The reframe (DSM‑5 shift)
The diagnosis no longer hinges on "medically unexplained." Somatic symptom disorder = ≥1 distressing somatic symptom + excessive thoughts/feelings/behaviours about it (health anxiety, disproportionate concern, time/energy consumed) for >6 months — whether or not a medical explanation exists. The pathology is the response, not the presence/absence of organic disease.
Map the related disorders
- Illness anxiety disorder — preoccupation with having/acquiring serious illness, minimal somatic symptoms, high health anxiety, checking/reassurance or maladaptive avoidance.
- Functional neurological symptom disorder (conversion) — neurological symptoms with positive incompatibility signs (e.g., Hoover's sign, tremor entrainment) — a rule‑in, not a diagnosis of exclusion.
- Factitious disorder — intentional falsification for the sick role (no external incentive) — distinct from malingering (external incentive; not a mental disorder).
The clinical stance
Avoid both errors: "it's all physical" (endless investigation, iatrogenic harm) and "it's all psychological" (missed disease, alienation). Never say "it's all in your head." Validate the symptom, explain mechanism (attention/autonomic amplification, functional pathways), consolidate care with one clinician, limit repeat investigations, and use CBT.
Pitfalls
- Diagnosing by absence of findings rather than positive features (esp. FND).
- Serial over‑investigation reinforcing illness behaviour.
Pearls
- 🎯 SSD = the disproportionate response, not "unexplained symptom."
- 🩺 FND is diagnosed on positive signs — it's a rule‑in.
Next → Disruptions of the integrated self — dissociative disorders (Concept 27).