Wednesday, 20 January 2021

Somatic Symptom (Somatization) Disorder Diagnosis, differential,

Somatic Symptom (Somatization) Disorder


Vignette
The medical team requested you to see a 31-year-old woman in a medical ward who has been an in-patient for 2 weeks undergoing investigations for constant pain in her upper abdomen for the last 2 months. We initially thought this to be gastric or duodenal, but endoscopy was negative. Recently, it has been informed by her husband that she has presented to several hospitals over the past 2 years complaining about a wide variety of symptoms and different pains for which they had identified no physical cause despite multiple investigations. In addition, she is concerned about her physical symptoms but does not consider them as a warning sign of any serious underlying disease. After a detailed discussion about the case, the medical team has a psychiatric opinion. 


What is the most likely diagnosis?
Enlist the differential diagnosis in this case. 
What information in history supports the most likely diagnosis?
How will you manage this patient?
What is Briquet's syndrome?


Diagnosis
Somatic symptom disorder/ somatization disorder


Suggested by a wide variety of symptoms for which cause has not been recognised as yet. The patient is concerned about the symptoms but does not worry about a serious underlying diagnosis, which is consistent with the diagnosis of somatization disorder/somatoform pain disorder. 
Differential Diagnosis
Somatoform Pain Disorder
Illness Anxiety Disorder, Hypochondriasis
Depressive Disorder with Somatic Symptoms
Dependence on opioid analgesics
Briquets syndrome


Briquet’s syndrome is a term used for somatization disorder in the past. Paul Briquet first introduced it to refer to a syndrome of multiple-longstanding somatic complaints, for which no cause could be found out. Patients felt ill/sick with symptoms from various organ systems for years. (He did not name it himself). 


Management

Somatization


Medically unexplained symptoms affecting multiple organ systems first presenting before age 40


How can I help you today?
Whose idea was it to be referred?
List of complaints – mostly pain? (somatoform pain disorder)
Other physical ailments in the last 2 years? Fluctuate/vary – depending on…?
How often see GP? 
Reassured by doctors?
Alternative therapies? Healers?
Do you ever worry this could be all caused by a particular illness? What’s causing this?
Focus more on ix or Tx?
Can you link the onset with any particular events or traumas in your life?
Do you know anyone with this –friends/family, or read about it?
Dislike a particular part of the body?
Court case pending?


MSE
Mood- depression/mania
Anxiety – OCD – do you try and resist these thoughts? Seem odd to you? Own thoughts?
Unpleasant? Do anything to counteract these thoughts?
Psychosis


Ideally PD screen – fights, suspiciousness, impulsive, anxious, dependent, empty? Insight – whats your explanation, could it be your mind converting psychological distress into physical distress? Would you be interested in psychological therapy?




Impact – family responded? (secondary gain?)
Drugs and Alcohol – coping?
Driving
Risk – to self to others from others neglect


Psychiatric history 
Meds
PMHx – LD, epilepsy, Head Injury. Conditions diagnosed by GP ?
Forensic – any pending court cases or claims?


Different diagnosis
- undiagnosed physical illness
- other psychiatric illness – mood, psychosis


- other somatoform illness – somatoform pain disorder, hypochondriasis/BDD conversion
- factitious, malingering.




Plan


It’s clear that you are in a lot of distress and Im here to help.  



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