Past case 3: somatic symptom disorder

Question 1

You are a GP and are asked to see Jalena, a 25 year old university student who presents frequently to your practice with a variety of non-specific symptoms including fatigue, chest pain, palpitations, shortness of breath and gastrointestinal pain. She lives at home with her parents who are refugees from the former Yugoslavia. She presents today with headaches, pins and needles and dizziness and requests an MRI. She is convinced that she has a brain tumour and concedes to also feeling very stressed by her conflicting pressures from uni, work in the family restaurant and at home, caring for her disabled mother, who recently had surgery for chronic back pain which originated from war related traumatic injuries. Despite extensive investigations, no physical cause has ever been found for Jalena’s symptoms. She is a social drinker, and uses no illicit drugs. When she has time, she enjoys going out with friends. She eats and sleeps well most of the time and takes no medication other than paracetamol. She has previously rejected referral to a psychologist or psychiatrist, which she interpreted as the doctor dismissing her complaints as “all in my head”.

Answer 1

Impression
Summarise the case - aka repeat back to examiner the salient features, then lead into provisional diagnosis.
Given variety of physical symptoms with no medical cause, this is most likely a presentation of somatic symptom disorder.

Key differentials to consider in this presentation including

• hypochondriasis (illness anxiety disorder): given concerns regarding physical health, suggesting of brain tumour (catastrophising)
• Anxiety disorder: panic attack/disorder, GAD, social phobia, PTSD (given immigration and past trauma/conflict), OCD
• Conversion disorder (altho no significant neurological symptoms except for parasthaesia and dizziness)
• Mood disorders: MDD, melancholic, psychotic
• rule out psychosis and other psychotic disorders (esp delusional disorder)
• consider co-morbidities and SUD as potentially implicated in this presentation
• also consider potential personality disorder as explanation for recurrent presentation, in particular cluster A (anxious) personality disorder
• rule out malingering disorder/factitious (Munchausen’s) syndrome

Priorities
Would want to conduct a complete psychiatric H/E/I in order to fully assess this patient and the presentation. Given previous attempts at engaging patient with psychiatric services, would need to carefully invest in therapeutic alliance, ensure patient feels heard and concerns are addressed, would need to attend to psychoeducation and utilise a non-judgemental approach. Also need to rigorously exclude any organic/physical cause for presentation and treat accordingly

Question 2

Somatic symptom disorder - History

Answer 2

History

• characterise sx, duration, any past diagnoses, treatments administered, what worked what hasn’t. ask about specific neurological symptoms
• ask about specific concerns for health (brain tumour), characterise onset and severity.
• Ask about impact of the symptoms on the patients life and functioning - qualitative severity assessment
• screen for mood disturbance, psychotic, manic, suicidal features of presentation
• risk assessment: TOSH, SI
• PMHx: need to rule out red-flag causes of current presentation. would conduct a general systems review In order to rule out any organic causes of the presentation
• ask about psych risk factors: trauma, immigration, other developmental (education, work, relationships)
• Fam Hx
• Substances
• Developmental
• Forensic
• Social: work, home life, relationships

Utilise symptom severity scale 8 (SS8) to assess the burden of the patients symptoms on their life and functioning.

Would want to acknowledge the patient’s physical and emotional suffering, as well as validate their symptoms and presentation and assure them that the potential presence of a psychiatric disorder doesn’t negate the reality of their suffering.

Question 3

Somatic symptom disorder - Examination

Answer 3

Examination
- General observation + vital signs + anthropometric measurements
- neurological examination (in particular, cranial nerves)
Mental State Examination
- A/B: defiance, preoccupation with psychical symptoms and complaints, incongruence (malingering/factitious)
- TC: preoccupation, TOSH, SI
- Insight: limited as not considering non-medical cause, not willing to engage (historically)

Question 4

Somatic symptom disorder - Investigations

Answer 4

Investigations
would be guided by previously conducted assessments, and level of suspicion for various organic causes of the presentation based on history and examination findings.

Any additional investigations should only be based on clinical signs, should be utilised judiciously:

• bedside: vitals + anthropometric + general obs
• bloods: dependent
• imaging: dependent

Question 5

Somatic symptom disorder - Management

Answer 5

Management
Safety/risk
- outpatient management with community mental health follow-up

Biological
Explain how one management option does involve the use of medications, but is not first line, as should try psychotherapy first to attempt to alleviate sx
- otherwise, same management plan as GAD: SSRI’s, SNRI’s, use bento’s if significant and severe emotional distress
- other meds to treat any co-morbid conditions as necessary, or to assist with substance use disorder/withdrawal

Psychological

• CBT: psychoeducation, investigate relationship between thoughts, emotions, and physical symptoms; graded exposure; de-arousal strategies
• psychodynamic therapy
• counselling
• psychoeducation
• ensure is it the same physician to prevent overuse of medical services, minimise referrals to any medical specialists, limit any further investigations which may validate misplaced patient concern.

Social

• support networks
• regular GP follow up and ultimate TOC