Psychiatric Evaluation

Hi, I’m Marissa Bass. My gastroenterologist referred me here. I’m not quite sure why because I certainly have a medical problem. Let me tell you about it.
I have serious abdominal pain, right here, often makes me feel like throwing up. I worry all the time about my GI symptoms. Sometimes I have constipation and sometimes I have diarrhea. It’s probably Crohn’s, ulcerative colitis, or maybe even cancer. They’ve done tests but haven’t discovered the problem yet. The doctors even tried PPIs and medications for symptomatic relief and I have rare and too many side effects. I’m sure something isn’t right.
It could be any of those, so I’ve sought out third and fourth opinions at a number of major diagnostic centers. [bitter laugh] Unfortunately, even these “experts” with their evaluations and follow ups just give quote unquote unremarkable findings.
Because I refused to be put off as a woman who just made it up in her mind, I did finally get a diagnosis of Irritable Bowel Syndrome or “flare ups.”
This seems … well, reasonable, but I don’t think it gets at the heart of my problems, which are more severe than a diagnosis of IBS can explain. I’m sure that the doctors must have missed something, a rare medical disease, or a negative laboratory result was incorrect.
I am having difficulty sleeping since I worry about having a serious illness. I haven’t been as interested in my exercise classes. I feel guilty about missing family gatherings and work. My low energy is low and I’m often distracted and feel on edge. I have a decreased appetite due to feeling sick all the time. You would too!
I’ll concede that all these constant worries and stress have made me depressed and irritable. I often feel like screaming at the doctors, my husband, family, and friends for not caring enough or understanding a missed diagnosis.
My friends and family have even said I’m acting like a child because I’m constantly identifying a new diagnosis and staying home from work.
I think my internist and gastroenteritis do not believe me and just referred me to you as a punishment or to shut me up.
I’m here so that you can help me prove them wrong.

Chart Notes
Marissa Bass, 40-year-old female.
Medications: none.
Height: 5 feet 10 inches.
Weight: 130 pounds.
Lab/tests: Physical exam, laboratory tests, urine and stool analysis, colonoscopy, endoscopy, abdominal ultrasound, CT scan and MRI; Barium X-ray, Manometry; Esophageal PH monitoring, hydrogen breath test (Rule out lactose intolerance), urea breath tests (rule out peptic ulcer). Transient elastography (rule out liver fibrosis). All tests are unremarkable.

In addition, Marissa has completed home colorectal cancer, home fecal occult, bleeding, home food allergy, home lead poisoning, and heavy metal poisoning tests. She indicates that she has taken significant time off work to pursue this matter, both for medical appointments, research time, and illness.

Questions:

1. What questions should you ask Marissa during her psychiatric evaluation?
2. You find that top three differential diagnoses for Marissa’s mood disorder include: Delusional disorder, Factitious disorder, and Somatic symptom disorder. What DSM-5 criteria support these differentials?
3. What is 1 screening tool you could use to confirm a diagnosis? Explain your rationale.
4. You determined that Marissa has somatic symptom disorder. What types of psychotherapy would be beneficial for her? Give a rationale for your recommendations.
5. What pharmacology, if any, would you prescribe? Explain the mechanism of action, risk, and benefits.
6. How would you build a therapeutic alliance with Marissa to address the connection between her physical symptoms and her mood disorder?