Somatic Symptom Disorder (SSD) is a psychiatric condition in which the individual excessively focuses on bodily symptoms, perceives these symptoms as severe and threatening, and consequently experiences anxiety, behavioral changes and functional impairment. This diagnosis, introduced in DSM-5, replaced several conditions that were previously grouped under “somatoform disorders.” SSD is defined not only by the presence of physical complaints but also by the degree of cognitive and emotional responses to these complaints.

This disorder is highly prevalent in the general population and is commonly encountered in both primary care and specialized clinical settings, leading to reduced quality of life and increased utilization of health services.

DSM-5 Diagnostic Criteria for Somatic Symptom Disorder

According to DSM-5, the diagnosis of Somatic Symptom Disorder requires the following:

• One or more somatic symptoms that are distressing or result in significant disruption of daily life.
• Excessive thoughts, feelings or behaviors related to the somatic symptoms or associated health concerns, as manifested by at least one of the following:
  • Disproportionate and persistent thoughts about the seriousness of symptoms
  • Persistently high level of health-related anxiety
  • Excessive time and energy devoted to these symptoms or health concerns
• The symptomatic state is persistent (typically more than six months), although any one symptom may not be continuously present.

These criteria apply to individuals with both diagnosed medical conditions and medically unexplained complaints. The key factor is the psychological impact of the symptoms on the individual.

Symptoms of Somatic Symptom Disorder

SSD presents with a wide variety of clinical manifestations. The most common symptoms include:

• Chronic recurrent pain (e.g., head, back, abdominal pain)
• Fatigue and weakness
• Gastrointestinal problems (bloating, constipation, nausea)
• Cardiac complaints (palpitations, chest pain)
• Neurological symptoms (dizziness, fainting sensations)

These physical complaints are typically accompanied by intense health anxiety. Patients may firmly believe they suffer from a serious illness despite repeated medical reassurance that no organic cause is present. Doctor shopping, repeated diagnostic testing and reassurance-seeking behaviors are common. In addition, depressive symptoms (sadness, hopelessness) and anxiety symptoms (restlessness, tension) often co-occur.

Etiology of Somatic Symptom Disorder

The etiology of SSD is multifactorial and best explained through a biopsychosocial model.

1. Biological Factors

• Genetic predisposition plays a significant role.
• Functional abnormalities have been identified in central nervous system regions involved in pain and emotional processing, particularly the insula and anterior cingulate cortex.
• Heightened sensitivity of the autonomic nervous system and dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis have been reported (Kroenke et al., 2011).

2. Psychological Factors

• Tendency toward catastrophic thinking (e.g., interpreting minor pain as evidence of a life-threatening illness)
• Learned coping mechanisms from childhood (e.g., receiving attention through illness)
• History of depression, anxiety or trauma
• Low stress tolerance

3. Social Factors

• Family history of chronic illness or overprotective parenting
• Health care access and reinforcement through frequent medical consultations
• Use of illness as a means of avoiding stressful occupational or social situations (secondary gain)

Risk Factors for Somatic Symptom Disorder

• Female gender
• Low educational and socioeconomic status
• Traumatic life events (particularly childhood abuse)
• Family history of psychiatric disorders
• Comorbid anxiety or depression
• Personality traits (e.g., high neuroticism, histrionic characteristics)

These risk factors increase vulnerability, with childhood adverse experiences in particular serving as a foundation for SSD in later life.

Diagnosis of Somatic Symptom Disorder

The diagnostic process focuses less on the medical explanation of symptoms and more on how the individual perceives and responds to them. Diagnosis is based on a detailed psychiatric history and systematic assessment using DSM-5 criteria.

Differential diagnosis must consider:

• Organic medical conditions that could explain the symptoms
• Anxiety disorders (particularly illness anxiety disorder)
• Major depressive disorder
• Somatization disorder (DSM-IV diagnosis)
• Conversion disorder

Psychometric instruments such as PHQ-15 or SSD-12 may be used. Biological tests should only be performed when necessary to avoid unnecessary medical investigations.

Treatment of Somatic Symptom Disorder

SSD treatment requires a holistic approach. The goal is not to completely eliminate symptoms but to enable the individual to function effectively despite them.

• Psychotherapy (Primary Approach)
  • Cognitive Behavioral Therapy (CBT): Considered the most effective intervention. Aims to challenge catastrophic thoughts, reduce avoidance behaviors and restructure body-related perceptions. Meta-analyses indicate that CBT significantly reduces symptom severity and health anxiety (Henningsen et al., 2018).
  • Mindfulness-Based Approaches: Enhance emotional awareness and help regulate the individual’s relationship with their body.
• Psychoeducation
  • Providing information about the disorder
  • Raising awareness of the relationship between stress and physical symptoms
  • Teaching strategies for functional engagement with the health care system
• Pharmacotherapy
  • Antidepressants (especially SSRIs): Effective for comorbid depression and anxiety, with indirect benefits on somatic symptoms.
  • Anxiolytics: Should be used with caution and on a short-term basis due to risk of dependency.
• Multidisciplinary Approach
  • Collaboration among psychiatrists, primary care physicians, psychologists and physiotherapists is essential.
  • Unnecessary investigations and referrals should be avoided. A “one physician–one plan” strategy is recommended.

Impact on Daily Life

SSD can significantly reduce quality of life. It may lead to occupational impairment, interpersonal difficulties, frequent medical visits and inability to fulfill domestic responsibilities. It is also associated with increased risk of depression, panic disorder, substance use and suicidality.

At the societal level, excessive use of health services, increased health care costs and strained doctor-patient relationships are notable consequences. Early diagnosis and effective management are therefore crucial for both individual and public health.

Somatic Symptom Disorder is a psychiatric condition arising from the interaction of biological and psychosocial factors. Although it can severely impair quality of life, it is a manageable disorder when approached with accurate diagnosis and appropriate interventions. Diagnostic evaluations must carefully exclude organic illness while avoiding unnecessary interventions. Psychotherapy-centered, multidisciplinary and individualized treatment strategies can lead to substantial improvements in functioning and well-being.