Cardiovascular Somatic Symptom Disorder

When physical symptoms like chest pain or palpitations cause overwhelming distress despite medical tests showing little or no serious heart problems, you may be experiencing a condition where the mind and body are deeply connected in ways that affect daily life.

Table of contents

• What Is Somatic Symptom Disorder
• Cardiovascular Symptoms and Somatic Symptom Disorder
• How Common Is This Condition
• What Causes Somatic Symptom Disorder
• How Is It Diagnosed
• Treatment Options

What Is Somatic Symptom Disorder

Somatic symptom disorder (SSD) is a mental health condition in which a person experiences extreme focus on physical symptoms that causes major emotional distress and problems with daily functioning^[1]. You may or may not have another diagnosed medical condition associated with these symptoms, but your reaction to the symptoms is not normal.

The symptoms reported may have no medical explanation or be normal bodily sensations or discomfort. Even when a medical cause is there, the person’s anxiety is disproportionate to the symptom^[13]. The distress people experience from pain and other problems is real, regardless of whether or not a physical explanation can be found^[14].

Health concerns may become such a central focus of your life that it’s hard to function, sometimes leading to disability^[1]. People with this condition often think the worst about their symptoms and frequently seek medical care, continuing to search for an explanation even when other serious conditions have been excluded.

Cardiovascular Symptoms and Somatic Symptom Disorder

People with heart-related conditions frequently experience both disease-specific symptoms and general somatic symptoms. Research has shown that in patients with coronary heart disease, the most common somatic symptoms include trouble sleeping, feeling tired or having low energy, pain in the arms, legs, or joints, back pain, and shortness of breath^[3]. Interestingly, chest pain, one of the more disease-specific symptoms of heart disease, was reported by only 45.2% of patients, while five or more somatic symptoms were reported by at least 50% of patients.

In patients with myocardial bridge, a condition where heart muscle tissue covers part of a coronary artery, somatic symptom disorder is particularly relevant. These patients often experience chest pain accompanied by non-specific complaints^[2]. The number of somatic symptoms has been shown to correlate with functional impairment and decreased quality of life.

Cardiovascular-related symptoms in somatic symptom disorder can include palpitations (feeling like your heart is racing or pounding), dizziness, chest discomfort, and shortness of breath^[10]. These symptoms may persist even after medical tests show no serious heart condition, or they may seem much worse than what doctors would expect based on test results.

How Common Is This Condition

The prevalence of somatic symptom disorder in the general population is estimated at 5% to 7%, making it one of the most common categories of patient concerns in the primary care setting^[4]. An estimated 20% to 25% of patients who present with acute somatic symptoms go on to develop a chronic somatic illness.

Females tend to present with somatic symptom disorder more often than males, with an estimated female-to-male ratio of 10:1^[4]. These disorders can begin in childhood, adolescence, or adulthood. The condition is common across cultures and can begin as early as the preschool years^[5].

What Causes Somatic Symptom Disorder

The exact cause of somatic symptom disorder isn’t clear, but several factors may play a role. Somatic symptoms may result from a heightened awareness of certain bodily sensations, combined with a tendency to interpret these sensations as signs of a medical illness^[4].

Studies have determined that risk factors for chronic and severe somatic symptoms include childhood neglect, sexual abuse, chaotic lifestyle, and a history of alcohol and substance abuse^[4]. The condition has also been associated with personality disorders. People who have a history of physical or sexual abuse may be more likely to have this disorder, though not everyone with somatic symptom disorder has a history of abuse^[6].

Additional factors that may be involved include having a negative outlook, being more physically and emotionally sensitive to pain and other sensations, family history or upbringing, and genetics^[6]. Psychosocial stressors and culture also affect how patients present to the physician.

The brain plays an important role through what scientists call “predictive processing.” The brain constantly makes predictions about the most likely interpretation of sensory impressions. These predictions incorporate expectations, beliefs, and past experiences with symptoms, which unconsciously influence perception^[20]. This means expectations can play a role in perception for all patients, and in chronic illnesses, expectations may play a more significant role in symptom perception than in acute conditions.

How Is It Diagnosed

You will have a complete physical exam, and your doctor may do certain tests to find any physical causes of your symptoms^[6]. The types of tests that are done depend on what symptoms you have. This is important because physical symptoms can be related to medical problems, and it’s essential to rule out any serious conditions.

Your provider may refer you to a mental health professional who may conduct a psychological evaluation to talk about your symptoms, fears or concerns, stressful situations, relationship problems, and family history^[8]. They may also have you fill out a psychological self-assessment or questionnaire.

For a diagnosis of somatic symptom disorder, the following criteria must be met^[8]:

• You have one or more somatic symptoms (such as pain or fatigue) that are distressing or cause problems in your daily life
• You have excessive and persistent thoughts about the seriousness of your symptoms, you have a persistently high level of anxiety about your health or symptoms, or you devote too much time and energy to your symptoms or health concerns
• You continue to have symptoms that concern you, typically for more than six months, even though the symptoms may vary

In addition to a comprehensive clinical interview and assessment for diagnostic criteria, screening instruments such as the Patient Health Questionnaire-15 or the Somatic Symptom Scale-8 should be considered in patients with suspected somatic symptom disorder^[4].

Treatment Options

The goal of treatment is to improve your symptoms and your ability to function in daily life^[8]. Treatment can help ease symptoms, help you cope, and improve your quality of life. Having a supportive relationship with your provider is vital for your treatment^[6].

You should have only one primary care provider. This will help you avoid having unneeded, and sometimes potentially harmful, tests, procedures, and treatments^[6]. Your provider should schedule regular appointments to review your symptoms and how you are coping. Regular, non-invasive medical assessment reduces anxiety and limits health care-seeking behavior.

Psychotherapy

Cognitive behavioral therapy (CBT) is a type of talk therapy that can help treat somatic symptom disorder^[6]. This therapy is effective for the treatment of somatic symptom disorder^[4]. Working with a therapist can help relieve your pain and other symptoms. During therapy, you will learn to:

• Look at your feelings and beliefs about health and your symptoms
• Find ways to reduce stress and anxiety about symptoms
• Stop focusing as much on your physical symptoms
• Recognize what seems to make the pain or other symptoms worse
• Cope with the pain or other symptoms
• Stay active and social, even if you still have pain or other symptoms
• Function better in your daily life

Mindfulness-based therapy is also effective for treating somatic symptom disorder^[4]. These approaches help patients focus on the present moment and develop a different relationship with their symptoms.

Medications

You may take antidepressants to help reduce anxiety and depression^[6]. Selective serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants have been effective in alleviating symptoms^[4]. Amitriptyline and St. John’s wort are also effective pharmacologic treatments for somatic symptom disorder.

Other antidepressants (monoamine oxidase inhibitors, bupropion, anticonvulsants, and antipsychotics) are ineffective for the treatment of somatic symptom disorder and should be avoided^[4]. Your therapist will also treat depression or other mental health illnesses you may have.

Primary Care Management

The best-suited approach is stepped care with close cooperation of primary care, a somatic specialist, and mental health care professionals operating on the basis of a biopsychosocial model^[10]. This means integrating both physical and psychological factors in understanding and treating your symptoms.

Your primary care physician should inform you that the symptoms do not appear to be due to a life-threatening, disabling medical condition and should schedule regular visits for reassessment^[11]. The physician should accept your physical symptoms and not pursue a goal of complete symptom resolution. Instead, the focus should be on helping you remain active and limit the effect of symptoms on quality of life and daily functioning.

Referral to a mental health professional may be necessary when treatment by the primary care physician is ineffective^[4]. Tactful explanation and management of somatic symptoms and thoughtful timing of referral to behavioral health specialists are likely to strengthen the therapeutic relationship and maximize chances for treatment success^[12].