Psychiatry and Behavioral Health Rotation

Psychiatry: Somatic symptom disorder

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 1 somatic symptom(s) which are distressing to the patient or leads to a significant amount of 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

  1. One or more somatic symptoms that are distressing or result in significant disruption of daily life.
  2. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following:
  3. Disproportionate and persistent thoughts about the seriousness of one’s symptoms.
  4. Persistently high level of anxiety about health or symptoms.
  5. Excessive time and energy devoted to these symptoms or health concerns.
  6. 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 include 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 combinations 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.
Congratulations - you have completed Somatic Symptom Disorder. You scored %%SCORE%% out of %%TOTAL%%. Your performance has been rated as %%RATING%%
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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?
A
Discharge her from care
Hint:
Discharging a patient with somatic symptom disorder from care can lead to increased problems because of feelings of abandonment.
B
Establish a primary care provider
C
Send her directly to the ER
Hint:
Her chest pain is not consistent with angina, so its work-up is not emergent.
D
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.
E
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 physician the patient trusts.
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