173 Complex Somatic Symptom Disorder (CSSD)

(Not currently located in the DSM-IV-TR)

Proposed changes in the DSM-V include grouping the following disorders into a single category: Somatization Disorder, Undifferentiated Somatoform Disorder, Hypochondriasis, Pain Disorder Associated With Both Psychological Factors and a General Medical Condition, and Pain Disorder Associated With Psychological Factors. This new category would focus on both the physical symptoms and the psychological dysfunctions, with more emphasis on cognitive distortions than previous diagnostic categories.

CSSD is characterized by a disproportionate or maladaptive reaction to somatic symptoms or concerns. The disorder can occur in conjunction with a general medical or psychiatric disorders or it can occur alone. Treatment of the symptoms is usually unsuccessful; in fact, treatment may exacerbate symptoms.

Symptoms may be either specific, such as localized pain, or more general, such as fatigue or multiple symptoms. Anxiety-causing symptoms are usually ordinary bodily sensations, or discomfort not associated with a known serious medical condition.

Interestingly, patients diagnosed with CSSD typically have a poor health-related quality of life as compared to patients diagnosed with other medical conditions or those with similar symptoms.

DSM-V Criteria

Symptom clusters A, B, and C must be met for a diagnosis of Complex Somatic Symptom Disorder

• A. Somatic Symptoms
  • One or more somatic symptoms that are distressing and/or result in significant disruption in daily life.
• B. Excessive thoughts, feelings, and behaviors related to these somatic symptoms or associated health concerns: At least two of the following are required to meet this criterion:
  • High level of health-related anxiety.
  • Disproportionate and persistent concerns about the medical seriousness of one’s symptoms.
  • Excessive time and energy devoted to the symptoms or health concerns.*
• C. Chronicity: Although any one symptom may not be continuously present, the state of being symptomatic is chronic (at least 6 months).

For patients who fulfill the CSSD criteria, the following optional specifiers may be applied to a diagnosis of CSSD where on of the following dominates the clinical presentation:

• 1. Predominant somatic complaints (previously, somatization disorder)
• 2. Predominant health anxiety (previously, hypochondriasis). If patients present solely with health-related anxiety with minimal somatic symptoms, they may be more appropriately diagnosed as having an anxiety disorder.
• 3. Predominant Pain (previously pain disorder). This classification is reserved for individuals presenting predominantly with pain complaints who also have many of the features described under criterion B. Patients with other presentations of pain may better fit other psychiatric diagnoses such as adjustment disorder or psychological factors affecting a medical condition.

For assessing severity of CSSD, metrics are available for rating the presence and severity of somatic symptoms (see for instance PHQ, Kroenke et al, 2002). Scales are also available for assessing severity of the patient’s misattributions, excessive concerns and preoccupations (see for instance Whiteley inventory, Pilowsky, 1967)

*Criteria B is still under active discussion

See here for the DSM-V proposed changes to this category: DSM-V