Patient:

27year old, white, female, newlywed (March 2019), employed as an office manager, lives with husband, with a reported past psych hx of depression and anxiety (treated with Zoloft 200 mg), with a reported PMhx of back pain x 2 years, Presented to Mindful Urgent Care secondary to increased anxiety and depressive symptoms, and to establish psychiatric care. Patient states she is currently on Zoloft 200 mg with no improvement of depressive and anxiety symptoms. States her depression and anxiety was well controlled on Zoloft in the past, but recently she feels like it’s not helping anymore. Reports her psychiatrist no longer takes her insurance. Reports she is currently seeing a therapist 2 times a month. Reports constant fear of dying and states she visits the doctor constantly to be evaluated. States “I always think its cancer and I am going to die”. Patient reports undergoing excessive imaging and testing to reassure herself that she is not suffering from a deadly condition. States she has been going to PT for her back pain after the specialist found no abnormalities. States she is currently seeing a GYN specialist because she feels she might have vaginal or ovarian cancer. She reports symptoms of back pain x 2 years and vaginal burning/irritation x 2 months. States “I think there is a huge mass from my back to my vagina”. States she has no control over her fear of death even after she has been cleared by multiple specialist for her symptoms. States she has been this way since she was very young, but her anxiety about having a deadly condition has become worse over the years. States the excessive worrying has highly impacted her work and daily life. States she has not been sexually active with her husband for the past 2 months due to the constant anxiety. She reports constant frustration about not knowing why she suffers from her physical symptoms. States recently she not only fears her own death, but also her mothers.

Patient reports 1/10 on the depression scale with symptoms of isolation, decreased appetite, anhedonia, decreased focus and concentration, rumination, and fatigue. States she is anxious from the moment she wakes up till the time she goes to bed. States she has 3-4 panic attacks a week with symptoms of chest pain, sweating, nausea, fear of losing control, irritability and crying spells. States she avoids taking the train and now also fears going to work because of the panic attacks. Reports she has to miss work often and her symptoms her performance at work. Patient at this time denies active or passive thoughts of SI, with no intent or plan. Patient adamantly denies any manic s/sx such as, racing thoughts, grandiose beliefs, irritability, changes in or inappropriate social behaviors, elation, euphoria, unable to focus, hypersexual acts, hyper verbal speech pattern, decrease sleep pattern with increase in energy. Patient adamantly denies any childhood illnesses, denies ever attempting suicide in her lifetime, denies ever being hospitalized for mental health issues, denies ever being treated at a rehab/detox facility, denies ever being sexually/ emotionally/ or physically abused, and at this time denies self-harm/SI/HI/PI/AH/VH or drugs/etoh use.

Approach to the Patient with Multiple Somatic Symptoms

Croicu, Carmen et al. Medical Clinics, Volume 98, Issue 5, 1079 – 1095

This review article was published in 2014 by Medical Clinics of North America

Medical Clinics of North America is a bimonthly peer-reviewed medical journal published by Elsevier. Each issue of the journal contains up-to-date review articles on a specific medical topic.

2014 Review Article’s summary:

• Patients can frequently present with multiple somatic complaints.
• If somatic complaint is due to acute psychosocial stressors, the somatic symptoms can resolve without any specific treatment.
• Risk factors for patients with chronic multiple somatic symptoms (20% to 25% of cases) include childhood abuse and neglect, childhood illness, and co-occurring psychiatric illness.
• Chronic and can be associated with high use of medical services leading to increase the risk of iatrogenic complications.
• In treating patients with chronic somatic symptoms, the main goal is not to cure the disease but to improve function and help the patient cope more effectively with symptoms.
• Primary provider should continue to collaborate with the patient to alleviate suffering and distress from their symptoms- and that’s why we encourage the PCP f/U

According to the article PCP’s should:

Schedule time-limited regular appointments (eg, every 4–6 weeks) rather than erratic appointments to address complaints

Perform a brief physical examination at each visit to address new symptoms or health concerns

Avoid unnecessary diagnostic tests unless objective evidence of a disease is present

Treat comorbid psychiatric disorders and alcohol and substance abuse problems

Minimize polypharmacy, tapering and discontinuing medications with high potential for abuse (eg, narcotic agents, sedatives)

Prescribe regular dosing of pain medications and avoid as needed analgesics (especially opiates)

Encourage mobility to prevent physical deconditioning (eg, physical therapy, regular exercise)

Integration of mental health treatment into primary care may improve the care of patients with somatic symptoms and increase physician satisfaction.

A meta-analysis of 79 randomized trials of collaborative care depression and anxiety interventions in primary care^. found that depression and anxiety outcomes were improved for up to 2 years compared with usual care approaches.

According to this article:

• CBT has the strongest and most consistent evidence for its efficacy among different psychotherapeutic modalities.
• In a review of 13 randomized controlled trials (RCTs) of treatment modalities for somatoform disorders, Kroenke showed that CBT was effective in most studies (supported by 11 of 13 RCTs).
• A recent meta-analysis including 10 randomized and 6 nonrandomized trials suggested that psychotherapy for more severe forms of somatoform disorder that were treated in secondary and tertiary care was more effective than usual treatment with respect to reduction of physical symptoms and functional impairment (eg, life satisfaction, interpersonal problems, maladaptive cognitions and behavior).
• When a depressive or anxiety disorder is diagnosed, both psychopharmacologic treatment and psychotherapy should be considered as treatment options.
• Antidepressants may be helpful in relieving chronic pain symptoms, independent of the presence of a comorbid psychiatric disease.
• The serotonin-norepinephrine reuptake inhibitors, such as venlafaxine and duloxetine, have been found mostly effective in treating neuropathic pain.
• There is increasing evidence that dual-acting antidepressants that modulate both norepinephrine and serotonin receptors may ameliorate other somatic symptoms as well.
• It is important to optimize the management of pain that commonly co-occurs with depression, because this can improve treatment outcomes and quality of life.
• Some studies have shown that although the burden of physical symptoms diminishes significantly in the first month of selective serotonin reuptake inhibitor (SSRI) treatment, patients with moderately severe pain at the start of treatment are 2-fold less likely to respond to antidepressant treatment.
• Avoid prescribing opioids due to the negative consequences associated with opioid therapy, such as frequent visits to the emergency room for opioid prescriptions, misuse to self-medicate, and development of tolerance and addiction.