Authors: Mathilde Horn, Thomas Fovet, Vincent Sobanski, Ali Amad
Categories: Case Report, Somatic Symptom Disorder, Pheochromocytoma, Iatrogenesis, Biopsychosocial
Source: BMC Psychiatry
Authors: Mathilde Horn, Thomas Fovet, Vincent Sobanski, Ali Amad
Somatic Symptom Disorder (SSD) is defined as persistent and clinically significant somatic symptoms accompanied by excessive and inappropriate health-related thoughts, feelings and behaviours. The causes of SSD are not fully understood, but the biopsychosocial model posits that they result from vulnerability to both precipitating and maintaining factors that contribute to the progression of symptoms from short-term/acute distress presentation to a more persistent and even disabling problem.
We report the case of a patient who developed a SSD after a prolonged period of medical care that ultimately led to the diagnosis of pheochromocytoma. After surgery (that should have resolved the initially-presenting problem), both physical symptoms and distress persisted, suggesting that SSD was present and remained even after treatment of the original/underlying physical symptom profile.
This case report emphasizes the importance of early diagnosis of SSD when a patient presents with excessive health-related thoughts or behaviors, and not only after physical diagnoses have been ruled out. Based on the predictive model of SSD, early SSD treatment may help to reduce physical symptoms, regardless of their etiology. Diagnosing SSD and investigating the potential etiology of physical symptoms should be seen as complementary approaches, rather than opposing ones.
Somatic Symptom Disorder (SSD) is defined as persistent and clinically significant somatic symptoms (criterion A) accompanied by excessive and disproportionate health-related thoughts, feelings and behaviors (criterion B) [1]. SSDs are highly prevalent in all areas of medicine, they result in long-term negative consequences such as impairment of patients'quality of life but also high levels of healthcare utilization [2, 3]. Until 2013, somatoform disorders were defined negatively by the lack of medical condition that may account for the physical symptoms. DSM-5 introduced a positive diagnosis of SSD, which no longer requires the persistent symptoms to be medically unexplained. SSD may thus co-occur with another medical condition if physical symptoms persist and are associated with disproportionate thoughts, feelings or behaviors [1]. This major evolution raises questions regarding the mechanisms underlying SSD but also the potential role of the healthcare system implicated in potential contributions to the emergence of this disorder.
The causes of SSD are not yet fully understood [3]. Henningsen's etiological model [4], supplemented by Lowe et al. [2] includes biopsychosocial vulnerability, precipitating factors, and maintaining factors that contribute to the transition from short-term to persistent disabling symptoms. Predisposing factors include sociodemographic, psychological, and biomedical factors. Triggering factors may include infections, injuries, medical or surgical procedures, or current life stressors. Factors that may contribute to the maintenance of the condition include selective attention towards interoceptive cues, heightened perception of bodily sensations, catastrophizing cognitive interpretations, somatosensory amplification, and dysfunctional illness behaviours [4]. While this vulnerability-stress model is supported by several authors [2–6], there is a lack of prospective data demonstrating the transition from acute to chronic somatic symptoms while integrating pathophysiological, psychological, and social factors.
We report the case of a patient who developed SSD after an extended period of medical care that ultimately led to the diagnosis of pheochromocytoma. We propose that iatrogenic factors resulting from medical intervention may have contributed to the development of SSD.
Mr T, a 46-year-old man, was referred to our hospital's internal medicine department for persistent episodes of sweating, dizziness, arthralgia, asthenia and headaches. The symptoms had been present for 7 years in the context of burnout and the loss of his father. The first diagnosis that was considered was panic attacks. Mr. T was therefore referred to a psychiatrist and treated with antidepressants and anxiolytics, with no apparent improvement. The symptoms remained the same and the clinical examination showed no abnormalities, in particular no hypertension. Over five years, as the symptoms persisted, the patient was referred by his general practitioner to various specialists including 3 ophthalmologists for asthenia and headaches, 1 otolaryngologist to investigate dizziness, 1 rheumatologist for the arthralgia, 2 psychologists and 1 psychomotor therapist. Extensive diagnostic investigations, including clinical examination, brain MRI, polysomnography, and bone scintigraphy, failed to reveal any abnormalities. Finally, his general practitioner requested an internal medicine consultation. During this consultation, the patient presented with the same physical symptoms and seemed very concerned about his symptoms. He claimed to have adjusted his lifestyle to limit the intensity of the symptoms, stopped smoking and drinking alcohol, has started yoga and limited his time at work. All these changes were judged to be positive with a reduction in the severity of the symptoms, but no complete resolution. Given the paroxysmal nature of sensations of dizziness, headaches and sweating, measurement of catecholamines and tryptase levels was scheduled, and the patient was referred at the same time to the psychiatrist in order to explore the possibility of functional symptoms.
This psychiatric evaluation revealed an obsessive–compulsive personality (Personality Diagnostic Questionnaire-4) without any anxiety or depressive disorder (Hamilton Anxiety and Depression Scale: A4, D4). The patient reported being concerned about his health and was convinced that doctors did not take his physical problems seriously. He reported difficulty falling asleep and daytime asthenia. He reported a period of stress when the symptoms began, related to stressful work conditions, but that this situation had now resolved. He reported psychological distress due to the unexplained symptoms, which were disabling. Although he was not convinced of a psychiatric disorder, he was willing to accept any proposed treatment if it was relevant to regaining function. The screening assessment for SSD revealed a Patient Health Questionnaire-15 (PHQ-15) score of 10 (cut-off = 9) and a Somatic Symptom Disorder-B Criteria Scale (SSD-12) score of 26 (cut-off = 23), suggesting a risk of SSD [7, 8]. The diagnosis of SSD was subsequently confirmed during the psychiatric consultation. The patient was informed of this and, while he expressed ongoing anxiety regarding his condition, he accepted it without difficulty. Hypnosis was suggested as a treatment option and accepted by the patient.
Measurement of catecholamines demonstrated high plasma normetanephrines (1,69 nmol/l, normal value < 0.71) and 24-h urinary total metanephrines 1269 nmol (normal value < 281). An abdominal MRI revealed the presence of a left adrenal mass. The patient was diagnosed to be suffering from pheochromocytoma and surgery was planned for a tumor resection.
During the following psychiatric consultation conducted before the surgery, the standardized assessment for SSD revealed a PHQ-15 = 7 and SSD-12 = 7, indicating the regression of SSD symptoms. Mr. T was no longer worried, was able to concentrate again and felt his physical problems were taken seriously. While physical treatment has not yet begun, the deliverance of a clear diagnosis and the planification of treatment allowed to decrease preoccupation and anxiety for symptoms, but also the intensity of physical symptoms.
However, a few weeks after the operation, Mr T. consulted the surgeon because of persistent paresthesias in his hands. The possibility of an alternative neurological diagnosis was considered, however the random occurrence of paresthesias alternating between the right and left hand, while the biological test and clinical examination were normal, led the medical team to hypothesise that there might be a functional cause. Figure 1 represent the patient's history.Fig. 1Life Chart of Mr T. variability of concern about physical according to intensity of physical symptom and illness course
This case report highlights important considerations for clinical practice, particularly the potential iatrogenesis of excessive medical intervention.
The biopsychosocial model developed by Engel suggests that illness or disease is caused by a complex mixture of biological, psychological and social factors [9]. Based on this biopsychosocial model, recent integrative work postulates that persistent symptoms in SSD result from the interaction of physical triggers and psychosocial factors [6, 10]. In the case of Mr T., the history and the evolution of the symptoms suggest that it was the pheochromocytoma which was initially at the origin of the symptoms presented by the patient. Then, the lack of a clear diagnosis, repeated investigations and the feeling of lack of attention from clinicians led the patient to develop anxiety and excessive preoccupation, resulting in disproportionate attention to bodily sensations and catastrophic cognitive interpretations. According to the biopsychosocial model, the persistence of physical symptoms over several years is likely to be due to a biological factor, i.e. an underdiagnosed pheochromocytoma, combined with psychosocial a pre-existing anxious personality, anxiety caused by repeated consultations and examinations, frustration at the lack of effective treatment, and exaggerated attention to physical sensations.
Importantly, as soon as the diagnosis of pheochromocytoma was evoked, the patient’s anxiety but also the intensity of his physical symptoms decreased significantly. This suggests that a large part of the symptom experience was related to the worry about his health and focus on his sensations rather than the physical symptoms associated with the pheochromocytoma. This is consistent with the predictive model of SSD, which suggests that physical symptoms in people with SSD are due to individual predictions rather than actual psychophysiological changes, i.e., individuals may experience symptoms as soon as they are expected [11, 12]. Furthermore, the recurrence of symptoms after surgery) illustrates that the symptoms could not only be explained by pheochromocytoma alone. Surgery eliminated symptoms related to an underlying medical aetiology. The persistence of physical symptoms suggests that the physical symptoms were not only related to the tumor but also to other factors, in particular the late diagnosis, the repetition of examinations and the lack of consideration of symptoms due to the absence of abnormal examinations. All these factors have exacerbated both the patient's stress and the exaggerated/renewed attention to bodily sensations, resulting in the perception of symptoms while the biological cause was being treated.
These findings underscore the need to consider both biological and psychosocial factors in the diagnosis and treatment of persistent physical symptoms. Early identification of SSD can help to reduce anxiety and concern about physical symptoms, which may lead to a reduction in the severity of symptoms. However, detection and accurate diagnostic identification of a patient’s contributing biological factors is concurrently needed to address underlying physical symptoms and begin reducing a patient’s distress. In most cases of patients with SSD, the initial biological cause of SSD resolves spontaneously, but in some patients it persists and requires specific treatment. Viewing Mr T's suffering as a consequence of either a physical or a psychological problem (with multiple switches from one to the other) probably contributed to delaying physical diagnosis and increasing worry. An integrative approach that includes both biological, psychological and environmental factors should be proposed when patients present with persistent symptoms.
This case report demonstrates that inadequate consideration of patient distress and the repetition of consultations and investigations may be significant risk factors for anxiety. This in turn may promote the development or persistence of physical symptoms. In contrast to health anxiety or hypochondriasis, where individuals are preoccupied with the possibility of having one or more serious, progressive or life-threatening illnesses [13](ICD 11), people with SSD have actual physical symptoms that lead them to contact with the health care system. In recent years, there has been increasing interest in the role of illness or contact with the healthcare system in the development of SSD, suggesting a potential iatrogenesis of inadequate or excessive contact with healthcare providers.
For several years, a history of medical events has been identified as a predisposing factor [3, 14–16], but it is now being considered as a precipitating factor that could be the starting point for symptoms. When symptoms are not easily explained by medical conditions, patients may become frustrated by the lack of effective treatment, and clinicians may experience these disorders as difficult to treat [4, 17]. This may explain why SSD are more common when approaches to care are complicated, particularly for functional disorders or conditions with atypical clinical presentations, such as pheochromocytoma. The importance of a good doctor-patient relationship and acknowledging patients'concerns has been suggested as effective in preventing the risk of SSD. [18].
In Mr T's case, we believe that the precipitating factor was not only the medical event (i.e. the pheochromocytoma), but also the way in which it was been managed. The physical symptoms were due to a serious medical illness. The patient’s health-related preoccupation were exacerbated with repeated focus in clinical care and even became excessive due to these repeated investigations (albeit at the request of the patient, and in an appropriate attempt to respond to the patient’s need); however, the patient’s perception of his healthcare providers’ judgment of his symptoms to be medically disproportionate/inauthentic (thought to be caused solely by anxiety) may have inadvertently contributed to his psychological distress and physical reactivity to stress, both exacerbating risk of SSD.
Finally, this case report emphasizes the importance of early diagnosis of SSD when a patient presents with inappropriate health-related thoughts or behaviors, such as excessive anxiety or repeated medical consultations, and not only after physical diagnoses have been ruled out. Based on the predictive model of SSD, early treatment of SSD may help to reduce physical symptoms, regardless of their aetiology. Treatment for SSD should include a physical and psychological approach. Cognitive behavioural therapy has been found to be useful in reducing both psychological distress and physical symptoms [18]. Diagnosing SSD and investigating the potential aetiology of physical symptoms should be seen as complementary, rather than opposing, approaches [19].