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Abdominal pain and nausea after gallbladder removal, numb and tingling arm. All medical test normal. Worrisome

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42 yo male with a 20 month history of unusual symptoms. In retrospect it is thought that a stress event 18 months ago may have initiated recurrent morning abdominal pain especially after eating breakfast. Gall bladder was removed with no improvement. Pain morphed to nausea (still particularly after eating in the morning) and then coexisted with pronounced fatigue, numbness and tingling of the arms...

"Physical discomfort" would disrupt sleep at about 5AM. Upon rising, showering and getting ready, physical discomfort would subside. Within 20 minutes of eating breakfast pronounced fatigue, numbness and tingling in arms and an overall sense of severe discomfort would force pt. to lie down. After resting for 15 minutes, discomfort subsides and pt. is able to go to work. Pt. though sometimes reports feeling "post dromal" during subsequent morning hours, as in a migraine attack-- but with no headache or visual disturbances. Little "crashes" like this might recur three and four times a day but unlike the morning crash it is not associated with eating.

Multiple trials of medications for multiple diagnoses have failed including PPI and antibiotics for GI potential; Trials of Lexapro, Zoloft, Effexor Wellbutrin, Seoquel, Deplin and Valium, Adderall, Dexadrine, Emsam, thyroxine for depression and anxiety. All meds caused intolerable side effects and little if any improvement. Many were discontinued within a week of starting them. Wellbutrin was tolerated for 6 months but did not make much improvement and "crashes" became even more acute. Hormonal replacement was tried as well and patient now has testopel pellets inserted.

Patient maintains that their main stressor in life is not knowing what causes these "crashes XXXXXXX Sleep is disturbed, sometimes with hypnogogic hallucinations. A sleep study and MRI (16 months ago) revealed no significant findings. All labs have been normal. Blood sugar/metabolic studies like thyroid et cetera have all proved normal. Vital signs all normal. Cortisol elevated but all other labs WNL.

Interestingly the patient does not experience much abdominal discomfort anymore yet the dramatic waves of fatigue, numbness and tingling, and yawning persist.
Mood/affect can be positive yet these rather acute onset crashes will still occur. Pt. continues to be told that this is atypical depression yet there is no weight gain (or loss), no rejection sensitivity, no feelings of helplessness or sadness UNLESS he is in the midst of a crash. Yet as this illness continues he is reaching points of despair because it is so odd.

Side notes: patient spends hours trying to figure this out and arranges many consultations. At these consultations he is given more things "to try XXXXXXX Not sure this is helpful as said since there have been so many trials over the 20 months with varying medications at varying doses.

Patient is otherwise very healthy, physically fit. He states his is happy in life if only this illness could be resolved. These crashes seem to happen so acutely even on "good days XXXXXXX

Posted Tue, 26 Feb 2013 in Mental Health
Answered by Dr. Jonas Sundarakumar 1 hour later
Hello and welcome to Healthcare Magic. Thanks for your query.

Let me first highlight the salient points in the patient's clinical hisory:

- 42 year-old male with "medically unexplained symptoms"
- Initially started as "persistent" (despite medication and despite gall bladder removal) abdominal pain, then nausea
- Currently, episodes of severe physical discomfort, fatigue, numbness, tingling, etc.
- All lab investigations normal (except elevated cortisol)
- MRI and sleep study normal
- Reports "untolerable" side effects with almost any psychiatric medication (from various different classes)

Well, given the current scenario, the most probable diagnosis I would consider is a Somatoform Disorder. The reasons are:

- His symptoms profile cannot be explained by any known medical condition.

- More importantly, the symptoms do not seem to have any physiological plausibility - for example, even if we hypothetically say that he may be having some "unknown medical condition", still such dramatic episodes should have some physiological triggers which correlate with the onset of these symptoms. One episode during sleep (that too only at 5am and not any other time during sleep - and the sleep study was normal), then one episode specifically after breakfast (not after any other meals) and few other random episodes without any particular triggers - makes it physiologically unexplainable or plausible.

- All tests (blood, endocrine, neuro-imaging) are completely normal. (the cortisol elevation may just be an indicator of stress)

- The patient's symptom profile is also changing / morphing. Initial abdominal pain, specifically after meals, then nausea, then these episodes. There is nothing that can explain why despite all possible treatments including a gall bladder removal, the abdominal pain did not subside and why all of a sudden, it subsided and was replaced by some other symptoms ocuring at the same time.

- It is unlikely that a person experiencing such "severe and disabling" episodes can be fully functional otherwise.

- Just because the person does not come out with an obvious stressor, doesn't mean that he there is no psychological basis for his symptoms. In fact, most patients with somatoform disorders don't express any stressors openly.

Also, in my opinion, I don't think this is a major depression / atypical depression - which is probably why none of the anti-depressant medication are working and are unlikely to work also.

When these somatic symptoms become chronic or long-standing, the patient himself becomes engrossed and with his symptoms and oftem, even if the psychological conflict is resolved, the "somatic pre-occupation" becomes well set in his mind as an "illness" itself. Unforutunately, the multiple medical consultations, investigations, and attempts to find a diagnosis, only end up re-inforcing this "illness model".

In my opinion, what this patient needs is PSYCHOTHERAPY. This is the primary and predominant treatment method for somatoform disorders. Like I mentioned earlier, since the this problem has been long-standing, intense and prolonged psychotherapy may be required. Even if the patient believes that there is no stressor or conflict psychological basis for his problem, yet he should be made to understand that when there are an unexplainable and "untreatable" pain symptoms, psychological therapy will help him handle the pain better and cope up with it. (This is why in most specialized pain clinics, a psychiatrist is an integral part of the team). There can be a wide range of psychotherapies which can be beneficial - Cognitive Behaviour Therapy, Psychoanalytical psychotherapy, Hypnotherapy, etc. etc. and they require both a dedicated therapist as well as a motivated patient to bring out successful therapy.

Wish you all the best.

Dr. Jonas Sundarakumar
Consultant Psychiatrist
Above answer was peer-reviewed by
Follow-up: Abdominal pain and nausea after gallbladder removal, numb and tingling arm. All medical test normal. Worrisome 15 hours later
Thank you Dr. Sundarakumar. I believe your hypothesis may be correct. The patient is my husband and he is an internist. I did not share that information initially. i wrote to an online doctor to try to find an unbiased, objective opinion and your response is in line with what I have been thinking as well. I am concerned that my husband continues to bounce around providers and search for magic pills. He has consulted with endocrine and neuro via phone and psych as a patient (but also colleague). He now sees a second psychiatrist who again gave him more medications "to try." At no time has my husband received behavioral therapy nor does he think it will do any good at all. However, he is becoming more and more desperate and now discussing TMS or ECT as a last ditch effort. This route scares me especially since he has not really had an adequate trial of any one drug regimen other than wellbutrin and deplin. Most of these other drugs have been discontinued after 1-3 weeks. This has been a long ordeal and he is constantly researching online for a diagnosis. Through this 20 month journey has been able to work and exercise daily - yet his hour by hour assessment of "crashes," "dips," "waves" or "symptoms" continue to the point where sometimes he says he "cannot do it anymore." Baffling. I am not why the psychiatrist will not offer therapy. Is it because of his profession?
Answered by Dr. Jonas Sundarakumar 17 hours later
Hello again,

I can understand that this whole ordeal is putting both of you through a very distressing time.

Well, though your husband's problems may sound very rare and baffling to you (and I am not undermining the magnitude or significance of this problem to you in any way), yet, based on my clinical experience as a psychiatrist, I can tell you that this is a 'typical' case of a somatoform disorder. Maybe, the intensity of the problem (such as the extensivity of the research, investigations and desparate attempts for treatment options) are more because of his profession.

Like I had mentioned earlier, beyond a particular point, when the person becomes too preoccupied with his symptoms, it starts clouding his reasoning and soon this evolves into a very strong belief and conviction that he is having some major undiagnosed / "sinister" medical condition. Once this belief becomes embedded in his mind, then, naturally, the next step is desparate attempts to search for a magical cure through some form of external treatment.

In my opinion, in such cases, medication do not have a major role in treatment. Many experts believe that multiple trials of medication or other treatments (like rTMS, ECT, etc.) only end-up re-inforcing the "medical model" which the person is clinging on to.

I'm not sure why his psychiatrists are hesitating to initiate therapy. The reason could be that it maybe his profession as they may percieve that it may be "very difficult" to engage a doctor in therapy. Neverthless, this may be the only solution and has to be undertaken. I would suggest that you look for a XXXXXXX psychiatrist (much XXXXXXX to your husband), someone who is definitely not known to him and someone who specializes in psychotherapy. Such a person will not only be experienced in dealing with such a case, but will also be able to have a strong say in order to engage your husband in the management plan. You should also co-ordinate with the therapist and try to ensure that your husband doesn't continue to be running after further investigations, research or any other magical cures. I know that all this sounds very difficult and challenging, but I guess, this is the only way out. So, you'll have to be strong and persistent in your efforts.

Wish you all the best.

Dr. Jonas Sundarakumar
Consultant Psychiatrist
Above answer was peer-reviewed by
Follow-up: Abdominal pain and nausea after gallbladder removal, numb and tingling arm. All medical test normal. Worrisome 1 hour later
Thank you very much Dr. Sundarakumar. I do very much appreciate your time and assistance.

With Best Regards,
Answered by Dr. Jonas Sundarakumar 15 minutes later
You're welcome.

Best wishes,
Dr. Jonas Sundarakumar
Consultant Psychiatrist

(Kindly close the query and leave a review if you are happy with my answers.)
Above answer was peer-reviewed by
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