of treatment.

Reasons a patient with SSD would be prescribed medication if comorbilities such as depression and anxiety were also present. These comorbidites may make SSD harder to treat and resolve. The following may be prescribed or used to help control depression and anxiety and aid in the treatment of SSD.

• Tricyclic antidepresents (TCA)
  
• Serotonin Reuptake Inhibitors (SSRI)
  
• Serotonin and Nonadrenaline Reuptake Inhibitors (SNRI)
  
• Antipsychotics
  
• Herbal medications: opiates and trace elements
  

Diagnostic Tests/Lab Tests/Lab Values

Criteria for SSD as defined by the American Psychiatric Assocation (APA):

Table 1.

Criteria for Somatic Symptom Disorder.

A. One or more somatic symptoms that are distressing or result in significant disruption of daily life.

B. Excessive thoughts, feelings, behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following:

Disproportionate and persistent thoughts about the seriousness of one's symptoms. Persistently high level of anxiety about health or symptoms. Excessive time and energy devoted to these symptoms or health concerns.

C. Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months).

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright (c) 2013). American Psychiatric Association. All rights reserved.

The diagnostic criteria for SSD focuses not only on somatic symptoms but also on psychological responses, including the patient's emotions, thinking and behavior of their symptoms. The severity of SSD can also be diagnosed as mild, moderate or severe. Diagnosis may or may not include another diagnosed medical conditions. Medically unexplained symptoms are no longer included in the diagnostic criteria and are discouraged. Describing the patients symptoms as medically unexplained is inaccurate because oftentimes symptoms are unexamined. In addition, patients suffering from somatic complaints may feel that medical professionals view their symptoms as inauthentic.

The interrater reliability of diagnoses for SSD was listed as 0.61 in adult diagnoses. B-type criteria also has good test-retest reliability among physicians with an ICC of 0.680. Global rating of the severity of a patient's symptoms was found to have acceptable reliability with an ICC of 0.483.

Etiology/Causes

There is no adequate evidence for the cause of SSD.

Systemic Involvement

Patients diagnosed with the DSM-V disoder may present with the following systemic symptoms:

Cardiac

• Shortness of breath
• Palpitations
• Chest pain
  

Gastrointestinal

• Vomiting
• Abdominal pain
• Difficulty swallowing
• Nausea
• Bloating
• Diarrhea
  

Musculoskeletal

• Pain in the legs or arms
• Back and joint pain
  

Neurological

• Headaches
• Dizziness
• Amnesia
• Vision changes
• Paralysis or muscle weakness
  

Urogenital

• Pain during urination
• Low libido
• Dyspareunia
• Impotence
• Dysmenorrhea 
  

Medical Management (current best evidence)

The components of SSD currently treated include the following: 

• Somatic symptoms
  
• Health related anxiety
  
• Preoccupation and rumination about health concerns
  
• Unhelpful illness behaviors
  

Treatments used as interventions for these components include:

• Psychiatric consultation intervention (PCI)
  
• Cognitive based therapy (CBT)
  
• Behavioral techniques (relaxation training and mindfulness)
  
• Other psychotherapies
  
• Psychotropic medications
  

Cognitive Based Therapy

• Focuses on stress management, activity regulation, emotional awareness, cognitive restructuring, and interpersonal communication.
  

Goals

• Reduce physiological arousal through relaxation techniques
  
• Enhance activity regulation through increasing exercise and pleasurable and meaningful activities and pacing activities
  
• Increase awareness of emotions
  
• Modify dysfunctional beliefs
  
• Enhance communication of thoughts and emotions
  
• Reduce spousal reinforcement of illness behavior
  

Psychiatric Consultation Intervention

• Consists of a letter sent to the PCP 
  
• Considered best evidence-based treatment for somatization disorder in 2006.
  

Letter Recommendations

• Schedule appointments with patients on regular basis instead of as-needed appointments.
  
• Perform brief physical examinations focusing on area of discomfort at each visit.
  
• Avoid unneccessary diagnostic procedures, invasive treatments and hospitalizations
  
• Avoid explaining symptoms with statements such as "Your symptoms are all in your head"
  

Data from the study by Allen et al suggests that a "10-session CBP produces improvements in somatization symptoms and functioning over and above those obtained from PCI, the only established treatment for [somatization disorder]".

Physical Therapy Management (current best evidence)

Physical therapy should be patient-specific and include manual therapy and/or manipulation.

Goals for the Physical Therapist or Clinician

• Be empathetic
  
• Instead of focusing on each physical symptom get the big picture by asking questions such as "How do these problems affect you?" or "How can I help you today?". It will be difficult to help the patient focus on the most important issues related to their health.
  
• Refer the patient for psychotherapy
  
• Establish realistic timeframes for goals of treatment
  
• Ensure patient compliance
  
• Communicate with other healthcare providers to ensure you are not providing conflicting treatment
  
• Encourage the patient to become active and independent in managing their health to reduce dependency on their spouse, significant other or caregivers
  
• Perform a thorough exam and evaluation, avoiding unneccessary tests
  
• Avoid therapeutic procedures unless necessary. These patients often have unrealistic expectations and may become angry if those expectations are unmet.
  

If you feel it is necessary to avoid or terminate the therapist-patient relationship the following approaches are recommended: 

• Be genuinely empathetic
  
• Smile, remain friendly and ensure the patient does not feel you are uncomfortable
  
• "Assure the patient that the pain is 'real' (because it is) and that there is no need to prove it to anyone"
  
• Respect the knowledge and experience of the patient or spouse/companion and their frustrations
  
• Keep communication clear and concise
  
• Do not charge a fee if you decide to not treat a patient and communicate your decision upon entering the examination room
  

Outcome measures that are avaliable include the following:

• The Somatic Symptom Scale- 8 (SSS-8). This scale has excellent item characteristics and good reliability (0.81)
  
• Total Somatic Symptom Score. This scale provides a predictor of health care status.
  

Alternative/Holistic Management (current best evidence)

Current best evidence is not available for the DSM-V code of SSD; however, numerous articles have suggested alternative management for somatoform and somatization disorders.

• Massage therapy
  
• Manual therapy and/or manipulations
  
• Supplements (B-complex vitamins, flaxseed oil, DL-phenylalanine and many others)
  
• Acupuncture
  

• Mindfulness or Mindfulness Cognitive Based Therapy (MCBT)
  

Mindfulness

• Mindfulness-based stress reduction has been proven to reduce symptoms of stress, anxiety, fatigue and depression in patients diagnosed with somatization disorder, as defined by the DSM-IV code.
• It consists of mental training focusing on "non-judgmental awareness of moment-to-moment experience [that] may positively affect accuracy of perception, acceptance of intractable health-related changes, realistic sense of control, and appreciation of available life experiences".
• Mindfulness may also be associated with changes in the brain that regulate cognition and emotion.
  

Mindfulness-Based Cognitive Therapy (Mindfulness Therapy)

• This approach is one that can be a potentially useful intervention in patients with numerous somatic pain complaints.
• MBCT is a combination of mindfulness and cognitive based therapy
• Fjorback et al found that MBCT was comparable to enhanced treatment as usual, consisting of an individualized cognitive based therapy approach and advice on general lifestyle changes related to exercise, nutrition, medication, and networks
• In a separate study analyzing the economic consequences of MBCT by Fjorback et al, the cost of mindfulness therapy was significantly increased in comparison to enhanced treatment as usual; however, long term costs related to permanent health-related benefits was significantly decreased over a 15-month period.
  

• "Preliminary evidence suggests that mindfulness therapy may prevent disability pension at 15-month follow-up and may reduce health care costs compared to enhanced treatment as usual. Thus, mindfulness therapy may have a potential to significantly reduce societal costs, improve function, and increase effectiveness of care"
  

Differential Diagnosis

Disorders likely to be misdiagnosed as somatic symptom disorders:

• Early-stage connective tissue disorders (ex. systemic lupus erythematosus and rheumatoid arthritis)
  
• Central nervous system disorders (ex. brain tumor, multiple sclerosis, epilepsy, dementia, stroke, and myasthenia gravis)
  
• Endocrine disorders (ex. hypoglycemia, thyroid dysfunction and porphyria)
  

Illness Anxiety Disorder

• On the left hand side of the flowchart below, disorders previously included in the DSM-IV code of somatoform disorder are listed. DSM-V has simplified its definition by placing these disorders into one of two groups, IAD (illness anxiety disorder) or Somatic Symptom disorder. This will help medical professionals in differentiating IAD and SSD.

• Somatic symptom disorder includes somatization disorder, undifferentiated somatoform disorder, pain disorders and hypochondriasis with somatic symptoms. Hypochondriasis without somatic symptoms is not considered under the realm of SSD and is considered an illness anxiety disorder.
  

Case Reports/ Case Studies

Physical Therapy Management of a Patient with Recurrent Conversion Disorder with a History of a Below-Knee Amputation: A Case Report

SPECT scan in somatization disorder patients: an exploratory study of eleven cases

Resources

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References

see adding references tutorial.