Understanding Somatic Symptom Disorder

Dear Theresa,

I am sorry that your niece is having such a difficult time. Having physical symptoms that cannot be explained medically is extremely frustrating, for both patient and family. The person experiencing the symptoms often feels like something is gravely wrong with her body and feels that we — family members and providers alike — are minimizing their physical concerns and claiming it is “all in your head.”

We are only just beginning to scratch the surface of the interplay between the body and the mind. At some point in our lives, we all experience physical responses to emotional situations. These can be positive, the fluttery feelings of excitement before a first date, for example, or negative, like the headache after a stressful day at work or an upset stomach before an exam. For some individuals, these physical symptoms proliferate and lead to a great deal of distress and disability, interfering with their ability to function both at home and at work.

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In psychiatry, there are a cluster of illnesses linked to perception of, or concern about physical ailments. This includes illness anxiety disorder (the new name for hypochondriasis) and somatic symptom disorder.  Although it would be necessary to do a full evaluation, from what you describe it sounds as though your niece could be dealing with somatic symptom disorder. With this illness, individuals have physical symptoms for which there is no physical explanation or for which the symptoms are out of proportion to a physical disease. Individuals with this illness experience a significant amount of anxiety worrying about their symptoms and spend a great deal of energy focused on these health concerns. There can be one primary symptom, like unexplained belly pain, or a number of different symptoms affecting many different areas of the body, such as you describe for your niece.  

Likely, we all have someone in our lives struggling with somatic symptom disorder as it affects 5 percent to 7 percent of people and is more common among women. While anyone can be affected, there are certain factors that increase risk. This includes stressful life events, as well as childhood trauma and sexual abuse.

Somatic symptom disorder is an illness of exclusion — a diagnosis one settles upon when all of the appropriate work-ups have been negative. Unfortunately, there certainly are cases where the “it’s all in your head” attitude is taken too soon, leading to missing a treatable physical condition that was only diagnosed later. Therefore, a thorough work-up by a thoughtful physician who is listening closely to the different symptoms being expressed is very important. On the flip side of the coin, these individuals are at risk of being subjected to increasingly invasive or potentially dangerous tests and procedures, which cause more harm without bringing about an explanation or relief from the symptoms. For example, repeated CT scans lead to excessive exposure to radiation and exploratory surgeries can come with a slew of potential complications. This whole process can be frustrating for a patient who wants answers. It sounds as though your niece has undergone a number of medical evaluations without a clear explanation for her symptoms. 

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This leads to the complicated question of what to do. Once a thorough evaluation has revealed no apparent physical source, it’s time to shift focus and figure out how to deal with these very real symptoms and make them less disabling. First, to deal with the anxiety that arises from these symptoms — and the concern that there may be something lurking — these individuals tend to benefit from regular appointments with their primary care doctor, as you have seen with your niece in this last year.  Regular contact with her doctor gives the individual and her physician the opportunity to monitor these symptoms over time. Establishing a strong relationship with a physician can also help them work together to decide when further testing is appropriate or when a wait-and-see approach is wiser.  

For treatment, there is evidence that antidepressants, like SSRIs or SNRIs, show some benefit. These may act by inhibiting descending pain pathways and decreasing inflammation. For those seeking an alternative approach, St. John’s Wort has also been shown to be helpful. While I know your niece was reluctant, for those willing to engage in psychotherapy, this can also be beneficial. Of the therapies, cognitive behavioral (CBT) therapy has been shown to have the most evidence around reducing somatic symptoms. CBT works by encouraging the individual to reattribute those symptoms to psychosocial or normal physiological causes rather than focus on other somatic concerns.

Somatic symptom disorder is extremely challenging to deal with for the patient, her family, and her medical providers. While we believe these are driven in no small part by psychological factors, the physical feelings experienced by the individual are real and can be quite disabling. Your niece is lucky to have you in her corner, offering her support and empathy, as she struggles with this illness. I wish you both the best in dealing with this difficult disorder.

Dr. Riddle



Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. (2013). Arlington, VA: American Psychiatric Association.

Hoedeman, R., Blankenstein, A. H., van der Feltz-Cornelis, C. M., Krol, B., Stewart, R., & Groothoff, J. W. (2010). Consultation letters for medically unexplained physical symptoms in primary care. Cochrane Database Syst Rev(12), CD006524.

Isaac, M. L., & Paauw, D. S. (2014). Medically unexplained symptoms. Med Clin North Am, 98(3), 663-672.

Kleinstauber, M., Witthoft, M., Steffanowski, A., van Marwijk, H., Hiller, W., & Lambert, M. J. (2014). Pharmacological interventions for somatoform disorders in adults. Cochrane Database Syst Rev, 11, CD010628.

van Dessel, N., den Boeft, M., van der Wouden, J. C., Kleinstauber, M., Leone, S. S., Terluin, B., . . . van Marwijk, H. (2014). Non-pharmacological interventions for somatoform disorders and medically unexplained physical symptoms (MUPS) in adults. Cochrane Database Syst Rev, 11, CD011142.

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  • Mickey April 18, 2016 at 1:06 pm

    I do wish this young woman would consider psychotherapy. She could explore what triggers these episodes of physical symptoms. I remember how upset my stomach used to be when I went to work. It was a stressful place but no option to look for another job. Would she be open to acupressure? Jin Shin Jyutsu has a marvelous way of shifting one’s perspective sometimes as well as relieving physical symptoms. God bless her.