Core diagnostic features

• One or more somatic symptoms that are distressing or disrupt daily life.
• Excessive and disproportionate thoughts, anxiety or time/energy devoted to the symptoms (persistent preoccupation >6 months may be present).
• Symptoms may be present with or without identifiable medical condition—the key is the maladaptive response and impairment.

Common presentations

• Chronic pain syndromes (fibromyalgia‑like), persistent fatigue, functional GI symptoms (IBS‑like), non‑cardiac chest pain, and unexplained neurological complaints.
• High healthcare utilisation, frequent appointments, multiple investigations and frustration for clinicians and patients.

Assessment checklist

1. Comprehensive history: onset, course, triggers, symptom beliefs, health behaviours (checking, doctor‑shopping), prior investigations and treatments.
2. Focused physical examination and targeted investigations for red flags—avoid repetitive testing once serious causes excluded.
3. Mental health screen: depression, anxiety, PTSD, panic, and substance use; assess for coexisting somatic disorders (e.g., functional neurological disorder).
4. Functional assessment: work/school impact, activity limitation, and social consequences; quantify using standardized measures when available.

Differential diagnosis

• Rule out primary medical causes; differentiate from illness anxiety disorder (preoccupation with having disease despite minimal symptoms), factitious disorder, and malingering.
• Consider overlap with mood/anxiety disorders—treating these often reduces somatic preoccupation.

Management principles

1. Validate: acknowledge real suffering and avoid implying symptoms are “fake.” Build therapeutic alliance.
2. Agree a care plan: appoint a single clinician as coordinator, limit unnecessary investigations, schedule regular follow‑ups and set functional goals.
3. Treat comorbid psychiatric conditions: manage depression, anxiety and PTSD actively—this often improves somatic distress.
4. Use evidence‑based therapies: CBT adapted for somatic symptoms, ACT and mindfulness, and graded functional rehabilitation for pain/fatigue.

Cognitive behavioural strategies

• CBT targets catastrophic interpretations, reassurance‑seeking, avoidance and unhelpful behaviours. Key techniques: behavioural experiments, activity scheduling, pacing, and cognitive restructuring.
• Use brief CBT modules in primary care where specialist access limited—focus on symptom management, sleep, and graded activity.

Rehabilitation & functional recovery

• Physiotherapy and OT focusing on graded activity, pacing and return‑to‑work strategies rather than symptom elimination alone.
• Set measurable, activity‑based goals (e.g., minutes walked, work hours) and monitor progress with diaries and objective metrics.

Pharmacologic approaches

• No medication treats SSD specifically—use pharmacotherapy to treat comorbid depression/anxiety (SSRIs/SNRIs) and consider low‑dose antidepressants for chronic pain where evidence supports.
• Avoid long‑term opioids and benzodiazepines; where present, develop a collaborative taper plan to reduce harm and dependence.

When to escalate / red flags

• New focal neurological signs, unexplained weight loss, haemoptysis, severe chest pain, or other features suggestive of serious organic disease—urgent medical review required.
• Severe depression, active suicidal ideation or rapid functional decline—urgent psychiatric input required.

Key takeaways

• SSD is defined by excessive thoughts/behaviours about distressing somatic symptoms—management emphasises validation, limiting unnecessary tests, CBT and graded rehabilitation to restore function.
• Coordinate care with a named clinician, treat comorbid mental health conditions, and use measurable activity goals to track recovery.
• Escalate urgently for red flags or significant psychiatric risk and involve multidisciplinary teams for complex or refractory cases.