My Brain Hurts!

“All emotions, even those that are suppressed and unexpressed, have physical effects. Unexpressed emotions tend to stay in the body like small ticking time bombs—they are illnesses in incubation.” 
― Marilyn Van M. Derbur, Miss America by Day 

The ambiguity with somatic symptom disorder originates from the concept of somatoform disorders (for example: somatization disorder and hypochondriasis) which were excluded from the DSMV, published in 2013. Hence, we are talking about a new disorder that has been recently updated compared to other well established psychiatric disorders.  

Several studies, based upon community surveys and multiple primary care studies in the United States, claim that somatic symptom disorder is common in the general population (4 to 6 %) and more specifically in primary care takers (17%). 

Diagnosis: 

In order to fit the diagnosis of somatic symptom disorder one should report at least one or more somatic symptoms that are distressing and/or lead to significant impairment in daily life activities. One may experience disproportionate and continuous thoughts about the gravity of their symptoms, which manifests as persistent anxiety as well as behaviors, devoting time and energy on the somatic symptoms or associated health concerns. These can involve seeking numerous doctor appointments or performing several health exams for personal relief, which are not medically required. In addition, it is not mandatory to complain of continuous somatic symptoms to be diagnosed with somatic symptom disorder, the symptoms may be intermittent. However, they should last for a period of at least 6 months to fit the diagnosis.   

Some signs that guide our thinking towards this disorder are: female gender, low socio-economic status, child abuse and psychiatric disorder (more specifically generalized anxiety disorder and depressive disorders), lack of education, family history of chronic illness, and primary caretakers as previously mentioned. 

Symptoms: 

• One or more long standing somatic symptom that cause distress and/or psychological or social impairment 
• Complaints of multiple symptoms related to several organ systems 
•  Excessive thoughts, worry, behaviors revolving around the somatic symptoms or to health concern  
• Multiple doctor visits with dense medical record (blood tests, imaging…)  
• Some common symptoms include:
  • Nonspecific symptoms: Fatigue, syncope, dizziness 
  • Pain symptoms: Musculoskeletal pain (joint, leg, arm), Chest pain, headaches 
  • Gastrointestinal symptoms: Nausea, abdominal pain, bloating, gas, diarrhea, constipation  
  • Cardiopulmonary symptoms: Shortness of breath, palpitations  
  • Neurologic symptoms: Affected range of motion, sensory loss, weakness, paralysis 
  • Reproductive organ symptoms: Painful intercourse, painful menses, and erectile dysfunction/impotency  

Management:  

For the management of these patients, keep in mind that most of the time you are not the first health care provider this patient has consulted. Patients may seek several medical opinions (“Doctor shopping”) and insights on their medical condition which can vary, further contributing to the condition. The success of treatment in these patients revolves around the approach of the physician towards the patient with structured monthly visits, involvement of psychotherapy sessions, psychoeducation, antidepressants (SSRIs and SNRIs) as some of the comorbid psychopathologies include generalized anxiety disorders and depressive disorders (hitting two birds with one stone) and referring to a psychiatrist for treatment resistant patients.  

References:

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington 2013

Voigt K, Wollburg E, Weinmann N, Herzog A, Meyer B, Langs G, Löwe B. Predictive validity and clinical utility of DSM-5 Somatic Symptom Disorder–comparison with DSM-IV somatoform disorders and additional criteria for consideration. J Psychosom Res. 2012 Nov;73(5):345-50. doi: 10.1016/j.jpsychores.2012.08.020. Epub 2012 Sep 20. PMID: 23062807.

Dimsdale JE, Creed F, Escobar J, Sharpe M, Wulsin L, Barsky A, Lee S, Irwin MR, Levenson J. Somatic symptom disorder: an important change in DSM. J Psychosom Res. 2013 Sep;75(3):223-8. doi: 10.1016/j.jpsychores.2013.06.033. Epub 2013 Jul 25. PMID: 23972410.

Fink P, Sørensen L, Engberg M, Holm M, Munk-Jørgensen P. Somatization in primary care. Prevalence, health care utilization, and general practitioner recognition. Psychosomatics. 1999 Jul-Aug;40(4):330-8. doi: 10.1016/S0033-3182(99)71228-4. PMID: 10402880.