MODEL ANSWERS

Behaviour and Appearance:

Ben is a young man who is groomed, dressed neatly wearing a white, striped business shirt. There was good rapport and he was engaging. There were no obvious physical or neurological abnormalities on inspection. There were no psychomotor disturbances.

Orientation and Cognition:

Though these were not formally tested, Ben appeared oriented. He was fully conscious.

Affect and Mood:

Affect had full range, was reactive and generally appropriate. A few times, he was smiling while talking about his multiple worries. Mood was subjectively reported as worried but denied feeling depressed or overly anxious. Objectively, his mood was euthymic and relaxed.

Thought Form:

He was logical and coherent. His answers to questions were mostly goal oriented. While answering questions, he frequently returned to his multiple somatic worries.

Speech:

He had normal volume, rate and rhythm.

Thought Content:

He had multiple preoccupations with several undiagnosed physical complaints. These included back pains and stomach aches. He was worried that these symptoms are due to serious illnesses even though repeated tests have been negative. They are consistent with overvalued ideas. Probably these preoccupations are technically not delusions though these have to be directly questioned later. He denied panic symptoms and compulsions. He has phobia of heights. There was no paranoia.

Perceptual Disturbances:

There was no evidence for hallucinations.

Insight and Judgment:

He had poor insight into his condition. His judgement is poor as evidence by innumerable doctor visits and insistence in having invasive procedures.

Safety Concerns:

He denied having thoughts of suicide or harm to others. Indirectly, he has a medium risk of inadvertently causing harm to self because of multiple invasive diagnostic tests.

MODEL ANSWERS

Preferred Diagnosis in Axis 1 is either Hypochondriasis or Somatization Disorder. He has features of both diagnoses. The patient needs to be asked further questions to confirm a somatization disorder.

Differential Diagnosis would be Generalized Anxiety Disorder (GAD). He has a lot of the physical symptoms found in GAD. However, his worries are mostly somatic in nature. In GAD, the worries are more global.

MODEL ANSWERS

Safety issues:

There are no acute safety concerns with this patient. He can be clearly managed in the community setting. However, long term, he is at risk from multiple invasive diagnostic procedures.

Gathering more information and establishing the diagnosis:

All of his medical records should be reviewed so that no further unnecessary procedures are ordered (unless clearly indicated). Details of his symptoms should be further reviewed. This includes onset of symptoms (were they related to stressful events?) and their frequency and severity. Are his beliefs delusional in intensity?

Biopsychosocial management:

1. It is very important to establish a good therapeutic relationship with this patient. The general practitioner should be the central figure in coordinating his care, if needed, with other specialists.

2. Educating the patient about the working diagnosis is important.

3. Cognitive behavioural strategies which include relaxation strategies, thought stopping and distraction techniques can be helpful with his worries and physical symptoms.

4. Medications, in particular, SSRI antidepressants may be trialled to control his anxiety symptoms. Side effects should be explained and monitored.

5. Involving the patient’s supports or family in the care should be considered.