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.
Table 2
Undifferentiated somatoform disorder: diagnostic criteria
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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 ).
Table 3
Diagnostic criteria for delusional disorder
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| 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.