Somatoform disorders: food for thought

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

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.