Somatic Symptom Disorder

Treatment Approaches

1. Establishing a Therapeutic Alliance and Regular Care: One of the most effective strategies in managing somatic symptom disorder is to have regular, scheduled visits with a trusted healthcare providerpsychiatry.org. At You Psychiatry Clinic, a psychiatric nurse practitioner or psychiatrist will often take on the role of that regular provider in collaboration with your primary care physician. Instead of the patient seeking emergency evaluations or new doctors whenever a symptom flares, we set up a routine (for example, a brief check-in appointment every 2-4 weeks). This has a dual purpose: it provides consistent support and reassures the patient that their symptoms are being monitored, and it helps avoid unnecessary urgent care visits or duplicate testingpsychiatry.org. In the initial sessions, the provider will thoroughly review all relevant medical workups (with your permission, obtaining records from your physicians) to truly understand what’s been ruled out and what minor issues might exist. We validate that your symptoms are real – we might say, “I see you’ve had chest pain for 2 years; it’s been evaluated with heart tests that are normal, which is good news, but I know the pain still hurts and worries you. I believe that you feel this pain.” This validation is crucial because many patients with SSD feel dismissed. We then set expectations: for instance, instead of chasing each new symptom with a barrage of tests, we’ll use each regular visit to address concerns systematically. We might also let the patient know that we will still coordinate with their medical providers; we’re not taking over as their internist, but we’ll serve as a point person for their health anxiety. Essentially, the patient agrees to bring new symptoms to us first unless it’s a clear emergency. This way, they don’t feel alone with their sensations between appointments – they have a plan (“Okay, I’ll write down my symptoms and Dr. X will go over them next week with me”). Having this structured approach often reduces panic and healthcare overusepsychiatry.org.

2. Cognitive-Behavioral Therapy (CBT) for Health Anxiety: CBT is a frontline therapy for somatic symptom disorder. Through telepsychiatry, our therapists can work with patients to change the way they think about and respond to physical symptoms. Key components of CBT in this context include:

• Psychoeducation: We educate patients on how stress and anxiety can actually produce physical sensations (for instance, explaining how anxiety can cause heart racing, chest tightness, gastrointestinal upset by triggering the autonomic nervous system). We normalize certain bodily sensations as benign (like “heart palpitations are common and usually harmless in healthy hearts, here’s why”) which can take some fear out of them. We also explain the vicious cycle: worry amplifies focus on symptoms, which amplifies perceived intensity, which fuels more worrypsychiatry.org. Just mapping this out can be an “aha” moment for patients.
• Cognitive restructuring: We identify and challenge catastrophic thoughts. For example, a patient might think “My headache means I have a brain tumor.” We would work on evaluating that thought: examining evidence (e.g., “You’ve had an MRI that was clear”), probabilities (“Brain tumors are rare, especially with a normal MRI. What are other possible reasons for headaches?”), and alternative explanations (“Maybe this is a tension headache from stress”). We don’t dismiss their concern, but rather help them find more balanced thinking (“It’s very unlikely I have a brain tumor; this headache could be stress-related or a migraine, which though painful, is not life-threatening”). Over time, patients learn to catch themselves in catastrophic predictions and reframe them. We may use thought logs where they write down scary thoughts and then practice coming up with rational responses.
• Behavioral modifications: One common behavior in SSD is excessive checking or reassurance-seeking – such as constantly taking one’s pulse, googling symptoms, or asking family for reassurance. Another might be avoidance – like avoiding exercise for fear of triggering symptoms. In CBT, we aim to reduce these unhelpful behaviors gradually. For instance, if a patient checks their blood pressure 20 times a day, we set a goal to cut that to, say, 5 times, then eventually once a day, then perhaps even less. Or if they compulsively search the internet, we might institute a “no Googling” rule for a week as an experiment to see if anxiety lessens (often it does). We teach them distraction and replacement techniques: when the urge to check arises, do a breathing exercise or engage in a hobby for 15 minutes first. For avoidance, we create a graded exposure plan. Example: a patient avoids exercise due to palpitations fear. We might start with light walking for 5 minutes (with the provider’s assurance it’s safe given medical clearance). They do that and monitor anxiety – often, it’s tolerable and maybe the palpitations aren’t as bad as feared. Then we incrementally increase intensity or duration. This exposure teaches the patient that the feared outcome (e.g., having a heart attack from slight exertion) doesn’t occur and that they can handle the discomfort.
• Body focus retraining: Some therapies use techniques to shift attention away from internal sensations. For example, mindfulness training can help patients notice symptoms without judgment and then let them pass. Or techniques like progressive muscle relaxation can reduce muscle tension that might be causing some pain. Biofeedback can also be useful – e.g., showing a patient how their muscle tension or heart rate changes with stress and how they can consciously calm it. Telepsychiatry allows for some biofeedback-like exercises if the patient has compatible devices (like a smart watch for heart rate or a blood pressure machine to practice relaxation and see the numbers change). We integrate those into therapy if appropriate.
• Addressing underlying emotional issues: Often, there are emotional conflicts or stressors the patient hasn’t fully expressed (sometimes focusing on the body is a way, often unconscious, to express distress or get care). Therapy provides a safe space to talk about these. For instance, a patient might finally share: “Ever since my divorce, I’ve been so lonely,” which might be fueling their physical preoccupations. By working through grief, loss, or anger, the intensity of somatic symptoms can decrease. We might also identify if there are any secondary gains to the sick role (maybe it’s the only time they feel cared for). Gently, we find alternative ways for them to get those needs met (like strengthening social support, asking for help more directly instead of via illness).

3. Medication Management: There is no specific drug for somatic symptom disorder, but we often use medications to treat co-occurring anxiety and depression, which in turn usually alleviates the intensity of somatic worries. Antidepressants, particularly SSRIs or SNRIs, have been shown to reduce somatic symptoms and health anxiety in many patientspsychiatry.org. For example, an SSRI like escitalopram might help decrease the overall anxiety level, making catastrophic thinking less frequent and reducing the physical manifestations of stress (like pain amplification or GI upset). Some patients with SSD respond well to SNRIs (like duloxetine) especially if chronic pain is a prominent symptom, since SNRIs can help certain pain syndromes. The psychiatric provider will choose a medication based on the patient’s profile: for someone with a lot of muscle pain and insomnia, maybe a low-dose tricyclic like amitriptyline at night could be helpful (it can aid sleep and pain, and also ease depression). If panic attacks are part of the picture, SSRIs or possibly benzodiazepines can be considered; however, we are cautious with benzos (like alprazolam or lorazepam) because these can sometimes reinforce health-related behaviors or lead to dependence. If used, it’s typically short-term to break a severe cycle of anxiety, with a plan to taper. Anxiolytic medication like buspirone is another option for chronic worry – it’s non-addictive and can be added if needed. Sometimes beta-blockers (like propranolol) are given to manage the physical symptoms of anxiety (palpitations, tremors), thereby reducing one source of health concern. Over telepsychiatry sessions, we monitor the patient’s response closely. We might use standardized scales like PHQ-9 (for depression) or GAD-7 (for anxiety) to track progress quantitatively. We also invite feedback: “Since starting the sertraline, have you noticed any change in how often you think about your symptoms or visit doctors?” It can take a few weeks to see improvement, so we encourage patience and continuation of therapy concurrently. If one medication doesn’t help sufficiently, we may adjust the dose or try another class. We also watch for side effects – ironically, patients with SSD can be very sensitive to side effect fears (they might interpret a mild side effect as a serious issue). We address that proactively: discussing what side effects are common and benign (e.g., initial nausea or headache from an SSRI which usually pass) so they don’t catastrophize those. As the person’s mood and anxiety improve on medication, we often see an interesting shift: suddenly they’ll say, “I guess I haven’t thought about my stomach as much this week,” or “I felt a twinge of chest pain but I was able to shrug it off and it went away.” That’s a sign treatment is working.

4. Long-Term Management and Relapse Prevention: Somatic symptom disorder can be chronic, waxing and waning with stress. Our goal is not only to alleviate current symptoms but also to give patients tools to manage future ones. Over time, many patients learn to trust their bodies more and fear them less. As therapy and possibly medication take effect, we might see a drastic reduction in doctor visits and a marked improvement in quality of life. For maintenance, we often continue regular brief visits perhaps monthly or every couple of months, to check in. Research and clinical guidance suggest that continuing some scheduled contact (even if symptoms greatly improved) can prevent relapsepsychiatry.org. During these maintenance visits (which can be via telehealth for convenience), we reinforce progress, quickly address any new minor symptom in a rational manner (preventing the spiral of catastrophic thinking), and adjust any treatments as needed. If the patient successfully reframed their health anxieties, we praise that and maybe “graduate” them to less frequent sessions with the understanding they can reach out if stress increases. We also help them consolidate lifestyle changes: encouraging regular exercise (which is beneficial for mental and physical health), good sleep, and possibly practices like yoga or meditation which might keep somatic hypervigilance at bay. If family dynamics contributed to their symptoms (like a spouse who was over-reassuring or inadvertently encouraging sick role), by this stage we usually have addressed that – family members might note the patient is much more engaged in life now, and we highlight that positive change. In cases where a real medical condition is present alongside SSD, we ensure that’s being managed appropriately, and that the patient isn’t over-managing it. For instance, a patient might indeed have mild hypertension, but with health anxiety they used to check BP 10 times a day – now we have them down to once in morning and following their doctor’s plan calmly. We keep communication open with their primary care so everyone is aware of the strategy (often PCPs are relieved to have psych helping, as it reduces unnecessary workload on them and tests). We teach patients how to handle new symptoms: instead of panicking, they might wait a few days to see if it resolves, or apply CBT techniques to it; they also know to discuss with us instead of immediately seeking an ER unless red-flag signs are present.

For relapse prevention, sometimes boosters of therapy are useful – say a year later a big stressor happens (loss of a loved one) and the patient finds old health worries creeping back; a few sessions can reinforce their coping mechanisms. We encourage patients to continue any practice that helped (e.g., if mindfulness was useful, keep it up; if an SSRI made a big difference and no side effects, we might maintain it long-term). We would taper medication only after careful consideration that the health anxiety is at bay and under good self-control, and we’d do it slowly while monitoring for any return of excessive worry.

To conclude, our treatment approach for somatic symptom disorder is comprehensive and patient-centered: we aim to break the cycle of worry and doctor visits by building trust, using evidence-based therapy to change thought and behavior patterns, appropriately utilizing medication to relieve underlying anxiety/depression, and empowering the patient with knowledge and coping skills. Over time, patients often shift from being controlled by their symptoms to controlling their response to symptoms. It’s incredibly rewarding when a patient says something like, “You know, I had a weird ache last week and normally I would’ve freaked out, but I did my relaxation exercises and it went away. I realized not every sensation means I’m seriously ill.” That statement marks a victory – it shows they have learned to reinterpret their body in a healthier way, which is the essence of overcoming somatic symptom disorder. With the combination of our regular supportive presence and their own growing resilience, many patients reclaim their peace of mind and get back to living life rather than constantly fearing death or disease.