Woman Who Has Felt Unwell for Many Years

December 31, 2006

A 41-year-old woman presents as a new patient, with complaintsof chest pain and palpitations that occur intermittentlyand are not associated with activity, meals, or position.She says these symptoms have been present forsome time, and she expresses frustration that her previousphysician was unable to find their cause or to amelioratethem.

A 41-year-old woman presents as a new patient, with complaints of chest pain and palpitations that occur intermittently and are not associated with activity, meals, or position. She says these symptoms have been present for some time, and she expresses frustration that her previous physician was unable to find their cause or to ameliorate them.

HISTORY AND REVIEW OF SYMPTOMS
To investigate her chest pain and palpitations, her last physician ordered an ECG, a dobutamine echocardiogram, and a chest radiograph; results of all of these were unremarkable. She was also referred to a gastroenterologist, who ordered an esophagogastroduodenoscopy; results of this study were normal as well. The primary care physician told her there was no physical cause of her symptoms and prescribed lorazepam, but the regimen had no effect.

The patient has been feeling unwell for 12 years, although before then she was healthy. During this time, she has seen 11 different primary care providers and consulted multiple specialists. She has had 2 normal pregnancies and a tubal ligation. She last saw her gynecologist 2 months ago; results of a Papanicolaou test and mammogram were normal. She takes no medications other than a multivitamin; she has no known drug allergies. She is a social drinker (1 to 2 glasses of wine on a weekend) and does not smoke. She works as a manager of a law office and states that her symptoms have begun to affect her job performance.

Review of symptoms reveals that the patient has had similar symptoms at other times in the past. In addition, she has had episodes of “bowel problems,” headache, and insomnia; however, she has been told that evaluations for these problems revealed no abnormalities.

PHYSICAL EXAMINATION

This well-appearing woman looks her age; height is 1.63 m (64 in) and weight, 65 kg (143 lb). Temperature is 36.9°C (98.4°F); heart rate, 80 beats per minute; respiration rate, 12 breaths per minute; and blood pressure, 110/ 72 mm Hg. Head, eyes, ears, nose, and throat are normal. Neck is without thyromegaly or lymphadenopathy. Lungs, heart, and abdomen are normal. Skin is without lesions. Results of a neurologic examination are unremarkable.

LABORATORY STUDIES
Results of diagnostic studies done in the past year- including a comprehensive metabolic panel, lipid panel, thyroid-stimulating hormone measurement, urinalysis, and cardiac and GI evaluations-were all normal. Most recently, hemoglobin level was 11.4 g/dL; hematocrit, 39.6%; and mean corpuscular volume, 74 fL.

Which of the following is the most likely cause of the patient’s symptoms?A. Chronic fatigue syndrome.
B.
Fibromyalgia.
C.
Somatization disorder.
D. Adrenal insufficiency.

(Answer and discussion on next page.)

CORRECT ANSWER: C


This patient has had multiple physical ailments over a period of years. These have prompted numerous diagnostic studies, the results of which have all been unremarkable. This clinical scenario, coupled with negative results from a current medical evaluation, is diagnostic of somatization disorder (choice C).

Patients with somatization disorder experience psychological distress in the form of physical symptoms, for which they seek medical attention. Somatization is often defined as physical symptoms that cause distress but for which there is no corresponding tissue damage and which cannot be explained by physical examination findings or results of diagnostic studies.1 Patients can present with almost any symptom, including pain syndromes, GI symptoms, cardiopulmonary symptoms, pseudoneurologic symptoms, and genitourinary symptoms. Somatization is commonly seen in medical practice. Numerous studies have demonstrated that between 20% and 50% of visits to primary care providers, as well as 20% of visits to specialists, result in no explanation for the patient’s symptoms.



Chronic fatigue syndrome is defined by an upper respiratory tract illness associated with fatigue of acute onset in an otherwise well individual, and residual fatigue that persists despite resolution of the initial illness. The fatigue is often exacerbated by exercise, and it may be associated with self-reported cognition and sleep problems, headache, joint pain, and myalgias for which there are no correlating physical or laboratory findings. Fatigue is not a principal complaint in this patient; moreover, her symptoms are not exacerbated by activity. Thus, choice A is incorrect.

Fibromyalgia occurs most often in women and is defined by progressive, debilitating pain; fatigue; sleep disturbances; headache; and irritable bowel symptoms. Affected patients have multiple tender areas of muscle and tendon without associated physical examination findings. This woman has had some symptoms commonly seen in fibromyalgia-but again, the pain and fatigue that are so characteristic of this condition are not present. Thus, choice B is also incorrect.

Patients with adrenal insufficiency can have fatigue and malaise that are exacerbated by exertion, generalized weakness, weight loss, and irritable bowel symptoms. Physical examination may reveal relative hypotension and hyperpigmentation that is especially noticeable in areas exposed to light or friction. Laboratory studies usually reveal hyponatremia and hyperkalemia. Laboratory studies have shown no abnormal results in this patient; her blood pressure is normal; and no skin lesions are evident. Thus, choice D is clearly not correct.

Approach to the patient with somatization disorder.
Somatization disorder can be a source of considerable frustration for both clinicians and patients. 1,2 Affected patients generate a disproportionate number of medical expenses. There is no specific treatment for somatization disorder. The key to successful treatment is long-term coordination of care by the primary care provider. Because of the strong association between somatization disorder and underlying psychiatric illnesses-especially anxiety and depression-the approach to the condition is similar to that used in other psychiatric illnesses. Central tenets include the following:

•Patients need to know that their disease is real and that they are not malingering. Tell them that they have a diagnosis and what it is.

•Acknowledge the uncertain nature of the illness, and avoid the debate about whether it is organic or psychiatric.

•Although there is no cure per se, patients’ symptoms can be attenuated through appropriate treatment.

•Keep in mind that there may be some patients with somatization disorder whom you cannot help.

Patients require regularly scheduled visits; these lessen the need for phone calls and emergency department visits. Each visit should include an appropriate, directed history taking and physical examination. However, additional diagnostic testing for ongoing problems is rarely helpful; patients with somatization disorder are usually not reassured by negative test results. Evaluate patients’ symptoms cautiously, and place greater emphasis on physical examination findings. The clinician’s normal tendency to “diagnose and treat” is often counterproductive in patients with somatization disorder.3

The only treatment modalities for which there is evidence of effectiveness are psychotropic medications and nonsomatic therapy. Numerous studies have documented the deleterious effects of opiate and non-opiate analgesics in patients with somatization disorder. Drugs that have been most effective are antidepressants and agents such as gabapentin. Traditionally, tricyclic antidepressants have been used as adjuvant analgesics; however, recent studies suggest that selective serotonin reuptake inhibitors and serotonergic-noradrenergic antidepressants are also effective-because they raise serotonin levels.4 All of these agents can ameliorate physical symptoms as well as address the associated psychiatric disorder.

Nonsomatic therapies that have been successful include relational therapy, cognitive behavioral therapy, and psychodynamic psychotherapy. These therapies can often be used in a primary care setting. Recent studies of group cognitive behavioral therapy in patients with somatization disorder found that study participants who received such therapy had fewer somatic symptoms, less health-related anxiety, and a higher level of functioning than controls.5Outcome of this case. The patient was informed of the working diagnosis of somatization disorder and offered a trial of antidepressant therapy. She said she wanted to think it over; at 2 months after her initial visit, she had not made a follow-up appointment.

References:

REFERENCES:


1.

Chamerlain JR. Approaches to somatoform disorders in primary care.

Adv Stud Med

. 2003;3:438-447.

2.

Jackson JL, Kroenke K. The effect of unmet expectations among adults presenting with physical symptoms.

Ann Intern Med

. 2001;134:889-897.

3.

Epstein RM, Quill TE, McWhinney IR. Somatization reconsidered: incorporating the patient’s experienceof illness.

Arch Intern Med

. 1999;159:215.

4.

Fishbain D. Evidence-based data on pain relief with antidepressants.

Ann Med

. 2000;32:305-316.

5.

Barsky AJ, Ahern DK. Cognitive behavior therapy for hypochondriasis: a randomized controlled trial.

JAMA

. 2004;291:1464-1470.