Somatic Symptom Disorder

 

Am Fam Physician. 2016 Jan 1;93(1):49-54A.

  Patient information: A handout on this topic is available at http://familydoctor.org/familydoctor/en/diseases-conditions/somatoform-disorders/symptoms.html.

Author disclosure: No relevant financial affiliations.

With the release of the Diagnostic and Statistical Manual of Mental Disorders, 5th ed., the diagnostic category previously known as somatoform disorders is now called somatic symptom and related disorders. The revisions were intended to increase their relevance in the primary care setting. The main feature of this disorder is a patient's concern with physical symptoms that he or she attributes to a nonpsychiatric disease. Primary care physicians often treat patients who manifest symptoms for which there are no biologic cause, and patients with somatic symptom disorder may be subjected to unnecessary testing and procedures. As a result, appropriate diagnosis is essential. Screening instruments are useful in determining the presence of somatic symptom disorder. It is important for the primary care physician to schedule regular appointments, establish a strong therapeutic alliance, acknowledge and legitimize the patient's symptoms, and limit diagnostic testing or referrals to subspecialists. Proven treatments include cognitive behavior therapy, mindfulness-based therapy, and pharmacotherapy. The use of selective serotonin reuptake inhibitors or tricyclic antidepressants has been effective in alleviating symptoms. Referral to a mental health professional may be necessary when treatment by the primary care physician is ineffective.

Somatization is said to be present when psychological or emotional distress is manifested in the form of physical symptoms that are otherwise medically unexplained.1 Patients with multiple persistent physical symptoms that seem to have no apparent biologic basis are common in patients presenting to primary care.2

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

In addition to a comprehensive clinical interview and assessment for diagnostic criteria, the use of screening instruments, such as the Patient Health Questionnaire-15 or the Somatic Symptom Scale-8, should be considered in patients with suspected somatic symptom disorder.

C

14, 15

Cognitive behavior therapy and mindfulness-based therapy are effective for the treatment of somatic symptom disorder.

B

1824

Amitriptyline, selective serotonin reuptake inhibitors, and St. John's wort are effective pharmacologic treatments for somatic symptom disorder.

B

2527

Other antidepressants (monoamine oxidase inhibitors, bupropion [Wellbutrin], anticonvulsants, and antipsychotics) are ineffective for the treatment of somatic symptom disorder and should be avoided.

B

25


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

In addition to a comprehensive clinical interview and assessment for diagnostic criteria, the use of screening instruments, such as the Patient Health Questionnaire-15 or the Somatic Symptom Scale-8, should be considered in patients with suspected somatic symptom disorder.

C

14, 15

Cognitive behavior therapy and mindfulness-based therapy are effective for the treatment of somatic symptom disorder.

B

1824

Amitriptyline, selective serotonin reuptake inhibitors, and St. John's wort are effective pharmacologic treatments for somatic symptom disorder.

B

2527

Other antidepressants (monoamine oxidase inhibitors, bupropion [Wellbutrin], anticonvulsants, and antipsychotics) are ineffective for the treatment of somatic symptom disorder and should be avoided.

B

25


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

In the Diagnostic and Statistical Manual of Mental Disorders, 5th ed., (DSM-5), the nomenclature for the diagnostic category previously known as somatoform disorders was changed to somatic symptom and related disorders.3 The purpose of this change was to better define these disorders to make them more relevant to the primary care setting.

Somatic symptom disorder may be no less debilitating than physical disorders.4 Patients experiencing somatization whose physicians incorrectly think they may have a biologic disorder can experience harm from unnecessary testing and treatment.5 Some physicians find patients with somatic symptom disorder frustrating, and may describe them in derogatory terms. They may consider physical disorders genuine, while essentially accusing somaticizing patients of manufacturing their symptoms.6 This article provides practical suggestions for improving the care of these patients.

Epidemiology

The Authors

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STUART L. KURLANSIK, PhD, is a behavioral medicine faculty member at Virtua Family Medicine Residency Program, Voorhees, N.J., and a clinical professor of psychology at Philadelphia (Pa.) College of Osteopathic Medicine....

MARIO S. MAFFEI, MD, is program director at Virtua Family Medicine Residency Program.

Address correspondence to Stuart L. Kurlansik, PhD, Virtua Health, 2225 Evesham Rd., Ste. 101, Voorhees, NJ 08043 (e-mail: skurlansik@virtua.org). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

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