A 37-year-old white male comes to your office for evaluation of multiple complaints. He has seen three other physicians but has been dissatisfied with their treatment. He states that he has been in poor health for most of his adult life, and lists the following complaints: difficulty swallowing, palpitations, shortness of breath, impotence, difficulty urinating, vomiting, diarrhea, bloating, muscle weakness, joint pains, dizziness, fainting, poor vision, and headaches. A thorough physical examination reveals no physical cause for any of his complains. He sleeps well and has not lost any weight recently.
The most likely diagnosis is:
Correct Answer D:
Somatization disorder is the most likely diagnosis in problem patients who are not depressed or anxious. These patients claim to have been in poor health all their lives, but have not had any outward signs of disease or abnormal physical findings. According to DSM-IV-TR diagnostic criteria for somatization disorder, they must have at least 8 specific complaints lasting for at least 2 years and starting before the age of 30, with no evidence for other psychological disease such as panic attacks. Frequently seen complaints include vomiting, abdominal pain, painful extremities, shortness of breath, palpitations, amnesia, difficulty swallowing, a burning sensation in the sex organs, and painful menstruation.
Note:
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition does not use the term somatization, and has eliminated the category of diagnoses called somatoform disorders. For patients with prominent somatic symptoms that cause distress and impair psychosocial functioning, DSM-V has replaced the category of somatoform disorders with a category called somatic symptom and related disorders.
Which one of the following is a clinical feature of somatization disorder?
Correct Answer B:
The clinical features of somatization disorder include an onset in the teens or 20s, multiple unexplained symptoms, frequent concurrent psychiatric symptoms, drug and alcohol abuse, dramatic and emotional presentations, a history of multiple surgical operations, and providing imprecise and often inaccurate medical histories.
A 30-year-old female patient, who visits the urgent care clinic frequently, complains of a “burning sensation” during sexual intercourse. She has no pregnancy history and has a normal physical and pelvic exam. Her medical record indicates that she has been in for multiple physical complaints with no evidence of disease by repeated examinations. In order to make the diagnosis of somatization disorder, her complains over the past several years should consist of the following, except:
Correct Answer C:
ls with somatization disorder may experience symptoms of depression or anxiety; however, these symptoms are not always present and are not necessary for the diagnosis (choice C).
Somatization disorder is characterized by many somatic symptoms that cannot be explained adequately based on physical and laboratory examinations (choice B). Specific characteristics of somatization disorder include the following:
Every mental disorder has to be "clinically significant." (symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning). (choice D)
A 24-year-old female patient presents to your office with a complaint of stomach pain. When asked about the duration, she replies that the pain has been there constantly for the past 5 years. The pain is located around the umbilicus, not relieved with medications, not related to foods and does not increase or decrease with movement.
She also complains of a chronic back pain, nausea, bloating, dysmenorrhea, dysphagia, dyspareunia, headaches and an episode of deafness. When asked about any past interventions regarding all these problems, she said that she underwent two upper endoscopies, one colonoscopy and two CT-scans and no abnormalities were detected. Her physical exam is normal.
Which of the following is the most likely diagnosis?
Correct Answer E:
The most likely diagnosis of this patient is somatization disorder. It usually presents with multiple somatic complaints involving different organ systems (2 GIT symptoms, 4 pain symptoms, sexual and neurologic symptoms) with a negative workup. It is seen predominantly in women and usually presents before the age of 30.
Hypochondriasis is the major differential of somatization. Be careful! The hypochondriatic patient will also complain of multiple symptoms; however, she will name only one disease and will try to convince you with this diagnosis. In other words, the patient will tell you “I think I have brain tumor, heart attack…”
Pain syndrome patients will complain of multiple pain symptoms and only pain.
Chronic fatigue syndrome is a condition causing persistent fatigue that lasts for at least 6 months and is not due to another medical condition (e.g., hypothyroidism).
Fibromyalgia is a chronic condition that presents with pain, stiffness, and tenderness of the muscles, tendons, and joints with a characteristic tenderness involving specific points in the body. Fibromyalgia is also characterized by restless sleep, chronic fatigue, anxiety, and depression.
A 35-year-old female sees you because she has lost her voice. She has had no recent upper respiratory infection symptoms, cough, or heartburn, and she has not done anything that would strain her voice. Examination of the head and neck appear normal. A review of her chart shows this has happened before, but an ear, nose, and throat evaluation found no abnormalities. She also has been seen numerous times in the past few years for headaches, chest pains, abdominal pains, rectal pressure, and vaginal symptoms. Despite several workups and referrals, no definite cause has been found and the symptoms persist.
Which one of the following would be the most reasonable plan of action?
Somatization disorders should be considered in patients who have a history of various complaints over a several-year period that involve multiple organ systems. There is no test to confirm this diagnosis. It is often intertwined in other psychiatric problems, including anxiety disorder, personality disorder, and depression. Treatment includes testing to make sure that there is nothing physically wrong, while building a trusting relationship with the patient. Once this is accomplished, it is reasonable to discuss the disorder with the patient. Cognitive therapy has been shown to be of value, as well as regularly scheduled office visits for monitoring and support. Medicines for coexisting psychiatric problems also are of benefit. In addition, referral for psychiatric consultation may be worthwhile.
Food allergies can cause a variety of symptoms, but usually not to the extent seen with this patient, and testing for this might confuse the issue. Lorazepam may help the symptoms if there is a coexisting anxiety disorder, but it will not address the underlying problem. Laryngeal esophageal reflux can cause hoarseness and will respond to proton pump inhibitors, but given the repetitive nature of her symptoms and the previous negative workups, it is not consistent with the whole picture.
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