CASE ILLUSTRATION 1
Ms. A, a 57-year-old woman, makes an appointment with a new clinician. She presents with a 10-year history of multiple, unexplained symptoms. She has seen many physicians over the past decade, including several primary care physicians and numerous subspecialists. Her principal complaints today include abdominal pain, chest pain, headache, palpitations, fatigue, and intermittent dizziness. She brings a thick stack of records from some of her prior physicians. These records include multiple laboratory tests and diagnostic procedures, none of which has identified any cause for her symptoms.
Clinician: How can I help you today, Ms. A?
Patient (sighing): I don’t know. A friend of mine saw you a few months ago and said you were very good. I hope you can help me. I’ve had these problems for years now, and no one seems to be able to figure them out. Maybe you can. I know there’s something wrong. I’ve been so sick.
Clinician: Why don’t you tell me about your symptoms?
Patient: Well, it all began about 10 years ago… .
Clinicians are taught that patients will present with symptoms (subjective complaints) and signs (objective findings) that suggest the presence of a pathophysiological process. They are trained to recognize these presentations and to diagnose the underlying disease so that they may institute the appropriate treatment. Satisfaction for the care provider arises from the ability to perform these tasks proficiently and ameliorate suffering. Patients typically come to the clinician’s office seeking an explanation for and relief from their symptoms. Difficulties arise in the relationship when the patient presents with symptoms and the clinician can find no disease to explain them. Complications can also arise when clinicians focus too much on somatic symptoms and not the underlying etiology of the symptoms, which in many cases can be psychological rather than physical. Symptoms that lack discernible physical pathology, which can be seen in up to 40% of primary care patients, have been referred to variously as medically unexplained, functional, or related to “somatization.” The term somatization has had changing definitions over the years, and is now best defined under the umbrella of the somatic symptom and related disorders.
The term somatic symptom disorder (SSD) as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), is broadly characterized by somatic (physical) symptoms that are either very distressing or result in significant disruption of functioning, as well as excessive and disproportionate thoughts, feelings, and behaviors regarding those symptoms. Many patients who experience and report physical symptoms that cause distress but lack a corresponding level of tissue damage or pathology meet criteria for SSD. The previous DSM-IV diagnostic labels including somatization disorder, hypochondriasis, pain disorder and undifferentiated somatoform disorder have been removed, partly due to their pejorative connotations. Collectively, the somatic symptom and related disorders have replaced the somatoform disorders of the DSM-IV. Regardless of the terminology, it is much more common, especially in primary ...