Patient will present as → a 25-year-old female who presents today with multiple complaints that have been ongoing for more than 6 months. She reports that “it all started about 10 months ago with pain in my neck, shoulders, back, legs, and feet.” She denies any trauma. There is no family history of juvenile rheumatoid arthritis or osteoarthritis. She stated that the pains do not respond to treatments, and they “just come and go making it difficult to hold a job.” She is constantly worried about her symptoms. Now, she has a headache, abdominal pain, bloating and “some seizures.” She previously had seen a headache specialist, gastroenterologist, and obtained a number of electrocardiograms in the emergency department. Their respective thorough workup was negative. Her mother had similar episodes as well. On physical exam, you note an anxious woman with a depressed affect. No significant physical exam findings are noted. Labs/imaging are all within normal range.
Key Points:
- More than one somatic symptom that is distressing to the patient or causes significant disruption in the patient's life.
- The patient experiences excessive thoughts, feelings, and behaviors in relation to their somatic symptoms or their health concerns.
- The somatic symptom must be persistent for ≥ 6 months although these symptoms don't have to always be present
DSM-5 Diagnostic Criteria
- One or more somatic symptoms that are distressing or result in significant disruption of daily life.
- Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following:
- Disproportionate and persistent thoughts about the seriousness of one’s symptoms.
- Persistently high level of anxiety about health or symptoms.
- Excessive time and energy are devoted to these symptoms or health concerns.
- Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months).
Specify if:
- With predominant pain (previously pain disorder): This specifier is for individuals whose somatic symptoms predominantly involve pain.
Specify if:
- Persistent: A persistent course is characterized by severe symptoms, marked impairment, and long duration (more than 6 months).
Specify current severity:
- Mild: Only one of the symptoms specified in Criterion B is fulfilled.
- Moderate: Two or more of the symptoms specified in Criterion B are fulfilled.
- Severe: Two or more of the symptoms specified in Criterion B are fulfilled, plus there are multiple somatic complaints (or one very severe somatic symptom).
Treatment of somatic symptom disorder is multifactorial and includes the following:
- A clinician-patient relationship that is based on trust, empathy, and understanding.
- Patient’s somatic symptoms should not be dismissed as frivolous. It is important that the clinician acknowledges these symptoms and finds ways to mitigate them.
- Multiple visits should be arranged to properly monitor these symptoms as well. If possible, one clinician should be responsible for the management of care.
- Drugs that can be abused should be avoided.
Once the patient is ready to work on the root of the problems, one of these psychological therapies, or a combination, should be used: group therapy and hypnosis.
- Biofeedback behavioral therapy
- Social support from friends and family go a long way to mitigate somatic symptom disorder.
Flashcards ready when you areYou have opened several Quizlet sets recently. Loading this one only when needed helps prevent a temporary Quizlet limit.
Congratulations - you have completed Somatic Symptom Disorder.
You scored %%SCORE%% out of %%TOTAL%%.
Your performance has been rated as %%RATING%%
Your answers are highlighted below.
Question 1 |
A 27-year-old woman presents to her gynecologist for follow-up for irregular, painful menstrual cycles. She has undergone a complete workup, which is negative. She is very distressed about her condition and states that she thinks it's probably related to whatever is causing her bouts of generalized "weakness," which have been occurring about once a month for the last year and associated with a headache. She has a past medical history of several food intolerances and irritable bowel syndrome, both of which cause her significant abdominal pain and are managed by a gastroenterologist. She states that she's recently had episodes of chest pain, lasting 20-30 minutes, unrelated to exercise, and requests to be referred to both a cardiologist and a neurologist. On exam, she is a thin, athletic woman who appears healthy. What is the most appropriate next step in treatment?
Discharge her from care Hint: Discharging a patient with somatic symptom disorder from care can lead to increased problems because of feelings of abandonment.
| |
Establish a primary care provider | |
Send her directly to the ER Hint: Her chest pain is not consistent with angina, so its work-up is not emergent. | |
Refer her to a psychiatrist Hint: A psychiatrist or therapist may be very helpful to this patient, but she will likely be resistant to this referral initially since she believes her problems to be organic in nature. Instead, a primary physician should work on establishing a therapeutic relationship with her now.
| |
Refer her to both a cardiologist and a neurologist Hint: Although she may need to see these specialists eventually, a primary care physician should first evaluate her condition as a whole. Unnecessary specialist referrals in somatic symptom disorder can lead to iatrogenic harm from unnecessary diagnostic testing. |
Question 1 Explanation:
This patient has somatic symptom disorder. One of the most important steps in treatment for this disorder is regular (at least monthly) follow-up with a consistent primary care provider the patient trusts.
Question 2 |
A 45-year-old man with a known 10-year history of fibromyalgia presents to your clinic. He states that his chronic, widespread pain has become his entire focus. He spends several hours per day reading online forums about new and experimental treatments, is convinced his condition is progressively destroying his body despite reassurance, and has frequent, anxious thoughts about becoming completely disabled. This preoccupation has caused him to stop participating in social activities and has strained his marriage. According to DSM-5 criteria, what feature of this patient's presentation is essential to make a concurrent diagnosis of Somatic Symptom Disorder?
His physical symptoms are medically unexplained Hint: This is a criterion from the outdated DSM-IV definition of somatoform disorders. The DSM-5 explicitly allows for a diagnosis of SSD in the presence of a co-existing and explanatory medical condition like fibromyalgia. | |
His excessive thoughts, feelings, and behaviors related to his pain are disproportionate | |
His symptoms have been present for more than one year Hint: The DSM-5 specifies a duration of symptoms being persistent for typically more than six months. While his 10-year history meets this, it is not the key feature that allows the diagnosis in the context of a known medical disease. | |
He is "doctor shopping" for a cure Hint: "Doctor shopping" can be a manifestation of the excessive behaviors seen in SSD, but it is a behavior, not the core diagnostic criterion itself. The criterion is the broader category of excessive thoughts, feelings, or behaviors. | |
His fibromyalgia is objectively worsening on physical exam Hint: The diagnosis of SSD is based on the patient's psychological and behavioral response, not on the objective severity or progression of the underlying physical condition. A person with stable fibromyalgia can still develop SSD if their psychological response becomes excessive. |
Question 2 Explanation:
This question highlights a key feature of the DSM-5 diagnosis of Somatic Symptom Disorder (SSD). A crucial change from previous diagnostic frameworks is that SSD can be diagnosed in a patient who has a well-established medical condition (like fibromyalgia). The diagnosis is not based on the symptoms being "medically unexplained," but rather on the patient's psychological and behavioral response to them. The essential feature that allows for the diagnosis of SSD in this case is that his thoughts (convinced his body is being destroyed), feelings (anxiety), and behaviors (excessive research, social withdrawal) related to his pain are excessive, disproportionate, and cause significant functional impairment. This psychological and behavioral component is the core of the SSD diagnosis, regardless of the presence of an underlying medical condition.
Question 3 |
A 38-year-old teacher diagnosed with somatic symptom disorder continues to experience multiple somatic complaints despite 4 months of regularly scheduled primary care visits. She has comorbid generalized anxiety disorder and reports that her physical symptoms interfere with teaching. She continues to decline psychiatric referral. She has no substance use history. What is the most appropriate next step in management?
Refer for intensive medical workup at a tertiary care center Hint: Additional testing reinforces illness behavior and rarely provides lasting reassurance | |
Start sertraline at a low dose with gradual titration | |
Prescribe lorazepam for symptom relief Hint: Benzodiazepines risk dependence and don't address underlying disorder; should be avoided | |
Recommend she take medical leave from teaching Hint: Encourages sick role; treatment should focus on maintaining function | |
Schedule visits only when new symptoms arise Hint: Regular scheduled visits are essential; symptom-contingent visits reinforce illness behavior |
Question 3 Explanation:
For treatment-resistant somatic symptom disorder with comorbid anxiety disorder, SSRIs are the most appropriate pharmacological intervention. Starting sertraline at a low dose (25-50mg) with gradual titration is crucial because these patients have somatic sensitivity and low threshold for perceiving side effects. Evidence shows SSRIs provide large clinical benefit for somatic symptoms, with improvement occurring three times more often than placebo. The medication addresses both the somatic symptoms and comorbid anxiety. Slow titration every 4 weeks minimizes adverse effects that could become new somatic complaints. Combined with continued regular visits, this approach optimizes outcomes while maintaining the therapeutic relationship.
Once you are finished, click the button below. Any items you have not completed will be marked incorrect.
There are 3 questions to complete.
|
List |