Somatic Symptom Disorder: Effective Techniques for Diagnosing and Managing This Complex Condition in Primary Care Practices
ABSTRACT: Patients with somatic symptom disorder (SSD) can be a challenge for primary care clinicians, as these individuals generally maintain an intense attachment to the sense that something is wrong with them. Simple reassurance and a negative workup are often not sufficient to allay their concerns. Patients with somatization tend to experience higher-than-average levels of anxiety and social dysfunction (eg, days missed from work), and clinicians often feel frustrated by these individuals’ refusal to see things the clinicians’ way. This article provides an overview of SSD, focusing on diagnosis and techniques that can help effectively manage this complex condition, including relaxation training and cognitive–behavioral therapy.
Historically, somatoform disorders have been defined as chronic psychiatric conditions characterized by multiple medically unexplained physical symptoms that are serious enough to significantly interfere with a patient’s ability to perform important daily activities, such as working or meeting family responsibilities. The term somatization is commonly used in the behavioral health realm, and the American Psychiatric Association’s (APA’s) 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has made significant changes to the criteria for diagnosing somatoform disorders, which are now dubbed somatic symptom disorder (SSD) and related disorders.1 The APA’s new criteria focus on persistent somatic symptoms (present for at least 6 months) that disrupt patients’ daily life. In the previous version of the DSM-5—the DSM-IV-TR—there was significant overlap between the various somatoform disorders, making it difficult for nonpsychiatric physicians to distinguish between them.2
In primary care practices, clinicians often refer to patients with somatization as having “medically unexplained symptoms”3; however, the new DSM-5 criteria no longer require that symptoms are medically unexplained for a diagnosis of SSD to be made.1 Although patients’ symptoms may or may not be associated with another medical condition, they still need to be significantly distressing or disruptive to daily life and accompanied by excessive thoughts, feelings, or behaviors.1 In the general population, the prevalence of somatization severe enough to interfere with patients’ daily function is approximately 6%.4 The prevalence in primary care offices is closer to 10%.5
Regardless of what name is tied to the condition, somatization is costly to the healthcare system and to the patient, as these individuals have higher rates of medical care use, including outpatient visits, testing, procedures, and hospitalizations. In one study, patients with somatization accumulated twice the annual medical care costs of nonsomatizing patients.6 In addition to being costly to the healthcare system, these patients experience chronic symptoms that are distressing and disabling. A study that compared patients with somatization with a control population 3 years after presentation found that those with somatization had missed significantly more time from work than controls.7 In another study, somatizing patients’ degree of disability was equal to or greater than that associated with many major, chronic medical disorders.8
We have all seen patients who remain certain that they have a medical disorder despite affirmations that no disease has been found. These patients find it frustrating that we cannot cure them, and we are often frustrated that these patients cannot accept our reassurance that we have used our best judgment in evaluating them. In this article, we describe how to establish an SSD diagnosis and review helpful treatment techniques that the reader can incorporate into their primary care practice to improve the care of these complex patients.
Establishing the Diagnosis
One somatization screening tool that is commonly used in primary care practices is the Patient Health Questionnaire 15-Item (PHQ-15) Somatic Symptom Severity Screener, which emphasizes the number of symptoms and the extent to which they are troubling (Figure 1).9 A study that administered the PHQ-15 to 6000 patients in 8 general internal medicine and family practice clinics and 7 obstetrics-gynecology clinics found that as PHQ-15 somatic symptom severity increased, there was a substantial stepwise decrement in functional status, as assessed by the 20-item Short-Form General Health Survey, and increased symptom-related difficulty, sick days, and healthcare use.9 Based on their findings, the authors concluded that the PHQ-15 “may be useful in screening for somatization and in monitoring somatic symptom severity in clinical practice and research.”9 It is important to note, however, that the items in the PHQ-15 include the most prevalent somatization disorder symptoms per the DSM-IV-TR, which also required a certain number of symptoms to be present from among 4 symptom groups (ie, pain, gastrointestinal, sexual/reproductive, and pseudoneurological).10 The SSD criteria no longer have this requirement.1 As previously stated, the symptoms that are present just need to be persistent and significantly distressing or disruptive to daily life.
Figure 1. The PHQ-15 screening instrument for somatization. This screening instrument was developed by Drs. Robert L. Spitzer, Janet B. W. Williams, Kurt Kroenke, and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display, or distribute.
In our practice, we do not use the PHQ-15 or any other formal screeners, but typically arrive at the diagnosis after observing all or most of the following:
1. A persistent attachment to the belief that an organic illness is present despite clinical assessments demonstrating otherwise.
2. A multiplicity of symptoms. In our experience, the presence of multiple symptoms renders an SSD diagnosis more likely.
3. A vagueness and ambiguity of the symptoms. Instead of saying “I feel pressure in my chest,” patients with SSD are more prone to say something like “I have a tired heart.”
4. Denial of any connection between psychosocial distress and the patient’s somatic distress. In contrast, patients with an organic disease often acknowledge that stress makes them feel worse.
5. Expression of disappointment that multiple previous providers have not successfully diagnosed the illness and/or disappointment when there is a negative test result. When clinicians deliver news to patients of normal clinical findings, they generally expect patients to welcome such results and anticipate that patients’ symptoms will resolve, enabling them to resume normal functioning, but this is not always the case with SSD. For example, a 9-year follow-up study of patients with chest pain found that an elevated somatization score on the Symptom Checklist-90-Revised predicted a 5-fold increased risk of persistent symptoms.11 In general, negative test results do not reassure patients who have a low probability of a serious disease, a finding that has been demonstrated in patients with dyspepsia, back pain, chest pain, headache, and palpitations.12
Treating Somatic Symptom Disorder
Patients with SSD often have symptoms that are difficult to ameliorate. One study found that physical symptoms in primary care patients were less responsive to treatment when disease was absent than when disease was present.13 In this study, 68% of patients thought to have an organic disease reported resolution of their symptoms 6 months after presentation compared with only 38% of somatizers; the study defined somatizers as persons who had an emotional disorder but who presented with physical symptoms that could not be attributed to an organic disease.13 In a study that used a Danish registry to assess the outcomes of surgical and medical treatments in persistent somatizers (defined as persons with more than 6 medically unexplained general hospital admissions in their lifetimes) found that surgical interventions were generally unsuccessful in 75% of cases, whereas medical treatments were unsuccessful in approximately 66% of cases.14 With time, many patients with somatization improve, but some remain resistant to treatment. Five years after presentation, 21% of a group with multisomatoform disorder (characterized by ≥3 medically inexplicable, troublesome physical symptoms and a ≥2-year history of somatization) continued to meet the criteria for this disorder.15
Despite SSD persisting in many patients, there are treatments that have demonstrated efficacy for these patients. Most of these treatments have been developed and implemented in behavioral healthcare settings and focus on cognitive–behavioral approaches to patients’ health misunderstandings; however, these approaches can also be implemented in primary care. A study of a 12-month intervention consisting of cognitive–behavioral, pharmacological, and other treatment modalities administered by nurse practitioners in a primary care setting demonstrated significant improvement in symptom scores in the treated group versus the control group.16
In the section that follows, we elaborate on two techniques that can be used to decrease patients’ anxiety, improve their quality of life, and lower the volume of repeat medical visits: mind–body relaxation and cognitive–behavioral therapy. These techniques can be seamlessly incorporated into usual medical care so that patients do not have to be referred to behavioral health clinics, which may be perceived by some as a threatening next step, and primary care physicians can avoid the natural inclination to feel defeat at failing to reassure patients with SSD of their “wellness.”
Mind–Body Relaxation
We present relaxation techniques to patients as a way to address their distressing somatic symptoms. As an example, irritable bowel symptoms are described in terms of overactive innervation of the gastrointestinal tract, and the relaxation techniques are framed as a way of calming these overactive nerves. The training includes focused head-to-toe relaxation, abdominal (diaphragmatic) breathing, and mental imagery. Patients are given permission to temporarily step away from their worrisome thoughts and to focus on a single calming and pleasurable image, such as the mountains or seashore, with accompanying sensations of warmth or a gentle breeze. Two 10- to 15-minute daily practice sessions are encouraged, and patients are told to use these techniques during times of stress.
Cognitive–Behavioral Therapy
A cognitive–behavioral technique we find especially useful is cognitive restructuring, as this comes naturally to primary care physicians, who are used to “meeting patients on their own turf.” Cognitive restructuring helps identify and restructure negative thinking patterns. Rather than focus on a “cure,” we work on reducing the severity of symptoms, which can be achieved using numerous techniques, such as the following:
• Asking patients to measure and record the intensity of a symptom and then having them focus on increasing the intensity and then on decreasing the intensity. This gives patients an increased sense of control. We provide patients with the rationale “if you can make it worse, then you must also be able to make it better.”
• Teaching patients distraction techniques. For example, we might say something like “When you notice a bothersome symptom, try to think of a soup that begins with the letter ‘A,’ and then with the letter ‘B,’ and so on.”
• Providing reassurance. Rather than arguing with patients about whether or not their symptoms represent a “real” disease, we point out that most symptoms are benign and that it is normal to frequently notice bothersome symptoms. For example, we might point out that 45% of people have back pain in a given year. Sometimes a patient will respond: “Okay, I’m not alone in this. It’s common to have some recurring symptoms.”
• Guiding them to consider less-threatening symptoms. We ask patients to choose a bothersome symptom and instead of assuming the most worrisome diagnosis, to play devil’s advocate and build a case for a more benign etiology. We try to frame this discussion in the most sympathetic manner, as we want patients to know that we understand their suffering and are working to collaborate with them so that they feel better.
We find it useful to give patients “homework” to solidify their cognitive restructuring. Providing patients with worksheets enables us to efficiently identify their understanding and participation in cognitive restructuring. The worksheets are given out in the following sequence:
1. The first worksheet (Figure 2) asks patients to write down an annoying symptom (eg, heartburn), and then notice what activity (eg, kids arguing) and what alarming or worrisome thought (“I’m getting an ulcer”) exacerbates the symptom.
2. At a subsequent session, an expanded worksheet (Figure 3) asks patients to consider other possible positive responses to the identified symptom (eg, listen to relaxing music, doing a jigsaw puzzle), and to note the effect of the intervention.
3. At a follow-up visit, we provide a worksheet (Figure 4) on which the patient should list another symptom (eg, palpitations), list the first thought that comes to mind (“I must be having a heart attack”), then list alternative explanations (“I had two cups of coffee and I’m worried about work”), and finally list possible helpful behavioral responses (eg, “my heart will slow down if I take deep breaths”).
Just as we might ask a patient with diabetes to bring in glucose meter results, we ask the patient to bring these worksheets to their clinical visits. The worksheets help to engage the patients and make the visits more efficient.
The aforementioned strategies for minimizing and tolerating somatic symptoms are helpful regardless of the etiology of the symptom or the care setting the patient is being treated in. For example, it is common for patients who have completed chemotherapy and other cancer treatments to worry that any symptom might represent a recurrence of their cancer. While healthcare providers might share this concern, they also have to consider “what might this symptom represent other than cancer?” In doing so, they can help patients create a list of alternate possibilities, and the patient can then conduct a series of “experiments” to see if simple remedies alleviate their symptoms, such as stretching to relieve back pain.
Implementing Cognitive–Behavioral Strategies in Primary Care
During treatment, it is important for healthcare providers to recognize their own sense of frustration when communicating with patients who tenaciously hold onto what we perceive as “misunderstandings.” In one survey, 93% of British general practitioners agreed that somatizing patients are “difficult to manage.”17 In an editorial, Jackson and Kay describe a feeling of “heartsink” when seeing certain patients’ names on the day’s schedule.18 They note that instead of shouldering the burden of “fixing the patient,” healthcare providers should share the responsibility with the patient and reorient both patients’ and providers’ goals. They also suggest that we should “make [cognitive–behavioral therapy] available in every primary care setting,” urging a multidisciplinary
approach to care.
While treating patients with SSD, empathy is critical. It is important to remember that we all occasionally frighten ourselves when we think that a minor twinge might represent a cancer, heart disease, or some other life-threatening illness. This insight can help us to identify a bit with somatizing patients. In addition, somatization has been associated with a history of traumatic events, including childhood abuse, which can add another level of complexity to treating patients with SSD. Furthermore, most patients with a mood disorder initially present to primary care practices with somatic symptoms, and we routinely screen these patients for depression. If depression is present, treatment may significantly lessen somatic symptoms.
Although the use of relaxation and cognitive restructuring techniques can help many patients, others may benefit from receiving behavioral health input. In particular, a patient’s inability to focus on these techniques in primary care may signal a preoccupation with other deep-seated issues, such as an underlying mood disorder or history of abuse, which may require the skills of behavioral health clinicians to elucidate and address; thus, primary care clinicians’ use of the aforementioned techniques can become part of a stepped care approach, suggesting behavioral health referral to those patients who do not show improvements in their somatization.
Time pressures are a major concern in primary care practices, and some may think that cognitive treatments are not feasible in this setting. In our experience, these treatments can be delivered efficiently and incorporated into a usual short visit. Using the worksheets accompanying this article (Figures 2-4), we can speed up the visit by helping focus the patient away from reiterating worries and guiding him or her into a plan of action. The worksheets also elicit the specifics that clinicians can include in a brief note and facilitate coding the level of service by time. We code these visits using the main physical symptom (eg, headache) as the primary diagnosis, rather than the diagnosis of somatization disorder. There are several reasons for this: (1) it prevents stigmatization of the patient; (2) it fosters trust and respect, as the patient may take umbrage at the use of a diagnosis that suggests mistrust; and (3) it represents our continuing effort to keep an open mind regarding the possibility that an organic basis for symptoms may develop.
Finally, when developing an organized approach to treating patients with SSD, it is helpful to obtain organizational support from insurers or healthcare organizations. These organizations have begun to focus additional resources in areas of high cost (eg, patients with diabetes mellitus, chronic renal disease, end-of-life needs). Practices are creating care models to avoid repeat hospitalizations. High-utilizing patients with medically unexplained symptoms represent another opportunity to improve care and lower healthcare costs. In a randomized trial, our treatment model decreased average 1-year outpatient costs from $3574 to $2991.19 This was attributed to statistically significant (P<.01) decreases in measures of somatization, health anxiety, and psychiatric symptoms persisting 1 year after treatment. As patients become more comfortable they become less demanding of more tests and we become better stewards of healthcare resources while continuing to be vigilant for possible organic disease. In addition, patients are moved away from an adversarial role to one of increased self-acceptance. A Dutch primary care group that studied the usefulness of mindfulness-based cognitive therapy in a group of patients with medically unexplained symptoms reported improvements in patients’ social functioning.20 Qualitatively, patients reported “it gave me rest, inner rest,” and “I have created more peace in my life.”
Conclusion
The goal of this article was to demonstrate that the aforementioned relaxation and cognitive–behavioral therapy principles can be incorporated into primary care practices, and that the techniques employed are not so different from usual practice. With increased confidence that a structured approach can have a positive effect on patients’ understanding and function, we expect both patient and clinician satisfaction will improve. At the same time, treatment goals should remain modest. Instead of seeking to “cure” patients of their somatic symptoms and illness beliefs, healthcare providers should seek to lessen the burden of patients’ symptoms. This approach can foster trust between patients and providers and ultimately lead to improvements in patients’ quality of life while reducing healthcare costs. ν
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Mark Bauer, MD, is an internist at Harvard Vanguard Medical Associates, Watertown, MA, and assistant professor of population medicine at Harvard Medical School, Boston, MA.
Derek Hersey, MPAS, PA-C, is a primary care physician assistant at Harvard Vanguard Medical Associates, Cambridge, MA.
Daniel Kasuba, PA-C, is a primary care physician assistant at Harvard Vanguard Medical Associates, Boston, MA.
Jane Lauridsen, RNC, ANP, BSN, MS, has retired as a nurse practitioner from Harvard Vanguard Medical Associates, Cambridge, MA.
Ann Stewart, MSN, NP, is a nurse practitioner in Medical Oncology, Dana Farber Cancer Institute, Boston, MA.
Arthur Barsky, MD, is director of psychosomatic research, Department of Psychiatry, Brigham and Women’s Hospital, and professor of psychiatry at Harvard Medical School, Boston, MA.