Somatic symptom disorder — structured clinical viva

This is a systems and alliance problem as much as a diagnostic one. The medical request to “tell him it is psychiatric” risks dualism and rupture. SSD formulation is compatible with keeping red-flag review open. Escalating diazepam/codeine and high utilisation signal iatrogenic and substance risk plus untreated depression/health-anxiety behaviours.[1][2][6]

1. Engage and validate. Symptoms real; goal is safety, function, and reducing suffering — not proving fakeness. Reflect anger about feeling dismissed.[2]

2. Diagnostic defence. DSM-5 SSD = distressing symptoms + disproportionate thoughts/feelings/behaviours; not defined by normal tests alone; medical disease can coexist. Differentiate IAD, FND, factitious/malingering carefully.[1]

3. Shared medical plan. Document what has been done, red-flag triggers for re-investigation, single coordinating clinician, stop unfocused cascades. This is collaborative C-L, not psychiatric ownership of all bodily symptoms.[2][6]

4. Psychological care. CBT for health anxiety/multi-symptom presentations (Barsky; CHAMP for medical settings); modest effect-size humility (Cochrane).[3][4][5]

5. Medication. Treat depression; deprescribe long-term benzodiazepine where safe; avoid opioid/benzo stack; pharmacological anti-somatoform evidence limited.[7]

6. Disposition. Scheduled outpatient reviews, crisis plan, risk assessment for suicide, GP letter with thresholds.[2][6]

Q: Does a normal MRI exclude serious disease forever?
No. Pattern change and red flags reopen work-up; SSD is not a permanent shield against new pathology.[2]

Q: Name psychological trial evidence.
Barsky CBT for hypochondriasis; Tyrer CHAMP CBT for health anxiety in medical patients; van Dessel Cochrane non-pharmacological synthesis.[3][4][5]

Q: What do you say to the medical team?
Frame both–and care, shared thresholds, and that pejorative “it’s psychiatric” dumps worsen outcomes and utilisation.[2][6]

Q: Medication first-line for “SSD itself”?
No robust first-line anti-somatic drug; treat comorbidity; limited Cochrane pharmacological signals.[7]