Somatisation Disorder

Case Study

Patient: Emma, 34-year-old Female

Presenting Complaint:

Emma visits her GP complaining of chronic pain, digestive issues, and unexplained fatigue for the past three years despite multiple medical tests showing no clear cause.

History of Presenting Illness:

• Reports frequent headaches, abdominal pain, and joint pain that move from one area to another.
• Has undergone multiple investigations (MRI, endoscopy, blood tests), all normal.
• Feels doctors are not taking her symptoms seriously, leading to frustration.
• Symptoms worsen during stress or personal conflicts.
• Has seen multiple specialists (neurologist, gastroenterologist, rheumatologist) but has no definitive diagnosis.
• No major psychiatric history, though admits to past emotional trauma.

Examination Findings:

• General: Anxious but cooperative.
• Physical Examination: No objective signs of illness.
• Neurological & Musculoskeletal: No focal deficits, normal reflexes.
• Mood & Behavior: Expresses significant distress over symptoms.

Diagnosis:

Emma meets the criteria for Somatisation Disorder (Somatic Symptom Disorder), given the presence of multiple unexplained physical symptoms, high health-related anxiety, and excessive medical consultations despite no organic cause.

Management:

1. Psychological Support – Cognitive Behavioral Therapy (CBT) to address symptom amplification.
2. Regular GP Follow-Ups – Avoid unnecessary investigations but ensure patient feels heard.
3. Stress Management – Relaxation techniques, mindfulness.
4. Gradual Reduction in Medical Appointments – To avoid reinforcing health anxiety.

Over time, Emma learned coping strategies to manage stress-related symptoms and reduced excessive health-seeking behaviors.

Definition

• Somatisation disorder (also referred to as somatic symptom disorder in DSM-5) is a chronic condition characterised by excessive focus on physical symptoms that cannot be fully explained by a medical condition.
• Leads to significant distress, frequent healthcare use, and impaired daily functioning.

Unlike malingering or factitious disorder, symptoms are not intentionally produced.

Causes & Risk Factors

Pathophysiology

• Altered Brain Processing of Bodily Sensations → Increased Sensory Awareness & Catastrophic Interpretation of Symptoms.
• Heightened Autonomic Arousal → Exaggerated Perception of Pain & Discomfort.

Psychosocial Factors (Stress, Trauma, Past Illness Experiences) → Influence the Development & Maintenance of Symptoms.

Risk Factors for Somatisation Disorder

🔹 Emotional distress is commonly expressed through physical symptoms.

Clinical Features

Common Symptoms of Somatisation Disorder

🔹 Symptoms are often multiple, fluctuating, and disproportionate to clinical findings.

Key Features of Diagnosis

• Symptoms Involve Multiple Organ Systems.
• Excessive Concern About Health Despite Reassurance.
• Repeated Consultations & Investigations With Negative Findings.
• Significant Psychological Distress Related to Symptoms.
• Chronic & Fluctuating Course Over Years.

🔹 Patients may be resistant to psychological explanations and request further medical investigations.

Referral Criteria (NICE Guidelines)

Urgent Referral (If High-Risk Features Are Present)

• Acute Suicidal Ideation or Self-Harm.
• Severe Functional Impairment Affecting ADLs.
• Comorbid Severe Depression or Anxiety.
• Symptoms Suggestive of a Missed Organic Cause (Red Flags).

Routine Referral (If Persistent Symptoms Affect Functioning)

• Chronic Symptoms Impacting Quality of Life.
• Excessive Health Anxiety With Repeated Unnecessary Investigations.
• Psychological Distress That May Benefit From Therapy.

🔹 A multidisciplinary approach is needed, including primary care, psychiatry, and psychology.

Diagnosis & Screening Tools

Clinical Diagnosis (Based on DSM-5 Criteria for Somatic Symptom Disorder)

🔹 The focus is on the patient’s emotional distress rather than the presence of unexplained symptoms.

Screening Tools for Somatisation

Investigations to Rule Out Organic Causes

🔹 Extensive investigations should be avoided once organic causes are excluded.

Differential Diagnosis

🔹 Somatisation disorder differs from illness anxiety disorder, where health anxiety is the primary feature.

Management (NICE Guidelines)

General Principles

• Avoid Unnecessary Investigations & Medicalisation of Symptoms.
• Acknowledge Symptoms as Real but Reframe the Focus to Psychological Factors.
• Empathic, Supportive Doctor-Patient Relationship to Reduce Health Anxiety.

Psychological Therapies (First-Line Management)

🔹 CBT is the most evidence-based therapy for somatisation disorder.

Pharmacological Treatment (If Comorbid Anxiety or Depression Present)

🔹 Medication should be used cautiously and only when symptoms cause significant distress.

Prognosis & Complications

Prognosis

Complications of Somatisation Disorder

🔹 Multidisciplinary management improves outcomes.

UKMLA Key Points

• Best first-line treatment for somatisation disorder: Cognitive Behavioural Therapy (CBT).
• Best way to diagnose: Clinical Criteria (DSM-5) + PHQ-15 Score.
• When to refer urgently: Severe health anxiety, self-harm risk, psychiatric comorbidities.
• Best long-term management strategy: Reassurance, Regular GP Follow-Ups, Psychological Therapy.