Introduction
Somatic Symptom and Related Disorders (SSRDs), as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), encompass a cluster of psychiatric conditions characterized by excessive and maladaptive thoughts, feelings, and behaviors in response to somatic symptoms. These disorders often present in medical settings and are associated with significant impairment, high utilization of healthcare resources, and clinicians are not always trained in best practices to help these patients. Proper diagnosis and evidence-based treatment are essential for improving outcomes in this complex population. This article reviews the current diagnostic criteria, epidemiology, and best practices in managing SSRDs for mental health providers.
Diagnostic Overview
SSRDs include several distinct disorders:
- Somatic Symptom Disorder (SSD)
Characterized by one or more distressing somatic symptoms that are accompanied by excessive thoughts, feelings, or behaviors related to those symptoms. Importantly, the symptoms may or may not be medically explained. The focus is on the psychological response to the symptoms rather than the presence or absence of a medical explanation. - Illness Anxiety Disorder (IAD)
Previously known as hypochondriasis, IAD involves preoccupation with having or acquiring a serious illness despite minimal or no somatic symptoms. Patients frequently misinterpret normal bodily sensations and engage in repeated health checks or avoidant behaviors. - Conversion Disorder (Functional Neurological Symptom Disorder)
This condition involves neurological symptoms (e.g., paralysis, seizures, blindness) that are inconsistent with recognized medical conditions. Symptoms often emerge in the context of psychological stress or trauma. - Psychological Factors Affecting Other Medical Conditions
This diagnosis applies when psychological or behavioral factors significantly affect the course, treatment, or outcome of a medical illness. - Factitious Disorder
Involves intentional falsification of physical or psychological symptoms without obvious external incentives, distinguishing it from malingering.
Epidemiology and Clinical Features
SSRDs are common across healthcare settings. SSD affects approximately 5-7% of the general population, with a higher prevalence in women. IAD affects 1.3-10% of the population, with equal gender distribution. Conversion disorder is more frequently diagnosed in females and typically presents in adolescence or early adulthood.
Patients with SSRDs often have co-occurring psychiatric disorders such as depression or anxiety. Adverse childhood experiences, trauma, and chronic stress are significant risk factors. Additionally, these patients often have complex relationships with the healthcare system—frequent visits, diagnostic procedures, and a feeling of being misunderstood or invalidated are possible.
Challenges in Diagnosis
Diagnosing SSRDs requires careful differentiation from medical conditions, malingering, and other psychiatric disorders. The DSM-5-TR emphasizes the need to avoid over pathologizing patients with medically unexplained symptoms and instead focus on the degree of psychological distress and functional impairment.
Clinicians are best served to conduct comprehensive assessments that include medical, psychiatric, and psychosocial components. Collateral information from family and medical records is often helpful. Importantly, SSRDs are not diagnoses of exclusion but require positive identification of specific clinical features.
Best Practices in Treatment
- Psychoeducation and Therapeutic Alliance
Establishing a strong therapeutic alliance is foundational. Patients often feel invalidated by previous medical encounters, so clinicians must acknowledge their suffering without reinforcing somatic preoccupation. Psychoeducation should reframe the illness using a biopsychosocial model, emphasizing the truly felt nature of the symptoms while introducing the role of stress and emotional factors. - Cognitive Behavioral Therapy (CBT)
CBT is the most evidence-based treatment for SSRDs. It targets beliefs and thoughts about illness and health, and avoidant or excessive health behaviors. CBT helps patients develop more accurate appraisals of bodily sensations and encourages gradual re-engagement in activities. - Mindfulness and Acceptance-Based Therapies
Interventions such as mindfulness-based stress reduction (MBSR) and acceptance and commitment therapy (ACT) show promise by helping patients observe their symptoms non-judgmentally and reduce experiential avoidance. These approaches may be particularly helpful in patients with chronic pain or functional neurological symptoms. - Pharmacotherapy
While no medications are FDA-approved specifically for SSRDs, selective serotonin reuptake inhibitors (SSRIs) may be helpful when comorbid depression or anxiety is present. SNRIs and tricyclic antidepressants have also shown utility in somatoform pain syndromes. For example, the SNRI Duloxetine has an FDA approval for chronic pain. However, polypharmacy and iatrogenic harm should be avoided. - Interdisciplinary Care and Coordination
Patients benefit from collaborative care models involving primary care providers, psychiatrists, psychologists, physical therapists, and sometimes neurologists or pain specialists. Coordinated care prevents redundant testing and provides consistent messaging. Regular case conferences and shared treatment plans are key to success. - Limit Medical Investigations and Set Boundaries
While it is essential to rule out medical conditions, repeated investigations reinforce illness behavior. Providers should adopt a “diagnostic closure” strategy, providing reassurance based on appropriate evaluation, and shift focus to functional recovery. Structured visits, time-limited appointments, and continuity with a single provider help reduce fragmentation. - Address Trauma and Comorbidities
Because many patients have histories of trauma, integrating trauma-informed care is essential. Screening for PTSD, dissociation, and borderline personality disorder is often appropriate. Psychotherapy targeting trauma (e.g., EMDR, trauma-focused CBT) can reduce somatic symptom intensity.
Conclusion
Somatic Symptom and Related Disorders are complex conditions that straddle the boundary between psychiatry and medicine. When properly diagnosed and treated using evidence-based, multidisciplinary approaches, many patients experience significant improvements in functioning and quality of life. Mental health providers play a critical role in destigmatizing these conditions, guiding collaborative care, and helping patients shift from symptom preoccupation to adaptive functioning.
AUTHOR:
Shawn Singh Sidhu, MD, DFAPA, DFAACAP
Co-Medical Director, Vista Hill Foundation
Vista Hill Native American SmartCare Program