A psychiatrist on a consult team is asked to see a 32-year-old woman for depression

A psychiatrist on a consult team is asked to see a 32-year-old woman for depression. She was admitted to the hospital for a workup of nausea, vomiting, and abdominal pain. The medical team has so far found no reason for these symptoms. In talking to the patient, the psychiatrist learns that she has had many medical problems and, over the past 10 years, has been in the hospital more than 10 times. She reports having had excessive menstrual bleeding and a miscarriage, as well as difficulty becoming aroused during sexual intercourse. She cannot tolerate high-fiber foods and has heartburn and bloating. Two years ago, she had a lump in her throat and had difficulty swallowing, but nothing was found during that admission. In the past couple of years, she has had frequent migraine headaches and blurred vision and has seen several neurologists. She also hurt her back and now has chronic back pain. Which of the following is the most likely diagnosis?

A. Conversion disorder
B. Generalized anxiety disorder
C. Masked depression
D. Pain disorder
E. Somatization disorder

Explanation: The correct answer is E. Somatization disorder is characterized by multiple medical complaints, resulting in significant diagnostic testing and medical interventions and causing impaired social and occupational functioning. The symptoms, which cannot be explained by medical findings, include pain in at least four sites, one pseudoneurologic symptom, one sexual dysfunction
symptom, and at least two or more gastrointestinal symptoms. Conversion disorder (choice A) is a constellation of one or more neurologic symptoms associated with psychological conflict . The symptoms include deficits affecting motor or sensory function under voluntary control, disturbances of consciousness, and pseudoseizures. There is a clear temporal association of the onset of symptoms and a stressor. The symptoms are not consciously produced and are not due to any other medical or psychiatric condition. Generalized anxiety disorder (choice B) is defined by an unrealistic or excessive worry about activities or life events lasting at least 6 months. In addition, six of the following types of symptoms must be present: fatigability, muscle tension, irritability, troubles falling or staying asleep, difficulty concentrating, and restlessness. The symptoms cause significant impairment in everyday functioning. Masked depression (choice C) can be presented through somatic complaints, which can be cardiovascular, gastrointestinal, urinary, or orthopedic, along with depressive symptoms. The disorder meets criteria for depressive disorder but usually not for somatization disorder. Pain disorder (choice D) is characterized by pain as a prominent feature, along with psychological factors that precipitate, exacerbate, and contribute to its severity. It results in impairment of everyday functioning and is not due to any other psychiatric or medical condition. If a general medical condition is present, it doesn’t have a role in its onset or maintenance.