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Mark ~ f> 6t ~ ~ , GJIIA)

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A 26-year-old graduate student comes to the office due to chronic headaches that he
describes as "debilitating." He tends to experience the headaches at night and has
difficulty falling asleep. He has no fever or vomiting. The patient has had similar
headaches for the past year and underwent a complete workup last year that included a
brain CT scan and ophthalmological evaluation; all were negative. His physical
examination is normal. Despite reassurance from the physician, the patient continues to
be excessively worried and thinks he may have a brain tumor or aneurysm. He has an
upcoming deadline for his dissertation and is concerned that his insomnia is affecting his
productivity. He is unable to focus on his studies due to persistent worrisome thoughts.
Which of the following is the most appropriate next step in management?

0 A. Explain the benign nature of the headache

0 B. Initiate a discussion about current emotional stressors
0 C. Order additional diagnostic testing
0 D. Prescribe a benzodiazepine
0 E. Prescribe zolpidem for insomnia
0 F. Provide reassurance that all tests were negative
0 G. Refer for neurology consultation

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Item: ~'?Mark ~ f> 6t ~ ~ , GJIIA)
0. ld : 3845 Prevoous Next Lab Values Notes Calculator Reverse Color Text Zoom

A 26-year-old graduate student comes to the office due to chronic headaches that he
describes as "debilitating." He tends to experience the headaches at night and has
difficulty falling asleep. He has no fever or vomiting. The patient has had similar
headaches for the past year and underwent a complete workup last year that included a
brain CT scan and ophthalmological evaluation: all were negative. His physical
examination is normal. Despite reassurance from the physician. the patient continues to
be excessively worried and thinks he may have a brain tumor or aneurysm. He has an
upcoming deadline for his dissertation and is concerned that his insomnia is affecting his
productivity. He is unable to focus on his studies due to persistent worrisome thoughts.
Which of the following is the most appropriate next step in management?

A Explain the benign nature of the headache [3%)

B. Initiate a discussion about current emotional stressors [85%)
C. Order additional diagnostic testing [0%)
D. Prescribe a benzodiazepine [3%)
E. Prescribe iolpidem for insomnia [4%)
F. Provide reassurance that all tests were negative [5%)
G. Refer for neurology consultation [0%)

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Explanation: User

Somatic symptom disorder

• >1 somatic symptom(s) causing distress

& functional impairment
• Excessive thoughts or behaviors related
to somatic symptoms
Clinical o Unwarranted, persistent thoughts about·
features seriousness of symptoms
o Persistent anxiety about health or symptoms
o Excessive time & energy devoted to symptoms
• >6 months duration

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Item: ~'?Mark ~ f> 6t ~ ~ , GJIIA)
0. ld : 3845 Prevoous Next Lab Values Notes Calculator Reverse Color Text Zoom

Explanation: User

Somatic symptom disorder

• >1 somatic symptom(s) causing distress

& functional impairment
• Excessive thoughts or behaviors related
to somatic symptoms
Clinical o Unwarranted, persistent thoughts about
features seriousness of symptoms
o Persistent anxiety about health or symptoms
o Excessive time & energy devoted to symptoms
• >6 months duration

• Regularly scheduled visits with same provider

• Limit unnecessary workup & specialist referrals
• Legitimize symptoms but make functional
Management improvement the goal
• Focus on stress reduction & improving
coping strategies
• Mental health referral if patient will accept
@UWorld

This patient's excessive preoccupation and persistent anxiety about his headaches are
suggestive of somatic symptom disorder. Symptoms are typically more prominent
during periods of psychological stress. Optimal management includes regularly
scheduled visits with a single provider to develop the physician-patient relationship and
monitor the condition, while avoiding unnecessary diagnostic testing (Choice C) and
specialist referrals. The physician should focus on discussing the role of
psychosocial stressors on somatic symptoms and promoting stress reduction and
healthy behaviors (eg, sleep hygiene, relaxation techniques, exercise, diet, return to
productive activities).

(Choices A and F) Providing reassurance or repeated explanations is minimally

effective as these patients are rarely reassured by negative findings.
(Choices 0 and E) Benzodiazepines and zolpidem can be used in the short-term
 • Limit unnecessary workup & specialist referrals
• Legitimize symptoms but make functional
Management improvement the goal
• Focus on stress reduction & improving
coping strategies
• Mental health referral if patient will accept
@UWot1d

This patient's excessive preoccupation and persistent anxiety about his headaches are
suggestive of somatic symptom disorder. Symptoms are typically more prominent
during periods of psychological stress. Optimal management includes regularly
scheduled visits with a single provider to develop the physician-patient relationship and
monitor the condition, while avoiding unnecessary diagnostic testing (Choice C) and
specialist referrals. The physician should focus on discussing the role of
psychosocial stressors on somatic symptoms and promoting stress reduction and
healthy behaviors (eg, sleep hygiene, relaxation techniques, exercise, diet, return to
productive activities).
(Choices A and F) Providing reassurance or repeated explanations is minimally
effective as these patients are rarely reassured by negative findings.

(Choices 0 and E) Benzodiazepines and zolpidem can be used in the short-term

treatment of anxiety and insomnia. However, these interventions would provide only
temporary relief. They do not treat the core issue of this patient's preoccupation and
excessive concern with his physical symptoms.
(Choice G) The patient had a complete workup, including a negative CT scan, and has
no focal neurological findings. There is no indication for a neurological evaluation. A
referral inappropriately defers the problem to another physician.
Educational objective:
Somatic symptom disorder involves excessive and disproportionate preoccupation with
somatic symptoms, resulting in high health care utilization and functional impairment.
Because symptoms often wo.rsen during·periods of stress, patients should be asked
about their current emotional stressors and counseled regarding stress reduction.

References:
1. Somatic symptom disorder.

Time Spent: 2 seconds Copyright © UWorld Last updated: [10/20/2016)

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