May 30, 2025 • 19 mins
⚕️ FREE MSRA PODCAST – Somatisation Disorder
🎧 A deep dive into chronic physical symptoms without clear cause – perfect for exams and real-world GP cases.
🧠 Key Learning Points
📌 Definition
• A psychiatric condition involving persistent physical symptoms that can’t be fully explained medically, leading to distress and functional impairment.
📌 Causes & Risk Factors
• Genetic predisposition
• Childhood trauma or abuse
• Neurotic personality traits
• Poor coping skills
• Heightened perception of bodily sensations
🧠 Mnemonic: TUNE IN – Trauma, Unconscious factors, Neuroticism, Early Illness, Insecure coping, No clear cause
📌 Pathophysiology
• Not fully understood
• Involves altered pain perception and brain processing
• Psychological stress leads to physical symptom expression
📌 Symptoms
• Multiple, chronic physical complaints across systems
• Common: GI symptoms, fatigue, pain, palpitations, dizziness
• Patient focus on symptoms is disproportionate
🎯 Mnemonic: PAINS – Pain, Abdominal upset, Illness belief, Neurological signs, Somatic preoccupation
📌 Differential Diagnosis
• Illness anxiety disorder
• Factitious disorder
• Malingering
• Depression/anxiety
• Real medical conditions
📌 Diagnosis
• Clinical diagnosis after ruling out organic disease
• Key features: chronicity, multiple vague symptoms, high health anxiety
🧠 Red flag: Patient distress outweighs clinical findings
📌 Management
• CBT as first-line therapy
• Empathetic explanation and psychoeducation
• SSRIs for comorbid depression/anxiety
• Regular GP reviews, avoid over-investigating
• Emphasise function over symptom elimination
📍 NICE Focus: Patient-centred explanation, avoid reinforcing illness behaviour
📌 Complications
• Depression, anxiety, social withdrawal
• Repeated unnecessary investigations
• High healthcare use
• Risk of iatrogenic harm
📌 Prognosis
• Variable – can improve with early, supportive intervention
• Often chronic with episodic flares
📎 More MSRA Resources for Somatisation Disorder
📝 Revision Notes: https://www.passthemsra.com/topic/somatization-disorder-revision-notes/
🧠 Flashcards: https://www.passthemsra.com/topic/somatization-disorder-flashcards/
💬 Accordion Q&A Notes: https://www.passthemsra.com/topic/somatization-disorder-accordion-qa-notes/
🚀 Rapid Quiz: https://www.passthemsra.com/topic/somatization-disorder-rapid-quiz/
🎓 Full Course: https://www.passthemsra.com/courses/psychiatry-for-the-msra/
#MSRA #MSRARevision #MSRATextbook #MSRAQuiz #MSRAQuestionBank #MSRAFlashcards #MSRAQandANotes #MSRAAccordions #MultiSpecialityRecruitmentAssessment #MSRAOnlineRevision #MSRARevisionWebsite #SomatisationDisorder #Psychiatry
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
OK, let's unpack this. Imagine you're experiencing
persistent, genuinely distressing physical symptoms.
Maybe chronic pain, Digestive issues that just won't shift.
Crippling fatigue. You feel unwell.
It's definitely affecting your life.
But test after test comes back normal.
Your doctor can't find a clear medical explanation.
(00:23):
How incredibly frustrating and maybe even isolating must that
feel. Absolutely for the person
experiencing it, obviously, but it's, well, it's challenging for
clinicians too. Yeah, that disconnect, you know,
between someone's real sufferingand the limits of what standard
medical tests can show. That's really the heart of these
kinds of conditions. It really is.
(00:44):
Exactly. And that experience brings us
straight into today's deep dive.We're going to tackle somatic
symptom disorder. Which used to often be called
summatization disorder, right? We've got a stack of pretty
detailed revision notes and overviews here, perfect for
anyone needing a really high yield breakdown.
Maybe you're studying, maybe youjust want to understand it
better. Yeah.
So our mission today is basically to pull out the
(01:06):
absolute must know Nuggets from these sources.
Think of it like streamlining your revision notes.
What do you really need to graspabout SSD's definition?
The causes, how it looks, Diagnosis, management?
Let's make sure these key pointsstick.
OK, let's do it. So starting with the basics from
these notes, how do they define somatic symptom disorder at its
(01:28):
core? Well, the fundamental thing,
according to these sources, is having multiple physical
symptoms. But crucially, these symptoms
don't have a clear, identifiablemedical cause found through
investigation. But it's more than just
unexplained symptoms, isn't it? Definitely.
The key is that these symptoms are chronic, they persist, and
they're severe enough to cause real distress or significantly
(01:49):
mess up your daily functioning. And the focus of that distress
is quite specific. Yes, that's a good point.
Usually the main worry isn't like, Oh no, I have a terrible
disease, although that can happen in related conditions.
In SSD itself, the distress is really focused on the physical
symptoms, the pain, the nausea, whatever it is, and the
thoughts, feelings, behaviours around those symptoms are sort
(02:12):
of disproportionate. Right.
And this whole concept, it's actually been labelled
differently over time. The notes highlight quite a big
evolution in the diagnostic manuals.
They really do. If you look back at ICD 10, it
used the term somatization that required multiple recurrent
changing physical symptoms for at least two years before you
(02:32):
even get referred. Two years.
Yeah, then ICD 11, the newer 1 uses bodily distress disorder
that focuses more on the physical symptoms plus the
person frequently seeking medical help even when tests are
negative. But the really big shift, the
one that seems most important clinically, is with the DSM 5.
This is where it gets, well, really interesting and
definitely a high yield point ifyou're revising DSM 5 brought in
(02:55):
somatic symptom disorder or SSD as this broader term, replacing
several older diagnosis like somatization disorder and the
critical change. The absolute key takeaway from
DSM 5 is that the symptoms don'thave to be medically unexplained
anymore. Really.
How does that work? So someone could have a
diagnosed medical condition likesay, heart disease, but if their
(03:17):
thoughts, feelings or behavioursabout their symptoms are
excessive, disproportionate and cause significant distress or
life disruption, they could alsomeet the criteria for SSD.
And that old rule about needing a specific number of symptoms
from different body systems? That's gone too in DSM 5.
Wow, OK, that is a massive change in thinking.
It's less about whether the symptom has a known physical
(03:39):
cause and more about the person's reaction and how much
it impacts their life. Exactly.
It's about the response to the symptom.
OK, so we've got the what and how that definition is evolved.
What about the why the aetiology?
The causes seems pretty complex based on this material.
Oh, it is. The sources are clear.
There's no single smoking done. It's a really complex mix of
(04:01):
biological, psychological and sociocultural factors all
playing together. Like what sort of things?
We're talking potential genetic links the notes mentioned, maybe
neuroendocrine genes, but it's not fully pinned down.
Early life stuff like trauma or significant illness.
Maybe even some differences in how the brain processes
information. Neurobiological abnormalities
(04:22):
perhaps? It seems like some people might
just be more tuned in to their bodies.
Physically, that's mentioned a heightened perception of normal
bodily sensations, like the volume knob is turned up on
internal signals. Most people would just philtre
out right and this rarely happens in isolation.
You mean comorbidities? Other conditions alongside.
It yes very common. You often find SSD along with
(04:43):
things like irritable bowel syndrome, chronic pain, PTSD,
anxiety, depression, even antisocial personality disorder
in some cases, interestingly. And the psychological angle is
pretty big too. Definitely things like
catastrophizing, you know, jumping to the worst possible
conclusion from a minor symptom and a high levels of health
anxiety are major factors. The sources also sort of float
(05:05):
the idea that maybe unconsciously the symptoms might
serve a purpose for some people,like seeking attention or maybe
getting out of difficult situations or expectations.
And the trauma link comes up again here.
It does. A history of abuse, sexual or
physical, is definitely associated with increased risk.
It seems like these negative psychological factors and past
experiences can make it more likely that even minor physical
(05:28):
feelings escalate in the person's mind and become really
severe, disabling symptoms. OK, So for a revision on causes
ideology, we're thinking biopsychosocial genetics, early
life brain differences perhaps for bio catastrophizing, health
anxiety, trauma, maybe unconscious factors for psycho
and then sociocultural like how illness is viewed in their
(05:49):
environment. OK, building on that, what makes
someone more likely to develop SSD?
The risk factors. The notes pull out some key
ones. Think about vulnerability, a
family history of SSD points to maybe genetic or shared
environmental stuff makes sense.History of childhood abuse or
trauma as we said is a big one. Certain personality traits,
(06:11):
especially neuroticism, that tendency towards worry, negative
emotions, being emotionally unstable that increases
susceptibility, and just not having good ways to cope with
psychological distress. If you can't manage stress well
emotionally, it might come out physically instead.
Right, so family history, traumahistory, personality style and
(06:32):
coping skills. Got it.
Now let's try to get underneath it.
The pathophysiology, what's actually happening physically?
What are the sources say? Well, this section is pretty
direct actually. The sources state quite clearly
that the underlying pathophysiology of SSD is just
not well understood. So despite all the research, we
don't have a clear biological pathway yet.
Not really, no. The main ideas The hypotheses
(06:55):
involve things like maybe alterations and how the brain
processes pain signals that heighten sensitivity to normal
bodily sensations we mentioned earlier, and maybe maladaptive
cognitive and emotional responses to stress somehow
affecting physical processes. It's also noted logically that
if someone also has anxiety or depression, that can definitely
(07:17):
influence how their physical symptoms show up and how long
they stick around. That makes sense, given that the
physical symptoms can look like so many other things.
How do doctors actually figure this out?
This must be where differential diagnosis are crucial.
Absolutely critical job number one for the clinician is to rule
out other medical conditions that could actually be causing
the physical symptoms. Requires a really thorough
(07:39):
history, a physical exam, and, you know, targeted tests, labs,
imaging, whatever's appropriate.What kinds of things need ruling
out? Well, obviously actual organic
medical diseases, but also otherrelated disorders like illness,
anxiety disorder, where the mainworry is about having a serious
illness rather than the symptomsthemselves being the main focus
of distress. And then you've got factitious
(08:02):
disorder. That's where someone
deliberately makes up or fakes symptoms because they want to be
in the sick roll. Right, Chausens is a term people
might know. Exactly, and malingering which
is faking symptoms for some kindof external gain like money or
avoiding work. The key difference with SSD is
intent. In SSD the suffering is real,
it's genuine distress. It's not intentionally faked for
(08:26):
gain or just to be seen as sick.OK, so a big medical workup to
exclude other causes and a psychiatric assessment to look
at the whole picture and rule out those other conditions or
deliberate faking. Got it.
How common is this? Who gets SSD?
Let's touch on the epidemiology.Yeah, the numbers vary a bit,
probably depends on how it's diagnosed and who they're
studying. The sources mentioned UK
(08:47):
estimates anywhere from like .2%up to 2% of the population.
That's quite a range. It is a general population
figure of five. 7% is also citedsometimes.
In demographics, more common in anyone.
It can affect anyone really, allages, both genders, but it's
generally thought to be more common in women and it often
starts before age 30. The notes also flag potential
(09:09):
geographic or cultural differences.
Like one German study found it was higher about 7.7% in primary
care settings, which makes sense, that's where people first
go with physical issues. And another finding mentioned
was it being more common in people over 60 in China, so how
it presents might vary with culture or age.
Interesting. OK, now let's get really
(09:29):
specific. Yeah.
What does SSD actually look likeday-to-day?
What are the clinical features someone might present with?
The absolute hallmark, as we've said, is multiple physical
symptoms across different organ systems, and these symptoms
either lack a clear medical explanation or the person's
reaction to them is just way outof proportion.
The key is the breadth. It's not usually just one thing.
(09:50):
Can we run through some examplesfrom the notes?
We can group them by body systemto make it stick for revision.
Good plan, think system by system.
So cardiac you might get shortness of breath, feeling
your heart race, palpitations, chest pain, GI,
gastrointestinal. This is super common.
Vomiting, belly pain, trouble swallowing, feeling sick,
bloating, diarrhoea, lots of gutstuff.
(10:12):
Musculoskeletal pain is big here.
Pain in the limbs, back pain, joint pain, neurological things
like headaches, dizziness, even memory loss reported sometimes
vision changes, maybe weakness or paralysis that can't be
explained neurologically and urogenital.
Painful urination, low sex drive, painful sex impotence in
(10:33):
men and for women, issues with periods, Painful, irregular or
really heavy bleeding. That's a massive, varied list.
How on earth do you remember allthat for an exam?
It's less about memorising everysingle symptom and more about
recognising the pattern. Multiple symptoms across many
different body systems, often shifting or changing overtime.
Like symptoms are sort of jumping around and remember that
(10:56):
key DSM 5 point, the focus on the disproportionate thoughts,
feelings or behaviours about thesymptoms.
Is the person spending huge amounts of time and energy
focused on them? Are they constantly anxious
about minor sensations? That's a really important
diagnostic clue now. And the impact on their life is
pretty major. Oh absolutely.
These aren't just trivial aches and pains.
The symptoms are severe enough to really interfere with daily
(11:19):
life, work, relationships. Stress often makes them worse
too, which can create a nasty cycle.
And often you'll find if you diginto the history, there's a
lifelong pattern of feeling sickly or having various
physical complaints going way back.
OK, so we know what it looks like.
How is the diagnosis actually made?
We're talking about ruling things out, but is there a
(11:40):
positive way to diagnose it? Yes, exactly.
While it often feels like a diagnosis of exclusion because
you've ruled out so much else, the sources do stress that you
can make a positive diagnosis. It's based on recognising a
typical cluster of futures, but only after you've done a
thorough medical work up to ruleout other causes.
OK. What are those typical features
then? This sounds like key revision
(12:01):
stuff. Definitely high yield.
You're looking for one. Multiple symptoms across
different organ systems that pattern again, two symptoms that
are often vague, subjective. They feel worse to the patient
than objective tests or exams might suggest. 3A chronic
course. It's been going on a long time
4. Often the presence of another
(12:22):
psychiatric disorder like anxiety or depression.
Very common 5. Evidence of extensive prior
medical testing. They've likely seen lots of
doctors and had lots of tests 6 and sometimes a tendency to
reject previous doctor's conclusions when no physical
cause was found. OK, that's a pretty clear
(12:42):
checklist. Multiple vague chronic
psychomorbidity common. Lots of tests done, maybe
rejection of previous findings. And there was that interesting
point about the Doctor's own feelings.
Yeah, the notes mentioned this. It's quite intriguing if a
clinician finds themselves feeling really frustrated or
overwhelmed, or like they're just banging their head against
a wall. Despite all the tests, that
(13:03):
emotional reaction can actually be a bit of a flag.
It might prompt them to considersomatization as a possibility.
That is fascinating sort of diagnostic clue from your own
reaction. OK, so the diagnosis is made.
What then? How do you actually help someone
with SSD? What does the management look
like? Right management needs to be
multidisciplinary, usually a mixof approaches and absolutely
central is building a good trusting relationship between
(13:24):
the patient and their main healthcare provider.
Psychotherapy is really key. What?
Kinds of therapy work best. CBT Cognitive behavioural
therapy is mentioned a lot. It helps patients spot and
challenge those unhelpful thoughts about their symptoms,
learn better coping strategies, and maybe gradually become more
active even with the symptoms. Psychodynamic therapy also gets
(13:44):
a mention for exploring potential unconscious roots.
There's also talk of short term intervention therapy, maybe 8 to
16 sessions focused specificallyon improving function and
reducing distress. And mindfulness therapy is noted
as being feasible, acceptable, sometimes used alongside meds.
Speaking of meds, what about pharmacotherapy?
Do drugs help? SSRI's, the antidepressants are
(14:07):
mentioned, but the evidence specifically for treating the
physical symptoms of SSD itself.The sources say it's pretty low
quality evidence actually. However, SSRI's are often very
useful because anxiety and depression are so commonly
comorbid, so they treat those underlying or coexisting mood
issues. If you do use them, the advice
is start low, go slow with the dose.
(14:29):
Patients with SSD can sometimes be quite sensitive to side
effects, right? Other antidepressants might also
be used for those associated psychiatric conditions.
So medication is more for the associated anxiety and
depression, not a direct fix forthe physical symptoms
themselves. That seems to be the general
idea from these notes, yes. But maybe the single most
important part of management highlighted is actually
(14:52):
communication and empowering theYeah.
Tell me more about that. That sounds crucial.
How do you have that conversation?
Absolutely high yield for anyonein practise.
Doctors need to explain the diagnosis, explain the
condition, but do it really empathetically.
It's vital to involve the patient in understanding their
symptoms from this different angle, explaining it in a way
(15:13):
that validates their suffering, acknowledges their pain is real,
while gently shifting the focus away from this endless search
for a hidden disease towards managing the symptoms and
improving their life. That's empowering.
It's shown to improve well-being.
That first conversation about SSD is apparently critical.
You have to explain it without making them feel like you're
(15:35):
saying it's all in their head orthat they're making it up.
The symptoms are real and distressing to them, whatever
the underlying mechanism. So it's about acknowledging the
reality of their experience, butintroducing this idea of how
stress, thoughts, feelings can genuinely manifest physically.
Exactly that and helping them develop better coping strategies
is central. The notes mention things like
(15:55):
using open-ended questions or techniques like BATHE.
That's an acronym background effect, Trouble handling
empathy. It's a way for clinicians to
gently explore the psychosocial stressors in someone's life,
which often tie into symptom flare ups.
Having one consistent supportivemain doctor or healthcare
provider is also really helpful.Rather than bouncing around
(16:16):
specialists, regular, maybe brief check INS to see how
symptoms are, review coping strategies.
That builds trust. What about general health
advice? Lifestyle stuff.
Yeah, encouraging physical exercise is important not just
for fitness, but it can help mood and self esteem too.
Stress management techniques obviously key, and here's a
really crucial point for prevention.
(16:37):
Go on. People with SSD can still get
actual physical diseases later on.
Just because they have SSD doesn't mean every new symptom
is part of it. So they still need regular
health screenings just like anyone else for their age and
risk factors. You can't just dismiss
everything. That's a really vital point for
ongoing care. OK, so what's the general
outlook for someone with SSD? What does the prognosis look
(16:59):
like? It varies quite a bit honestly.
Depends on the person, how severe the symptoms are, and
critically, whether they get theright kind of help.
The good news is, with appropriate interventions,
people can see significant improvement in their symptoms
and how well they function day-to-day.
That's encouraging. But the notes also say, you
know, it's often a chronic condition and having other
(17:19):
psychiatric issues alongside it can make it a long term
challenge. Ongoing management might well be
needed. And what about complications?
If it's not managed well, what can go wrong?
The complications can be pretty significant, unfortunately.
Obviously a major impact on quality of life, difficulty
functioning at work, socially, there's a big burden on
healthcare, frequent visits, hospital stays, endless tests,
(17:43):
which racks up costs, high risk of developing or worsening
anxiety and depression. That frustration and
misunderstanding between patients and doctors we talked
about that can really damage therelationship and actually make
the symptoms worse, perpetuate them it.
Sounds like a real negative cycle.
It absolutely can be. Symptoms get really entrenched.
There are even risks from all the investigations, you know,
(18:04):
complications from invasive tests, radiation exposure and
sadly there's a risk of becomingdependent on substances,
alcohol, painkillers, sedatives,just trying to cope with the
chronic like distress and pain. Wow, that really covers a huge
amount of ground from those notes.
Definition, evolution, causes, features, diagnosis, management,
prognosis, complications. It really paints a picture of a
(18:27):
very challenging condition, but one that's so important to
understand properly. It is complex, no doubt effects
patients profoundly, and definitely requires a really
thoughtful, empathetic approach from clinicians.
Getting your head around these key points from the revision
material is pretty essential forspotting it and managing it
appropriately. So thinking about everything
(18:48):
we've discussed, the patient's experience, the difficulties in
diagnosis, that need for really empathetic communication, what
does this whole mean? How might a deeper understanding
of somatic symptom disorder not just help with diagnosis and
management, but maybe fundamentally shift that dynamic
between patient and doctor? When physical symptoms just
don't fit neatly into a standarddisease box, That's maybe
(19:11):
something for you to Mull over. Yeah, definitely food for
thought. And look if you are working
through complex topics like thisone and you need some high yield
questions to really test your knowledge for revision.
You should absolutely head over to pass them sra.com.
They've got questions specifically designed to help
you nail this stuff effectively for exams like the MSRA.
And for more free resources, things to support your learning
(19:32):
journey more broadly, do check out free m-sra.com.
OK, That wraps up this deep diveon somatic symptom disorder.
Thanks so much for joining us. Thank you.
OK, let's unpack this. Imagine you're experiencing
persistent, genuinely distressing physical symptoms.
Maybe chronic pain, Digestive issues that just won't shift.
Crippling fatigue. You feel unwell.
It's definitely affecting your life.
But test after test comes back normal.
Your doctor can't find a clear medical explanation.
(00:23):
How incredibly frustrating and maybe even isolating must that
feel. Absolutely for the person
experiencing it, obviously, but it's, well, it's challenging for
clinicians too. Yeah, that disconnect, you know,
between someone's real sufferingand the limits of what standard
medical tests can show. That's really the heart of these
kinds of conditions. It really is.
(00:44):
Exactly. And that experience brings us
straight into today's deep dive.We're going to tackle somatic
symptom disorder. Which used to often be called
summatization disorder, right? We've got a stack of pretty
detailed revision notes and overviews here, perfect for
anyone needing a really high yield breakdown.
Maybe you're studying, maybe youjust want to understand it
better. Yeah.
So our mission today is basically to pull out the
(01:06):
absolute must know Nuggets from these sources.
Think of it like streamlining your revision notes.
What do you really need to graspabout SSD's definition?
The causes, how it looks, Diagnosis, management?
Let's make sure these key pointsstick.
OK, let's do it. So starting with the basics from
these notes, how do they define somatic symptom disorder at its
(01:28):
core? Well, the fundamental thing,
according to these sources, is having multiple physical
symptoms. But crucially, these symptoms
don't have a clear, identifiablemedical cause found through
investigation. But it's more than just
unexplained symptoms, isn't it? Definitely.
The key is that these symptoms are chronic, they persist, and
they're severe enough to cause real distress or significantly
(01:49):
mess up your daily functioning. And the focus of that distress
is quite specific. Yes, that's a good point.
Usually the main worry isn't like, Oh no, I have a terrible
disease, although that can happen in related conditions.
In SSD itself, the distress is really focused on the physical
symptoms, the pain, the nausea, whatever it is, and the
thoughts, feelings, behaviours around those symptoms are sort
(02:12):
of disproportionate. Right.
And this whole concept, it's actually been labelled
differently over time. The notes highlight quite a big
evolution in the diagnostic manuals.
They really do. If you look back at ICD 10, it
used the term somatization that required multiple recurrent
changing physical symptoms for at least two years before you
(02:32):
even get referred. Two years.
Yeah, then ICD 11, the newer 1 uses bodily distress disorder
that focuses more on the physical symptoms plus the
person frequently seeking medical help even when tests are
negative. But the really big shift, the
one that seems most important clinically, is with the DSM 5.
This is where it gets, well, really interesting and
definitely a high yield point ifyou're revising DSM 5 brought in
(02:55):
somatic symptom disorder or SSD as this broader term, replacing
several older diagnosis like somatization disorder and the
critical change. The absolute key takeaway from
DSM 5 is that the symptoms don'thave to be medically unexplained
anymore. Really.
How does that work? So someone could have a
diagnosed medical condition likesay, heart disease, but if their
(03:17):
thoughts, feelings or behavioursabout their symptoms are
excessive, disproportionate and cause significant distress or
life disruption, they could alsomeet the criteria for SSD.
And that old rule about needing a specific number of symptoms
from different body systems? That's gone too in DSM 5.
Wow, OK, that is a massive change in thinking.
It's less about whether the symptom has a known physical
(03:39):
cause and more about the person's reaction and how much
it impacts their life. Exactly.
It's about the response to the symptom.
OK, so we've got the what and how that definition is evolved.
What about the why the aetiology?
The causes seems pretty complex based on this material.
Oh, it is. The sources are clear.
There's no single smoking done. It's a really complex mix of
(04:01):
biological, psychological and sociocultural factors all
playing together. Like what sort of things?
We're talking potential genetic links the notes mentioned, maybe
neuroendocrine genes, but it's not fully pinned down.
Early life stuff like trauma or significant illness.
Maybe even some differences in how the brain processes
information. Neurobiological abnormalities
(04:22):
perhaps? It seems like some people might
just be more tuned in to their bodies.
Physically, that's mentioned a heightened perception of normal
bodily sensations, like the volume knob is turned up on
internal signals. Most people would just philtre
out right and this rarely happens in isolation.
You mean comorbidities? Other conditions alongside.
It yes very common. You often find SSD along with
(04:43):
things like irritable bowel syndrome, chronic pain, PTSD,
anxiety, depression, even antisocial personality disorder
in some cases, interestingly. And the psychological angle is
pretty big too. Definitely things like
catastrophizing, you know, jumping to the worst possible
conclusion from a minor symptom and a high levels of health
anxiety are major factors. The sources also sort of float
(05:05):
the idea that maybe unconsciously the symptoms might
serve a purpose for some people,like seeking attention or maybe
getting out of difficult situations or expectations.
And the trauma link comes up again here.
It does. A history of abuse, sexual or
physical, is definitely associated with increased risk.
It seems like these negative psychological factors and past
experiences can make it more likely that even minor physical
(05:28):
feelings escalate in the person's mind and become really
severe, disabling symptoms. OK, So for a revision on causes
ideology, we're thinking biopsychosocial genetics, early
life brain differences perhaps for bio catastrophizing, health
anxiety, trauma, maybe unconscious factors for psycho
and then sociocultural like how illness is viewed in their
(05:49):
environment. OK, building on that, what makes
someone more likely to develop SSD?
The risk factors. The notes pull out some key
ones. Think about vulnerability, a
family history of SSD points to maybe genetic or shared
environmental stuff makes sense.History of childhood abuse or
trauma as we said is a big one. Certain personality traits,
(06:11):
especially neuroticism, that tendency towards worry, negative
emotions, being emotionally unstable that increases
susceptibility, and just not having good ways to cope with
psychological distress. If you can't manage stress well
emotionally, it might come out physically instead.
Right, so family history, traumahistory, personality style and
(06:32):
coping skills. Got it.
Now let's try to get underneath it.
The pathophysiology, what's actually happening physically?
What are the sources say? Well, this section is pretty
direct actually. The sources state quite clearly
that the underlying pathophysiology of SSD is just
not well understood. So despite all the research, we
don't have a clear biological pathway yet.
Not really, no. The main ideas The hypotheses
(06:55):
involve things like maybe alterations and how the brain
processes pain signals that heighten sensitivity to normal
bodily sensations we mentioned earlier, and maybe maladaptive
cognitive and emotional responses to stress somehow
affecting physical processes. It's also noted logically that
if someone also has anxiety or depression, that can definitely
(07:17):
influence how their physical symptoms show up and how long
they stick around. That makes sense, given that the
physical symptoms can look like so many other things.
How do doctors actually figure this out?
This must be where differential diagnosis are crucial.
Absolutely critical job number one for the clinician is to rule
out other medical conditions that could actually be causing
the physical symptoms. Requires a really thorough
(07:39):
history, a physical exam, and, you know, targeted tests, labs,
imaging, whatever's appropriate.What kinds of things need ruling
out? Well, obviously actual organic
medical diseases, but also otherrelated disorders like illness,
anxiety disorder, where the mainworry is about having a serious
illness rather than the symptomsthemselves being the main focus
of distress. And then you've got factitious
(08:02):
disorder. That's where someone
deliberately makes up or fakes symptoms because they want to be
in the sick roll. Right, Chausens is a term people
might know. Exactly, and malingering which
is faking symptoms for some kindof external gain like money or
avoiding work. The key difference with SSD is
intent. In SSD the suffering is real,
it's genuine distress. It's not intentionally faked for
(08:26):
gain or just to be seen as sick.OK, so a big medical workup to
exclude other causes and a psychiatric assessment to look
at the whole picture and rule out those other conditions or
deliberate faking. Got it.
How common is this? Who gets SSD?
Let's touch on the epidemiology.Yeah, the numbers vary a bit,
probably depends on how it's diagnosed and who they're
studying. The sources mentioned UK
(08:47):
estimates anywhere from like .2%up to 2% of the population.
That's quite a range. It is a general population
figure of five. 7% is also citedsometimes.
In demographics, more common in anyone.
It can affect anyone really, allages, both genders, but it's
generally thought to be more common in women and it often
starts before age 30. The notes also flag potential
(09:09):
geographic or cultural differences.
Like one German study found it was higher about 7.7% in primary
care settings, which makes sense, that's where people first
go with physical issues. And another finding mentioned
was it being more common in people over 60 in China, so how
it presents might vary with culture or age.
Interesting. OK, now let's get really
(09:29):
specific. Yeah.
What does SSD actually look likeday-to-day?
What are the clinical features someone might present with?
The absolute hallmark, as we've said, is multiple physical
symptoms across different organ systems, and these symptoms
either lack a clear medical explanation or the person's
reaction to them is just way outof proportion.
The key is the breadth. It's not usually just one thing.
(09:50):
Can we run through some examplesfrom the notes?
We can group them by body systemto make it stick for revision.
Good plan, think system by system.
So cardiac you might get shortness of breath, feeling
your heart race, palpitations, chest pain, GI,
gastrointestinal. This is super common.
Vomiting, belly pain, trouble swallowing, feeling sick,
bloating, diarrhoea, lots of gutstuff.
(10:12):
Musculoskeletal pain is big here.
Pain in the limbs, back pain, joint pain, neurological things
like headaches, dizziness, even memory loss reported sometimes
vision changes, maybe weakness or paralysis that can't be
explained neurologically and urogenital.
Painful urination, low sex drive, painful sex impotence in
(10:33):
men and for women, issues with periods, Painful, irregular or
really heavy bleeding. That's a massive, varied list.
How on earth do you remember allthat for an exam?
It's less about memorising everysingle symptom and more about
recognising the pattern. Multiple symptoms across many
different body systems, often shifting or changing overtime.
Like symptoms are sort of jumping around and remember that
(10:56):
key DSM 5 point, the focus on the disproportionate thoughts,
feelings or behaviours about thesymptoms.
Is the person spending huge amounts of time and energy
focused on them? Are they constantly anxious
about minor sensations? That's a really important
diagnostic clue now. And the impact on their life is
pretty major. Oh absolutely.
These aren't just trivial aches and pains.
The symptoms are severe enough to really interfere with daily
(11:19):
life, work, relationships. Stress often makes them worse
too, which can create a nasty cycle.
And often you'll find if you diginto the history, there's a
lifelong pattern of feeling sickly or having various
physical complaints going way back.
OK, so we know what it looks like.
How is the diagnosis actually made?
We're talking about ruling things out, but is there a
(11:40):
positive way to diagnose it? Yes, exactly.
While it often feels like a diagnosis of exclusion because
you've ruled out so much else, the sources do stress that you
can make a positive diagnosis. It's based on recognising a
typical cluster of futures, but only after you've done a
thorough medical work up to ruleout other causes.
OK. What are those typical features
then? This sounds like key revision
(12:01):
stuff. Definitely high yield.
You're looking for one. Multiple symptoms across
different organ systems that pattern again, two symptoms that
are often vague, subjective. They feel worse to the patient
than objective tests or exams might suggest. 3A chronic
course. It's been going on a long time
4. Often the presence of another
(12:22):
psychiatric disorder like anxiety or depression.
Very common 5. Evidence of extensive prior
medical testing. They've likely seen lots of
doctors and had lots of tests 6 and sometimes a tendency to
reject previous doctor's conclusions when no physical
cause was found. OK, that's a pretty clear
(12:42):
checklist. Multiple vague chronic
psychomorbidity common. Lots of tests done, maybe
rejection of previous findings. And there was that interesting
point about the Doctor's own feelings.
Yeah, the notes mentioned this. It's quite intriguing if a
clinician finds themselves feeling really frustrated or
overwhelmed, or like they're just banging their head against
a wall. Despite all the tests, that
(13:03):
emotional reaction can actually be a bit of a flag.
It might prompt them to considersomatization as a possibility.
That is fascinating sort of diagnostic clue from your own
reaction. OK, so the diagnosis is made.
What then? How do you actually help someone
with SSD? What does the management look
like? Right management needs to be
multidisciplinary, usually a mixof approaches and absolutely
central is building a good trusting relationship between
(13:24):
the patient and their main healthcare provider.
Psychotherapy is really key. What?
Kinds of therapy work best. CBT Cognitive behavioural
therapy is mentioned a lot. It helps patients spot and
challenge those unhelpful thoughts about their symptoms,
learn better coping strategies, and maybe gradually become more
active even with the symptoms. Psychodynamic therapy also gets
(13:44):
a mention for exploring potential unconscious roots.
There's also talk of short term intervention therapy, maybe 8 to
16 sessions focused specificallyon improving function and
reducing distress. And mindfulness therapy is noted
as being feasible, acceptable, sometimes used alongside meds.
Speaking of meds, what about pharmacotherapy?
Do drugs help? SSRI's, the antidepressants are
(14:07):
mentioned, but the evidence specifically for treating the
physical symptoms of SSD itself.The sources say it's pretty low
quality evidence actually. However, SSRI's are often very
useful because anxiety and depression are so commonly
comorbid, so they treat those underlying or coexisting mood
issues. If you do use them, the advice
is start low, go slow with the dose.
(14:29):
Patients with SSD can sometimes be quite sensitive to side
effects, right? Other antidepressants might also
be used for those associated psychiatric conditions.
So medication is more for the associated anxiety and
depression, not a direct fix forthe physical symptoms
themselves. That seems to be the general
idea from these notes, yes. But maybe the single most
important part of management highlighted is actually
(14:52):
communication and empowering theYeah.
Tell me more about that. That sounds crucial.
How do you have that conversation?
Absolutely high yield for anyonein practise.
Doctors need to explain the diagnosis, explain the
condition, but do it really empathetically.
It's vital to involve the patient in understanding their
symptoms from this different angle, explaining it in a way
(15:13):
that validates their suffering, acknowledges their pain is real,
while gently shifting the focus away from this endless search
for a hidden disease towards managing the symptoms and
improving their life. That's empowering.
It's shown to improve well-being.
That first conversation about SSD is apparently critical.
You have to explain it without making them feel like you're
(15:35):
saying it's all in their head orthat they're making it up.
The symptoms are real and distressing to them, whatever
the underlying mechanism. So it's about acknowledging the
reality of their experience, butintroducing this idea of how
stress, thoughts, feelings can genuinely manifest physically.
Exactly that and helping them develop better coping strategies
is central. The notes mention things like
(15:55):
using open-ended questions or techniques like BATHE.
That's an acronym background effect, Trouble handling
empathy. It's a way for clinicians to
gently explore the psychosocial stressors in someone's life,
which often tie into symptom flare ups.
Having one consistent supportivemain doctor or healthcare
provider is also really helpful.Rather than bouncing around
(16:16):
specialists, regular, maybe brief check INS to see how
symptoms are, review coping strategies.
That builds trust. What about general health
advice? Lifestyle stuff.
Yeah, encouraging physical exercise is important not just
for fitness, but it can help mood and self esteem too.
Stress management techniques obviously key, and here's a
really crucial point for prevention.
(16:37):
Go on. People with SSD can still get
actual physical diseases later on.
Just because they have SSD doesn't mean every new symptom
is part of it. So they still need regular
health screenings just like anyone else for their age and
risk factors. You can't just dismiss
everything. That's a really vital point for
ongoing care. OK, so what's the general
outlook for someone with SSD? What does the prognosis look
(16:59):
like? It varies quite a bit honestly.
Depends on the person, how severe the symptoms are, and
critically, whether they get theright kind of help.
The good news is, with appropriate interventions,
people can see significant improvement in their symptoms
and how well they function day-to-day.
That's encouraging. But the notes also say, you
know, it's often a chronic condition and having other
(17:19):
psychiatric issues alongside it can make it a long term
challenge. Ongoing management might well be
needed. And what about complications?
If it's not managed well, what can go wrong?
The complications can be pretty significant, unfortunately.
Obviously a major impact on quality of life, difficulty
functioning at work, socially, there's a big burden on
healthcare, frequent visits, hospital stays, endless tests,
(17:43):
which racks up costs, high risk of developing or worsening
anxiety and depression. That frustration and
misunderstanding between patients and doctors we talked
about that can really damage therelationship and actually make
the symptoms worse, perpetuate them it.
Sounds like a real negative cycle.
It absolutely can be. Symptoms get really entrenched.
There are even risks from all the investigations, you know,
(18:04):
complications from invasive tests, radiation exposure and
sadly there's a risk of becomingdependent on substances,
alcohol, painkillers, sedatives,just trying to cope with the
chronic like distress and pain. Wow, that really covers a huge
amount of ground from those notes.
Definition, evolution, causes, features, diagnosis, management,
prognosis, complications. It really paints a picture of a
(18:27):
very challenging condition, but one that's so important to
understand properly. It is complex, no doubt effects
patients profoundly, and definitely requires a really
thoughtful, empathetic approach from clinicians.
Getting your head around these key points from the revision
material is pretty essential forspotting it and managing it
appropriately. So thinking about everything
(18:48):
we've discussed, the patient's experience, the difficulties in
diagnosis, that need for really empathetic communication, what
does this whole mean? How might a deeper understanding
of somatic symptom disorder not just help with diagnosis and
management, but maybe fundamentally shift that dynamic
between patient and doctor? When physical symptoms just
don't fit neatly into a standarddisease box, That's maybe
(19:11):
something for you to Mull over. Yeah, definitely food for
thought. And look if you are working
through complex topics like thisone and you need some high yield
questions to really test your knowledge for revision.
You should absolutely head over to pass them sra.com.
They've got questions specifically designed to help
you nail this stuff effectively for exams like the MSRA.
And for more free resources, things to support your learning
(19:32):
journey more broadly, do check out free m-sra.com.
OK, That wraps up this deep diveon somatic symptom disorder.
Thanks so much for joining us. Thank you.
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