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Stem
A 32-year-old woman is referred to you in primary care with a 14-month history of recurrent, multiple somatic symptoms — central chest pain, abdominal bloating, pelvic pain, daily headache, and profound fatigue. She has seen three cardiologists, two gastroenterologists, and a gynaecologist in the last year. Repeated investigations (ECG, troponin, exercise tolerance test, CT coronary angiogram, upper GI endoscopy, colonoscopy, pelvic ultrasound, FBC, ESR, CRP, TFT, coeliac serology, B12, folate, ferritin, vitamin D) have all been normal. She brings a large folder of test results. She spends 3 to 4 hours per day reading about her symptoms online, checks her pulse dozens of times daily, and has stopped going to work as a teacher. She is convinced the team has 'missed something serious' and is asking for an MRI whole body. She scored 18 on the PHQ-15. She has a history of childhood sexual abuse and her mother had breast cancer. Mood is low; sleep is poor; she has fleeting thoughts that 'life isn't worth it' but no plan or intent.
Questions
a) What is the most likely DSM-5-TR diagnosis? List the diagnostic criteria satisfied, and explain why the DSM-5 approach differs from the DSM-IV 'medically unexplained symptoms' criterion. (2 marks)
Somatic Symptom Disorder (SSD). Criteria: Criterion A — one or more distressing somatic symptoms (chest pain, abdominal bloating, pelvic pain, headache, fatigue) ✓. Criterion B — excessive thoughts, feelings, or behaviours related to the symptoms, with at least one of: disproportionate thoughts about seriousness (convinced 'something serious' has been missed), persistent high health anxiety (hours of internet research, repeated checking of pulse), or excessive time and energy devoted to symptoms (3 to 4 hours daily, multiple specialists, stopped working) ✓. Criterion C — persistent at least 6 months (14 months here) ✓.
Why DSM-5 differs from DSM-IV: DSM-5 dropped the requirement that symptoms be 'medically unexplained' — the disorder is now defined by the positive B-criterion (the maladaptive cognitive-affective-behavioural response), so SSD can be diagnosed in a patient WITH genuine medical disease if the response is excessive. This is theoretically sounder (you cannot prove a negative), clinically safer (avoids chasing ever-more tests), and reframes the disorder from exclusion to positive diagnosis. (1 mark for criteria, 1 mark for the conceptual shift.)
b) Outline your structured assessment of this patient, including the positive clinical signs or scales you would use. (3 marks)
- History — symptom onset, evolution, illness behaviour pattern (doctors seen, internet hours, checking, avoidance), healthcare utilisation, psychosocial stressor (childhood abuse, mother's cancer), comorbid mood/anxiety (PHQ-9, GAD-7), sleep, function, suicide risk (assess formally — fleeting thoughts here, no plan or intent).
- Functional analysis (A-B-C) — Antecedent (stressor, sensation), Behaviour (checking, internet, doctor-shopping), Consequence (attention, time off, transient relief that fades).
- Mental State Examination — appearance (large folder of tests, anxious, vigilant), mood (low), thought (illness preoccupation, catastrophic cognitions), insight (partial; resists psychological framing).
- Physical examination — focused, to exclude new objective signs and to demonstrate you are taking the symptoms seriously; targeted only.
- Screening scales — PHQ-15 (already done; 18 = severe somatic burden), Whiteley-7 for illness worry, SSD-12 for B-criterion severity, PHQ-9/GAD-7 for comorbid mood/anxiety.
- Collateral — from GP, prior specialist letters, family (with consent). (1 mark for history + functional analysis, 1 mark for MSE + targeted exam + scales, 1 mark for collateral + risk assessment.)
c) She asks for an MRI whole body 'to be sure.' Justify your decision to decline, and explain how you would frame it. (2 marks)
Decline. A whole-body MRI without clinical indication would: (1) fail to reassure — patients with SSD experience only transient relief from normal results, then anxiety resurges; (2) reinforce the illness behaviour cycle — each test confirms the belief that the next one might 'find something'; (3) produce harmful incidental findings (small nodules, cysts) that drive further spirals of investigation and anxiety; (4) expose her to iatrogenic harm. The principle: investigations should be targeted, time-limited, and clinically indicated, not reassurance-driven.
Framing: "Your symptoms are real and distressing. We have done careful, comprehensive tests over the last year that have ruled out serious disease. The pattern of your symptoms and the way they are affecting your life fit a recognised condition called Somatic Symptom Disorder — it's like a faulty alarm that keeps sounding even when there is no fire. The signal is real, but we need to retrain the wiring rather than keep looking for a fire. Doing more scans would actually make things worse, not better. I will see you regularly, examine you properly if anything changes, and we will work together on getting your function, sleep, and mood back." (1 mark for the clinical justification, 1 mark for the communication/framing.)
d) Outline your management plan, specifying the drug (with starting dose), the psychological therapy, and the follow-up structure. (3 marks)
- Pharmacological: sertraline — start at 25 to 50 mg once daily (half usual starting dose because SSD patients are somatically hypersensitive), titrate slowly over 2 to 4 weeks to 100 to 200 mg, expect 6 to 8 weeks for full effect; pre-warn about expected initial nausea, jitteriness, and sleep disturbance. SSRIs have evidence in SSD even without comorbid depression (independent analgesic and interoceptive effects). Avoid opioids, long-term benzodiazepines, and further unnecessary tests.
- Psychological: Cognitive Behavioural Therapy (CBT), 8 to 16 sessions with a trained therapist — psychoeducation (vicious-cycle model), cognitive restructuring of catastrophic illness beliefs, behavioural experiments (reducing safety behaviours like checking), graded return to activity, attention retraining, sleep and stress management.
- Follow-up structure: single medical home (you coordinate, not multiple specialists); regular scheduled appointments every 2 to 4 weeks regardless of symptoms (containment, reduces ER presentations); explicit contract that tests are not being repeated unless a new clinical sign appears; coordinate with mental-health services; involve family with consent; address childhood abuse and bereavement themes in CBT; vocational rehabilitation for return to teaching. (1 mark for drug + dose + titration, 1 mark for CBT, 1 mark for follow-up structure + harm avoidance.)