A 48-year-old woman comes to the office for the first time due to a 3-year history of diffuse abdominal pain, headaches, muscle pain and weakness, constipation, and an intermittent tingling sensation in the right arm. The symptoms are debilitating and frequently interfere with the patient's ability to work. She saw 2 other physicians this past year for similar symptoms but received no definitive diagnosis or treatment. The patient has no depressed mood or anhedonia. Medications include ibuprofen and polyethylene glycol as needed as well as daily multivitamins. She does not use tobacco, alcohol, or illicit drugs.
Vital signs are within normal limits. The patient grimaces on gentle abdominal palpation but not when she is actively engaged in conversation. There is no demonstrable extremity weakness or sensory loss. The remainder of the examination shows no abnormalities.
Complete blood counts, serum metabolic profile, erythrocyte sedimentation rate, TSH, vitamin B₁₂ levels, antinuclear antibody titer, and urinalysis performed 3 months ago by another physician were within reference range. Previous abdominal CT scans and MRI of the brain were also normal.
Which of the following is the most appropriate next step in management of this patient?

Question

Quizplus · Accepted Answer

This patient's multiple medically unexplained symptoms and high health care utilization are suggestive of somatic symptom disorder. Patients with somatic symptom disorder typically consult multiple providers and undergo extensive diagnostic testing but are rarely reassured by negative findings. In addition to monitoring the patient with regularly scheduled visits and minimizing unnecessary testing and consultations, the physician should recommend cognitive-behavioral therapy (CBT). CBT combines cognitive therapy, which addresses distorted health beliefs and expectations, with behavioral techniques (eg, systematic desensitization, progressive muscle relaxation, graduated exercise programs) and has been shown to be effective in helping to improve coping skills and daily functioning. Antidepressants (eg, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, tricyclics) have also proven to be beneficial and can be used alone or as an adjunct to CBT. (Choices A and E) An abdominal MRI and endoscopy are not indicated in a patient with normal CT scans, nonspecific history, and normal physical examination. Negative testing rarely provides lasting reassurance, and it exposes the patient to unnecessary risk and expense. (Choice B) Aripiprazole is a second-generation antipsychotic that has been used as an adjunct to antidepressants in treatment-resistant cases. However, it is not used as monotherapy for somatic symptom disorder. Antidepressants are first-line pharmacotherapy for somatic symptom disorder. (Choice C) Although patients with somatic symptom disorder should be reassured that serious medical disease has been ruled out, reassurance alone is rarely sufficient. Educational objective: First-line treatment of somatic symptom disorder consists of regularly scheduled follow-up visits together with psychotherapy and/or antidepressants. Among psychotherapies, cognitive-behavioral therapy has the best evidence. __________ References: Cognitive behavioral therapy for somatoform disorders. (http://www.ncbi.nlm.nih.gov/pubmed/20599134) Non-pharmacological interventions for somatoform disorders and medically unexplained physical symptoms (MUPS) in adults. (http://www.ncbi.nlm.nih.gov/pubmed/25362239)

A 48-Year-Old Woman Comes to the Office for the First