What is the diagnosis for a patient presenting with unspecified severe symptoms?

Diagnostic Approach for Patients with Unspecified Severe Symptoms

When evaluating a patient with unspecified severe symptoms, a thorough medical evaluation must be completed before considering somatic symptom disorder or tic disorder as the diagnosis.

Initial Medical Evaluation

Medical Causes to Rule Out First

• Organic disease must be excluded before considering psychiatric or somatic disorders 1
• Evaluate for:
  • Metabolic disorders (check electrolytes, especially potassium levels) 1
  • Infectious causes (meningitis, encephalitis) 1
  • Autoimmune conditions 1
  • Neurological disorders (stroke, structural lesions) 1
  • Medication adverse effects (antipsychotic effects, neuroleptic malignant syndrome, serotonin syndrome) 1

Key Components of Medical Workup

1. Focused history targeting:

   • Prior episodes of similar symptoms
   • Fluctuating symptoms (suggestive of Meniere's disease or autoimmune conditions) 1
   • Medication use and recent changes
   • Substance use history

2. Physical examination with attention to:

   • Vital signs (abnormalities may indicate medical emergency)
   • Neurological examination (focal deficits suggest organic disease)
   • Signs of systemic illness

3. Laboratory testing based on clinical suspicion:

   • Basic metabolic panel (particularly important to detect hypokalemia) 1
   • Complete blood count
   • Toxicology screening if substance use suspected 1

4. Imaging when indicated:

   • CT or MRI for suspected neurological causes 1
   • Consider CT enterography for persistent GI symptoms with suspected inflammatory bowel disease 1

Diagnostic Criteria for Somatic Symptom Disorder

If medical causes have been ruled out, consider somatic symptom disorder when the following DSM-5 criteria are met 1:

1. One or more somatic symptoms causing distress or disrupting daily life
2. Excessive thoughts, feelings, or behaviors related to symptoms, manifested by:
   • Disproportionate thoughts about symptom seriousness
   • Persistent high anxiety about symptoms
   • Excessive time/energy devoted to symptoms
3. Symptomatic state persisting >6 months (though individual symptoms may fluctuate)

Severity Classification

• Mild: Only one criterion from #2 above
• Moderate: Two or more criteria from #2
• Severe: Two or more criteria plus multiple somatic complaints

Diagnostic Criteria for Tic Cough (Previously Habit Cough)

Consider tic cough when the patient shows 1:

• Suppressibility (can temporarily stop the cough)
• Distractibility (symptoms decrease when attention is elsewhere)
• Suggestibility
• Variability in symptoms
• Presence of premonitory sensation

Important Clinical Considerations

1. Avoid premature psychiatric diagnosis:

   • Medical conditions are found in 19-63% of patients initially thought to have psychiatric disorders 1
   • History and physical examination have 94% sensitivity for identifying medical conditions in psychiatric patients 1

2. Special populations requiring extra caution:

   • Elderly patients (may have atypical presentations)
   • Patients with diabetes or immunosuppression
   • Children with developmental disorders 1

3. Diagnostic pitfalls:

   • Confusing somatic symptom disorder with malingering (which implies direct gain from feigning illness) 1
   • Mistaking conversion disorder for somatic symptom disorder 1
   • Overlooking medical conditions in patients with known psychiatric disorders 1

Management Approach

If somatic symptom disorder is diagnosed:

• Non-pharmacologic interventions (hypnosis, suggestion therapy) are more effective than medications 1
• Regular follow-up to monitor for emergence of organic disease
• Consider psychiatric consultation for treatment planning

If tic cough is diagnosed:

• Use the term "tic cough" rather than "habit cough" to align with DSM-5 classification 1
• Behavioral therapy approaches are typically most effective

Conclusion

The diagnosis of patients with unspecified severe symptoms requires a systematic approach to rule out organic disease before considering somatic symptom disorder or tic disorder. The diagnostic process should be thorough but efficient, with appropriate testing guided by clinical presentation rather than routine panels of tests.