Cases that Test Your Skills
Somatoform disorders: food for thought
Days after being jilted, Ms. M develops disabling fatigue and violent aversion to most foods. She insists her symptoms are physical, but numerous tests reveal no medical problem.
HISTORY: UNHAPPY NEW YEAR
On New Year’s Day Ms. M, age 43, begins experiencing persistent left-leg numbness, fatigue, and what she calls a “superallergic sensitivity to anything I put in my mouth.”
A few days later she sees her internist, who finds no medical cause and suspects that her symptoms are psychological. The internist prescribes fluoxetine, 10 mg/d. Fifteen minutes after taking the first dose, the patient reports “an anaphylactic episode,” which she describes as “screaming and shaking.”
Acting on the internist’s suggestion, Ms. M presents to me on Jan. 10. Her parents bring her to the appointment, as she feels too weak to drive.
A chemical engineer with a six-figure income, Ms. M has lived on her own most of her adult life but has stayed the past week with her elderly parents. With her vacation leave about to end, she says she is too weak and tired to return to work. She complains of extreme fatigue after eating most foods; after some meals, she says, welts surface throughout her body. Now living on bananas and homemade apple-sauce, she has lost 5 lbs in less than 2 weeks.
An only child, Ms. M is an award-winning athlete. She has enjoyed her career, which has taken her around the world. She has no significant psychiatric or medical history or family history of allergy or autoimmune disease. She says she is not depressed and is sleeping normally. Her Mini-Mental State Examination score of 30 indicates no cognitive impairment.
Ms. M denies feeling depressed. She mentions that her boyfriend broke off their relationship days before New Year’s Eve—the day on which she had expected they would become engaged. She sees no relationship between disappointment over this breakup and the symptoms that followed almost immediately. She has never had another intimate relationship and describes people she knows as “acquaintances” or “work buddies” rather than as friends.
Diagnostic criteria for hypochondriasis
Copyright 2000.American Psychiatric Association.
Ms. M refuses to try another psychotropic, fearing another “anaphylactic” episode like the one she described after the fluoxetine dose. She is willing to start psychotherapy, however.
Dr. Bernstein’s observations
Ms. M. complains of an array of food allergies and fatigue with no subjective feelings of depression. She has an athletic physique, is attractive without cosmetics, and is casually but neatly dressed, indicating good organization.
At this point, no physical or medical cause has been found for Ms. M’s symptoms, nor does she meet DSM-IV-TR criteria for hypochondriasis (Table 1). Her symptoms have persisted for 10 days—far short of the 6 months the diagnosis requires. Ms. M also believes that her medical problem is inconvenient but not serious.
Even though Ms. M denies feeling depressed, her symptoms most closely suggest depression with somatic complaints. She is not substantially distressed, but her symptoms are impairing her social and occupational functioning.
Antidepressants—particularly selective serotonin reuptake inhibitors—can help depressed patients with somatic symptoms, and low-dose atypical antipsychotics alternately are used to treat major depressive disorder with somatic delusions. Ms. M, however, will not try another medication, making psychotherapy my only treatment option.
TREATMENT: ‘SURFING’ FOR CLUES
For 6 months, Ms. M attends weekly psychodynamic psychotherapy sessions regularly and on time. She is courteous and pleasant, but her fatigue persists.
Early in treatment, Ms. M spends hours searching the Internet for doctors who specialize in malabsorption syndrome, allergy, and rare infectious diseases. Numerous internists, allergists, and immunologists perform blood work and other laboratory tests on her. She has the results—reams of clinical data—sent to me. I also order tests for HIV, syphilis, and gonorrhea. None of the results indicates a physical disorder. She refuses patch or intradermal testing for allergy, fearing anaphylaxis.
Ms. M also spends much of her day preparing her own meals. She introduces “new foods” one at a time, but reports that these trials often lead to fatigue and cause her to break out in welts. During psychotherapy, she points to bumps and rashes throughout her body that I cannot see.
Six months into psychotherapy, Ms. M is still staying with her parents and has not returned to work, citing disabling fatigue. Her parents, frustrated with her apparent unwillingness to get better, set a deadline for her to move out of their home. She finds an apartment nearby but about 2 miles from the train line she would use to commute to work. She refuses to take a taxi to the train station because of the expense, will not drive to the station because she cannot get up early, and will not drive directly to work for fear of tiring while driving. She refuses her company’s offer to let her work part time from home.
Ms. M’s company keeps her job open for her, but she is still not returning to work. After 1 year, the company finally fires her, then calls her a few months later asking if she’ll come back; she again says no. She collects disability benefits and taps into her savings and investment dividends to make ends meet. In discussing her lack of income during psychotherapy, Ms. M does not appear distressed.
Undifferentiated somatoform disorder: diagnostic criteria
Dr. Bernstein’s observations
Although Ms. M meets criteria for undifferentiated somatoform disorder ( Table 2), her belief that she has a medical problem is tenacious and her disability persists despite lack of a medical diagnosis. To me, this suggests a delusional disorder (Table 3 ).
Diagnostic criteria for delusional disorder
Somatic type: delusions that the person has some physical defect or general medical condition.
For 6 months, although she has cooperated with psychotherapy, Ms. M’s complaints have been unyielding. Despite our good relationship, she will not trust my recommendations to try a psychotropic. Nor does psychotherapy or the cooperation of her former employer enable her to resume her once-rewarding career, even part-time.
Ms. M is reclusive but not suspicious. She has no grandiose or paranoid delusions or hallucinations. She has had no depersonalization or derealization episodes, and no affective component exists. She is profoundly convinced that she suddenly developed severe, incapacitating food allergies. Her lifestyle has deteriorated—she feels unable to work and even her parents have virtually abandoned her—yet she seems oddly content.
How does Ms. M compare with other patients with:
- undifferentiated somatic disorder
- delusional disorder?
Dr. Bernstein’s observations
Somatoform disorder. Patients with undifferentiated somatoform disorder usually exhibit fluctuating symptoms, which often can be mitigated with psychodynamic therapy. In time, most accept that their problem is psychological rather than physical or that anxiety or depression are contributing to symptom fluctuation. Patients usually continue or resume social and vocational functioning.
By contrast, Ms. M believes immutably that her symptoms have an undiscovered physical cause. This belief has dramatically changed her life: She has sacrificed her career, social life, health insurance, even her financial security.
The depth and seeming permanence of Ms. M’s state does not distress her. She is not regressed nor affectively or cognitively impaired. She reports seeing and feeling welts and rashes that were not visible to me or to other medical/alternative medical specialists, suggesting reality testing impairment. I perceived no other break in reality testing during psychotherapy.
Delusional disorder can be treated with medication or cognitive-behavioral therapy. I once treated a young man who believed that his head was coming to a point, causing him tremendous emotional distress. An antipsychotic resulted in prompt remission.
By contrast, Ms. M has a delusional belief that food and medicine make her sick and could lead to anaphylaxis. She will not take medication, even in a hospital.
Perhaps someday we will find a neurobiological or biochemical cause for Ms. M’s behavior. Positron-emission tomography or augmented MRI could uncover such clues, but both tests require ingesting a foreign substance—something Ms. M will not do.
FOLLOW-UP: MS. M’S NEW LIFE
Having exhausted her savings and work disability benefits, Ms. M receives Social Security disability benefits. With her health insurance coverage having expired, she stops psychotherapy after 2 years and pursues no further medical workup.
Two years after presenting to me, she does not seem depressed but her presenting picture is unchanged. She sounds happy and cognitively intact. Her life revolves around her perceived disability.
Ms. M has spent much of the last 2 years alone in her apartment, content in her solitude. She has resumed playing tennis but only occasionally and has not resumed the sport for which she has won many awards. She says she feels slightly better but remains too tired to return to work. She has gradually expanded her menu to about a dozen foods. Despite her problems Ms. M, who is 5 feet 2 inches, has maintained her weight (114 lbs) and attractiveness.
All the while, Ms. M has refused medication. I repeatedly suggest hospitalization so that she can take psychotropics in a safe, supervised setting, but she declines.
- Pilowsky I. Abnormal Illness Behaviour. New York: John Wiley & Sons, 1997.
- Isaac A, Wise T. A low-frustration strategy for treating somatization. Current Psychiatry 2003;2(8):32-50.
Drug brand names
- Fluoxetine • Prozac
Dr. Bernstein reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.