What is somatic symptom disorder? You’ve heard the term “it’s all in your head,” but you’re probably not aware of the debate it has stirred in the medical community.
Nurse Lori Chapo-Kroger started having “mysterious” symptoms more than a decade ago. Her thinking became cloudy and her legs “felt like they were made of lead,” she told ABC News.
Long story short, Chapo-Kroger went to many doctors who said she was “crazy,” that the symptoms were all in her head.
She was eventually diagnosed with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), a disease associated with dysfunction of the brain, gastrointestinal, immune, endocrine, and cardiac systems
She was at the center of a controversy that has swirled around a psychiatric illness called somatic symptom disorder, or SSD, which later appeared in the latest Diagnostics and Standards Manual – or DMS5.
What is somatic symptom disorder?
Symptoms — such as extreme anxiety and overwhelming fear — suggest a person may be physical ill and are distressing or disrupt that person’s life. The symptoms are also often accompanied by "excessive and maladaptive thoughts, feelings and behaviors," according to the American Psychiatric Association. To be diagnosed, a person has the symptoms for at least six months.
Since somatic symptom disorder was proposed many doctors have been concerned that patients will be misdiagnosed as mentally ill and won't get the correct diagnosis and treatment. That would mostly affect people like Chapo-Kroger, who have complex chronic disorders that are poorly understood.
"Anytime someone has a chronic illness, you have a fixation on your health," Chapo-Kroger says. "Studies on people after heart surgery say they got depressed afterwards. Who wouldn't when they face their own mortality?"
A doctor who was part of the task force that created DSM-4, Allen Frances, MD, professor emeritus of psychiatry at Duke University, says some patients will be “written off as crocks” and won’t get the medical diagnostics they need.
Another doctor, Joel E. Dimsdale, MD, professor emeritus in psychiatry at University of California, San Diego, who reviewed the SSD diagnosis, says that patients who will be identified must demonstrate more than "existential" angst.
He tells ABC a diagnosis will give primary doctors information they need to get help for patients who have extreme anxiety about illness. But Dimsdale does agree, doctors must always "take symptoms very seriously," investigating all medical explanations.
Or is it really "all in your head"?
While the debate over the guidelines continue, there are doctors who believe some disorders are indeed psychosomatic in nature and have the medical histories that show it.
“Psychosomatic disorders are physical symptoms that mask psychological distress,” says Suzanne O’Sullivan, BsD, author of “It’s All in Your Head,” she writes. “The very nature of the physical presentation of the symptoms hides the distress at its root, so it is natural that those affected will automatically seek a medical disease to explain their suffering.”
She writes about a patient, Matthew, who was in a wheelchair and convinced he had multiple sclerosis, even though every diagnostic tool at O’Sullivan’s disposal had shown he didn’t. Eventually, even Matthew’s wife became exasperated with him.
“As much as Matthew was convinced he has MS, I was convinced he did not,” O’Sullivan says. “Although I had not gone as far as to call his paralysis psychosomatic I also told him that I was wondering about a psychological cause.”
O’Sullivan told him she wasn’t sure how or why his symptoms were happening, but that it was “possible that this is a sign that there is some stress that you are suppressing and it is leaking out in the form of a physical symptom.”
She said there was some “dysfunction” in the way the message telling Matthew’s legs to move is travelling from his brain to his legs but that she didn’t know how that happens. “I just know that it can happen and that it may help for Matthew to see a psychiatrist,” O’Sullivan told his frustrated and exhausted wife.
Having finally accepted the somatic symptom disorder diagnosis, Matthew received appropriate mental healthcare, began to get better, and started to walk again. His recovery wasn’t linear and, occasionally, other symptoms reared up.
O’Sullivan noted that he has had psychological issues in the past.
February 13, 2018
Christopher Nystuen, MD, MBA