SSD, illness anxiety, and chronic pain dual diagnosis (MEQ)

(i) Formulation and discriminators. Working diagnoses: somatic symptom disorder (multiple distressing somatic symptoms with disproportionate health anxiety and care-seeking) plus major depressive disorder. SSD does not require symptoms to be medically unexplained; the B-criteria (thoughts/feelings/behaviours) are central.[1] Discriminators: IAD would show minimal somatic symptoms with pure illness preoccupation; FND needs voluntary motor/sensory symptoms with positive functional signs; factitious requires intentional production for sick role; malingering intentional production for external incentive — neither is default without evidence. Keep organic red-flag surveillance open despite prior negative work-ups.[1][7]

(ii) Assessment. Alliance-first history; PHQ-15 severity; depression/anxiety/suicide risk; substance and opioid map (dose trajectory, multiple prescribers, withdrawal, OUD criteria, concurrent sedatives); prior investigations and what would change management; function and health beliefs; collateral GP. Investigations hypothesis-driven only.[2][8]

(iii) Stepped plan. Validate symptoms as real; positive non-dualistic explanation; scheduled GP reviews rather than PRN crisis only; limit unfocused tests; CBT for health anxiety/MUS (Barsky; Tyrer CHAMP; Cochrane non-pharmacological signal).[3][4][7] Treat depression. Consider duloxetine (commonly 30 mg oral daily then 60 mg) if pain–depression phenotype and no contraindications, or cautious low-dose night amitriptyline 10–25 mg oral for pain with anticholinergic/cardiac cautions — evidence humility required.[6] Functional goals (activity, sleep, work).

(iv) Opioids and communication. Apologise for dismissive language; reframe as brain–body amplification, not faking. Opioid PRN poly-prescribing is high risk; SPACE shows opioids not superior to non-opioids for function in key chronic pain groups; prefer multimodal non-opioid plan; if OUD criteria emerge, dual-diagnosis pathway with naloxone and addiction care — not abandonment.[5][8]