Date:
Patient:
Reason for Visit:
Initial evaluation for suspected somatic symptom disorder (SSD)
Follow-up for diagnosed SSD
Assessment of symptom response or management strategies
Medication review (if applicable)
History:
Presenting Illness:
Detailed description of physical symptoms (location, duration, severity, character).
Impact of symptoms on daily life (work, social activities, functional limitations).
Associated emotional distress or anxiety related to the symptoms.
Past medical history of medical workups for the reported symptoms (investigations and diagnoses).
Mental health history (previous diagnoses, treatment experiences).
Past Medical History (PMH):
Any relevant medical conditions potentially explaining some symptoms.
Medications (prescription and over-the-counter) currently being taken.
Social History:
Stressful life events or ongoing stressors.
Social support system (family, friends) and their response to the patient’s symptoms.
Occupational history (potential physical or psychological stressors).
Mental Status Exam (MSE):
Appearance: Note patient’s overall presentation (preoccupied with symptoms, anxious).
Mood and Affect: Assess mood state (depressed, anxious) and emotional expression (worried, focused on bodily sensations).
Speech: Evaluate speech patterns (rapid, pressured) or slow and hesitant.
Thought Process: Explore for preoccupation with physical symptoms, catastrophizing, or excessive health anxiety.
Thought Content: Assess for suicidal ideation or other concerning thoughts.
Sensorium: Ensure patient is oriented to time, place, and person.
Insight and Judgment: Evaluate patient’s understanding of the role of stress or psychological factors in their symptoms.
Assessment:
Clinical suspicion of SSD: Based on DSM-5 criteria, including one or more somatic symptoms that are distressing or disruptive, excessive thoughts about the seriousness of the symptoms, and significant associated distress or impairment.
Consider ruling out medical explanations for the symptoms through past medical history and potential future investigations (if deemed necessary).
Severity of symptoms: Mild, moderate, or severe based on symptom burden and impact on functioning.
Functional impairment: Evaluate how symptoms affect daily life (work, school, social interactions).
Differential diagnoses: Consider other medical or psychiatric conditions that may present with similar symptoms.
Plan:
Treatment approach:
Psychotherapy: First-line treatment for SSD.
Cognitive behavioral therapy (CBT): Focuses on identifying and modifying negative thoughts and behaviors that contribute to symptom focus and anxiety.
Acceptance and commitment therapy (ACT): Promotes acceptance of bodily sensations and living a valued life despite symptoms.
Medications (may be considered in some cases):
Antidepressants – may be helpful for co-occurring depression or anxiety.
Low-dose atypical antipsychotics – may be used off-label for some patients with severe symptom preoccupation.
Mind-body therapies:
Relaxation techniques (deep breathing, meditation).
Mindfulness practices.
Follow-up:
Regular follow-up appointments to monitor symptom response, treatment adherence, and adjust the plan as needed.
Consider involving collateral sources of information (e.g., family members) to track progress.
Patient education: Provide information about SSD, its causes, treatment options, and self-management strategies.
Explain the mind-body connection and how stress can exacerbate physical symptoms.
Emphasize the effectiveness of psychotherapy in managing SSD.
Encourage open communication about challenges and progress.
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of somatic symptom disorder.