Somatic symptom disorder is real, distressing physical symptoms combined with excessive worry, anxiety or preoccupation about them that disrupts daily life, with or without a medical explanation. It is treated with cognitive behavioral therapy, a coordinated plan with primary care, and antidepressants when depression, anxiety or pain are prominent. Treatment reduces symptom burden and restores function.
People with somatic symptom disorder often arrive at a psychiatric practice frustrated and wary, after years of tests, specialist visits and the implication that it is all in their head. At Stedfast Psychiatry we start from the opposite position: your symptoms are real, your suffering is real, and there is treatment that reduces both. We coordinate with your primary care physician, treat the depression and anxiety that frequently accompany the condition, and use therapies that have been shown to reduce symptom burden and restore function.
Symptoms of somatic symptom disorder
- One or more persistent physical symptoms such as pain, fatigue, dizziness, nausea, palpitations or weakness
- Disproportionate and persistent thoughts about the seriousness of the symptoms
- High levels of anxiety about health or symptoms
- Excessive time and energy devoted to the symptoms: researching, monitoring, seeking care
- Frequent medical visits, tests and specialist referrals without lasting reassurance
- Frustration with doctors and a feeling of not being believed
- Avoidance of activity, work or social life because of symptoms
- Co-occurring depression, anxiety, insomnia or a history of trauma
Causes and risk factors
Somatic symptom disorder arises from the interaction of body, brain and experience. Physical symptoms are produced by the nervous system interpreting signals from the body, and that interpretation is shaped by attention, expectation, emotion and prior experience. In people with the disorder, the brain's threat system amplifies bodily sensations, attention locks onto them, and worry sustains the physiological arousal that produces more sensations, a loop that can persist long after any original trigger has resolved.
Risk factors include a genetic tendency toward anxiety and negative emotion, childhood illness or illness in a parent, childhood adversity and trauma, a history of depression or anxiety, and a medical illness or injury that started the cycle. Social factors such as a stressful job, lack of support, and healthcare experiences that reinforce fear (repeated testing, contradictory opinions) contribute. Certain physical conditions, including fibromyalgia, irritable bowel syndrome, chronic fatigue and migraine, frequently coexist, and somatic symptom disorder can be diagnosed alongside a medical illness when the response to it is out of proportion.
Somatic symptom disorder is estimated to affect 5 to 7 percent of the general adult population and a considerably higher share of patients in primary care settings.
Source: American Psychiatric Association, DSM-5-TR
Cognitive behavioral therapy produces small to moderate reductions in somatic symptom severity and improvements in function compared with usual care, with benefits maintained at follow-up.
Source: Cochrane Database of Systematic Reviews, non-pharmacological interventions for somatoform disorders
Patients with persistent physical symptoms account for a disproportionate share of outpatient visits and healthcare costs; structured care plans with primary care reduce costs and improve function.
Source: Barsky et al., Archives of General Psychiatry; Smith et al., New England Journal of Medicine
Depression and anxiety disorders co-occur in roughly half of patients with somatic symptom disorder.
Source: Lowe et al., General Hospital Psychiatry
How we diagnose it at Stedfast Psychiatry
A good evaluation begins with listening. We take a full history of your symptoms, their course, what has been tried, and the medical workup to date, and we obtain records from your primary care physician and specialists so that we do not repeat tests or dismiss findings. We assess the thoughts and behaviors around the symptoms with the Patient Health Questionnaire-15 (PHQ-15) for symptom burden, the Somatic Symptom Disorder-B Criteria Scale (SSD-12) for the psychological criteria, and the PHQ-9 and GAD-7 for depression and anxiety. We ask about trauma, sleep, substance use and current stressors.
The DSM-5 criteria require at least one distressing somatic symptom with excessive thoughts, feelings or behaviors related to it for six months or more; a medical explanation for the symptom is not required and does not exclude the diagnosis. We distinguish somatic symptom disorder from illness anxiety disorder (high health anxiety with minimal symptoms), conversion disorder (neurological symptoms incompatible with disease), panic disorder, depression with physical symptoms, and factitious disorder. We also ensure that medical causes have been reasonably evaluated and coordinate with your physician about any gaps, because psychiatric treatment and appropriate medical care proceed together, not in sequence.
Treatment options
Medication management
No medication is approved specifically for somatic symptom disorder, but medication helps when depression, anxiety or pain are part of the picture, which is most of the time. Antidepressants, particularly SNRIs such as duloxetine and venlafaxine, reduce pain and fatigue as well as mood and anxiety symptoms, and SSRIs such as sertraline and escitalopram help the health anxiety component. Low-dose tricyclics such as amitriptyline help pain and sleep. We start low because people with somatic symptom disorder are often sensitive to side effects and attentive to bodily changes, and we explain what to expect in advance. We avoid long-term benzodiazepines and opioids, which worsen outcomes, and we review the full medication list with your physician to reduce polypharmacy. Treatment of insomnia and any coexisting medical conditions is coordinated.
Psychotherapy
Cognitive behavioral therapy is the best-supported treatment. It does not try to convince you the symptoms are not real; it works on the attention, interpretation and behavior that amplify them. Patients learn how the nervous system produces and sustains symptoms, how to redirect attention, how to test catastrophic predictions, how to reduce checking and reassurance seeking, and how to rebuild activity gradually without being governed by symptoms. Mindfulness-based approaches and acceptance and commitment therapy help people engage with life while symptoms are present. For patients with trauma histories, trauma-focused therapy addresses a common root. Psychodynamic approaches that explore the relationship between emotion and bodily experience help some patients. A key part of treatment is a structured care plan with your primary care physician: regular, scheduled visits rather than symptom-driven ones, a single coordinating clinician, and agreement to limit testing to what is medically indicated. This approach reduces costs and improves outcomes in controlled studies.
What to expect
The first visit is a 60 minute evaluation in which we listen to the full story, review your records and explain our understanding of what is happening in plain terms. You will leave with a plan that typically includes CBT, a coordinated approach with your primary care physician and, when depression, anxiety or pain are prominent, a medication. Therapy is usually weekly for three to four months. Follow-ups with the prescriber are every four to six weeks during adjustment. All of this can be done by telehealth anywhere in Florida or South Carolina, which many patients with chronic symptoms find easier than travel.
When to seek help
Consider an evaluation if physical symptoms and worry about them have dominated your life for months, if you have had extensive testing without answers or relief, if you are avoiding work or activities because of symptoms, or if a physician has suggested that stress or anxiety may be playing a role. Seek help sooner if you have become depressed or hopeless. If you have thoughts of suicide or self-harm, call or text 988, the Suicide and Crisis Lifeline, or go to the nearest emergency room.
How the diagnosis changed
Somatic symptom disorder replaced several older diagnoses in the DSM-5, including somatization disorder, undifferentiated somatoform disorder and pain disorder. The older diagnoses required that symptoms be medically unexplained, which put clinicians in the position of proving a negative and left patients feeling dismissed. The current diagnosis drops that requirement and focuses on the response to symptoms: the disproportionate worry, anxiety and time devoted to them. This means a person with a diagnosed medical condition such as heart disease or fibromyalgia can also have somatic symptom disorder if the psychological response is excessive and impairing, and it means treatment can begin without first exhausting every test.
Common presentations
Pain is the most common symptom, including back pain, headache, abdominal pain and widespread pain. Fatigue, dizziness, palpitations, shortness of breath, nausea, bowel symptoms, numbness and weakness are also common. Many patients have several symptoms that shift over time. The disorder is often recognized in primary care when a patient has a long list of visits and tests, multiple specialist referrals, frustration on both sides, and worsening function despite normal or nonspecific findings. The DSM-5 specifies a predominant pain subtype and grades severity by the number of psychological criteria met.
Differential diagnosis
Illness anxiety disorder involves preoccupation with having a serious disease with few or no somatic symptoms. Conversion disorder (functional neurological symptom disorder) involves neurological symptoms such as weakness, seizures or sensory loss that are inconsistent with recognized disease. Panic disorder produces intense bodily symptoms in discrete attacks. Depression commonly presents with pain, fatigue and bodily complaints, and generalized anxiety disorder with muscle tension and stomach symptoms; both can coexist with somatic symptom disorder. Factitious disorder involves intentional production of symptoms, and malingering involves fabrication for external gain; neither applies to the great majority of patients with somatic symptoms, who are suffering honestly. Undiagnosed medical illness must always remain in view, which is why coordination with primary care continues.
The role of primary care
Primary care is where somatic symptom disorder lives, and the strongest evidence for improving outcomes comes from structured collaboration between psychiatry and primary care. The elements include a single coordinating physician, regular brief visits scheduled in advance rather than in response to symptoms, a physical examination at each visit that acknowledges the symptom, limiting tests and referrals to those indicated by findings, avoiding statements that the symptoms are not real, and treating depression and anxiety. Consultation letters from psychiatry to primary care describing this approach have been shown in randomized trials to improve function and reduce costs. We provide them routinely with your consent.
Self-management
Patients do better when they understand the mechanism and have tools. Keep a regular daily structure with planned activity that is not contingent on how you feel. Build activity gradually and consistently rather than in bursts followed by crashes. Limit symptom research online and checking of the body. Prioritize sleep and regular exercise, both of which reduce bodily hypersensitivity. Identify stress and emotion as contributors without concluding that the symptoms are therefore imaginary. Bring one list of concerns to scheduled medical visits rather than making new appointments for each symptom.
Prognosis
Somatic symptom disorder tends to be chronic when untreated, with fluctuating symptoms and steadily increasing healthcare use. With CBT, coordinated medical care and treatment of co-occurring depression and anxiety, most patients achieve meaningful improvement in function, worry and quality of life, and many experience reduction in the symptoms themselves. Early intervention, a good relationship with a coordinating physician, and treatment of underlying trauma or mood disorders predict better outcomes. The symptoms may not vanish entirely, but they can stop running your life.
Frequently asked questions
Are you saying my symptoms are all in my head?
No. Your symptoms are produced by your nervous system and are as real as any other symptom; pain generated by sensitized nerve pathways hurts exactly as much as pain from an injury. The diagnosis is not about whether the symptom is real but about the worry, attention and behavior that have grown around it and that keep it going. Treatment targets those processes, and when they change, symptoms often lessen. We work alongside your medical doctors, not instead of them.
How is this different from illness anxiety disorder?
In somatic symptom disorder, the distressing physical symptoms are the main problem, and the worry is about them. In illness anxiety disorder, physical symptoms are mild or absent, and the main problem is fear of having or developing a serious illness. The two overlap and share treatments, especially CBT, but the emphasis differs: managing symptoms and function in one, managing health fear and checking in the other. A careful evaluation decides which fits.
Does treatment mean stopping medical tests?
It means making medical care more effective, not withdrawing it. We coordinate with your primary care physician on a plan: regular scheduled visits rather than visits driven by each new symptom, one clinician who oversees the whole picture, and testing when it is medically indicated rather than for reassurance. New or changed symptoms are still evaluated. Studies show this approach reduces unnecessary procedures, lowers costs and improves function and satisfaction.
Will an antidepressant help if I am not depressed?
It may. SNRIs such as duloxetine and tricyclics such as amitriptyline reduce pain, fatigue and bodily hypersensitivity through effects on the nervous system's pain pathways, independent of mood, and SSRIs reduce health anxiety. When depression or anxiety is present, which is common, the benefit is larger. We discuss the expected effects and side effects in detail beforehand, start at low doses, and increase slowly, because people with this condition often notice bodily changes acutely.
What does CBT for somatic symptoms involve?
It starts with an explanation of how symptoms are generated and amplified by the nervous system, which many patients find relieving because it makes sense of their experience. Then you learn practical skills: shifting attention away from bodily monitoring, examining and testing catastrophic beliefs, reducing checking and reassurance seeking, pacing activity to rebuild function without flare-ups, managing stress and sleep, and planning for setbacks. It is typically 10 to 16 sessions and works by video as well as in person.
Is somatic symptom disorder treatment covered by insurance and available by telehealth?
Yes. Psychiatric evaluation, therapy and medication management are covered by most commercial plans and Medicare with your usual copay; a self-pay new-patient visit is $185. Telehealth is well suited to this condition, and we see patients throughout Florida and South Carolina by video. With your permission we share our plan with your primary care physician so that care is coordinated.
Can children have somatic symptom disorder?
Yes. In children it often appears as recurrent stomach aches, headaches or fatigue with school absence and frequent visits to the pediatrician, and it is strongly linked to anxiety. Treatment involves the family and the school, with CBT adapted for the child's age, gradual return to full attendance and treatment of underlying anxiety. Our child and adolescent providers coordinate with pediatricians to make sure medical causes are addressed and that the child is not caught in cycles of testing.
How long does it take to improve?
Most people notice changes within the first two months of CBT: less time spent on symptoms, less fear, more activity. Symptom intensity often decreases more slowly, over three to six months, as the nervous system settles and attention shifts. Medication, when used, takes four to eight weeks to reach full effect. The condition has often been present for years, and the goal of treatment is sustained improvement in function and quality of life rather than the overnight disappearance of every symptom.
Where to get treatment for somatic symptom disorder
Evaluation and treatment for somatic symptom disorder is available at every Stedfast Psychiatry office and by video across Florida and South Carolina.
Related conditions
If you are thinking about harming yourself, call or text 988 now, or go to the nearest emergency room. This page is educational and does not replace an evaluation. Clinical content reviewed by Dr. David Husted, board-certified psychiatrist.