Somatic symptom disorder


Somatic Symptom Disorder (SSD) is a DSM 5 mental health diagnosis which might be given to an individual who suffers from chronic somatic symptoms and experiences a characteristic pattern of thoughts, feelings and behaviours related to their health concerns, which contributes to distress, and a disruption in daily functioning.  The term Somatic Symptom disorder (SSD) was introduced in 2013,  replacing the old terms related to “somatoform” (American Psychiatric Association, 2013).

Somatic means “of the body”; and a symptom is a subjective change in the functioning or experience of the body, which might be thought of as pointing to a condition of disease. In SSD, symptoms can involve anything from pain to shortness of breath. The word ‘Disorder’ indicates that the diagnosis should only be assigned when both the symptoms and associated psychological and behavioural responses to the symptoms are causing significant distress and disruption in the functioning of the individual. Experiencing symptoms and being concerned about them is of course a normal human experience. Therefore, to meet criteria for a diagnosis of SSD, the individual must experience characteristic psycho-pathological changes related to their health concerns. Assigning an SSD diagnosis would indicate that the patient might benefit from some psychological or behavioural interventions to improve their quality of life, regardless of the underlying cause of their symptom(s). SSD can affect anyone at any age and the tendency to suffer from SSD is underpinned by a complex interplay of biological, psychological and social factors.

Diagnostic Criteria (DSM-5) (American Psychiatric Association, 2013)

A.      One or more somatic symptoms that are distressing and/or result in significant disruption of daily life.

B.      Excessive thoughts, feelings, or behaviours related to the somatic symptoms or associated health concerns as manifested by at least one of the following:

1)        Disproportionate and persistent thoughts about the seriousness of one’s symptoms

2)        Persistently high level of anxiety about health or symptoms

3)        Excessive time and energy devoted to these symptoms or health concerns

C.      Although any one symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months).

Changes from DSM-IV, ICD-10; and potential implications

The concept Somatic Symptom Disorder “SSD” replaces the old concept of “somatoform disorders” used in DSM-IV, including undifferentiated somatoform disorder and hypochondriasis. There is some overlap with the new diagnosis in ICD-11 Bodily Distress Disorder, which is considered to largely replace the former category of somatoform disorders in ICD-10 (World Health Organisation 2022).

In DSM-IV and ICD-10 there was emphasis on somatoform symptoms being “medically unexplained” and thus on excluding other medical disorders. However now, SSD is a diagnosis based on the presence of characteristic symptoms rather than the exclusion of potential underlying medical disorders. The new SSD diagnosis includes criteria relating to affective (relating to emotion/mood), cognitive (relating to thinking), and behavioural elements. These changes are considered a progressive move towards understanding the individual in more holistic terms, away from unhelpful dichotomies of body and mind, or “mental versus physical”.

Other features

SSD can affect people in different ways and for some, can cause a high degree of impairment in day-to-day functioning and reduced quality of life (Liao et al 2019). It is not uncommon for someone with SSD to also experience some form of emotional difficulty, and depressive and anxiety disorders often occur in people affected by SSD (Cao et al., 2020; Toussaint et al., 2017). SSD is quite common in the general patient population, and research has shown that about a quarter of people with various physical illnesses meet the criteria for SSD. SSD seems also to be associated with functional somatic disorders such as irritable bowel syndrome, widespread chronic pain/fibromyalgia (Löwe et al., 2022). Early recognition of SSD is essential, in order to offer appropriate support/treatment and improve functioning and quality of life.

Occurrence of SSD – how common is it?

Estimations of prevalence differ depending on the population/subgroup studied, and a review of the evidence around this area showed the following (Löwe et al., 2022): General population studies using self-report questionnaires reported frequencies of 6.7 to 17.4% for SSD of the general population. The highest frequency of SSD was observed within mental health care settings specialising in SSD treatment with frequency rates ranging between 40.3 and 77.7%. In studies carried out in general medicine settings, frequency rates ranged from 3.5% to 45.5%. The lack of specific interview schedules for diagnosing SSD represents a gap in the research on the prevalence of SSD, as self-report instruments are thought to overestimate the presence of an illness (Löwe et al., 2022).

Risk factors

There exists a gap in the research when it comes to the risk factors for developing SSD. It has been shown that those who developed SSD had higher baseline health anxiety, a stronger tendency to catastrophise, a self-concept of perceived “bodily weakness”, showed more illness-related behaviours (eg. taking medication), and had higher levels of depression and anxiety (Limburg et al 2017). There has been some research assessing SSD in young people, showing the group with SSD had a higher tendency towards attachment difficulties and problems with mentalisation/reflexive functioning (the capacity to understand ourselves and others in terms of mental states) (Bizzi et al 2018). A systematic review found weak associations of SSD with various personality traits such as neuroticism and agreeableness, as well as introverted features (Macina 2021). It is important to note that research is scarce in this area with relatively small numbers of individuals studied, and there is more work to be done to clarify these factors and identify potential areas for intervention.

Causes/Explanatory Models

A common model used in healthcare to help explain the onset and course of disease involves looking at predisposing, precipitating (triggering) and perpetuating (maintaining) factors. Emerging research highlights the importance of an individual’s “expectations of symptoms'' as having a central role. Having certain illness expectations based on prior experience could be influenced further by emotional states in someone who has a tendency to catastrophise (think the worst) or who is prone to illness anxiety. This could lead to the development and continuation of persistent somatic symptoms. The power of expectations to predict symptom course and treatment has been shown in many conditions such as pain, rheumatoid arthritis, cancer, and so called “medically unexplained symptoms''; and addressing patient expectations about symptoms has been shown to improve outcomes and potentially help individuals with these problems (Löwe et al., 2022).  

Getting a diagnosis

Typically, a diagnosis can be made by specialists  in a somatic or mental health treatment setting, or ideally a centre with expertise in both mental and physical healthcare. The diagnosis of SSD is usually made in the healthcare setting most often by a doctor - this could be a primary care physician, hospital physician or specialist in the area of psychosomatic medicine or in consultant-liaison psychiatry. The primary care physician or family doctor will generally play an important role in coordinating treatment with a secondary care clinician if necessary. The diagnosis of SSD is essentially clinical, whereby the clinician undertakes a thorough medical and mental health history and physical examination. Diagnosis is based on the nature of the presenting symptoms, and is a “rule in” as opposed to “rule out” diagnosis - this means it is based on the presence of positive symptoms and signs that follow a characteristic pattern described above. 

Differential diagnosis (diagnoses considered by the healthcare professional when undertaking assessment)

People with somatic (physical) symptoms of any origin and co-occurring health severe health anxiety may be considered to fit a diagnosis of SSD. Those solely with health anxiety, without somatic symptoms could be assigned the diagnosis “illness anxiety disorder” (IAD). Panic disorder is also an important differential diagnosis. Depending on the presenting problem, other underlying medical conditions must also be considered and treated appropriately.

Instruments used in diagnosis

There are many scales/instruments that can be used to identify common somatic symptoms. Those for the “A” criterion have been outlined in a review by Zijlema et al (2013), and for the “B criterion” outlined by Toussaint et al (2020). 

Course of SSD and general outlook (prognosis)

The course of SSD is variable. One small study of adolescents undergoing inpatient treatment showed complete remission in 49%, some treatment response in 32%, and no changes in 19% (Gao et al., 2018). Limburg et al., 2017 found a persistence rate of 82% and a remission rate of 18% in a sample of adult outpatients with SSD. This study showed that patients who recovered from SSD reported less catastrophising at baseline compared with patients who did not recover (Limburg et al., 2017). Difficulty with motivation around engaging in treatment for SSD hinders recovery outcomes (Mander et al., 2017). It is important that factors reducing motivation for treatment are explored with the individual during treatment, as previous difficult experiences with the healthcare system are common. Research is growing in this area, and it is hoped that the implementation of robust science driven research will allow effective supports for individuals with SSD to develop.


Once the person receives a diagnosis, the goal of treatment is to improve symptoms and ability to function in daily life. Treatment should take a holistic patient-centred approach, tailored to an individual’s specific needs. It will likely depend on the underlying symptoms and what might be driving them. The diagnostic process is considered an important step in order for treatment to move forward successfully. When healthcare professionals are giving a diagnosis and carrying out treatment, it is important to communicate openly and honestly and not to fall into the trap of dualistic – that is “either mental or physical” thinking; or attempt to “reattribute” symptoms to a predominantly psychosocial cause (Henningson et al 2018). Individuals with these problems often have very negative experience in healthcare and it is crucial their experiences are validated and understood, just like any other healthcare problem.

 As is the case with any illness, healthy lifestyle measures such as maintaining regular physical activity, sleep hygiene, engagement with social activities and outlets/hobbies are important. For some individuals it might be helpful to set up regular scheduled appointments, and monitor and encourage strategies the individual is finding useful such as stress reduction, mindfulness or peer support groups. It is important that potential factors that maintain stress are addressed -such as bullying/abuse/financial difficulty/carer burden. Medication can be helpful for some people where depression, anxiety or pain is an issue.

Psychotherapy such as Cognitive Behavioural Therapy might be helpful to explore a pattern of thoughts, actions and behaviours that could be driving a negative cycle – for example tackling illness expectations or preoccupations about symptoms. Physiotherapy may be relevant for guiding exercise rehabilitation programs, or when energy, weakness or pain is a problem. In some cases, it can be helpful to liaise with other caregivers such as family/partner to support the individual in their care. One study of inpatient adolescents with SSD showed that recovery after discharge from hospital was almost 20 times more likely in those whose families fully accepted the SSD diagnosis compared to families with partial or no acceptance (Gao et al., 2018).

For some patients, especially those who have lived with these symptoms for many years, realistic treatment includes a focus on management of symptoms and improvements in quality of life. Acceptance of symptoms and the limitations they cause can be key in these situations, and many people are able to see some improvement in their condition. Supportive relationships with the healthcare team are key to this.  


Older diagnostic classifications described patients affected by somatoform disorders as “difficult,” repeatedly requesting investigations, and unwilling to accept explanations for their symptoms. The changes in diagnostic criteria are considered to represent a progressive movement away from mind-body dualism and views which are outdated, stigmatising and unhelpful for individuals with these difficulties. However, at the beginning, there were some who regarded the new diagnosis as loose, mislabelling and lacking specificity (Frances, 2013). There is now a considerable amount of empirical evidence that supports the new diagnostic classification (Löwe et al. 2022).

Future directions

Research is growing in the area of functional disorders and there are several networks of researchers who work in the area. It is hoped that such networks will integrate cross-disciplinary knowledge and research, translating this into better services and supports for functional disorders, and ultimately improve care for patients. (Löwe et al., 2022).


American Psychiatric Association, 2022. Diagnostic and Statistical Manual of Mental Disorders. Washington: American Psychiatric Publications Inc.

Ballering, A., Muijres, D., Uijen, A., Rosmalen, J., & olde Hartman, T. (2021). Sex differences in the trajectories to diagnosis of patients presenting with common somatic symptoms in primary care: an observational cohort study. Journal Of Psychosomatic Research149, 110589.

Bizzi, F., Ensink, K., Borelli, J., Mora, S. and Cavanna, D., 2018. Attachment and reflective functioning in children with somatic symptom disorders and disruptive behavior disorders. European Child & Adolescent Psychiatry, 28(5), pp.705-717.

Cao, J., Wei, J., Fritzsche, K., Toussaint, A., Li, T., Jiang, Y., Zhang, L., Zhang, Y., Chen, H., Wu, H., Ma, X., Li, W., Ren, J., Lu, W., Müller, A. and Leonhart, R., 2020. Prevalence of DSM-5 somatic symptom disorder in Chinese outpatients from general hospital care. General Hospital Psychiatry, 62, pp.63-71.

Frances, A., 2013. The new somatic symptom disorder in DSM-5 risks mislabeling many people as mentally ill. BMJ, 346(mar18 3), pp.f1580-f1580.

Gao, X., McSwiney, P., Court, A., Wiggins, A. and Sawyer, S., 2018. Somatic Symptom Disorders in Adolescent Inpatients. Journal of Adolescent Health, 63(6), pp.779-784.

Gierk, B., Kohlmann, S., Kroenke, K., Spangenberg, L., Zenger, M., Brähler, E. and Löwe, B., 2014. The Somatic Symptom Scale–8 (SSS-8). JAMA Internal Medicine, 174(3), p.399.

Henningsen, P., Zipfel, S., Sattel, H. and Creed, F., 2018. Management of Functional Somatic Syndromes and Bodily Distress. Psychotherapy and Psychosomatics, 87(1), pp.12-31.

World Health Organisation 2022 2022. ICD-11. [online] Available at: <> [Accessed 30 May 2022].

Kroenke, K., Spitzer, R., Williams, J. and Löwe, B., 2010. The Patient Health Questionnaire Somatic, Anxiety, and Depressive Symptom Scales: a systematic review. General Hospital Psychiatry, 32(4), pp.345-359.

Liao, S., Ma, H., Lin, Y. and Huang, W., 2019. Functioning and quality of life in patients with somatic symptom disorder: The association with comorbid depression. Comprehensive Psychiatry, 90, pp.88-94.

Limburg, K., Sattel, H., Dinkel, A., Radziej, K., Becker-Bense, S. and Lahmann, C., 2017. Course and predictors of DSM-5 somatic symptom disorder in patients with vertigo and dizziness symptoms – A longitudinal study. Comprehensive Psychiatry, 77, pp.1-11.

Löwe, B., Andresen, V., Van den Bergh, O., Huber, T., von dem Knesebeck, O., Lohse, A., Nestoriuc, Y., Schneider, G., Schneider, S., Schramm, C., Ständer, S., Vettorazzi, E., Zapf, A., Shedden-Mora, M. and Toussaint, A., 2022. Persistent SOMAtic symptoms ACROSS diseases — from risk factors to modification: scientific framework and overarching protocol of the interdisciplinary SOMACROSS research unit (RU 5211). BMJ Open, 12(1), p.e057596.

Löwe, B., Levenson, J., Depping, M., Hüsing, P., Kohlmann, S., Lehmann, M., Shedden-Mora, M., Toussaint, A., Uhlenbusch, N. and Weigel, A., 2022. Somatic symptom disorder: a scoping review on the empirical evidence of a new diagnosis. Psychological Medicine, 52(4), pp.632-648.

Macina, C., Bendel, R., Walter, M., & Wrege, J. S. (2021). Somatization and Somatic Symptom Disorder and its overlap with dimensionally measured personality pathology: A systematic review. Journal of Psychosomatic Research, 151, 110646.

Mander, J., Schaller, G., Bents, H., Dinger, U., Zipfel, S. and Junne, F., 2017. Increasing the treatment motivation of patients with somatic symptom disorder: applying the URICA-S scale. BMC Psychiatry, 17(1).

Mayou, R., 2014. Is the DSM-5 chapter on somatic symptom disorder any better than DSM-IV somatoform disorder?. British Journal of Psychiatry, 204(6), pp.418-419.

Toussaint, A., Hüsing, P., Kohlmann, S. and Löwe, B., 2020. Detecting DSM-5 somatic symptom disorder: criterion validity of the Patient Health Questionnaire-15 (PHQ-15) and the Somatic Symptom Scale-8 (SSS-8) in combination with the Somatic Symptom Disorder – B Criteria Scale (SSD-12). Psychological Medicine, 50(2), pp.324-333.

Toussaint, A., Riedl, B., Kehrer, S., Schneider, A., Löwe, B. and Linde, K., 2017. Validity of the Somatic Symptom Disorder–B Criteria Scale (SSD-12) in primary care. Family Practice, 35(3), pp.342-347.

Zijlema WL, Stolk RP, Löwe B, Rief W; BioSHaRE, White PD, Rosmalen JG. How to assess common somatic symptoms in large-scale studies: a systematic review of questionnaires. J Psychosom Res. 2013 Jun;74(6):459-68. doi: 10.1016/j.jpsychores.2013.03.093. Epub 2013


Acknowledgement: This text has been developed within the ETUDE innovation training network and will be used for publication on international Wikipedia pages.