Somatic Symptom Disorder &

Illness Anxiety Disorder

Theodore A. Stern, MD
Chief Emeritus, Avery D. Weisman, MD Consultation Service,
Director, Office for Clinical Careers,
Massachusetts General Hospital;
Ned H. Cassem Professor of Psychiatry in the field of Psychosomatic
Medicine/Consultation, Harvard Medical School;
Editor-in-Chief, Psychosomatics

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 Disclosures
“Neither I nor my spouse/partner has a relevant
financial relationship with a commercial interest
to disclose.”

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 Objectives
• Differentiate somatic symptoms from somatic
symptom and related disorders
• Define the DSM-5 criteria for:
– Somatic Symptom Disorder
– Illness Anxiety Disorder
• Discuss the evaluation and treatment

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 Definitions
• Main Entry: so·mat·ic
Function: adjective
Etymology: Greek sOmatikos, from sOmat-,
sOma
1 : of, relating to, or affecting the body
especially as distinguished from the psyche
2 : of, or relating to the wall of the body
Miriam-Webster Dictionary

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 Definitions

• Somatizing:
– Tendency to experience somatic stress in response
to psychosocial stress
– Distress is attributed to physical illness—
• Patients present to PCPs and specialists (not
psychiatrists)
– Patients seek medical help for their symptoms

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 Impact
• Somatizers account for a disproportionate
share of:
– Medical care
– Laboratory tests
– Procedures
– Hospital stays
– Total health care costs (up to $30 billion per year)
• 90% of costs are billed to top 10% of patients

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 Differential Diagnosis

• Consider a medical cause

– Initial workup looks for medical conditions
– Consider illnesses that present with symptoms
from a variety of organ systems
• e.g., multiple sclerosis, lupus
– Don’t be fooled by unusual presentations or
strange affect
• A medical etiology may still be present

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 Differential
• Functional somatic symptoms
– symptoms not a syndrome
• Symptoms without identifiable medical
etiology may be manifestations of psychiatric
illness
– e.g., palpitations with panic; fatigue with
depression)
– These are much more common than is a Somatic
Symptom Disorder

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 Functional Somatic Symptoms:
Differential Diagnosis
• Depressive disorders
• Anxiety disorders
• Substance abuse disorders
• Psychotic disorders
• Personality disorders
• Voluntary symptom production
– Malingering
– Factitious disorders

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 Functional Somatic Symptoms
• Depression • Anxiety
– Insomnia – Dyspnea
– Fatigue – Palpitations
– Anorexia – Chest pain
– Weight loss – Choking
– Dizziness
– Paresthesias
– Sweating

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 Evaluation
• Rule-out as medical causes of symptoms:
– General medical condition
– Functional symptoms
– Voluntary production of symptoms
• i.e., factitious disorder or malingering
• Then consider Somatic Symptom Disorder or
Illness Anxiety Disorder

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 Somatic Symptom Disorder:
Criteria
-One or more distressing somatic symptoms that disrupt daily
life.
-Excessive thoughts, feelings, or behaviors related to the somatic
symptoms or health concerns with at least one of:
1. Disproportionate and persistent thoughts about the seriousness of ones
symptoms.
2. Persistently high anxiety about health symptoms.
3. Excessive time and energy devoted to these health concerns.
-A somatic symptom may not be present continuously, but being
symptomatic is persistent
usually more than 6 months
predominantly persistent pain
DSM-5, 2013

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 Somatic Symptom Disorder
• Symptoms may not be associated with
another medical illness
– SSD and concurrent medical illness are not
mutually exclusive
• These individuals often think the worst about
their health
– In severe cases, symptoms dominate all aspects of
life

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 Somatic Symptom Disorder:
Epidemiology
• Prevalence
– Adults: 5-7%
– Female > male
• Co-morbid psychiatric diagnoses are common:
– Major depression
– Anxiety disorders
– Panic disorder
– Substance abuse
– Personality disorders

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 Somatic Symptom Disorder:
Epidemiology
• Negative affectivity (neuroticism) is often
present
• More common with:
– Lower socioeconomic status
– Lower levels of education
– Recent stressful events
– A history of sexual abuse
• Consequences:
– Marked impairment of health status

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 Illness Anxiety Disorder:
Criteria
-Preoccupation with having or acquiring serious
illness
-Anxiety about health is high.
-The individual performs excessive health-related
behaviors or exhibits maladaptive avoidance.
-Care-seeking type and care-avoidant type
-Illness preoccupation for at least 6 months.
-Illness preoccupation not better explained by
another mental disorder.
DSM-5 2013

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 Illness Anxiety Disorder
• Most with hypochondriasis have SSD, however, some have
Illness Anxiety Disorder
• Prevalence in primary care clinics: 3-8%
• If physical signs/symptoms present, they are usually normal
physiologic sensations (e.g., dizziness)
• When medical conditions occur, worry is out of proportion
• Concerns about illness don’t respond to usual medical
reassurance
• Examine themselves repeatedly
• Voracious internet searchers
• Often doctor shop, but don’t seek mental health care

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 Illness Anxiety Disorder:
Course
• Onset in early and middle adulthood
• Sometimes develops after (benign) threat to
health
• History of serious childhood illness may
predispose
• Chronic and relapsing
• Significant decrements in quality of life
– Concerns often:
• interfere with interpersonal relationships
• disrupt family life
• damage work performance

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 Treatment Approaches
• Develop a long-term relationship with PCP
• Allow them to maintain the sick role
• Schedule regular appointments with a set length
• Set an agenda for the visit & set limits
• Seek to “maintain vs cure”
• Inquire about stress during the physical examination
• Consider psychiatric referral as adjunct
– treat co-morbid psychiatric illnesses
• **Avoid iatrogenesis
– e.g., unnecessary procedures

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 Treatment Approaches
• Experiential
– Decrease somatic sensations
• biofeedback, hypnosis, massage, meds for concomitant diagnoses
– Physical reactivation & Physical therapy
• Cognitive
– Re-attribute sensations to benign causes
– Distraction
• Behavioral
– Contract to “save” symptoms for regular visit rather than
emergency visit

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 Treatment Approaches
• Use suggestion and reassurance
– Say: “the weakness in your legs really laid you up;
the good news is that you don’t have MS….”
– Avoid: “it’s all in your head.”
• Dynamic therapy
• Marital therapy
• Group therapy

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 Conclusion
• For SSD, distinguish between somatic symptoms and
a medical etiology
• Differentiate functional somatic symptoms from
somatic symptom and related disorders
• Look for and treat co-morbid psychiatric illnesses
• SSD and IAD are often chronic conditions
– Seek to “care rather than cure”
• Both cause significant decrements in quality of life
• Avoid iatrogenesis

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 References
• American Psychiatric Association: Diagnostic and Statistical
Manual for Mental Disorders—Fifth edition (DSM-5),
Arlington, VA, 2013, American Psychiatric Press.
• Kontos N, Beach SR, Smith FA, et al: Psychosomatic conditions:
Somatic symptom and related disorders, functional somatic
syndromes, and deception syndromes: In: Stern TA,
Freudenreich O, Smith FA, et al, editors: Massachusetts
General Hospital Handbook of General Hospital Psychiatry, ed
7, Philadelphia, 2018, Elsevier.
• Kontos N: Somatic symptom and related disorders: In: Stern
TA, Herman JB, Rubin DB, editors: Massachusetts General
Hospital Psychiatry Update & Board Preparation, ed 4,
Boston, 2018, MGH Psychiatry Academy.

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