Somatic symptom disorder with predominant pain treated by electroconvulsive therapy: a case report

Abstract

<h3>Introduction</h3> Somatic symptom disorder is a challenging condition for which there are limited pharmacological modalities available for treatment. There have been no epidemiologic studies on somatic symptom disorder since the adoption of DSM-5 in 2013, but somatic symptom disorder has been considered with a prevalence of around 5 % based on previous research in somatization disorder (Creed et al. 2004). The diagnosis of somatic symptom disorder is often delayed. As somatic symptoms progress to the level of functional decline, patients are eventually referred to psychiatrists for additional assessment and treatment. Unfortunately, the underlying neurobiology of this condition is largely unknown. Given these circumstances, the current treatment guideline recommends initial treatment targeting comorbid depressive symptoms or anxiety as well as a cognitive behavior approach. Patients benefit from scheduled visits with a primary care provider and collaborative care among all providers (Kurlansik et al. 2016). The goal of treatment is not to cure symptoms but the management of symptoms to maintain an individual's function in life. However, there are certain refractory and debilitating cases of somatic symptom disorder despite multiple trials and therapeutic approaches. As with the indication of electroconvulsive therapy (ECT) for refractory depression, bipolar disorder, and schizophrenia, there have been several case reports highlighting ECT for the treatment of somatic symptom disorder (Gahr et al. 2011, Suda et al. 2008). <h3>Methods</h3> We present a case of somatic symptom disorder (with predominant pain in chest, abdomen, and back) refractory to multiple medications without primary mood disorders, which was eventually treated with an acute course of ECT. <h3>Results</h3> A 68-year-old male with no previous psychiatric history self-presented to the emergency room with the chief complaint of pain frequently over the course of three years, with greater than 50 presentations in 12 months. Chief complaints included left-sided-chest pain, facial paresthesias, and numbness and tingling sensation in his left arm and ankle. Broad medical workup including EKG, troponin, EMG, chest and abdomen CT, brain and whole spine MRI showed no medical cause for the pain. Trials of duloxetine, nortriptyline, gabapentin, Tramadol and hydromorphone were tried without improvement. Weekly cognitive behavioral therapy for his nonadaptive health seeking behavior and anxiety was conducted. Eventually, he was admitted to the hospital to pursue an ECT trial to target his chronic pain symptoms diagnosed as a somatic symptom disorder. Prior to his initial ECT treatment, pain was rated as 10 plus out of 10. Following one ECT treatment, pain was rated as two on the day of treatment. He initially experienced side effects of ECT including generalized confusion and disorientation to time and place, however this resolved within several hours. Pain increased to 5 one day after the first ECT, however it continued to improve over the course of receiving ECT with 0 after the sixth session over the two weeks. Throughout the course of ECT, his mood was reported as "fine" with a stable score of 15 in PHQ-9. <h3>Conclusions</h3> We suggest that ECT could be considered as a possible treatment option for refractory somatic symptom disorder. It is unclear about the efficacy of ECT for somatic symptom disorder with the current evidence base. Further research with a large number of cases and with a focus on the biological approach are still needed to elucidate the underlying mechanism of action to support the indication of ECT for somatic symptom disorder. <h3>This research was funded by</h3> All authors have no funding to report.