A 31-year-old woman comes to the office due to chronic abdominal pain that is unrelated to meals and has persisted for the past 2 years. The patient reports no weight loss, nausea, vomiting, fever, or changes in bowel movements. She has consulted several physicians and undergone endoscopy, colonoscopy, and CT scan of the abdomen, as well as an exploratory laparoscopy, all without any significant findings. The patient was placed on sick leave because she has been unable to focus on anything other than her physical discomfort. She is anxious and frustrated that physicians have been unable to arrive at a diagnosis and fears that she will be unable to return to work. Other medical issues include obesity and tension headaches. Family history is significant for hypertension and diabetes in her father, who died of colon cancer at age 59. Physical examination shows diffuse abdominal tenderness on palpation and no other abnormalities. Which of the following is the most likely diagnosis?

Question

A 31-year-old woman comes to the office due to chronic abdominal pain that is unrelated to meals and has persisted for the past 2 years.  The patient reports no weight loss, nausea, vomiting, fever, or changes in bowel movements.  She has consulted several physicians and undergone endoscopy, colonoscopy, and CT scan of the abdomen, as well as an exploratory laparoscopy, all without any significant findings.  The patient was placed on sick leave because she has been unable to focus on anything other than her physical discomfort.  She is anxious and frustrated that physicians have been unable to arrive at a diagnosis and fears that she will be unable to return to work.  Other medical issues include obesity and tension headaches.  Family history is significant for hypertension and diabetes in her father, who died of colon cancer at age 59.  Physical examination shows diffuse abdominal tenderness on palpation and no other abnormalities.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d805_5e53_bc81_4d20bd1a07c0_MD0003_00 This patient's persistent and excessive anxiety and time-consuming behavior in response to her abdominal pain are most consistent with somatic symptom disorder (SSD). Patients with SSD typically consult multiple providers and undergo extensive diagnostic testing with negative results. Although patients frequently have multiple somatic symptoms, only one (eg, pain in this patient) is required for the diagnosis. The symptoms may be associated with another medical condition, and concurrent medical illness is not mutually exclusive. SSD can be differentiated from illness anxiety disorder (formerly known as hypochondriasis) by the presence of significant somatic symptoms. Patients with illness anxiety disorder have minimal to no symptoms (Choice C). They are concerned primarily with the idea of having a serious illness. (Choice A) Conversion disorder (also known as functional neurologic symptom disorder) involves unexplained serious neurologic symptoms that are inconsistent with known neurophysiology, often preceded by an emotional trigger (eg, tragic event, argument). (Choices B and D) Both factitious disorder and malingering are characterized by the intentional falsification of symptoms, whereas patients with SSD are not trying to be deceptive. Patients with factitious disorder have no obvious external reward and are motivated by the desire to assume the sick role. In contrast, a diagnosis of malingering requires evidence of external benefit (eg, avoiding jail, obtaining disability benefits, obtaining narcotics). There is no evidence that this patient has intentionally falsified symptoms and no obvious external reward. Educational objective: Somatic symptom disorder involves excessive anxiety and behaviors related to ≥1 somatic symptoms. These patients typically have high health care use and undergo multiple tests with negative results. References: Somatic symptom disorder. (http://www.ncbi.nlm.nih.gov/pubmed/26760840) Somatic symptom disorder, a new DSM-5 diagnosis of an old clinical challenge. (http://www.ncbi.nlm.nih.gov/pubmed/26759438)

A 31-Year-Old Woman Comes to the Office Due to Chronic