The Reality Behind Vague and Persistent Complaints – Somatic Symptom Disorder

Every doctor encounters patients suffering from symptoms and complaints for which no specific physical cause can be found. According to an article published on June 15, 2024, in The Lancet, one third of all symptoms have no somatic explanation .

Brief explanations of the article's most important terms:

• Symptom: A sign or complaint experienced by a patient, usually an indication of a disease or disorder.
• Somatic: Bodily or physical; relating to the body.
• Persistent physical symptoms: Physical complaints that continue for a long time without a specific organic cause.
• Somatoform disorders: Conditions for which no physical cause is found and which are thought to be associated with psychological factors.
• Predictive processing: A mechanism through which the brain shapes perception by making predictions about sensory impressions.

What Is Somatic Symptom Disorder?

Somatic symptom disorder is a condition in which no specific physical cause can be found, but the patient experiences substantial complaints.

Patients generally experience a wide range of symptoms without an obvious cause. These include

• persistent pain,
• dizziness,
• cardiovascular complaints,
• digestive problems,
• gait disturbances,
• exhaustion and fatigue.

There is often a marked discrepancy between the distress perceived by the patient and their physical functioning and examination findings.

In recent years, an explanatory umbrella term has emerged for these health problems: Persistent physical symptoms. This term includes functional physical complaints that last for months or longer without a clear organic cause, such as chronic fatigue syndrome, irritable bowel syndrome, or fibromyalgia. It also encompasses persistent complaints in patients with an underlying condition.

According to The Lancet article, 70% of people with chronic kidney disease experience fatigue, while 63% of patients with coronary artery disease have persistent pain in their arms, legs, or joints. 31% of patients with ulcerative colitis in remission report persistent gastrointestinal symptoms.

In the 10th Revision of the International Classification of Diseases (ICD), the term "somatoform disorders" is used when no organic cause can be identified. However, ICD-11 has replaced this term with the category of "somatic symptom disorders".

Completely ruling out physical causes is no longer necessary for this diagnosis. Instead, the focus is on psychological and behavioral abnormalities, anxiety, heightened attention to symptoms, frequent doctor visits, and the belief that one has a serious physical illness.

The "Prediction Machine"

It is essential to understand the new model underlying the concept of somatic symptom disorders. We need to understand what a person complaining of persistent physical symptoms is experiencing.

Previously, the bottom-up model of perception was widely accepted. It began with a painful stimulus, with pain believed to cause psychological symptoms secondarily. Now, however, the brain's role has come to the forefront. Terms such as "predictive processing" or "predictive coding" are central: the brain constantly makes predictions about the most likely interpretation of sensory impressions.

Experiencing Symptoms Due to Expectations and Anxiety in the Absence of an Actual Organic Cause

The brain makes predictions about sensory impressions by taking into account factors such as expectations, beliefs, and previous experiences of symptoms. These predictions unconsciously play an important role in patients' perceptions. This applies to all patients, whether or not they have an organic illness. The phenomenon may cause patients to experience symptoms even without a clear sensory stimulus.

Perception is always a biopsychosocial phenomenon, and illnesses are not strictly physical or psychological but a combination of both.

The proportions of these components vary, particularly in chronic conditions, where expectations play a greater role in pain perception than in fresh injuries. Because predictive processing is a general mechanism of perception, it may play a role in various illnesses.

The good news is that many factors, such as heightened attention to symptoms, dysfunctional expectations, or avoidance behavior, can be positively managed and treated.

What Can Doctors Do?

Doctors treating patients with functional physical complaints are advised to focus on three key points:

1. Take the Subjective Experience into Account: The psychological dimension matters in every illness. Always ask questions such as "How are you coping with your symptoms? What are your expectations for the future?" For example, a patient who has had back pain for weeks, believes the condition is worsening, and thinks they will no longer be able to work is less likely to return to work than a patient who is confident of recovering.
2. Communicate Carefully: How doctors communicate with patients about their symptoms is crucial. For example, a brain MRI in a patient with tension headache may show a slight increase in signal intensity in certain areas. If the doctor says, "It could be MS (multiple sclerosis), but I don't think so," the patient will focus on the possibility of MS.
3. Treat Both Body and Mind: There is no need to rely on only one therapeutic approach. For example, irritable bowel syndrome can be treated with both medication and psychotherapy. This does not mean the condition is entirely psychological. Exercise therapy can positively change the patient's expectations and relieve symptoms by showing that movement does not increase pain.

A Doctor's 'Toolbox'

Last year, a Norwegian study published in eClinicalMedicine demonstrated the effectiveness of this approach in treating medically unexplained physical symptoms (MUPS).

The study enrolled 541 patients with medically unexplained physical symptoms in a two-arm randomized controlled trial. One group used the Individual Challenge Inventory Tool (ICIT) for 11 weeks, while the other received standard treatment.

ICIT is a structured communication tool developed by the study's lead authors and based on cognitive behavioral therapy . The 103 participating general practitioners were trained in using ICIT.

The main aim of ICIT is to empower patients and improve their coping skills in daily life and at work.

General practitioners using ICIT were instructed to follow three steps:

1. Validate Patients' Feelings: Acknowledge the feelings and concerns your patients experience, and show understanding.

2. Offer a Symptom Explanation Model Based on the Concept of Allostatic Load: Explain to patients how their symptoms relate to stress and allostatic load, the body's process of adapting to stress.

3. Develop a Collaborative Activity Plan Addressing the Patient's Specific Problems: Work with your patients to prepare a task list, problem list, or list of options to address their specific difficulties. This plan encourages patient engagement and collaboration.

In the study, patients had two or more sessions with their general practitioners. Outcomes were assessed individually, and the primary outcome was patient-reported change in functioning, symptoms, and quality of life. Secondary endpoints included work ability.

In the cognitive behavioral therapy group, the proportion experiencing a significant overall improvement in functioning, symptoms, and quality of life was 76% (223 patients), compared with 38% (236 patients) in the control group receiving standard care (mean difference, -0.8; 95% CI, -1.0 to -0.6; P < 0.0001).

After 11 weeks, absence from work fell by 27 percentage points in the therapy group (from 52.0 to 25.2), compared with only 4 percentage points in the standard care group (from 49.7 to 45.7).

Conclusion

Somatic symptom disorder is characterized by complaints for which no specific physical cause can be found but which adversely affect patients' quality of life. Both physical and psychological factors need to be considered in treating this disorder. Approaches based on cognitive behavioral therapy may help patients manage their symptoms and improve their quality of life. In particular, considering psychosocial factors and communicating carefully between doctor and patient may lead to substantial improvements in treatment. Research shows that these approaches are effective, improving patients' functioning and reducing sickness absence. Holistic and multidisciplinary approaches should therefore be adopted when treating patients with somatic symptom disorder.