Approach and Treatment of Patients with Somatic Symptom and Related Disorders

AUTHOR

Ellen Feldman, MD, Altru Health System, Grand Forks, ND

PEER REVIEWER

Glen D. Solomon, MD, FACP, Professor and Chair, Department of Internal Medicine, Wright State University Boonshoft School of Medicine, Dayton, OH

EXECUTIVE SUMMARY

The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) nomenclature and diagnostic criteria deemphasize “medically unexplained symptoms” and instead focuses on the presence of unexpected, magnified, or disproportionate physical symptoms, with or without an underlying known medical condition.

• Other diagnoses under this new heading include illness anxiety disorder (rather than the DSM-4’s hypochondriasis), functional neurological symptom disorder (or conversion disorder), and factitious disorder.
• Despite this lack of clarity, patients with such presentations are not uncommon. Some studies estimate a prevalence rate of “somatic disorders” in 4% to 6% of the general population and up to 17% in primary care.
• The first systematic medical description of hysteria was made by Paul Briquet in 1859. Briquet’s syndrome later became known as somatization disorder, a precursor of what now is known as somatic symptom disorder.
• In factitious disorder, historically known as Munchausen syndrome, the patient deliberately falsifies symptoms of illness to receive emotional gratification or a nonconcrete reward (as opposed to malingering, which generally is tied to avoidance of a task or obligation). Risk factors for this disorder include female sex, a connection to employment in the healthcare industry, and family conflict.
• The management of somatic symptom disorder centers on improvement in how the patient copes with the symptoms, not on eliminating the symptoms. This approach enables the provider and patient to focus on reducing the thoughts and behaviors that are preventing optimal functioning.

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Introduction

It is a busy morning at the clinic. In examination room one, a well-groomed young woman sits stiffly near the edge of her seat, waiting to “establish care.”

At first glance, there is nothing unusual about this scene. However, as the provider steps into the room, ready to start the visit, everything changes. Suddenly the patient stands and extends three folders overflowing with paper into the provider’s outstretched hand. Each folder is neatly labeled with color-coordinated tabs projecting from the sides. “I know my records were transferred here,” she states, before introductions can be completed, “but I thought I would hand-carry these copies of tests and results, just in case. I am hoping these will help you figure out why I am always dizzy and where my pain is from. No one has been able to give me answers.”

This presentation is far from diagnostic. But the suggestion of ongoing, unexplained symptoms despite an extensive workup may trigger the provider to refer to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) and consider a group of diagnoses within the general category of somatic symptom and related disorders at the forefront of the differential.¹

Many clinicians understandably are confused about the terminology and diagnoses within this heading. Somatic symptom and related disorders is relatively new terminology, first appearing with the release of DSM-5 in 2013 and unchanged in the recently released DSM-5 Text Revision (TR). This category sprung from efforts to reconceptualize a group of disorders known in DSM-4 as “somatoform disorders,” or disorders in which a patient presents with an array of clinically significant symptoms unable to be explained by a medical illness.^1,2

The shift in DSM-5 nomenclature and diagnostic criteria deemphasizes “medically unexplained symptoms” and instead focuses on the presence of unexpected, magnified, or disproportionate physical symptoms, with or without an underlying known medical condition. Along these lines, a new core diagnosis — somatic symptom disorder — is defined. Other diagnoses under this new heading include illness anxiety disorder (rather than DSM-4’s hypochondriasis), functional neurological symptom disorder (or conversion disorder), and factitious disorder.^1-3

Adding to what seems to be a growing diagnostic muddle, the International Classification of Diseases (ICD) contains a different set of diagnoses and criteria. ICD-10 refers to a “pattern of recurring polysymptomatic somatic complaints resulting in medical treatment or impaired daily function ... ” as Somatization Disorders, while ICD-11 drops this classification and creates a new category entitled Bodily Distress Disorders.⁴

There clearly remains uncertainty in the field regarding not only terminology but treatment of the patient with prominent somatic symptoms that appear to be excessive or unable to be completely explained by a recognized medical condition and that cause distress and impaired functioning.

Despite this lack of clarity, patients with such presentations are not uncommon. Some studies estimate a prevalence rate of “somatic disorders” in 4% to 6% in the general population and up to 17% in primary care. Given that symptoms are physical in nature, patients with somatic disorders are more likely to present to a primary medical provider than to a mental health provider. Thus, developing a better understanding of this often-perplexing condition has clinical relevance for clinicians on the front lines of medical care.^5,6

The major diagnoses in the DSM-5 (and DSM-5-TR) somatic symptom and related disorder classification are somatic symptom disorder (SSD), illness anxiety disorder, functional neurological symptom disorder, and factitious disorder, as noted earlier.^1,2 This paper views this group of mental illnesses through the lens of the clinician, starting with a brief historical view to help put the diagnostic criteria in context and moving quickly to epidemiology, presentation, differential, and treatment. Patient examples highlight clinical issues and are used to illustrate approaches to patient care.

Definitions

• Somatic (adj.): “Pertaining to the body” (as distinct from the soul, spirit, or mind), 1775, from French somatique and directly from Latinized form of Greek sōmatikos “of the body,” from sōma (genitive sōmatos) “the body.”⁷

• Hysteria: Coined in medical Latin as an abstract noun from Greek hystera “womb,” variant of *udero- “abdomen, womb, stomach.” Originally defined as a neurotic condition peculiar to women and thought to be caused by a dysfunction of the uterus. With abstract noun ending -ia. General sense of “unhealthy emotion or excitement.”⁸

History of Somatic Symptoms and Related Disorders: Putting These Diagnoses in Context

A look back in time reveals that even the earliest physicians recognized a pattern of unusual symptoms and behaviors in some patients and attempted to explain this phenomenon.

For example, the Greek physician Hippocrates, in the 5th century BC, used the term “hysteria” to describe a variety of unexplained disorders or behaviors in women, such as fainting spells, feelings of suffocation, and convulsions, which he believed were caused by a “bad” or unfulfilled uterus.⁹

This concept of hysteria continued, and in the 1st century BC, Aulus Cornelius Celsus described a syndrome akin to epilepsy, but “ … differs in that the eyes are not turned, nor does froth issue forth, nor are there any convulsions: there is only a deep sleep.” Moving further in time, Claudius Gallen, in the 2nd century AD, recommended purges and herbs for hysteria and related disorders. This early view of unexplained medical symptoms being attributable to a flaw in women unfortunately continued well into the 20th century.^9,10

The first systematic medical description of hysteria was made by Paul Briquet in 1859. Briquet’s syndrome later became known as somatization disorder, a precursor of what is now known as somatic symptom disorder, the main diagnosis in the collection of disorders known as somatic symptoms and related disorders in the current DSM.^9,10

One of Briquet’s contemporaries, Sigmond Freud, introduced the concept of male hysteria, which broadened the diagnostic criteria. However, an underlying pejorative view of this condition continued.^9-11

The first and second editions of the DSM (1952 and 1968, respectively) continued to use the term hysteria in several contexts, but by 1980 the DSM-3 dropped this language and introduced somataform disorders to refer to a group of “disorders characterized by physical symptoms, not explained by organic factors.” Included in this grouping were hypochondriasis and somatization disorder. DSM-4 further defined the concept of somataform disorders as the “presence of physical symptoms, which suggest a general medical condition and are not fully explained by a general medical condition, substance use, or another mental disorder.”^9-11

DSM-5 took a new view and attempted to apply current knowledge of neurobiology, epigenetics, environmental forces, and brain development. The focus in the newly created category of somatic symptom and related disorders reflects the understanding that all neuropsychiatric conditions are mediated by the brain, and that, despite our ability to perform highly technological imaging and tests, there remain areas of brain function that are not completely understood. The idea of “organic” vs. functional disease is dropped in our current DSM edition and replaced with a deeper integrative picture of the mind-body connection.¹¹

Excluded from this understanding are patients presenting with evidence of feigning symptoms for concrete gain. This pattern of behavior is known as malingering and, while sometimes in the differential, is otherwise not related to the disorders discussed in this paper.¹¹

The reconceptualized view of somatic symptoms and related disorders has potential clinical utility. Rather than the patient feeling blamed or shamed for symptoms, they can be helped to understand that complex brain processes are at the root of symptoms.^3,11 See Table 1 for diagnostic criteria.

Etiology

There have been psychological and biological hypotheses put forth to explain the development of this group of diagnoses. Current thinking is that there is a complex interaction of neurodevelopmental, environmental, genetic, and, possibly, epigenetic factors implicated in the pathophysiology surrounding these disorders.^16,17

It is thought that SSD presents in individuals who have a magnified awareness of physical or bodily sensations and tend to interpret these sensations as reflective of a pathological process or illness. Although the exact etiology is unknown, research looking at genetic factors and considering the significance of the presence of a history of adverse childhood events (including sexual and physical abuse and neglect) in many patients with somatic illness is ongoing.^16-18

Likewise, the etiology of illness anxiety disorder is unknown. One school of thought is that individuals with illness anxiety disorder may not be comfortable with bodily sensations that others perceive as “normal” and may interpret these sensations as indicative of illness. Risk factors include having an anxiety disorder (in general), being raised in a family with parents who excessively focused on and worried about health issues, and experiencing serious illness as a child (either personally or in a close family member). Recently, it has been postulated that spending long periods of time on internet activity related to health concerns can fuel or increase the risk for developing illness-related anxiety.^16,17,19

There is consensus that functional neurological disorder emerges from interactions involving both neurologic and psychologic mechanisms. Imaging studies often show changes in activation levels of specific brain areas in functional disorders, and some studies have shown unusually strong neurological connections between areas of the brain involved in emotional regulation and areas directing motor activation. Adverse childhood events are risk factors for development of functional neurological disorder, as are preexisting neurologic disorders (patients may have comorbid seizures and functional seizures, for example).^16,17,20

The etiology of factitious disorder is unknown, although several theories to explain the development of this disorder have been proposed. Unfortunately, there are no robust, long-term studies supporting the theories. However, a handful of limited studies provide a suggestion of common factors in patients with factitious disorder. For example, data obtained from an online chat group revealed that the vast majority of the 57 participants described emotional or physical abuse during childhood. A different review of 20 cases of factitious disorder found that 60% of this group reported a long-term childhood illness.^16,17,21,22

Putting this information together with other case histories and studies gives weight to a long-held theory that factitious disorder evolves from developmental issues and, specifically, early trauma and difficulty with attachment. Given the association of “cluster B” personality disorders (including borderline personality disorder) with these same adversities, it is not surprising that many patients with factitious disorder also have a personality disorder.^21,22

Since some patients have described uncontrollable urges to “play the sick role,” there has been some speculation that factitious disorder also can be viewed through the lens of addiction.^21,22

It is notable that, as with the other disorders discussed today, factitious disorders may occur in the presence of a documented medical condition. For example, a patient with diabetes may manipulate blood glucose readings or inject additional insulin to exacerbate a course of illness.^21,22

Epidemiology and Clinical Presentation

The changes in terminology over time and inconsistent global diagnostic criteria for disorders presenting with prominent and distressing somatic complaints (with or without an underlying medical illness) make it difficult to accurately determine the prevalence rates of the disorders now included in the somatic symptoms and related disorder category. Many of the prevalence estimates are based on studies of “somatization” (a broad term rather than a diagnosis) and/or somataform disorder from the DSM-4 (prior to the 2013 reclassification of these disorders).²³

Broad community studies in the United States and Western Europe estimate a lifetime prevalence of “somatization” in 4% to 6% of a general population of adults. These numbers rise significantly when looking at the subpopulation of patients presenting to a primary care office. Six studies looking at this group and defining somatization as presenting with at least four unexplained physical symptoms in men or at least six such symptoms in women found a prevalence estimate of 17%.²³

There often is symptom overlap among these disorders and with other disorders of mental health. For example, patients with depression often present with somatic complaints, but this alone does not necessarily indicate a diagnosis of SSD. However, depression and other disorders of mental health frequently are comorbid with the disorders within the somatic symptom and related illness category.^23,24

Clinical vignettes are presented to illustrate how delving into history and obtaining collateral information may help to differentiate among the somatic disorders and evaluate comorbidity.

M. is a 25-year-old medical lab technician, well known to the provider for treatment of irritable bowel syndrome since late adolescence. She comes to the clinic eight months after the birth of her first child, stating that she has been unable to return to her baseline level of functioning. She notes abdominal discomfort occurring when “even looking at my baby and definitely when I pick him up,” headaches, memory problems, intermittent severe diarrhea, and excessive daytime fatigue despite sleeping well at night. Screens for depression and anxiety are unremarkable, and she has had no thoughts of self-harm, suicide, or homicide, stating, “Oh no, I would never kill anyone, including myself!” A complete physical exam is benign, and basic labs show mild hypokalemia.

A higher prevalence of SSD, up to 60% in some studies, is found in patients with fibromyalgia, irritable bowel syndrome, and chronic fatigue. Other risk factors include female sex, lower socioeconomic and/or educational level, a history of childhood trauma and/or childhood chronic illness, comorbid psychiatric disorder, comorbid general medical disorder, and a family history of chronic illness.^25,26

Notably, it is suspected that prodromal symptoms of SSD may be seen in childhood and/or adolescence. In fact, prevalence rates of “persistent distressing somatic symptoms with psychological concerns” were found in 5% of adolescents in a community sample, which is consistent with the adult prevalence estimates.^25,26

When the provider asks M. which symptoms bother her the most, she states, “None of them, really. That’s not what gets to me. It is all the worrying that is the worst. I am just so worried that something bad happened to me when I gave birth.” When asked to elaborate, M. says, “I keep wondering if maybe I had a stroke. Somehow, I feel like I am different from before I had this baby. I had an epidural — maybe that caused these aftereffects and changed my brain. I stay up at night searching the internet to see if this is possible, and I think I may have found someone else who has similar symptoms.”

Illness anxiety disorder prevalence in primary care is extrapolated from the outdated hypochondriasis diagnosis in older DSM editions. Notably, this diagnosis often occurs in comorbid form — often with another anxiety disorder (such as generalized anxiety disorder). One distinguishing feature from SSD is the lack of prominent somatic symptoms in illness anxiety disorder, and the focus on worries about health.

The prevalence of this disorder in primary care is thought to be 3% to 8%, often occurring in young to middle adulthood and progressing along a waxing and waning pattern.^27,28

M. notes that her concern about a stroke intensified after a visit to the emergency department a few weeks ago, when she woke with numbness and tingling in both arms and a sensation of heaviness in her left leg. She states, “They checked bloodwork and did a brain scan, and told me nothing was wrong with me — that it is all in my head, but that I should see a neurologist, just in case. In case of what? I made an appointment, but I cannot get in for months. I still think there is a problem, and it all began during childbirth.”

There are few prevalence studies of functional neurologic symptom disorder, but prevalence estimates range from 0.05% to 1% in the general population and significantly higher in neurologic practices. The two subtypes seen most frequently are motor involvement (such as weakness or paralysis) and seizure.^20,29

This disorder, formerly known as conversion disorder, once was considered a diagnosis of exclusion, with a poor prognosis and limited treatment options. Recent progress in the field has begun to identify disrupted brain circuits responsible for the pathophysiologic patterns seen with this disorder. Although research continues, current recommendations are for a multidisciplinary approach, with rehabilitation and psychological interventions (depending on presentation and severity of dysfunction).^20,29

Shortly after M.’s visit, her partner calls the clinic with concerns, stating that he had learned that M. had visited three other primary care clinics over the last month. He notes, “I see bills for bloodwork from several different clinics or labs, and some of them look like duplicates.” He explains that his call was precipitated after finding laxatives hidden in the bathroom, “which,” he says, “may explain why M. has been having diarrhea. When I mentioned finding these to M., she got very upset.”

Factitious disorder, historically known as Munchausen syndrome, may be exhibited in the identified patient or imposed on another, such as a child or another vulnerable individual. In either case, the patient deliberately falsifies symptoms of illness to receive emotional gratification or a nonconcrete reward (as opposed to malingering, which generally is tied to avoidance of a task or obligation). The prevalence of factious disorder is unknown, in part because of the secrecy inherent to the disorder. Additionally, when patients are confronted with behaviors consistent with inducing symptoms, many individuals simply drop out of treatment, making it difficult to accurately calculate prevalence statistics.^21,22

Risk factors for this disorder include female sex, a connection to employment in the healthcare industry, and family conflict.^21,22

Although there may appear to be an overlap between factitious disorder and functional neurologic symptom disorder, these two, in part, are differentiated by the overt actions that are an integral component of factitious disorder. Although a patient with factitious disorder may not have an awareness of the motivations underlying actions such as putting blood in a urine sample or self-administering a toxin, the patient is fully cognizant of these attempts to mimic symptoms of a disease. On the other hand, patients with functional neurologic disorder develop sensory or motor deficits without any conscious effort to do so.^20-22

The provider says that if M. is willing, she and her partner could come to the next appointment together. At that appointment, the provider notes that the partner had called with concerns about M. seeing multiple providers and possibly misusing laxatives. The provider states to M., “You must be under a lot of stress to go to these lengths to get care. Is there anything your partner or I can do to help?”

Evaluation and Treatment

Many providers find patients with a diagnosis falling under the somatic illness and related disorder category to be frustrating and difficult to manage. On the other hand, many of these patients feel frustrated with medical systems and report that clinicians dismiss their concerns. Although there is no “one size fits all” strategy, developing a general approach to patients with these diagnoses can make the medical encounters more effective and satisfying for both the provider and the patient.³⁰

It is worth repeating that each of these disorders can occur in the presence or absence of another general medical problem. Considering a disorder from the general category of somatic symptom and related disorders does not equate to ruling out other comorbid or underlying conditions.^26,31-33

Some basic guidelines are:^26,31-33

• Consider diagnoses from the somatic symptom and related disorders category early in the differential for patients with unremitting symptoms, even while continuing a complete workup.
• Establish an alliance with the patient and acknowledge that the symptoms are real, despite the lack of “real” findings.
• Screen for depression, anxiety, suicidal thinking, and substance use, noting that each of these can affect the presentation of symptoms.
• Carefully consider the risks and benefits of each test and invasive procedure; refrain from unnecessary interventions, realizing that a negative test result most likely will not provide reassurance and may fuel the search for an “answer.”
• Openly communicate with the patient and provide a clear explanation of the diagnosis under consideration.
• Redefine the expectation from curing a problem to managing symptoms and improving function.
• Arrange regular follow-up with the aim of decreasing urgent phone calls/appointments/emergency department visits and allow appointment times to be available when the patient is not acutely symptomatic.
• Try to avoid/reduce the use of multiple pharmaceutical agents and evaluate current medications for effectiveness and necessity.
• Consider a referral for a behavioral or talk therapy intervention, such as cognitive behavioral therapy (CBT) or relaxation training.

The following clinical scenario demonstrates the application of some of these guidelines in patients with somatic symptom disorder (SSD). Many of these guidelines are applicable for patients with illness anxiety disorder as well.

K., a 27-year-old male graduate student who is new to the area presents with generalized pain waxing and waning over four to six years. The diffuse pain often is accompanied by headaches, sleep problems, concentration difficulties, and memory problems that affect his functioning. He has had extensive workups in a pain clinic “back home” and past treatments with several non-opiate pain medications, antidepressants, stimulants, and muscle relaxers. He comes to this first appointment on fluoxetine 40 mg daily, gabapentin 300 mg three times daily (he often forgets doses), sumatriptan (Imitrex), and acetaminophen as needed. He states, “nothing is working … I can barely get to class and struggle to get my homework done. I worry my pain will get worse and I end up searching the internet for answers rather than getting work done or going out. I didn’t want to come here today because I figured there was not much you can do, but my roommate convinced me to give it a try.”

There are several ways to approach this patient. However, a careful review of past records and past workup is critical in determining if further testing or biomedical intervention is necessary. Although a complete physical exam can be completed at this first appointment, the complexity of the history may require several appointments to be fully understood.

It is useful to review the diagnostic criteria for somatic symptoms and related disorders. The presence of prominent somatic symptoms leads to a consideration of SSD. However, it is not the plethora of physical symptoms that determines the diagnosis, but it is the patient’s reaction to the symptoms that is pathognomonic of SSD. Notably, an individual must demonstrate “excessive thoughts, feelings, or behaviors” that lead to impairment in functioning to be diagnosed with this disorder.

Thus, SSD may be diagnosed with or without another general medical diagnosis. In general, the differential leans toward a mental health disorder, such as:^26,31-33

• factitious disorder: rule out any voluntary component to the symptoms;
• anxiety disorder: differentiate symptoms that are a result of anxiety or panic attack;
• body dysmorphic disorder: consider if the symptoms revolve around appearance or body part;
• functional neurologic symptom disorder: consider if the symptoms primarily are affecting voluntary motor or sensory function;
• illness anxiety disorder: check for somatic symptoms (mild or absent in illness anxiety disorder);
• consider the physiologic effect of any substances used — prescribed, over the counter, and “street drugs.”

In the current patient scenario, K.’s reaction to his symptoms points toward SSD. Evaluating for a general anxiety disorder and reviewing a substance use history (as well as considering if any of the prescribed agents are contributing to the headaches and fatigue) will be helpful in confirming or modifying this diagnosis and in generating recommendations for treatment. For example, prominent symptoms of anxiety, such as poor sleep, poor appetite, avoidant behavior, and/or panic symptoms, may trigger the use of medication sooner rather than later.^26,31-33

The severity of SSD in this case would be moderate, with two out of the three criteria (high levels of anxiety about the symptoms and excessive time/energy devoted to the symptoms) present. It can be difficult to assess if the reaction to symptoms is “excessive.” Diagnostic screens may be useful not only in recognizing SSD but also in determining its severity and assisting with an objective measure for “excessive thoughts, feelings, or behaviors.” It is important to note that a screen alone is never diagnostic but is meant to be used along with the clinical history and physical and any other supporting data.^26,31-33

Perhaps the most used screen for SSD in primary care is the Patient Health Questionnaire-15 (PHQ-15), a subsection of the Primary Care Evaluation of Mental Disorders (PRIME). (See Table 2.) The PHQ-15 is a self-administered, freely available tool consisting of 15 items designed to be used in a primary care office setting. The 15 somatic symptoms evaluated by this screen represent the most common symptoms presenting to primary care (excluding upper respiratory symptoms); 13 of the items relate to physical symptoms; two of the categories (low energy and sleep problems) are more ubiquitous and overlap with the PHQ-9 screen for depression. General cut-off scores for mild, moderate, and severe SSD are 5, 10, and 15, respectively.^26,34

K. sighs when he is asked to complete a PHQ-15, saying, “OK, fine, but believe me, I have filled this out before. My score does not usually change, and my pain does not either. I get the sense nobody really believes me or knows what to do to help me.” His score is 10, just reaching moderate range (consistent with his clinical picture).

K.’s remarks are typical of many patients with somatic disorders who feel discouraged and marginalized after multiple workups and interventions without a clear diagnosis, treatment plan, or pathway. At this point in the appointment, there may be a temptation to repeat past investigations or try a new intervention; however, without a clear rationale, this may serve only to frustrate K. more. Instead, changing this pattern and setting a new framework going forward is the first step in establishing a working relationship with K.^26,31-33

The provider acknowledges that K. has had multiple diagnostic workups and states that looking carefully into the complete history over time will be important. This leaves the door open for further workup in the future if indicated.

When asked, K. denies use of any illicit substances, notes he rarely drinks alcohol (“it makes everything worse”), and never has considered self-harm or suicide. He adds that he “hates” taking the gabapentin because it makes him “tired and foggy,” so he often skips doses. “My neurologist said to give it a try and I did, but then I had to move, so I just thought I could try lower doses, but it never helped,” he explains. The provider listens carefully and says, “In all of these years going to clinics and specialists, has anyone spoken to you about SSD?”

Open communication is essential with all patients, and especially is important in a situation like the one described here, where distrust lurks in the background even during the first interaction. For many patients, at least a tentative or working diagnosis and a clear explanation of the thought processes behind the diagnosis is reassuring.^26,31-33,35

In SSD (as in many areas of medicine), it is useful to avoid thinking about patient symptoms as “physical or mental” or “organic or functional” and instead consider the intrinsic ties and interaction between the mind and the body. Assure the patient that not being able to identify areas of pathology on slides or in bloodwork does not imply malingering or “faking” but instead may represent pathology or pathways we are not able to visualize with the tools available at this point.^26,31-33,35

It can be helpful to use other medical problems to illustrate the intimate connection between mind and body. For example, many individuals are familiar with the concept of stress causing elevation of blood pressure or lowering resistance to infection. Bringing up these or other examples may help a patient better understand that bodily symptoms can be generated and/or exacerbated by psychological or emotional factors.

After reviewing the diagnostic criteria for SSD and explaining that patients with SSD often have a heightened sensitivity to pain and other physical sensation, K. states, “That is possible … maybe. I told my doctors before that I think my experience of pain is unusual and not how most people experience pain. I have seen my friends completely functional after dental procedures, while I need days to recover. So, yes, I think we might be on the right track, but what do I do about it?”

The management of SSD centers on improvement in how the patient copes with the symptoms, not on eliminating the symptoms. This approach enables the provider and patient to focus on reducing the thoughts and behaviors that are preventing optimal functioning.^26,31-33,35

The provider notes to K., “You said that worry about your pain getting worse is keeping you from getting your work done or going out. Tell me more about this because that probably is the place to start.” K. responds, “I am not an anxious person — please let’s not go in that direction. My last doctor put me on the fluoxetine because he thought maybe anxiety caused my pain. But nothing changed. The only thing I worry about is that nobody knows what is wrong with me, and that is scary. But having a diagnosis, even a partial explanation, makes me feel better already.”

Having a diagnosis and feeling heard can be therapeutic. This especially is true for patients who have felt frustrated with the healthcare system.^26,31-33,35

The provider notes, “If having even a tentative diagnosis is helpful for you, that is a good first step. What do you think about working on ways to manage to get your work done even with the pain? In some ways, I think of this as akin to putting on headphones to drown out disturbing noises. You may not be able to stop the noise (or pain, in your case), but we can think about ways to turn down or tune out some of the pain.”

From here the provider has an opening to discuss stress management, sleep hygiene, and even basic behavioral interventions, such as resisting internet searches about symptoms and substituting functional actions (such as work completion or social interaction). Engaging the patient in setting one or two realistic goals can be useful in moving forward.

At this early stage in the relationship and with K’ s statement about not wanting to discuss anxiety, further delving into psychosocial and mental health issues may be counterproductive — waiting until trust is established and more information is forthcoming ultimately may be the more successful approach.^26,31-33,35

“Before we finish,” the provider continues, “I do want to circle back about the gabapentin and fluoxetine. It sounds like you are not taking a regular dose of gabapentin and you never thought it helped your pain.”

“Yes,” says K. “I maybe take 300 mg three times weekly and sometimes a little more. But it makes me tired and hard for me to think. Should I just stop it? Or maybe stop both medicines?”

Evaluating the potential harm and benefit of prescribed medications and understanding patient compliance factors and concerns (including financial and cultural factors) toward medications is a crucial component of an overall treatment plan. In this case, it sounds as though the use of gabapentin may be more detrimental than helpful. A useful principle to consider here is to only change one agent at a time to evaluate the effect of doing so (rather than stop and start a new medication immediately or stopping several agents at one time).³⁵

The provider, choosing with K. to stop the gabapentin, can view this first intervention as an opportunity to have K. come back soon for a return visit. Scheduling a return visit in a timely fashion often decreases urgent calls between visits. In general, scheduling regular visits (typically one to two months apart) rather than waiting until symptoms flare helps to keep the focus on the management of the response to symptoms rather than the intensity of the symptoms.^26,31-33

When patients with SSD fail to show improvement in symptom management, there are several steps to consider. One option, if available, is for the primary care clinician to consult with a psychiatrist regarding diagnosis, treatment efforts, and direction. This may provide an objective view of the interactions and an opportunity to look again at the options for psychological and behavioral interventions.^26,31-33

Although some patients may accept a direct referral to a psychiatrist, such a referral often is misinterpreted by patients with SSD as the provider giving up on them. In these cases, clarify that the primary care provider will remain primary in treatment and ask the patient to consider even a one-time consultation.^26,31-33

Pharmaceutical intervention generally is not a first-line treatment in SSD or any of the disorders in the somatic symptom and related disorders group. However, if depressive symptoms, pain, anxiety, or obsessive thinking appears to be prominent, and/or if the patient does not respond to initial management, consideration of antidepressant treatment is appropriate. Generally, start with a selective serotonin reuptake inhibitor (SSRI), such as fluoxetine or sertraline, at a low dose, with a slower than usual increase, since patients with these disorders typically are more sensitive to side effects.^26,31-33

Relaxation training and CBT (or a combination of the two) have shown small to moderate effects in helping manage response to symptoms in SSD and in illness anxiety disorder, with fewer studies available for functional neurologic symptom disorder and factitious disorder. Future studies will look at specific characteristics of the patient population most likely to respond to these interventions as well as the relative advantages and disadvantages of the delivery method (individual vs. group, for example).

Current data suggest that the large majority (70% to 90%) of patients with these disorders will refuse these interventions, but offering these options, especially if initial efforts at managing symptoms are not successful, is appropriate.^{26,31-33,36,37}

Many patients with functional neurologic disorder are co-managed with neurology. As with all these disorders, communication with all providers involved in patient management is essential in providing optimal care. The principles (discussed earlier) of establishing a therapeutic alliance with the patient, open communication of diagnostic considerations, and frequent, regularly scheduled appointments remain relevant for patients with this disorder.^20,38

In all the disorders discussed here, morbidity and mortality can result from overzealous medical interventions and procedures. A careful physical exam, especially when a patient presents with new symptoms, is appropriate. Testing should proceed only after a thoughtful discussion of risks and potential benefits.^26,32,38,39

Nowhere in medicine is this point better illustrated than in the care of patients with factitious disorder. A case report of one patient with factitious disorder revealed 850 hospital admissions at 650 different facilities and 42 surgeries. Although this is extreme (and predated electronic records), there remains likelihood that, even today, many cases go unrecognized and unreported.⁴⁰

Additional risk for poor outcome in factitious disorder is the lengths patients will go to prove a need for care. For example, a case series of 20 patients with factitious disorder found that behaviors associated with this disorder led to death of 20% of this group.^40,41

It can be challenging for providers to openly discuss this diagnosis with a patient, since, in factitious disorder, the patient deliberately is falsifying or inducing symptoms. Clinicians worry that patients may become offended or threaten legal action if “confronted” with a suspected diagnosis of factitious disorder. However, it is suspected that early detection and recognition of factitious disorder can prevent the multiple invasive and unnecessary procedures that can complicate a course of this illness.^21,22

Recommendations are to present patients with an entire differential, including factitious disorder. Make every attempt to present the information in a nonjudgmental way, perhaps noting that stress often can result in unusual actions and reactions. Expect that many patients will respond with denial (in a retrospective study of 71 patients, only 23% admitted to falsifying symptoms), but planting the seed can have unexpected results in the future. Notably, the treatment most studied for factitious disorder is psychotherapy, but these studies generally are of low quality and difficult to generalize.^21,22,40

In an effort to provide evidence-based recommendations for treatment of factitious disorder, Yates et al conducted a 2016 systematic review of 455 case reports of factitious disorder and found that 58.7% of this group induced illness or injury as opposed to falsifying reports of disease. This is higher than was suspected previously, and obviously elevates the risk for morbidity and poor outcomes.²²

Current guidelines suggest providers should consider factitious disorder early in a workup, when clinical presentation and objective evidence do not match. Yates et al noted that risk factors, including being a young adult female and having an association with a healthcare profession, were consistent in the systematic review and that the patients in this population sample presented with a variety of symptoms, but most frequently with endocrine, cardiac, or dermatologic symptoms. Additionally, this group noted that depressive symptoms were prominent and there was suggestive evidence that treatment for depression could mitigate the course of factitious illness.^21,22,40

Summary

The prominent disorders under the general DSM-5-TR category of somatic symptom and related disorders are SSD, illness anxiety disorder, functional neurologic disorder, and factitious disorder. These patients tend to present to a primary medical provider for treatment.

Developing an understanding of these disorders, recognizing the connection between the mind and body, and having a framework for addressing these “difficult” patients increases the likelihood of better outcomes for patients and decreases the likelihood of frustration for the clinician. General principles of care include:

• Consider these disorders early during a workup for patients with unremitting symptoms.
• Establish an alliance with the patient and legitimize the symptoms, even if no “legitimate” etiology is found.
• Establish open communication with the patient about diagnosis and treatment.
• Reframe treatment goals toward functional improvement rather than symptom elimination.
• Evaluate for comorbid general medical disease and psychiatric disorders and treat if these are indicated.
• Limit invasive tests and referrals.
• Schedule regular appointments (not dependent on symptom emergence).
• Communicate with all providers.

References

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