Somatic symptom disorder does not mean the symptom is imaginary. The criteria require real, distressing physical symptoms, and the diagnosis can be given to somebody who also has a diagnosed medical condition.
That has to come first, because the label reliably gets heard as an accusation, and the misreading is the main reason people refuse the help attached to it.
What actually changed in 2013
Before 2013 the relevant diagnosis was hypochondriasis, and it had two serious problems.
It rested on symptoms being medically unexplained. That meant it could only be arrived at by exclusion, after everything else had been ruled out. Which is a fragile basis for any diagnosis, because a condition found three years later retrospectively invalidates it.
And the word had become an insult. Nobody could be told they had it without hearing that they were making it up.
The revision split it into two diagnoses defined by what is present rather than by what could not be found. [apa-2013-dsm5-ssd]
Somatic symptom disorder. One or more genuinely distressing or disruptive physical symptoms, plus excessive thoughts, feelings or behaviours about them: disproportionate thoughts about their seriousness, persistently high health anxiety, or excessive time and energy going into them.
Illness anxiety disorder. Preoccupation with having or acquiring a serious illness, with somatic symptoms absent or only mild. This is where health anxiety in the everyday sense mostly lands, and our guide to illness anxiety disorder covers it in full, including the care-avoidant form that produces no appointments and so gets noticed by nobody.
One study of people who met the old criteria found roughly 74% met criteria for somatic symptom disorder and about 26% for illness anxiety disorder. Most of the people the old term described did have real symptoms.
Proportions from a study of people meeting DSM-IV hypochondriasis criteria reassessed against the DSM-5 categories, as cited in this article. Real reported values.
That split is the whole argument for the change. A category built on the absence of physical symptoms was being applied overwhelmingly to people who had them.
What is being described
Not whether the symptom is real. The response to it.
- Time. Hours a day occupied by the symptom, monitoring it, researching it, arranging appointments.
- Interpretation. A persistent conviction that it is more serious than the assessments suggest, or that something has been missed.
- Behaviour. Checking the area, comparing it with yesterday, seeking reassurance, requesting repeat investigations.
- Life. Work, exercise, plans and relationships narrowing around it.
Two people can have identical back pain and only one of them has this. The difference is not in the back.
This is why the treatment is not an argument about the symptom. Nobody gets better by being persuaded the pain is not there, and attempts to do that are why people disengage.
Why more tests stop helping
The trap here is the same one described in our guide to reassurance seeking, and it is worth being explicit about because the behaviour is so reasonable.
A clear scan produces relief. The relief teaches your brain that the worry was warranted and that the scan is what resolved it. So the next episode of doubt arrives sooner, and needs a bigger reassurance to settle. Meanwhile investigations carry their own costs: incidental findings, waiting, and further procedures generated by ambiguity.
Is the response the problem now?
Tick anything true over the past six months. This is a reflection prompt rather than a test, and it produces no diagnosis. None of these mean your symptom is not real.
0 of 8 ticked
None of that says the symptom is imaginary, and treating the response does not mean abandoning the medical question. The third item is the most diagnostic: reassurance wearing off faster over time is the signature of the loop rather than of an undiagnosed illness. The fifth is the one with the largest cost.
Attending to a symptom that is genuinely bothering you is sensible. It becomes worth addressing when the checking is taking real time and when relief from a normal result is measured in hours rather than months.
Nothing here matched. If fear of illness is present without much in the way of physical symptoms, our health anxiety guide covers that pattern instead.
No screener on this site measures health anxiety or somatic symptoms. The free anxiety screener uses the GAD-7 and is a general signal only.
What helps
Ask for treatment of the response, not a verdict on the symptom. These are separate questions and only one of them is stuck. You can accept help with how much of your life this is taking without conceding anything about what is causing it.
Settle on one clinician. Repeated new opinions restart the investigation cycle each time and are one of the more reliable ways to stay unwell. A relationship with somebody who knows the history is worth more than a fresh set of eyes.
Agree a plan for what would and would not trigger further tests. Written down, in advance, when nobody is frightened. It removes the negotiation from the moment it is hardest.
Reduce the checking before the belief. The belief usually shifts after the behaviour does, not before it. Our guide to reassurance seeking covers how to drop it in a workable order.
Restart what you stopped. Graded, not all at once. Activity given up to avoid provoking the symptom tends to shrink life faster than the symptom does.
Treatment works, including where the problem presents medically. A trial randomised 444 patients attending medical clinics across six hospitals to brief cognitive behavioural therapy or standard care, and the therapy group did better. [tyrer-2014-champ-ssd] The evidence for the illness anxiety side is reviewed in detail elsewhere. [scarella-2019-iad-ssd]
Our guide to CBT for health anxiety covers what the sessions involve.
When to seek help
Keep taking new or changing physical symptoms to a doctor. Having this pattern does not make you immune to illness, and the correct response to a new symptom is unchanged.
Ask for help with the response if a symptom is taking up hours of your day, if you have given things up because of it, if reassurance from clear results is wearing off faster, or if you have consulted several clinicians about the same complaint.
In some countries you can refer yourself to a talking therapy service without going through a doctor first, so it is worth asking. Describing how much time and activity the symptom is costing you is more useful than describing the symptom itself.
Go urgently if you have thoughts of harming yourself.
How MyFreud can help
What a clinician most needs, and what nobody can reconstruct in a ten-minute appointment, is the pattern: when it is worse, after what, and what else was happening. MyFreud gives you daily mood tracking that takes seconds, so what you bring is a record rather than the version recalled on a bad morning.
Download MyFreud and start today: App Store or Google Play.