All GPs will have seen patients who have intractable symptoms that do not respond to treatment and defy diagnosis, despite multiple referrals and investigations.
The dilemma is knowing whether their symptoms are due to a physical condition, or are more to do with the patient's state of mind.
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) groups somatisation disorder, hypochondriasis and pain disorder under the diagnosis of somatic symptom disorder.
For this diagnosis, there needs to be distressing somatic symptoms and abnormal thoughts, feelings and behaviours. Patients may or may not have physical medical conditions.
|Case study: Low back pain develops into somatic symptom disorder|
A 24-year-old woman presented with severe low back pain, which started a few days after a fall.
After taking a history and examining her, the GP diagnosed a soft tissue injury and prescribed strong analgesia and a muscle relaxant.
Over the next few months, the back pain settled, but the patient developed nausea, abdominal pain and intermittent loose stools. Her blood tests were normal.
Referral to gastroenterology
While waiting for the appointment, she started to complain of anxiety. This rapidly worsened and she was prescribed a short course of lorazepam.
The patient had numerous telephone consultations and appointments with the GP, culminating in a request for a home visit. She was diagnosed with generalised anxiety disorder and prescribed fluoxetine. Her physical symptoms, especially the constant swallowing, were still prominent and a cause of concern to her.
Endoscopies were normal and no cause was found for her persistent swallowing, nausea and loose stools.
The mixture of a physical disorder, a psychiatric disorder and somatic symptom disorder is not unusual and makes diagnosis more complicated. The symptoms are real, making it difficult to rule out organic pathology without investigations, but these should be kept to a minimum. Explaining somatic symptom disorder to patients is hard and they may be reluctant to accept this diagnosis.
- Patients with multiple, changing symptoms persisting for years. In general terms, these are the patients who seek symptom relief.
- Patients who are convinced they have a serious physical illness and keep requesting investigations. They often misinterpret normal bodily sensations as symptoms.
- Patients with unexplained GI, cardiac or respiratory symptoms. There is overlap with the 'medical' or 'organic' diagnoses of irritable bowel syndrome and non-cardiac chest pain, but these do not require the presence of abnormal thoughts, feelings and behaviours.
- Patients who have chronic pain, often in a non-anatomical distribution. There is a poor response to analgesia and the pain usually does not wake them at night. There is overlap with conditions such as fibromyalgia and atypical facial pain, but these do not require the presence of abnormal thoughts, feelings and behaviours.
Conversion disorder presents with striking neurological symptoms without evidence of a physical cause. Psychological factors may or may not be demonstrable at the time of diagnosis.
The symptoms lack any anatomical or physiological pattern and may reflect the patient's concept of illness. Examples are paralysis, fits, tremors, mutism, hyperparaesthesia or paraesthesia, blindness or deafness.
Body dysmorphic disorder
Body dysmorphic disorder presents with a preoccupation with a defect that may objectively seem insignificant. Patients often seek referrals to surgeons for correction of the perceived abnormality.
Factitious disorder, malingering
Factitious disorder and malingering involve intentional fabrication of symptoms to gain medical attention or financial benefit.
GPs are ideally placed to differentiate physical symptoms that are likely to have a physical cause and those that may be due to somatic symptom disorder.
The starting point for managing the condition is a positive diagnosis. It may need to be a diagnosis of exclusion, but investigations and referrals should be targeted to rule out possible pathology without increasing health anxiety.
Acknowledging the reality of the patient's symptoms is necessary to build trust in patients with somatic symptom disorder, who may have felt dismissed by clinicians in the past.
Exploring stresses or mood symptoms can help the patient make the link between physical symptoms and emotional issues that may underlie them. Simple strategies, such as reducing stress, learning relaxation techniques and setting realistic goals, can improve symptoms.
Antidepressants may have a role, especially if there is comorbid depression or anxiety; their analgesic or hypnotic effect can be useful.
Psychotherapy, including CBT, can be beneficial.
- Dr Jopling is a GP in Sunbury-on-Thames, Surrey