Management of somatic symptom disorder - Henningsen (2018) - Article

Many patients of somatic symptom disorder complain about pain on different places of the body or fatigue, weakness or cardiovascular disturbances. In most patients, suffering entails psychological and behavioural aspects like anxiety and checking behaviour. The spectrum is wide and bodily complaints are often attributed to organic disease. Somatoform disorders are single functional somatic syndrome diagnoses (such as fibromyalgia syndrome, FMS). After suffering unsuccessful treatment, patients often feel frustrated. Overall severity is explained by the total number of bodily symptoms and the health anxiety. Depression and anxiety, together with the bodily distress of the well-defined pathology characterize patients.

How is the somatic symptom disorder classified in the DSM-V?

The criteria that must be met according to the DSM-V are the following:

• One or more somatic symptoms that cause distress and disruption of daily life.
• One or more excessive thoughts, feelings and behaviours that are associated with concern about health. Thoughts about the seriousness of the symptoms, anxiety about symptoms and time and energy devoted to the symptoms or concern about health.
• The symptoms must last for more than 6 months.

When one of the symptoms is present the disorder is moderate, when two or more symptoms are present and there are multiple somatic complaints the classification is severe.  Illness anxiety disorder is when people experience hypochondriasis without bodily complaint. Because many patients have been mislabelled in the past, the classification of “medically unexplained” is not present in the DSM-V. The term bodily distress may describe the suffer from bodily symptoms but can be just psychological distress.

What is already known about somatic symptom disorder?

Genetics can contribute to the predisposition and chronic pain in general. However, the extend is limited. Epigenetic mechanisms are relevant as they are shaped by prenatal experiences. Childhood adversities seem to be a predictor of development of bodily distress. Attachment patterns formed in childhood can contribute, attachment anxiety can lead to health anxiety. Cultural influences can also contribute to the development of bodily distress, stressful work conditions and adverse life events can cause organic illness, but also bodily distress.

How is somatic symptom disorder diagnosed?

When individuals are referred with SSD in mind, it is not difficult to define the presence or absence of criteria. Measurement instruments include the Patient Health Questionnaire-15 (PHQ-15) for somatic symptom burden and the Whiteley index for health anxiety. There are some recommendations for adequately diagnosing SSD:

• Consider the possibility of SSD as early as possible.
• Avoid risky and repetitive investigations that serve to calm the patient
• Mind clues from the patient that indicate emotional distress beyond the scope of the main symptom.
• Assess experiences, expectations and illness behaviour. For example, body checking and avoidance.
• If SSD is diagnosed, decide if the condition is mild, moderate or severe.

How is somatic symptom disorder treated?

Treatment currently has moderate effect because bodily distress in general is covered by categories (such as SSD) that are used in mental health settings. However, research of the bodily patterns and psychobehavioural features of SSD should include a broader perspective. Currently there is no evidence for the efficacy of training and enhanced care of physicians. Not much evidence has been found for the effectiveness of antidepressants or hypnotherapy either.

Treatment exists of good management of this group of patients, the bodily complaints must be taken seriously even without a well-defined pathology. Encouraging the patient to take on a healthy lifestyle, hobbies and regular exercise can be helpful. In mild cases, these principles combined with waiting is enough but when the case is more severe, other approaches may help:

• Introducing contextual factors, providing of a blame-free narrative that is linked to both psychological and physical mechanisms.
• Encourage and monitor functional behaviour and attitudes. Stimulate relaxation, positive thinking, self-help guides and set realistic goals together with the patient.
• Provide pain relief medication or digestives. Allow medicine according to the patients wishes, they are temporarily helpful, but less effective than self-management.
• Consider antidepressants if pain is predominant or the patient gets depressed.
• Set appointments for intervals rather than waiting for initiation of the patient.
• Ensure that traumatic stressors are assessed.
• Consider multidisciplinary treatment including psychotherapy, occupational therapy and physiological therapy.

Psychotherapy is an established treatment but challenging in the beginning when patients often have difficulty accepting talking can help their cure. Some things could be helpful in such a situation:

• Clarify the motivation for psychotherapy consultation.
• Use the measures above in an appropriate manner.
• Listen to bodily complaints and experiences with doctors and health professionals. Also give feedback on the emotional aspects of these experiences.
• Give support in organisation of the history of complaints.
• Encourage the patient to see additional influence of psychosocial or biological context factors.
• Negotiate realistic and modest treatment goals.
• Resist concentration on bodily symptoms.
• Liaise with others involved in the care about relevant information.

BulletPoints

• Many patients of somatic symptom disorder complain about pain on different places of the body or fatigue, weakness or cardiovascular disturbances. In most patients, suffering entails psychological and behavioural aspects like anxiety and checking behaviour.
• Treatment exists of good management of this group of patients, the bodily complaints must be taken seriously even without a well-defined pathology.
• Psychotherapy is an established treatment but challenging in the beginning when patients often have difficulty accepting talking can help their cure.

ExamTicket

• You should be able to explain why diagnosing SSD is difficult.
• Make sure you can explain what kind of treatment is being used in patients suffering from SSD and why psychotherapy, although being used a lot, can be quite challenging at the beginning.
• You should be able to list some approaches on how to deal with patients with severe SSD. For example: providing a blame-free narrative that is linked to both psychological and physiological symptoms.