Diagnostic Overview
SSRDs include several distinct disorders:

1. Somatic Symptom Disorder (SSD)
   Characterized by one or more distressing somatic symptoms that are accompanied by excessive thoughts, feelings, or behaviors related to those symptoms. Importantly, the symptoms may or may not be medically explained. The focus is on the psychological response to the symptoms rather than the presence or absence of a medical explanation.
2. Illness Anxiety Disorder (IAD)
   Previously known as hypochondriasis, IAD involves preoccupation with having or acquiring a serious illness despite minimal or no somatic symptoms. Patients frequently misinterpret normal bodily sensations and engage in repeated health checks or avoidant behaviors.
3. Conversion Disorder (Functional Neurological Symptom Disorder)
   This condition involves neurological symptoms (e.g., paralysis, seizures, blindness) that are inconsistent with recognized medical conditions. Symptoms often emerge in the context of psychological stress or trauma.
4. Psychological Factors Affecting Other Medical Conditions
   This diagnosis applies when psychological or behavioral factors significantly affect the course, treatment, or outcome of a medical illness.
5. Factitious Disorder
   Involves intentional falsification of physical or psychological symptoms without obvious external incentives, distinguishing it from malingering.

Epidemiology and Clinical Features
SSRDs are common across healthcare settings. SSD affects approximately 5-7% of the general population, with a higher prevalence in women. IAD affects 1.3-10% of the population, with equal gender distribution. Conversion disorder is more frequently diagnosed in females and typically presents in adolescence or early adulthood.

Patients with SSRDs often have co-occurring psychiatric disorders such as depression or anxiety. Adverse childhood experiences, trauma, and chronic stress are significant risk factors. Additionally, these patients often have complex relationships with the healthcare system—frequent visits, diagnostic procedures, and a feeling of being misunderstood or invalidated are possible.

Challenges in Diagnosis
Diagnosing SSRDs requires careful differentiation from medical conditions, malingering, and other psychiatric disorders. The DSM-5-TR emphasizes the need to avoid over pathologizing patients with medically unexplained symptoms and instead focus on the degree of psychological distress and functional impairment.

Clinicians are best served to conduct comprehensive assessments that include medical, psychiatric, and psychosocial components. Collateral information from family and medical records is often helpful. Importantly, SSRDs are not diagnoses of exclusion but require positive identification of specific clinical features.

Best Practices in Treatment

1. Psychoeducation and Therapeutic Alliance
   Establishing a strong therapeutic alliance is foundational. Patients often feel invalidated by previous medical encounters, so clinicians must acknowledge their suffering without reinforcing somatic preoccupation. Psychoeducation should reframe the illness using a biopsychosocial model, emphasizing the truly felt nature of the symptoms while introducing the role of stress and emotional factors.
2. Cognitive Behavioral Therapy (CBT)
   CBT is the most evidence-based treatment for SSRDs. It targets beliefs and thoughts about illness and health, and avoidant or excessive health behaviors. CBT helps patients develop more accurate appraisals of bodily sensations and encourages gradual re-engagement in activities.
3. Mindfulness and Acceptance-Based Therapies
   Interventions such as mindfulness-based stress reduction (MBSR) and acceptance and commitment therapy (ACT) show promise by helping patients observe their symptoms non-judgmentally and reduce experiential avoidance. These approaches may be particularly helpful in patients with chronic pain or functional neurological symptoms.
4. Pharmacotherapy
   While no medications are FDA-approved specifically for SSRDs, selective serotonin reuptake inhibitors (SSRIs) may be helpful when comorbid depression or anxiety is present. SNRIs and tricyclic antidepressants have also shown utility in somatoform pain syndromes. For example, the SNRI Duloxetine has an FDA approval for chronic pain. However, polypharmacy and iatrogenic harm should be avoided.
5. Interdisciplinary Care and Coordination
   Patients benefit from collaborative care models involving primary care providers, psychiatrists, psychologists, physical therapists, and sometimes neurologists or pain specialists. Coordinated care prevents redundant testing and provides consistent messaging. Regular case conferences and shared treatment plans are key to success.
6. Limit Medical Investigations and Set Boundaries
   While it is essential to rule out medical conditions, repeated investigations reinforce illness behavior. Providers should adopt a “diagnostic closure” strategy, providing reassurance based on appropriate evaluation, and shift focus to functional recovery. Structured visits, time-limited appointments, and continuity with a single provider help reduce fragmentation.
7. Address Trauma and Comorbidities
   Because many patients have histories of trauma, integrating trauma-informed care is essential. Screening for PTSD, dissociation, and borderline personality disorder is often appropriate. Psychotherapy targeting trauma (e.g., EMDR, trauma-focused CBT) can reduce somatic symptom intensity.

Conclusion
Somatic Symptom and Related Disorders are complex conditions that straddle the boundary between psychiatry and medicine. When properly diagnosed and treated using evidence-based, multidisciplinary approaches, many patients experience significant improvements in functioning and quality of life. Mental health providers play a critical role in destigmatizing these conditions, guiding collaborative care, and helping patients shift from symptom preoccupation to adaptive functioning.

AUTHOR:

Shawn Singh Sidhu, MD, DFAPA, DFAACAP

Co-Medical Director, Vista Hill Foundation

Vista Hill Native American SmartCare Program

Concomitant psychiatric or medical disorders can be present in patients who are being assessed for GAD and may complicate accurate diagnosis and treatment. Initially, the patient should have a full psychiatric and medical history with appropriate consideration or referral for laboratory and physical examination. After a failed trial of treatment, the clinician should look for common coexisting conditions, such as depression, alcohol problems, bipolar disorder, and undiagnosed medical illness, e.g. endocrine (thyroid), pulmonary or cardiac disease.

Psychological therapies are an important first-line option in the management of GAD. “Psychoeducation,” including information to patients about the causes and treatment of their condition, has been recommended for all patients. This  includes paying attention to alcohol, caffeine, and tobacco consumption; regulating sleep; and the control of external stimuli for improving sleep. Simple coping techniques can be taught in the primary care setting for the control of worry, such as setting aside time to rationalize concerns, organizing these into minor and major worries, and identifying priorities and next steps toward addressing them.  Handouts may be helpful for patients to read and reference.

Antidepressants: The following antidepressants have demonstrated efficacy in GAD: SSRIs, SNRIs, tricyclic antidepressants, and trazodone. Of these, SSRIs and SNRIs are generally preferred as first-line therapy. They are usually better tolerated than the other classes of antidepressants.

Although the SSRIs are generally well tolerated, these agents are nonetheless associated with a range of adverse effects, including GI symptoms, somnolence, disrupted sleep, and agitation. Weight gain and sexual side effects can occur and can persist during the treatment period.

The SNRIs venlafaxine and duloxetine may also be effective. Adverse effects include those associated with the SSRIs, as well as orthostatic hypotension, increased blood pressure, sweating, and urinary hesitancy. Patients taking venlafaxine or duloxetine should be monitored for increases in blood pressure.

Benzodiazepines:  Historically, benzodiazepines have been widely used in the management of anxiety disorders. They have a rapid onset of action and are effective in GAD. While benzodiazepines improve core symptom, they are not recommended as monotherapy for depression, dysthymia, obsessive-compulsive disorder, and posttraumatic stress disorder, which co-commonly occur with GAD. However, benzodiazepines can be effective for panic and social anxiety disorders, as well as for insomnia, a common symptom. In severe cases, benzodiazepines are often prescribed as adjunctive therapy to help patients in acute crisis or while waiting for a SSRI orSNRI to take effect.

Benzodiazepine use can be problematic, particularly in older people, due to side effects such as falls, memory impairment, incoordination, drowsiness, and confusion.  Benzodiazepines can disrupt sleep architecture, and rebound insomnia may occur after stopping treatment.

Benzodiazepines have modest abuse potential and should not generally be administered to patients with a history of misuse of these drugs within the primary care setting. They are generally recommended only for short-term use and are not recommended for first-line long-term treatment of GAD, but they may have a role in the management of acute anxiety and in some cases in which somatic symptoms are more prominent than psychic symptoms

Buspirone: Buspirone, an azapirone that acts as a partial agonist at the 5HT1a receptor, is effective for the treatment of GAD though may be less effective than the benzodiazepines. Common side effects of buspirone included drowsiness, dizziness, and nausea.

Antihistamines: Hydroxyzine is an H1 antagonist that has been reported to be effective in the treatment of GAD symptoms in well-controlled studies.  It is typically used as a prn medication for breakthrough anxiety.

Atypical antipsychotics: Recent studies have suggested that atypical antipsychotics may also have a role in GAD. In patients who do not respond adequately to initial pharmacologic treatment, the addition of an atypical antipsychotic agent may provide additional benefit.

GAD is usually chronic with a waxing and waning course, and continued support and education is often required. Patients should be given clear information on how long treatment will take to become effective and how to cope with their symptoms in the meantime.

The use of appropriate screening tools and providing information to patients with GAD on their condition and its treatment are an important starting point toward increasing recognition and appropriate treatment of GAD.

Generalized anxiety disorder (GAD) is characterized by excessive, uncontrollable and often irrational worry, that is, apprehensive expectation about events or activities. This excessive worry often interferes with daily functioning, as individuals with GAD typically anticipate disaster, and are overly concerned about everyday matters such as health issues, money, death, family problems, friendship problems, interpersonal relationship problems, or work difficulties

The main diagnostic criteria of GAD are excessive anxiety and worry that is difficult to control, along with at least 3 from a list of 6 symptoms: restlessness, irritability, difficulty concentrating, muscle tension, sleep disturbances, and being easily fatigued and duration of the disorder for at least 6 months.  Symptoms must be distressing or impairing and not adequately explained by another related disorder.

Screening for GAD can potentially be helpful in improving detection rates in primary care, which can lead to more appropriate treatment and improved patient outcomes. GAD-7 was developed to facilitate the diagnosis. The scale has been shown to be an efficient tool that can screen for likely cases of GAD and can assess symptom severity and assist with the clinical assessment and treatment of GAD.  A link to the assessment tool is included.

The main treatment approaches for GAD include pharmacotherapy or psychotherapy or a combination of both. The often chronic and disabling nature of GAD means that some individuals may fail to respond fully to first-line treatment. Patients may therefore require a sequential trial of treatments.  Psychological therapies are an important first-line option in the management of GAD.

The treatment plan for GAD should account for (1) predominant symptoms, (2) severity of the condition, (3) presence of concomitant medical illness, (4) complications such as substance abuse or the risk of suicide, (5) outcomes of any previous treatments, (6) cost issues, (7) availability of treatment in a given area, and (8) patient preferences.

There are various options for medication management of GAD. Next week’s newsletter will focus on this topic.

GAD is frequently associated with other psychiatric conditions such as other mood or anxiety disorders, somatoform/pain disorders, medically unexplained symptoms, and substance use disorders.  It has also been linked with medical disorders such as heart disease, GI and chronic pain disorders.

Effective management of GAD has the potential to improve quality of life for patients and their families, as well as improve patient productivity and reduce the impact of the condition on health care resources.  The use of appropriate screening tools and providing information to patients with GAD on their condition and its treatment are an important starting point toward increasing recognition and appropriate treatment of GAD.

References:

http://www.integration.samhsa.gov/clinical-practice/GAD708.19.08Cartwright.pdf/

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2911006/