Somatic symptom disorder

Question 1

You are a GP who is about to see Mrs Smith who is regarded as an “impossible patient”. She attends at least twice a week and has been seen by every doctor in the practice over the last 10 years. She complains of a whole variety of symptoms but no serious medical condition has ever been diagnosed. How would you assess and manage?

Answer 1

Impression
Given the long history of attending for medical assessment, the string of symptoms but no unifying diagnosis, this likely represents a form of somatic symptom disorder if the patient has had the symptoms for >6 months. Other somatic disorders to consider include
- conversion disorder (neurological sx)
- hypochondriasis

Would want to exclude factitious or malingering, and exclude substance abuse/medicaiton induced causes.
There are some key psychiatric presentations including
- MDD/melancholic
- GAD/
- Delusional disorder

Would be of course important to conduct full assessment of the patient, including psych Hx and MSE and to rule out true organic causes.

Question 2

Somatic symptom disorder - History

Answer 2

History

• sx: collate patients symptoms, time-frame they have occurred
• ask about beliefs: thoughts, feelings, behaviours relating to the symptoms
• utilise somatic symptom scale-8 (SSS-8) to assess the burden of the patients symptoms
• screen for anxiety disorders (GAD, OCD, etc)
• psych screen: mania, depression, psychosis, etc
• ask about stressors, recent illnesses (PMHx)
• Rest of psych history

Question 3

Somatic symptom disorder - Examination

Answer 3

Examination

• MSE
• Relevant physical examination according to her sx
• Formulation

Question 4

Somatic symptom disorder - Investigations

Answer 4

Investigations

• refer to previous test results
• only order if clinical suspicion or inconclusive previous test results
• use any further investigations judiciously

Question 5

Somatic symptoms disorder - Management

Answer 5

Management
In management of somatic disorders, the focus is on functioning rather than the symptoms themselves.
Treatments are psychological, only role for biologicals is co-morbid psychiatric/physical illness.

Psychological

• CBT
• Psychoeducation
• psychodynamic therapy

Biological

• Graded exercise therapy if chronic fatigue, or other MSK issues
• SSRI if treatment resistant, or indicated by other psychiatric illness

Social

• regular review
• GP referral, and regular follow-up
• minimise doctor shopping and referrals to specialists