A 36-year-old woman comes to a new primary care provider due to diffuse abdominal pain and poor appetite. The patient has worked as an administrative assistant but recently quit her job "because I always felt uncomfortable. I couldn't get my work done because the pain was bothering me so much." She has difficulty describing the pain in detail and cannot identify any precipitants. Nothing appears to bring relief, although she has felt a little better since leaving her job.
The patient does not use tobacco or alcohol. Family history is noncontributory. Over the past several years, the patient has seen 3 different physicians and had several hospitalizations for similar symptoms; previous workups, including endoscopic studies and an exploratory laparotomy, have revealed no etiology for the pain.
Recent abdominal CT scan and abdominal ultrasound were normal. Physical examination and laboratory tests, including comprehensive metabolic panel, complete blood count, and urinalysis, are within normal limits.
In addition to explaining that serious illness has been ruled out, which of the following is the most appropriate next step in management of this patient?

Question

A 36-year-old woman comes to a new primary care provider due to diffuse abdominal pain and poor appetite.  The patient has worked as an administrative assistant but recently quit her job "because I always felt uncomfortable.  I couldn't get my work done because the pain was bothering me so much."  She has difficulty describing the pain in detail and cannot identify any precipitants.  Nothing appears to bring relief, although she has felt a little better since leaving her job.
The patient does not use tobacco or alcohol.  Family history is noncontributory.  Over the past several years, the patient has seen 3 different physicians and had several hospitalizations for similar symptoms; previous workups, including endoscopic studies and an exploratory laparotomy, have revealed no etiology for the pain.
Recent abdominal CT scan and abdominal ultrasound were normal.  Physical examination and laboratory tests, including comprehensive metabolic panel, complete blood count, and urinalysis, are within normal limits.
In addition to explaining that serious illness has been ruled out, which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_98b5_78b3_853d_2b594165ea68_MD0002_00 This patient's preoccupation with medically unexplained gastrointestinal symptoms and excessive health care use are characteristic of somatic symptom disorder. The best approach is for the primary care physician to reassure the patient that serious illness has been ruled out and schedule regular visits (eg, every 2-4 weeks) to develop the physician-patient relationship, monitor her condition, and avoid unnecessary diagnostic testing and specialist referrals. Physicians should treat symptoms conservatively and focus on the patient's functioning. Strategies include educating the patient about the impact of psychosocial stressors on somatic symptoms and promoting stress reduction and healthy behaviors (eg, diet, exercise, return to productive activities). In addition to regular follow-up and patient education, antidepressant medications (eg, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants) have been shown to be beneficial and can be used alone or in combination with cognitive-behavioral therapy (CBT). (Choices A and B) This patient would likely feel invalidated by being told her problems are stress-related or by being referred for psychiatric treatment at this initial visit as she has no insight into the nonmedical nature of her symptoms. Once the physician-patient relationship is established, the patient may be more receptive to the idea that her symptoms are exacerbated by psychological stress and may be willing to accept a psychiatric referral. Comorbid depressive and anxiety disorders are common in patients with somatic symptom disorder, and psychiatric consultation can assist with diagnosis and treatment planning. (Choice D) CBT has the best evidence for treating somatic symptom disorder compared with other types of psychotherapy. (Choice E) In contrast to as-needed, symptom-driven visits, regularly scheduled visits provide patients with an opportunity to discuss their concerns, while also having been shown to decrease health care use overall. Educational objective: Somatic symptom disorder is optimally managed through regularly scheduled visits with the same physician, who can minimize unnecessary diagnostic testing, inappropriate interventions, and specialist referrals. Antidepressants and cognitive-behavioral therapy have also been shown to be beneficial. __________ References: Approach to the patient with multiple somatic symptoms. (http://www.ncbi.nlm.nih.gov/pubmed/25134874)

A 36-Year-Old Woman Comes to a New Primary Care Provider