Cases That Test Your Skills

Somatoform disorders: food for thought

Author and Disclosure Information

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.

Table 1

Diagnostic criteria for hypochondriasis

  1. Preoccupation with fears of having, or the idea that one has, a serious disease based on the person’s misinterpretation of bodily symptoms.
  2. The preoccupation persists despite appropriate medical evaluation and reassurance.
  3. The belief in Criterion A is not of delusional intensity (as in delusional disorder, somatic type) and is not restricted to a circumscribed concern about appearance (as in body dysmorphic disorder).
  4. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  5. The disturbance lasts at least 6 months.
  6. The preoccupation is not better accounted for by generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, a major depressive episode, separation anxiety, or another somatoform disorder.
Specify if:
With poor insight: if, for most of the time during the current episode, the person does not recognize that the concern about having a serious illness is excessive or unreasonable.
Source: Tables 1 through 3 reprinted with permission from the Diagnostic and statistical manual of mental disorders (4th ed, text revision).
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.

Pages

Recommended Reading

Commentary: Clinical perspective on pediatric depression
MDedge Psychiatry
Prudent prescribing: Intelligent use of lab tests and other diagnostics
MDedge Psychiatry
Secondary amenorrhea: Don’t dismiss it as ‘normal’
MDedge Psychiatry
Choose precise BMI charts to track youths’ weight gain
MDedge Psychiatry
Taking the mystery out of missing persons
MDedge Psychiatry
Antipsychotic dosing for schizophrenia
MDedge Psychiatry
Recovery and reintegration
MDedge Psychiatry
High-dose antipsychotics
MDedge Psychiatry
Correction
MDedge Psychiatry
Risk taking adolescents: When and how to intervene
MDedge Psychiatry