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This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
Key points
- Physical symptoms + disproportionate, persistent thoughts/anxiety about health + excessive time/energy devoted to health concerns
- Replaced older terms: somatisation disorder, hypochondriasis, medically unexplained symptoms (MUS)
- Diagnosis does NOT require absence of medical explanation — the focus is on the disproportionate response to symptoms
- Management: therapeutic relationship, biopsychosocial formulation, CBT, graded activity, regular scheduled appointments
- Avoid: excessive investigations, dismissive attitudes ("it is all in your head"), and unhelpful reassurance loops
- Comorbid depression and anxiety are very common and should be treated
Overview
Somatic symptom disorder (SSD) is characterised by one or more distressing physical symptoms (e.g. pain, fatigue, GI symptoms, neurological symptoms) accompanied by excessive and disproportionate thoughts, feelings, or behaviours related to the symptoms. Importantly, the diagnosis focuses on the degree of distress and preoccupation rather than whether the symptoms have a medical explanation — symptoms may or may not be medically explained. This represents a shift from the older concept of "medically unexplained symptoms." In DSM-5, SSD replaces somatisation disorder and incorporates elements of hypochondriasis (health anxiety). Functional neurological disorder (FND) and illness anxiety disorder are related but distinct conditions.
Epidemiology
Medically unexplained or functional symptoms account for up to 30–50% of all GP and outpatient consultations. Somatic symptom disorder affects approximately 5–7% of the general population. It is more commonly diagnosed in women and in lower socioeconomic groups. Risk factors include childhood adversity, somatising family culture, alexithymia (difficulty identifying and expressing emotions), chronic physical illness, and comorbid anxiety or depression. Patients with SSD are high healthcare utiliser — they consult frequently, undergo numerous investigations, and may receive multiple diagnoses.
Clinical Features
Symptoms
Persistent physical symptoms: pain, fatigue, GI symptoms, neurological symptoms (dizziness, numbness, weakness)
Disproportionate and persistent thoughts about the seriousness of symptoms
Persistently high level of anxiety about health or symptoms
Excessive time and energy devoted to symptoms or health concerns
Frequent medical consultations and investigations seeking reassurance
Significant functional impairment: work, social activities, daily functioning
Reassurance from negative investigations provides only temporary relief
Signs
Multiple previous investigations and specialist referrals with no definitive diagnosis
Symptoms may not follow typical anatomical or physiological patterns
La belle indifference: apparent unconcern about symptoms (in some cases — not reliable)
Signs of anxiety or depression on MSE
Investigations
First-line
Clinical assessmentThorough history: symptom description, timeline, impact, health beliefs, previous investigations, psychosocial context. Avoid repeating investigations already done
Focused physical examinationAppropriate examination to exclude red flags — but avoid excessive/repeated investigation which reinforces health anxiety
PHQ-15Patient Health Questionnaire (somatic symptom severity): ≥10 moderate, ≥15 high severity
Second-line
Screen for comorbidityDepression (PHQ-9), anxiety (GAD-7) — present in majority of patients with SSD
Specialist
Specialist assessmentLiaison psychiatry or psychology — for complex or treatment-resistant cases
1
Therapeutic relationship
- Validate the symptoms as real — they are genuinely experienced even without a medical explanation
- Avoid dismissive language ("nothing wrong", "all in your head") — this is harmful and destroys therapeutic alliance
- Regular, scheduled appointments (not crisis-driven) — reduces anxiety and inappropriate healthcare use
- Single named clinician (usually GP) to coordinate care and avoid conflicting messages
2
Biopsychosocial formulation
- Explain symptoms using a biopsychosocial model: physical, psychological, and social factors all contribute
- Shift from "finding the cause" to "managing the symptoms and improving function"
- Negotiate shared management goals — improving quality of life and function rather than symptom elimination
3
Psychological intervention
- CBT: first-line psychological therapy — addresses health beliefs, safety behaviours, avoidance, and deconditioning
- Graded activity and exercise programmes — rebuild confidence and physical function
- Mindfulness-based approaches may help with symptom management
4
Pharmacotherapy
- Treat comorbid depression/anxiety with SSRI per standard guidelines
- Low-dose antidepressants (amitriptyline, duloxetine) may help with functional pain syndromes
- Avoid opioids and benzodiazepines — risk of dependence without benefit
Complications
- Iatrogenic harm: Excessive investigations, unnecessary surgery, polypharmacy — significant risk
- Functional impairment: Unable to work, social withdrawal, disability
- Depression and anxiety: Very common comorbidity — worsens functional symptoms
- Doctor-shopping: Multiple specialist opinions, conflicting advice, reinforcing illness behaviour
- Opioid dependence: If chronic pain is managed with opioids without addressing psychological factors
UKMLA Exam Tips
- 1SSD focus is on DISPROPORTIONATE response to symptoms — not on whether symptoms are medically explained
- 2Avoid excessive investigation — each negative test provides only temporary reassurance and reinforces the cycle
- 3Regular SCHEDULED appointments (not symptom-driven) are the cornerstone of primary care management
- 4CBT is first-line psychological therapy — targets health beliefs, catastrophising, avoidance, and safety behaviours
- 5Always validate symptoms as real — dismissiveness destroys the therapeutic relationship and worsens outcomes
- 6La belle indifference is NOT reliable for diagnosis — many patients with genuine neurological disease show this
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