Psychiatry · Year 3 · from Psychiatry
Case 1: Somatic Symptom Disorder
Patient Demographics
- Age: 42 years old
- Sex: Female
- Occupation: Former administrative assistant, currently on disability
Chief Complaint
"My doctors keep telling me nothing is wrong, but I know something terrible is happening to my body."
History of Present Illness
The patient is a 42-year-old woman referred by her primary care physician for psychiatric evaluation after 3 years of multiple unexplained physical complaints. She reports chronic abdominal pain, headaches, fatigue, and intermittent numbness in her extremities. She has seen 8 different specialists over the past 2 years, including gastroenterology, neurology, rheumatology, and cardiology. Extensive workups including MRI of the brain and spine, upper and lower endoscopy, nerve conduction studies, and multiple blood panels have been unremarkable or revealed only minor, non-explanatory findings.
The patient spends 4-6 hours daily researching her symptoms online, frequently identifying new conditions she believes she may have. She keeps a detailed symptom diary and brings stacks of printed internet articles to medical appointments. She has been to the emergency department 12 times in the past year for acute exacerbations of symptoms. She expresses frustration that "no one is taking me seriously" and has difficulty accepting reassurance from negative test results. She has stopped most social activities, stating she "doesn't have the energy" and fears her symptoms will worsen if she exerts herself. Her husband reports significant marital strain due to her health preoccupation.
Past Psychiatric History
- Depression diagnosed 10 years ago, treated briefly with sertraline
- No prior psychiatric hospitalizations
- History of childhood physical illness requiring multiple hospitalizations (pneumonia, appendectomy)
Mental Status Examination
Appearance: Well-groomed woman, appropriate attire, brings large binder of medical records
Behavior: Cooperative but focuses persistently on physical symptoms, frequently references medical documentation
Speech: Normal rate and rhythm, detail-oriented when describing symptoms
Mood: "Frustrated and exhausted"
Affect: Anxious, tearful when discussing impact on her life, brightens when discussing hope for new diagnoses
Thought Process: Linear but ruminative, returns repeatedly to physical concerns
Thought Content:
- Preoccupation with health and somatic symptoms
- Belief that serious illness is being missed
- No suicidal or homicidal ideation
- No psychotic symptoms
Perceptions: No hallucinations; describes symptoms in great detail
Cognition: Alert and oriented; attention and concentration intact
Insight: Limited - attributes all distress to undiagnosed medical illness
Judgment: Fair - willing to attend psychiatric evaluation
Psychiatric Workup
Screening Tools:
- PHQ-15 (somatic symptoms): 18 (high)
- PHQ-9: 12 (moderate depression)
- GAD-7: 14 (moderate anxiety)
Prior Medical Workup (all negative or non-explanatory):
- MRI brain and spine: Normal
- EGD/colonoscopy: Mild gastritis only
- Nerve conduction studies: Normal
- ANA, RF, ESR, CRP: Normal
- TSH, CBC, CMP: Normal
Diagnosis
Somatic Symptom Disorder, Persistent, Moderate (F45.1)
DSM-5 Criteria Met: A. One or more somatic symptoms that are distressing or result in significant disruption of daily life (multiple - abdominal pain, headaches, fatigue, numbness) B. Excessive thoughts, feelings, or behaviors related to somatic symptoms manifested by:
- Disproportionate and persistent thoughts about seriousness of symptoms
- Persistently high level of anxiety about health
- Excessive time and energy devoted to symptoms and health concerns
C. Although any one symptom may not be continuously present, the state of being symptomatic is persistent (>6 months, currently 3 years)
Specifiers: Persistent (severe symptoms, marked impairment, >6 months); Moderate (2+ Criterion B features)
Treatment Plan
Psychoeducation:
- Validate that symptoms are real and cause genuine suffering
- Explain the mind-body connection without implying symptoms are "imaginary"
- Discuss the diagnosis in non-stigmatizing terms
- Set realistic goals focused on function rather than symptom elimination
Primary Care Coordination:
- Establish single primary care provider as coordinator
- Schedule regular appointments (every 4 weeks) rather than symptom-driven visits
- Limit further specialty referrals and testing unless clearly indicated
- Brief, focused physical exams at each visit
Psychotherapy - Cognitive Behavioral Therapy:
- Address catastrophic interpretations of bodily sensations
- Reduce body-checking and reassurance-seeking behaviors
- Graduated behavioral activation
- Stress management and relaxation techniques
Pharmacotherapy:
- Duloxetine 30 mg daily, titrate to 60 mg (addresses comorbid depression, anxiety, and may help with somatic symptoms)
- Monitor for improvement in mood and function
Follow-up:
- Psychiatry in 4 weeks
- Weekly CBT sessions
- PCP monthly for scheduled visits