Psychiatry · Year 2 · from Psychiatry
Case 3: Somatic Symptom Disorder
Patient Presentation
Demographics: 48-year-old female
Chief Complaint: "My stomach has been hurting for 3 years and no one can figure out why. I know something is seriously wrong."
History of Present Illness: A 48-year-old woman presents with chronic abdominal pain that has persisted for 3 years. She describes the pain as constant, aching, and located throughout her abdomen. The pain "consumes her life" - she thinks about it constantly, spends hours daily researching possible causes online, and has seen over 15 specialists seeking an explanation. She has undergone extensive workup including 3 CT scans, 2 MRIs, 2 upper and lower endoscopies, multiple labs, and an exploratory laparoscopy - all essentially normal with only minor, non-specific findings. Despite reassurance from every physician that there is no serious disease, she remains convinced something is being missed. She checks her abdomen for lumps multiple times daily and keeps detailed symptom diaries. She has missed significant work and stopped socializing due to her symptoms and the time spent on medical appointments. She experiences significant anxiety about her health and fears she has undiagnosed cancer. She has comorbid depression. Her husband is frustrated with her constant focus on symptoms.
Physical Examination:
- Vital signs: Normal
- Abdomen: Soft, diffuse mild tenderness without localization, no masses, no organomegaly, normal bowel sounds
- All prior imaging and endoscopy reviewed - essentially normal
Mental Status Examination:
- Appearance: Well-groomed, anxious
- Behavior: Focused on physical symptoms, brought extensive medical records
- Mood: "Worried, frustrated"
- Affect: Anxious
- Thought content: Preoccupied with health concerns, fears of undiagnosed illness, no SI
- Insight: Limited - believes all prior doctors "missed something"
Workup:
- PHQ-15 (somatic symptom severity): Score 18 (high)
- PHQ-9: Score 14 (moderate depression)
- GAD-7: Score 12 (moderate anxiety)
- Review of extensive prior workup: No organic cause identified
Diagnosis: Somatic Symptom Disorder with predominant pain, severe, persistent
Treatment:
- Validated patient's suffering - "Your pain is real and significantly impacting your life"
- Explained diagnosis: The problem is not that nothing is wrong, but that the pain has become the center of her life with thoughts, feelings, and behaviors that have become excessive
- Treatment approach:
- Regular scheduled visits (every 2-4 weeks) rather than symptom-triggered visits
- Brief physical exam at each visit for reassurance
- Limit further diagnostic testing unless new objective findings
- Focus on function rather than symptom elimination
- Started duloxetine 30 mg, titrated to 60 mg (for pain, depression, and anxiety)
- Referral for CBT focused on:
- Reducing health-related anxiety
- Decreasing checking and reassurance-seeking behaviors
- Gradually increasing activities despite symptoms
- Cognitive restructuring of catastrophic health beliefs
- Physical therapy for deconditioning
- At 3-month follow-up: Pain unchanged but functional improvement
- No longer researching symptoms online; returned to part-time work
- Accepted that pain may persist but is not life-threatening
Clinical Pearl: Somatic symptom disorder emphasizes the excessive thoughts, feelings, and behaviors related to symptoms rather than the symptoms being "unexplained." Patients genuinely suffer and should be validated, not dismissed. Treatment involves regular scheduled visits (not just when symptomatic), limited testing, focus on function over symptom cure, and treating comorbid depression and anxiety. CBT addresses the cognitive and behavioral factors maintaining disability. The therapeutic relationship is essential - patients often feel invalidated by prior providers.
Clinical Image
Image Description: Diagram illustrating the multisystem medical complications of anorexia nervosa including: cardiac (bradycardia, hypotension, arrhythmias, QT prolongation), endocrine (amenorrhea, hypothermia, low T3), hematologic (leukopenia, anemia), musculoskeletal (osteoporosis), gastrointestinal (delayed gastric emptying, constipation), dermatologic (lanugo, hair loss, dry skin), and electrolyte abnormalities. Refeeding syndrome risk highlighted.
Attribution: Educational diagram of anorexia nervosa medical complications. For clinical teaching purposes.
Image Source: Create educational diagram or source from medical education resources on eating disorder complications