# Clinical Cases: Somatic Symptom and Dissociative Disorders ## 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 --- ## Case 2: Conversion Disorder (Functional Neurological Symptom Disorder) ### Patient Demographics - **Age:** 28 years old - **Sex:** Female - **Occupation:** Elementary school teacher ### Chief Complaint "I can't walk. My legs just stopped working." ### History of Present Illness The patient is a 28-year-old woman who presents with acute onset of bilateral leg weakness that began 5 days ago. She reports waking up and being unable to stand. She denies any preceding injury, illness, or trauma. Neurological evaluation in the ED including CT and MRI of the brain and spine was unremarkable. Nerve conduction studies and EMG were normal. She was admitted for further workup, which has remained negative. On further psychiatric history, the patient reveals that she had a significant argument with her fiance 6 days ago (the night before symptom onset) during which he disclosed he had been unfaithful. The wedding was scheduled for 3 weeks from now. She describes feeling "paralyzed" by the news and unable to decide what to do. She has no conscious awareness of a connection between the argument and her symptoms. She appears remarkably calm when discussing her inability to walk ("la belle indifference") but becomes tearful when discussing the relationship conflict. ### Neurological Examination **Motor Examination:** - Bilateral leg weakness (0/5 strength on initial testing) - Hoover's sign positive: Involuntary hip extension noted in the "weak" leg when testing hip flexion of the contralateral leg - Give-way weakness: Initial resistance followed by sudden collapse - Inconsistency: Patient observed to move legs when repositioning in bed when she believes she is not being observed **Sensory Examination:** - Reports complete numbness below the waist - Sensory loss splits exactly at midline (non-anatomic) - Vibration sense "absent" at iliac crest but present at sternum (anatomically implausible) **Reflexes:** Normal and symmetric throughout **Other:** - Gait: Unable to attempt - Coordination: Unable to assess in legs - No bowel or bladder dysfunction ### Mental Status Examination **Appearance:** Young woman in hospital gown, lying flat, legs motionless **Behavior:** Cooperative, calm demeanor despite severe symptoms **Speech:** Normal rate, rhythm, and volume **Mood:** "Okay, I guess" **Affect:** Incongruent with situation - calm and occasionally smiling despite paralysis ("la belle indifference") **Thought Process:** Linear, goal-directed **Thought Content:** - Focus on physical symptoms - Distress about relationship conflict when explored - No suicidal ideation - No psychotic symptoms **Insight:** Limited regarding connection between psychological stressors and physical symptoms **Judgment:** Fair - accepting of evaluation and treatment ### Diagnosis **Conversion Disorder (Functional Neurological Symptom Disorder) with Weakness (F44.4)** **DSM-5 Criteria Met:** A. One or more symptoms of altered voluntary motor function (bilateral leg weakness) B. Clinical findings provide evidence of incompatibility between symptom and recognized neurological conditions: - Positive Hoover's sign - Give-way weakness - Inconsistency between examination and observed function - Non-anatomic sensory findings C. Symptom not better explained by another medical or mental disorder D. Symptom causes clinically significant distress or impairment **Note:** Diagnosis made based on positive clinical findings of incompatibility, not simply absence of medical findings ### Treatment Plan **Communication of Diagnosis:** - Explain that symptoms are real and not "faked" - Use positive language: "The good news is your nervous system is intact. The problem is a software issue, not a hardware issue" - Explain that the brain is having difficulty sending the correct signals to the legs - Emphasize that this is a recognized, treatable condition **Physical Therapy:** - Core treatment for motor conversion symptoms - Graduated exercises with positive reinforcement - Focus on function rather than impairment - Avoid reinforcing sick role **Psychotherapy:** - Explore relationship stressors and emotional processing - Address decision-making regarding wedding - Supportive therapy initially, transitioning to insight-oriented work **Pharmacotherapy:** - Consider SSRI if comorbid depression or anxiety identified - Currently not indicated as primary treatment **Prognosis Discussion:** - Generally favorable with early intervention - Explain that recovery typically occurs over days to weeks with appropriate treatment - Avoid suggesting symptoms are permanent **Follow-up:** - Daily physical therapy - Psychiatry follow-up in 1 week - Discharge planning when ambulatory --- ## Case 3: Dissociative Identity Disorder ### Patient Demographics - **Age:** 34 years old - **Sex:** Female - **Occupation:** Freelance graphic designer ### Chief Complaint "I keep losing time. Hours go by that I can't account for, and I find things I don't remember doing." ### History of Present Illness The patient is a 34-year-old woman presenting for evaluation of dissociative symptoms. She reports experiencing significant gaps in memory for several years that have recently worsened. She describes "coming to" in unfamiliar locations, finding purchases she doesn't remember making, and discovering writings in her journal in handwriting that is slightly different from her own. She reports that friends and coworkers have told her she sometimes acts "like a completely different person" - more outgoing or more childlike - and she has no memory of these episodes. She has found herself addressed by different names by people who claim to know her. The patient has a documented history of severe childhood trauma, including physical and sexual abuse by a family member from ages 5-12. She was removed from the home at age 12 and placed in foster care. She reports that she has always had "blank spots" in her childhood memories and has never felt like she had a continuous sense of self. During the interview, the patient's demeanor shifts noticeably. Her voice becomes higher-pitched, her body language more childlike, and she refers to "the others" who "help protect the body." This alter state identifies as "Lily" and describes the function of keeping traumatic memories separate. After approximately 15 minutes, the patient's demeanor shifts back, and she has no memory of what was just discussed. ### Mental Status Examination **Appearance:** Initially appropriately dressed professional woman; during switch, posture and mannerisms become childlike **Behavior:** Initially guarded, becomes more open; observable switch in identity states during interview **Speech:** Variable - initially measured and professional; childlike pitch and vocabulary during alter state **Mood:** "Confused and scared" (host); "Okay, I'm just meeting you" (alter) **Affect:** Anxious, shifts dramatically during identity switches **Thought Process:** Linear during host state; more concrete and childlike during alter state **Thought Content:** - Distress about memory gaps - No current suicidal ideation (though history of self-harm) - No homicidal ideation - No apparent psychotic symptoms **Perceptions:** Reports hearing voices "inside my head" (distinct from external hallucinations) that comment on actions or argue among themselves; recognized as internal **Cognition:** Oriented to person, place, time; amnesia for alter states **Insight:** Developing - beginning to understand the dissociative nature of symptoms **Judgment:** Good - seeking help appropriately ### Diagnosis **Dissociative Identity Disorder (F44.81)** **DSM-5 Criteria Met:** A. Disruption of identity characterized by two or more distinct personality states (observed switch during interview, described "others") B. Recurrent gaps in recall of everyday events, important personal information, and/or traumatic events inconsistent with ordinary forgetting (significant time loss, amnesia for alter states) C. Symptoms cause clinically significant distress or impairment (difficulty maintaining employment, relationships, daily function) D. Disturbance not a normal part of cultural or religious practice E. Symptoms not attributable to substance use or medical condition **Comorbid Conditions:** - PTSD (likely, requires formal assessment) - History of non-suicidal self-injury ### Treatment Plan **Safety Assessment:** - Assess each identity state for suicidal or self-harm urges - Develop internal communication for safety - Create safety plan that all parts can access **Psychotherapy - Phase-Oriented Treatment:** 1. **Phase 1 (Stabilization):** - Establish safety and therapeutic alliance - Develop grounding techniques for dissociative episodes - Improve internal communication between identity states - Build affect regulation skills 2. **Phase 2 (Trauma Processing - future):** - Only after stabilization is achieved - Careful, paced processing of traumatic memories - Coordination among identity states 3. **Phase 3 (Integration - future):** - Working toward unified sense of self - Integration of identity states (not forced, but facilitated) **Pharmacotherapy:** - Sertraline 50 mg daily for comorbid PTSD symptoms - No medication specifically treats DID, but can address comorbid conditions **Grounding Techniques:** - 5-4-3-2-1 sensory grounding - Ice cube technique for acute dissociation - Safe place visualization **Follow-up:** - Weekly individual therapy with trauma-specialized therapist - Psychiatry monthly for medication management - Consider group therapy for trauma survivors when stabilized --- ## Image Attribution ![Dissociative Disorders Illustration](case_01_image.jpg) *Image: Medical illustration depicting the conceptual framework of dissociative disorders and the relationship between trauma, dissociation, and symptom development. Source: Wikimedia Commons. Used for educational purposes under Creative Commons license.*