Somatic symptom disorder: Why your doctor doesn't believe you're really sick

SSD is a mainly-female condition which medicine treats as real and common, but which has no solid scientific basis

If you become seriously ill, your doctor might decide that the symptoms are ‘all in your head’. To most people this would seem absurd, but to doctors it seems perfectly reasonable, because doctors believe in something called somatic symptom disorder (SSD). I haven’t been able to find any convincing scientific evidence that SSD exists. But medical professionals believe in it, and this makes it very important.

Somatic symptom disorder and its effect on patient care

Somatic symptom disorder (SSD, also called or somatoform disorder or somatization) is a simple idea: the patient has physical symptoms, but the symptoms are not caused by a problem in the body. Instead, the physical symptoms have psychological causes.

This is a bit subtle. If a doctor believes you have SSD, it doesn’t mean the doctor thinks you’re faking. The doctor thinks you really have the symptoms and you’re not doing it on purpose. However the doctor believes that, on some unconscious level, your mind is creating the symptoms.

Doctors are taught that, any time they see symptoms they don’t understand, they should suspect somatic symptom disorder. They’re taught that SSD is common (one source I read said it affects 5-7% of the population, another source said 11%) and that it mainly affects women (one source said SSD affects ten times as many women as men!)

Let’s take a moment to consider how wild this is: not only do doctors believe serious physical symptoms can be ‘all in your head’, they think this is common!

It doesn’t surprise me that SSD is viewed as something that mainly affects women and girls. We know that until the 1990s virtually all medical research was performed on men, and we know that medicine continues to be institutionally sexist. Women’s symptoms are far less likely to be recognized and understood than men’s. Many diseases that mainly affect women, from endometriosis to POTS, ME/CFS, Ehlers Danlos Syndrome and Long Covid, typically take years to be diagnosed. It’s obvious to me that medicine is putting everything it doesn’t understand (or prefers to ignore) in the ‘psychosomatic’ bucket.

As a patient, somatic symptom disorder can affect you whether you are diagnosed with it or not. I get the impression that doctors are reluctant to give this diagnosis because they know patients don’t like it and are likely to protest. Nevertheless the doctor may think you have SSD, and this can affect your care.

Diagnostic criteria

The DSM-5 criteria for diagnosis of somatic symptom disorder are:

• Somatic* symptom(s) that cause significant distress or disruption in daily living

• One or more thoughts, feelings, and/or behaviors that are related to the somatic symptom(s) which are persistent, excessive, associated with a high level of anxiety, and results in the devotion of excessive time and energy

• Symptoms lasting for more than 6 months

(*The word ‘somatic’ means ‘of the body’. For example: pain, fatigue, nausea, dizziness and abdominal cramps are all examples of ‘somatic’ symptoms.)

Dubious ‘evidence’ for the existence of somatic symptom disorder

I did not find any rigorous scientific evidence that SSD exists. That is to say, I did not find any rigorous scientific evidence that the symptoms of people diagnosed with SSD truly have psychological (or psychosocial) causes. However I did find a great deal of opinion, speculation, and insufficiently-rigorous science.

Clinical opinion: Many doctors have written articles expressing the opinion that their patients have somatic symptoms, and these articles have been published in scientific journals. But this isn’t evidence, it’s just opinion.

Diagnosis is seen as ‘evidence’. It is assumed that if a patient is diagnosed with SSD, their symptoms are in fact psychosomatic. And similarly, if a patient reports meeting the diagnostic criteria for SSD, it is assumed that their symptoms are psychosomatic.

The absence of any physical explanation for symptoms is taken as ‘evidence’ for somatic symptom disorder. This ignores the fact that most patients do not receive a thorough set of tests and referrals to specialists to rule out physical causes. It doesn’t take into account that some patients present in ways doctors find confusing or unexpected due to cultural differences, leading to missed diagnosis. It doesn’t take into account rare diseases which are often missed. It doesn’t take into account common but medically neglected diseases, such as ME/CFS, which are also often missed. (Even a common and medically recognized disease, endometriosis, typically takes 5-10 years to be diagnosed; patients spend years being told there is nothing wrong with them.) And it fails to acknowledge that medical science is not finished; there are still some medical conditions that science doesn’t understand and can’t explain.

The consistency of SSD diagnoses is taken as evidence that these diagnoses are correct. The diagnosis of somatic symptom disorder is given at similar rates, and is reported in similar ways, by different doctors in different places. But all this shows is that, if the doctors are making a mistake, they’re all making the same mistake.

Anxiety: SSD is associated with higher than usual levels of anxiety. However anxiety is required for an SSD diagnosis, so this certainly doesn’t prove anything. In any case, we know that seriously ill people have higher levels of depression and anxiety than healthy people. And I’d imagine that many people find the experience of having their illness dismissed as SSD to be anxiety-inducing. There seems to be an assumption that anxiety contributes to causing the symptoms, but there is no evidence to back this up.

Unblinded trials with subjective outcome measures: I found quite a few unblinded trials which seemed to show that talk therapy benefited those diagnosed with SSD. If talk therapy really relieved the symptoms of SSD, this would indeed be evidence that the symptoms have psychological causes. However, while these trials did have control groups, the control groups received ‘treatment as usual,’ which amounts to no treatment at all. The patients knew which group they were in, and the experimental group received a treatment while the control group did not. We know that any group of patients who are given therapy of any type will report improvement; this is known as the therapy effect, similar to the placebo effect.

Furthermore, these trials had subjective rather than objective outcome measures. In the trials I looked at the outcome measure was a survey. This is not ideal because people who have received a treatment often feel that they ‘should’ feel better; they almost feel obligated to say that they have improved. Combined with the lack of blinding, this amounts to a very poor study design. It reminds me of the deluge of poorly-designed clinical trials which for years seemed to show (wrongly) that ME/CFS could be treated with counseling and exercise.

Different standards for psychology than for biomedical research

Unfortunately, the standards for what is considered acceptably rigorous research are much lower in psychology than in medicine. Because of this, symptoms which biomedical science cannot explain, are easily ‘explained’ by sloppily-designed psychology studies. This gap in scientific rigour seems to be the place where somatic symptom disorder lives.

In conclusion

Doctors pride themselves on practising medicine in a way that is scientific and evidence-based. However medical students and doctors don’t have time to conduct an evidence review to check that everything they’re taught has a sound scientific basis. They simply assume that everything they’re taught is true.

Somatic symptom disorder is included in medical textbooks, medical training, and clinical guides as if it was a medical and scientific fact. However it has no real scientific basis. It is, more or less, a repackaging of the old, sexist idea of hysteria.

Medicine refuses to accept that anything is unexplained, so it dumps everything that is not understood in the ‘psychosomatic’ bin.

No doctor wants to admit that they don’t understand their patient’s symptoms and don’t know how to help. By believing that everything they don’t understand is psychosomatic, doctors save themselves the discomfort of accepting that there are limits to medical understanding in general, and to their own knowledge in particular.

Doctors’ belief in the existence of SSD undoubtedly contributes to patient dismissal, psychologization and medical gaslighting, all of which can cause tremendous harm.

Medicine tends to dump everything it doesn’t understand in the ‘psychosomatic’ bin. Image: Purple Plastic Box Filled With Paper by qubodup, OpenClipArt.org

References

1. D’Souza RS, Hooten WM. Somatic Symptom Disorder. [Updated 2023 Mar 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532253/

2. Löwe B, Levenson J, Depping M, Hüsing P, Kohlmann S, Lehmann M, Shedden-Mora M, Toussaint A, Uhlenbusch N, Weigel A. Somatic symptom disorder: a scoping review on the empirical evidence of a new diagnosis. Psychol Med. 2022 Mar;52(4):632-648. doi: 10.1017/S0033291721004177. Epub 2021 Nov 15. PMID: 34776017; PMCID: PMC8961337.

3. Town JM, Abbass A, Campbell S. Halifax somatic symptom disorder trial: A pilot randomized controlled trial of intensive short-term dynamic psychotherapy in the emergency department. J Psychosom Res. 2024 Dec;187:111889. doi: 10.1016/j.jpsychores.2024.111889. Epub 2024 Aug 22. PMID: 39241562.

4. Wang Y, Li L, Huang L, Ma J, Zheng L, Fritzsche K, Leonhart R, Toussaint AC, Schaefert R, Zhang L. Integrative group psychotherapy for patients with somatic symptom disorder: A randomized controlled trial. Psychiatry Res. 2024 Jan;331:115660. doi: 10.1016/j.psychres.2023.115660. Epub 2023 Dec 3. PMID: 38061179.