Cases That Test Your Skills

When the worry is worse than the actual illness

Current Psychiatry. 2020 August;19(8):46-51 | doi:10.12788/cp.0022

References

1. Diagnostic and statistical manual of mental disorders, 5th ed. Washington, DC: American Psychiatric Association; 2013.
2. Stern T, Freudenreich O, Smith F, et al. Massachusetts General Hospital Handbook of General Hospital Psychiatry, 7th ed. New York, NY: Elsevier; 2017.
3. Feldman MD, Eisendrath SJ. The spectrum of factitious disorders. Washington, DC: American Psychiatric Association; 1997.
4. Sadock BJ, Sadock VA, Ruiz P. Kaplan & Sadock’s synopsis of psychiatry: behavioral sciences/clinical psychiatry, 11th ed. Philadelphia, PA: Wolters Kluwer; 2014:470.
5. Pilowsky I. The concept of abnormal illness behavior. Psychosomatics. 1990;31(2):207-213.
6. Kirmayer LJ, Looper KJ. Abnormal illness behavior: physiological, psychological and social dimensions of coping with stress. Curr Opin Psychiatry. 2006;19(1):54-60.
7. Walker LS, Garber J, Greene JW. Somatic complaints in pediatric patients: a prospective study of the role of negative life events, child social and academic competence, and parental somatic symptoms. J Consult Clin Psychology. 1994;62(6):1213-1221.
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In the fall, Ms. S returns to high school for her senior year but has difficulty getting back into the routine and relating to her old friends. Ms. S continues to perseverate on thoughts of getting sick and her physical symptoms become overwhelming once again. She continues to be focused on any new symptoms she experiences, and to limit the types of foods she eats due to fear of the abdominal pain returning.

After several more months of psychiatric treatment, Ms. S reports significant relief from her abdominal pain, and no longer seeks corrective surgery for her SMAS. Although she occasionally struggles with perseverating thoughts and anxiety about her somatic symptoms such as abdominal pain and worrying about the types of foods she eats and becoming ill, she continues to work through symptoms of her somatic symptom disorder.

The authors’ observations

The main challenge of somatic symptom disorder is the patient’s “abnormal illness behavior.”^2,5,6 For pediatric patients, there may an association between a parent’s psychological status and the patient’s somatic symptoms. Abdominal symptoms in a pediatric patient have a strong association with a parent who presents with depression, anxiety, or somatization. The effects of the parent’s psychological status could also manifest in the form of modeling catastrophic thinking or through reinforcement. Parents with certain traits, such as disproportionate worry about pain, may pay more attention to their child’s symptoms, and hence, reward the child when he/she reports somatic symptoms.^7,8 In the case of Ms. S, her mother did not participate in therapy and the mother’s psychiatric history was never obtained.

OUTCOMES Making personal strides

Ms. S continues to use mindfulness skills as well as CBT to manage her symptoms of somatic symptom disorder. She continues to celebrate her weight gains, denies any thoughts of suicide or self-harm behaviors, and prepares for college by scheduling campus visits and completing admissions applications.

Bottom Line

Patients with somatic symptom disorder tend to have very high levels of worry about illness. Somatic symptoms in such patients may or may not have a medical explanation. Accurate diagnosis and careful management are necessary to reduce patient distress. Cognitive-behavioral therapy and mindfulness-based therapy may help relieve symptoms associated with this disorder.

Related Resources

Henningsen P. Management of somatic symptom disorder. Dialogues Clin Neurosci. 2018;20(1):23-91.
Rosic T, Kalra S, Samaan Z. Somatic symptom disorder, a new DSM-5 diagnosis of an old clinical challenge. BMJ Case Rep. 2016: bcr2015212553. doi: 10.1136/bcr-2015-212553.

Drug Brand Name

Doxepin • Silenor