Case 14: A woman with a folder of normal tests and pains everywhere

01The case

A 48-year-old woman is brought by her son for a psychiatric opinion. She complains of severe pain in the lower back, weak legs and tiredness, and also of headache, stomach ache, dizziness, nausea, numb limbs and difficulty breathing. She has brought a tidy folder of results and specialists' reports, and none of them has found a bodily or neurological cause for what she feels. She insists on more investigations to find out what is wrong with her.

02Summary

Diagnosis

Somatization disorder in ICD-10, one of the somatoform disorders; bodily distress disorder in ICD-11, somatic symptom disorder in DSM-5.

What points to it

• Many bodily complaints across several systems: pain, gut, nervous system, breathing, fatigue.
• Repeated investigations with no relevant findings.
• A typical way of seeking care: many specialists, a carefully kept file, and demands for more tests despite normal results.

What else it could be

Physical illness with varied, multisystem symptoms (thyroid disease, lupus, multiple sclerosis). Somatization disorder first presents before 40, so many symptoms appearing for the first time after 40 should be presumed physical until shown otherwise. At 48, find out when her complaints began, and search carefully for physical disease if they are new. Depression and anxiety often present with bodily symptoms and often coexist. In hypochondriasis the fear is of one particular disease rather than of the symptoms. In factitious disorder and malingering the symptoms are produced on purpose.

Management

• One named doctor, with regular planned appointments rather than visits on demand, and all referrals through that doctor.
• Accept her suffering as real, explain the normal results, and over time link the symptoms with stress and emotion.
• No new tests unless there are new objective signs.
• Notice your own frustration (countertransference), which can push towards more tests or towards rejecting her.
• CBT. An antidepressant, an SSRI, or a low-dose tricyclic for pain, especially when depression or anxiety is present.
• Avoid benzodiazepines and opioids: the risk of dependence is high.

Outlook

Chronic. Symptoms tend to persist and may spread to new systems. The aims are better coping and fewer harmful investigations and treatments, rather than cure.