Management of Body Dysmorphic Disorder in Dermatology Cosmetic

Abstract

Somatic symptom disorder is prevalent in patients in various medical specializations, primary healthcare settings, and the general public. One psychiatric diagnosis that falls within the category of obsessive-compulsive disorder and related disorders is body dysmorphic disorder. The patient is fixated on a minor, imaginary defect in their look. The patient magnifies even the slightest irregularities, which causes them to feel guilty and embarrassed and has a detrimental effect on their lives. Patients with body dysmorphic disorder were more common in general care and dermatology clinics than in psychiatric settings. It is not, however, a commonly recognized idea in dermatologists’ daily clinical practice. Body dysmorphic disorder, a somatoform disorder also referred to as dysmorphophobia, is a non-dermatological condition that is frequently misdiagnosed and goes untreated.

1. Introduction

Somatic symptom disorder (SSD) is defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) as the co-existence of one or more physical symptoms and excessive time, energy, emotions, and behavior associated with a mental illness. These symptoms may or may not be connected to a health issue. Research has looked at risk factors such as chaotic living, early maltreatment, sexual assault, and a history of alcohol and drug misuse, even though the exact cause of SSD is still unknown. Axis II personality disorders, such as avoidant, paranoid, self-defeating, and obsessive-compulsive, have also been linked to significant somatization. Psychosocial stressors are also connected to poor job performance and unemployment [1].

2. Types of somatic symptom disorder

2.1 Somatoform disorder

Recurrent subjective feelings of physical symptoms (hereafter referred to as somatoform symptoms) that are not related to any physical disease are characteristic of somatoform diseases. Physical abnormalities alone cannot explain the type and severity of somatoform symptoms. Children with attention-seeking behavior are often affected [2]. A systematic study of studies in 24 countries found that the prevalence of somatoform diseases varied from 26.2 to 34.8% among primary care patients [3].

Stress is often a predisposing factor for somatoform disorders, acting as a trigger and cause of their development. Persistent symptoms of somatoform disease may be related to a person’s personality, early life experiences (difficulties faced during childhood), events encountered, persistent stress, coping mechanisms (inability to handle the demands of daily life), unhealthy lifestyle (abuse drugs, inactivity, irregular sleep patterns), can be accompanied by medical or psychological disorders and can also be cultural factors [4].

Short-term goals of the treatment of somatoform disorder are to reduce symptoms, stop increasingly useless medical procedures, maintain a reasonable level of medical care, and initiate activities appropriate to the patient’s age. The long-term goal is to be able to return to age-appropriate activities, be able to manage psychological and environmental stressors and provide appropriate—not excessive—medical care [4].

2.2 Hypochondriasis

According to the International Classification of Diseases, 10th Edition (ICD-10), hypochondriasis is a distinct disease characterized by obsession with the possibility of one or more severe and progressive bodily disorders. ICD-10 and DSM-4 classify this disease as a somatoform disorder. ICD-10 includes body dysmorphic disorder, which falls into the category of hypochondriac disease. The DSM-5 classifies hypochondriasis as an illness anxiety disorder (IAD) and puts it in the category of somatic symptoms and related disorders. According to reports, the prevalence of hypochondriasis ranges from 0.8 to 8.5% in primary care studies and between 0.02% and 7% in general population studies [5].

Treatment for this disease includes [2]:

First line: Cognitive Behavioral Therapy (CBT) for restructuring cognition, exposing oneself, and preventing reactions to address maladaptive behavior.

Second line: Mindfulness-Based Cognitive Therapy (MBCT) integrates aspects of CBT with mindfulness meditation. Acceptance as well as commitment therapy includes commitment to changing behavior, acceptance of frightened thoughts and feelings, mindfulness training, and value clarification.

Third line: Before putting prospective solutions into action, problem resolution therapy includes recognizing, describing, and weighing them. Treatments for relaxation include diaphragmatic breathing, progressive muscle relaxation, and release-only muscle relaxation. Time management, assertiveness training, problem-solving, and relaxation techniques are all incorporated into behavioral stress management.

2.3 Illness anxiety disorder

IAD is a psychiatric disease defined by excessive anxiety that one may have or acquire as a significant medical problem that is untreated. The name hypochondriasis was previously used but was updated in the DSM-5 due to its derogatory implications. People with IAD experience persistent worry or anxiety that is connected to a significant medical condition and interferes with their daily functioning. Even when the laboratory findings and physical examinations are normal, this worry nevertheless exists. Individuals with IAD mistakenly perceive bodily sensations like sweating or digestion as signs of a serious illness, leading them to overanalyze these experiences. IAD is typically a long-term illness. IAD sufferers may feel uneasy experiencing typical bodily feelings and they might diagnose little alterations in the body as abnormal. IAD may arise if a person is raised in a home where health issues are regularly mentioned or if their parents worry excessively about their well-being [6].

When given a negative diagnosis, patients with IAD typically do not feel satisfied and see several doctors for the same illness. They thought that their prior physician was incompetent, inattentive, or ignored their significant medical condition, which could have had deleterious results. Most IAD patients fit into one of two categories [6, 7]: 1. care-seeking type. These patients regularly switch doctors and take advantage of the healthcare system. They might ask for multiple tests and procedures. 2. avoidant of care. These people stay away from doctors. They are highly anxious and worried that either their primary care physician or laboratory tests will reveal a life-threatening condition (such as cancer). A general medical problem does not make an IAD diagnosis impossible.

Helping patients with illnesses or anxiety disorders overcome their health anxiety is the primary objective of their treatment. It is important to acknowledge the patient’s worries and anxieties. Avoid sayings such as “it is all in your head.” Patients may be referred to additional medical professionals as needed. Excessive use of medical systems, pointless imaging investigations, expert referrals, and laboratory testing should be avoided once major medical diseases have been ruled out and an IAD diagnosis has been made. Patients should make an appointment for routine follow-up visits with both their psychiatrist and primary care provider. Regular follow-up will cut down on emergency room or other physician visits. Additionally, the physician can critically evaluate new symptoms and related stresses and triggers. The initial course of treatment for IAD is psychotherapy. Behavior modification techniques are used in CBT, a form of psychotherapy, to correct a patient’s dysfunctional, maladaptive cognitive beliefs. This could help with the patient’s excessive body inspection habit for disease indicators [6].

Pharmacological treatments are the second-line therapy for IAD. Antidepressants, such as selective serotonin reuptake inhibitors (SSRI) and serotonin norepinephrine reuptake inhibitors (SNRI), are effective in treating this disorder. Patients who respond well to antidepressant therapy are encouraged to stay on maintenance care for a minimum of 6–12 months. Most individuals require both medicine and psychotherapy at the same time [8].

2.4 Body dysmorphic disorder

Body dysmorphic disorder (BDD), or dysmorphophobia, is defined by the DSM-5 as an obsession with perceived physical appearance problems that are invisible to others or very slightly noticeable. One’s ability to function in social, intellectual, professional, and other arenas is severely hampered by this fixation since it is so strong. These behaviors usually take a long time, are challenging to cease, and upset the person. An average of 3–8 hours will be spent on this activity each day. Though perceived physical faults are most frequently found in the skin, hair, or nose, they can impact any body part [9].

Throughout their lives, people with this disorder are typically obsessed with five to seven different body parts. BDD is the idea that one’s muscles are too tiny or insufficient. Obsessed with their fantasies, they gaze at the mirror for hours on end, frequently comparing themselves to others. These patients never seem content with their doctor’s advice or cosmetic outcomes and often have irrational expectations. A kind of BDD known as BDD via proxy occurs when an individual becomes fixated on the perceived physical shortcomings of other people. It suggests that various factors, including cognitive, psychological, cultural, and biological factors, contribute to the emergence of BDD [10].

Studies have indicated a possible connection between borderline personality disorder and parental emotional, physical, or sexual abuse or neglect. According to one study, those with BDD reported more traumatic early experiences than did healthy controls. Studies show that BDD is three to eight times more common in those with first-degree relatives with these diseases than in the general population, pointing to a potential hereditary component for BDD [11].

BDD affects 0.7% to 2–4% of the overall population. Individuals suffering from additional mental illnesses, such as obsessive-compulsive disorder (OCD), which has a frequency of 8–37%; social phobia patients, 11–13%; substance abuse patients, trichotillomania patients, and anorexia nervosa patients, have higher prevalences of BDD (2–35%). The gender ratio of men to women varies from 1:1 to 3:2 [12].

Among the diagnostic standards are [13]:

1. The person is fixated on one or more imperfections or physical abnormalities that are undetectable to others or only seem minor to them.

2. The person frequently checks himself in the mirror, gives his appearance excessive grooming, or compares it to other people’s appearances.

3. The practice seriously impairs one’s ability to operate in social, professional, or other domains.

4. The behavior does not fit the criteria for an eating disorder diagnosis.

Typically, BDD symptoms appear in early adolescence. Although the exact cause of BDD is unknown, the majority of its patients have a history of adverse childhood experiences about their body image. Insecurity about one’s physique can result from sociocultural factors, such as the exaggerated standards set by performers or models. The four subdivisions of the clinical picture are as follows: 1. issues with appearance; 2. obsessive behavior; 3. functional impairments; 4. a propensity for suicide and self-harm [14].

3. Management of body dysmorphic disorder in cosmetic dermatology

Schut et al. stated that BDD symptoms are more common in patients who come to dermatological practice. It was found that the average participation rate of invited dermatological patients from all 17 countries was 82.4% across all centers. Patients with dermatological issues had five times the prevalence of BDD symptoms (10.5% vs. 2.1%) compared to those with healthy skin controls. Compared to healthy skin controls, patients with dermatological conditions such as vitiligo, hyperhidrosis, and alopecia had an adjusted odds ratio (OR) > 11 times higher chance of experiencing BDD symptoms. Similarly, patients with psoriasis, acne, Hidradenitis Suppurativa, prurigo, and bullous diseases had an adjusted OR > 6 times higher chance of experiencing BDD symptoms. A logistic regression model revealed a significant relationship between BDD symptoms and female sex, lower age, higher psychological stress, and stigmatization sentiments [15].

Patients with BDD may experience a variety of dermatological problems relating to their skin and hair. Skin pigmentation, acne, scars, excessive body or facial hair, facial asymmetry, thinning scalp hair, and aging symptoms are a few of the issues that surface. They often claim to be highly stressed. They have a history of compulsive behaviors, such as spending hours staring at themselves in the mirror. These patients may also undergo cosmetic surgery, and no matter how nicely the process goes, most of them will never be satisfied with the way they look. It was also shown that women were more likely than men to compare themselves to others when they gazed in the mirror [16].

3.1 Obstacles a dermatologist or cosmetic surgeon may face

Patients with BDD frequently see dermatologists or cosmetologists as their primary point of care. Since many patients are reluctant to talk about the amount of distress they experience as a result of their perceived handicap, it can be difficult to diagnose and recognize BDD. Few people genuinely express their worries and hope that a specific cosmetic operation will significantly improve their lives by fixing obvious flaws. These patients are characterized as having irrational expectations and being “difficult” or “insatiable.” These patients also frequently seek the advice of several different physicians, hopping from one to the other until their demands are fulfilled, and their concerns regarding their looks are acknowledged [17].

According to research, some people experience no change at all from medical or surgical procedures intended to improve their appearance, and in certain situations, their problems even get worse. There are multiple accounts of BDD patients harming themselves or filing lawsuits against their physicians for failing to provide acceptable outcomes. The significance of screening patients for BDD or other mental diseases before undergoing medical or surgical intervention is underscored by all of this [18].

The BDD dermatology-questionnaire version (BDDQ-DV), created by Dufresne et al., is a straightforward, adapted method for screening dermatology outpatients. For determining whether BDD is present, this questionnaire has a specificity of 94.7%, sensitivity of 100%, positive predictive value of 70%, and negative predictive value of 100% [19].

The STEP approach, first presented by Elsaie, is another helpful resource for pre-procedure screening. Its use is not restricted to BDD screening, although it helps determine a patient’s psychological suitability for cosmetic intervention. “S” stands for stress, and medical professionals use a patient’s appearance and behavior to gauge their stress. The letter “T” stands for “target,” denoting the area of the body that will be operated on and whether or not the expected outcomes are reasonable. “P” stands for proactive, and “E” stands for envision, or how the patient believes their life will improve following the intervention [20].

Empathy is a vital tool in the counseling of BDD patients. Patients are already under a great deal of stress about their issues. Therefore, brushing them off as unimportant is not a good idea. But it is also not a good idea to concede that they are flawed in any way. Instead, attention should be directed toward understanding their issues, how they impact them, and what kinds of treatments may be provided to help people live better lives. It is also crucial to educate patients on the length of their therapy, the dosage, and any potential adverse effects of the drug they are taking [14].

3.2 Handling

After receiving cosmetic therapy, BDD patients’ quality of life (QOL) and self-esteem did not improve, according to research by Wang et al. Because of this, most dermatologists and plastic surgeons decide against treating these individuals in any way. Consequently, most people agree that BDD should be immediately referred for psychiatric management and regarded as a contraindication to cosmetic surgery. As a result, cooperation between these two disciplines is necessary to deliver high-quality treatment [21].

There are not any Food and Drug Administration (FDA) approved drugs for BDD at the moment; the study methodology used to get approval was likely insufficient. Empirical evidence supports first-line methods, including SSRIs, as research-based data is far more limited. Although not recommended by the FDA for BDD, SSRI and CBT are used as the initial treatment strategy in this condition [22].

3.2.1 Serotonin-reuptake inhibitors

Second-generation antidepressants also reduce obsessive thinking and compulsive behavior. Serotonin reuptake inhibitors (SRI) are frequently used to treat a variety of disorders, including major depressive disorder, panic disorder, social anxiety, bulimia, hypochondriasis, post-traumatic stress disorder, and binge eating disorder. SRI can also help with impulsive and anxiety symptoms; on rare occasions, they can even help with pain or violence. The SRI that are currently prescribed in the US are clomipramine (Anafranil), citalopram (Celexa), fluoxetine (Prozac), escitalopram (Lexapro), sertraline (Zoloft), fluvoxamine (Luvox), and paroxetine (Paxil) [22].

Prior studies have demonstrated a substantial increase in compulsive thinking about the objects experienced, a decrease in depressive and anxious symptoms, and an improvement in quality of life among participants in therapy. For BDD, larger dosages of SRI and at least a 12-week course of treatment are typically necessary. Additionally, BDD-related distress and worries about performance faults are lessened with SRI therapy [23].

Studies comparing various SRI dosages for BDD need to be improved; this kind of research is crucial. Our clinical experience suggests that SRI dosages for BDD should be somewhat more significant than those for depression. SRI dosages may be insufficient to treat BDD, if medical professionals solely address depression symptoms adequately. Phillips employed escitalopram 29 ± 12 mg/day, citalopram 66 ± 36 mg/day, fluoxetine 67 ± 24 mg/day, and fluoxetine 308 ± 49 mg/day as average doses in the clinical practice [22]. Some people may benefit from using SRI higher than the maximum dosages advised by the pharmaceutical firm, such as escitalopram 50 mg/day, citalopram 80–100 mg/day, fluvoxamine 400 mg/day, or fluvoxamine 300 mg/day. However, the dose of Clomipramine should not exceed 250 mg per day. Various factors will determine the speed of increasing the dose. For patients who are genuinely ill or suicidal, it is best to titrate more quickly; however, titration also depends on patient preference, how well the medication is tolerated, and how often they contact their doctor. It is difficult to judge whether lower doses are beneficial. However, slower titrations may have the disadvantage of being unnecessary and protracted. Based on the patient’s condition, SRI titration modifications must be made [24].

Typically, the effects of SRI take time to manifest and may take anywhere from 12 to 16 weeks. So, treatment should be carried out for more than 16 weeks. SRI therapy is effective if it is continued for several years or even longer. There are not any significant risks to continuing SRI for many years. Patients who experience relapse after SRI discontinuation are good candidates for long-term SRI treatment [22].

Patients who stop receiving effective SRI medication will relapse over the next 6 months; therefore, caution is required while ending SRI therapy [24]. In patients who frequently relapse, their function and QoL are significantly impaired [25]. Treatment discontinuation can occur for several reasons, such as side effects, lack of access to treatment, or the desire to be free from medication. SRI should, however, be decreased gradually over a few months rather than all at once. Do not think that if you get CBT while on an SRI, it will lessen your chance of relapsing after you quit the medication. Redistributing SRI did not elicit the same strong reaction as the initial trial [22].

The adverse effects may be connected to the dose size administered because the SRI used in BDD may be more than in other diseases. SRI side effects are frequently manageable and often go away with time. When first prescribed, patients should be made aware of this. It is necessary to modify the dosage if adverse effects arise. Sedation or activation, sleeplessness, gastrointestinal symptoms including nausea and delayed orgasm, and symptoms like vivid dreams or dizziness after stopping an SRI are some of the side effects that are linked to these medications. Therefore, titrating slowly up or down when adjusting the dose is a good idea [26].

3.2.2 Cognitive behavioral therapy

According to the cognitive-behavioral model for borderline personality disorder, individuals with BDD exhibit repetitive activities as coping methods, such as checking mirrors and avoiding social situations, and focus their entire sense of self-worth on insignificant appearance defects. CBT aims to help the patient overcome their problematic thought patterns and behaviors by using cognitive restructuring and psychoeducation. One to five CBT sessions per week, lasting one to one-and-a-half hours, are administered for several weeks. It can be given as group CBT or one-on-one [27].

Assessment of BDD and associated symptoms is the first step in CBT. Physicians ought to inquire about BDD-related diseases, thoughts, actions, and body parts of concern. Asking about BDD symptoms is crucial because shyness frequently prevents them from being recognized in clinical settings [28]. Clinical practitioners should be on the lookout for clues in the patient’s appearance (e.g., skin peeling scars) and behavior (e.g., wearing camouflage) to conceal the condition; what the patient finds disturbing (e.g., feelings when people talk about them, stare at them); panic attacks (e.g., when looking in the mirror); depression; social anxiety; drug abuse; suicidal thoughts; and inability to remain at home. Furthermore, in a systematic clinical interview, differential diagnoses such as depression, social anxiety, eating disorders, and obsessive-compulsive disorder should be clarified. It is essential to screen for depression and suicidality early in treatment and regularly due to the high incidence of both conditions in BDD patients.

Therapists should utilize motivational interviewing [29] approaches that have been adapted for use in borderline personality disorder with patients who are unwilling to undergo CBT or whose ideas seem excessively delusional. Instead of immediately challenging the patient’s views, the therapist should first show empathy for the patient’s misery connected to body image (“I see that you are suffering because you are very worried about your appearance”). Let us attempt to lessen this anxiety. Furthermore, non-judgmental Socratic inquiries such as “What are the benefits of trying CBT for BDD?” might be employed as delusional [30].

The therapist should then provide psychoeducation about BDD, including its frequency, typical symptoms, and the differences between body image and appearance. After that, based on the latter’s particular symptoms, the patient and the therapist develop a personalized BDD model. Theories concerning the biological, social, and psychological elements that lead to the development of body image problems are included in these models. It is critical to assess patients’ circumstances to determine what sustains their issues with body image. These elements include emotional reactions, triggers for unfavorable appearance-related beliefs, interpreting these thoughts, and (maladaptive) coping mechanisms. This will help determine the essential modules and the course of treatment. Cognitive strategies include recognizing, evaluating, and generating alternative beliefs. The therapist exposes the patient to common mental errors associated with BDD, like “mind reading” and “all-or-nothing thinking.” Following that, patients are urged to keep an eye on their thought processes based on how they seem inside and outside sessions and recognize cognitive errors [30].

Therapists can begin assessing the patient’s thoughts once they can recognize their cognitive errors and maladaptive thoughts. False core beliefs must be addressed after the patient recognizes and reframes instinctive ideas about their appearance. “I am incapable” or “I am unlovable” are typical core beliefs in BDD. In therapy, core beliefs often emerge. Cognitive restructuring, behavioral experiments, and self-esteem-building techniques effectively overcome negative underlying beliefs. These techniques teach patients to broaden the scope of their self-esteem beyond appearance values, such as ability, achievement, and morality [31].

The therapist and patient should review the patient’s BDD model before starting Preventing exposure and rituals (PE/R) to help identify the patient’s rituals (such as excessive mirror checking), avoidance behaviors (such as avoiding traveling the subway), and the purpose behind those rituals. Together, the patient and therapist create a hierarchy of anxiety-inducing and -avoidance circumstances. Patients frequently shy away from everyday tasks that can highlight their alleged shortcomings. Scenarios that will broaden the patient’s social experience in general should be included in the hierarchy. The therapist can advise going out twice a week with friends rather than shunning them on days when she thinks her nose is particularly “big” [32].

The patient typically concentrates solely on the area of his body that bothers him and is too near the mirror, exaggerating perceived flaws and perpetuating maladaptive BDD behaviors. Patients who undergo perceptual retraining are able to overcome incorrect impressions of their bodies and acquire healthy mirror-related behaviors (e.g., refraining from approaching mirrors too closely or avoiding them entirely). When the patient is standing a conversational distance away from the mirror—two to three feet, for example—the therapist assists them in describing their entire body, from head to toe. During perceptual (mirror) retraining, patients learn to describe themselves more objectively, such as “There is a small bump on the bridge of my nose,” as opposed to using judgmental language, such as “My nose is big and crooked.”

Therapists advise their clients not to engage in ritualistic behaviors like caressing or dozing off in uncomfortable spots. Patients are urged to work on focusing on other aspects of their surroundings, such as the flavor of the food and the conversations that they hear, rather than how they look or how other people seem [30].

Psychoeducation and cognitive behavioral techniques specifically designed to address shape/weight concerns are often beneficial for patients with considerable concerns about their appearance, including those with muscle dysmorphia. Therapists can assist patients in weighing the advantages and disadvantages of cosmetic surgery without passing judgment by using cognitive and motivational techniques to dispel maladaptive ideas about the benefits of surgery. Patients with BDD frequently experience depression, which might complicate their care [30].

3.2.3 Electroconvulsive therapy

Electroconvulsive therapy, or ECT, involves applying electricity to the brain. The main conditions that ECT is used to treat include schizophrenia, bipolar disorder, and major depressive disorder (MDD). ECT is not mentioned as a substitute treatment for OCD that is recalcitrant, albeit [33]. In reality, ECT-related deaths are a very rare event [34]. The primary reason is a deficiency of evidence-based data [35]. In recent years, ECT has drawn more interest as a treatment for OCD. In a prior trial, it was only judged to be helpful in two out of 25 instances and was limited to individuals with severe depression who were contemplating suicide. Surgical methods such as modified leukotomy, capsulotomy, subcaudate tractotomy, and bilateral anterior cingulotomy are the last resort when no other treatments work to relieve severe symptoms of BDD [23]. In individuals with BDD comorbidity, ECT may be safely used to treat a major depressive episode that is resistant to treatment. ECT potentially improves both depressive and body dysmorphic symptoms [36].

4. Conclusion

One way to think of somatization is as a process that essentially develops as a coping mechanism for stress. Somatosensory amplification is another idea where somatic sensations are perceived as severe, frightening, or unsettling. There are three components to somatization. (i) Hypervigilance (to bodily sensations); (ii) specificity (to weak sensations); and (iii) intensification (to make them more concerning) through affect and cognition. Recurrent subjective feelings of physical symptoms (henceforth referred to as somatoform symptoms) that are unrelated to any physical illness are the hallmark of somatoform diseases. One characteristic unites all these illnesses’ subtypes: the preponderance and persistence of somatic symptoms linked to significant suffering and impairment.

Most BDD patients first see a cosmetic outpatient because the disorder is underdiagnosed and misdiagnosed. When their demands are not met, they may feel unsatisfied with their cosmetic procedures and may resort to violence or take legal action against the practitioner. This illness highlights how crucial it is for dermatologists and cosmetic surgeons to understand BDD and be prepared with screening techniques to recognize cases as soon as possible and refer patients to a colleague who works in psychology. Consequently, to treat BDD patients holistically, the two specialists need to collaborate.

Acknowledgments

We would like to express our gratitude to Farida Ulfa for her timely and efficient collaboration. Her dedication, professionalism, and prompt response to queries have made the research process smoother and more efficient.

Conflict of interest

The authors declare no conflict of interest.

Appendices and nomenclature

BDD	body dysmorphic disorder
BDDQ-DV	BDD dermatology-questionnaire version
BSI	Bradford somatic inventory
CBT	cognitive behavioral therapy
DSM V	diagnostic and statistical manual of mental disorders, fifth edition
FDA	Food and Drug Administration
IAD	illness anxiety disorder
IAS	illness attitude scale
ICD-10	International Classification of Diseases, 10th Edition
MBCT	mindfulness-based cognitive therapy
PHQ-15	Patient Health Questionnaire-15
QoL	quality of life
SASS-R	the scale for assessment of somatic symptoms
SNRIs	serotonin and norepinephrine reuptake inhibitors
SRI	serotonin reuptake inhibitor
SSRI	selective serotonin reuptake inhibitor
SSD	somatic symptom disorder
SSS	somatic symptom scale
SSS-8	Somatic Symptom Scale-8
WI	The Whiteley Index