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Non-Commercial Use Only Clinics and Practice 2012; volume 2:e11 Hypochondriacal delusion in an In this report, we describe a woman with a hypochondriacal delusion who doesn’t meet Correspondence: Annemiek Dols, Valeriusplein elderly woman recovers quickly the criteria for a severe mood disorder, somati- 14, 1075BH Amsterdam, The Netherlands. with electroconvulsive therapy zation disorder or hypochondriasis according Tel. +31.20788.5565 - Fax: +31.7885.577. to the Diagnostic Statistical Manuel (DSM) IV- E-mail: [email protected] Annemieke Dols, Didi Rhebergen, TR criteria.4 Eventually she was diagnosed Key words: hypochondria, melancholia, weight Piet Eikelenboom, Max L. Stek with melancholia and recovered quickly with loss, ECT. Department of Old Age Psychiatry GGZ electroconvulsive therapy (ECT) (Figure 1). In addition we performed a literature search on inGeest/VUmc, Amsterdam, Conflict of interest: the authors declare no poten- ECT and hypochondriasis, hypochondriacal/ tial conflicts of interests. the Netherlands somatic delusion/psychosis and severe depres- sion with hypochondriacal/somatic delusion/ Received for publication: 11 November 2011. psychosis. Revision received: 11 November 2011. Accepted for publication: 2 January 2012. Abstract This work is licensed under a Creative Commons Attribution NonCommercial 3.0 License (CC BY- A 72-year-old woman without any medical Case Report NC 3.0). and psychiatric history, suffered from nausea, pain in the epigastria and constipation for over A 72-year-old female without a somatic or ©Copyright A. Dols et al., 2012 a year. She eventually lost 20 kilograms despite psychiatric medical history was referred Licensee PAGEPress, Italy nightly drip-feeding. Extensive additional tests Clinics and Practice 2012; 2:e11 against her will to an outpatient psychiatric doi:10.4081/cp.2012.e11 did not reveal any clues for her complaints. clinic by her gastroenterologist after a year of She remained convinced that her symptoms suffering nausea, pain in the epigastria and were a side-effect of anti-fungal medication constipation. The patient was convinced she plained of lack of appetite, disturbed sleep, she used. She was diagnosed with hypochon- had a physical illness and no psychiatric ill- diminished interest and inner turmoil. There dria. In the course of time her ideas about her ness. Her long lasting complaints had started 3 only was no psychomotor disturbance. Assuming a somatic symptoms became delusional and she days after the start of oral nystatine prescribed depression with psychotic features she was was diagnosed with a hypochondriacal delu- for a Candida infection of the mouth, which treated in vain with amitriptyline during 4 sion as part of melancholia, without depressed she developed shortly after getting a complete weeks with adequate blood levels and then mood or loss of interest or pleasure as promi- set of dentures. Her appetite was diminisheduse nent features. It is important to recognize and she also complained of a bitter taste in her refused further treatment. A second opinion melancholia as soon as possible by continually mouth. A thorough work up, including repeat- confirmed a probable diagnosis of melancho- evaluating other symptoms of depression. This ed physical examinations, gastroscopy, blood lia, a mood disorder with a hypochondriacal may enable to avoid repetitive and exhaustive tests and an angiography of the abdominal delusion. ECT was started after extensive somatic examinations, which are not indicat- arteries did not reveal a plausible cause for her counseling with the patient and her husband. ed, and to start effective treatment. In our complaints. Despite nightly drip-feeding the Unilateral brief pulse ECT was administered patient electroconvulsive therapy resulted in a patient lost more than 20 kilograms during her twice weekly using a Thymatron IV, starting fast and complete recovery. frequent visits with the gastroenterologist. with a 70% dose setting (75 mCoulombs) At first psychiatric examination she was resulting in 54-second motoric seizure and preoccupied with her somatic symptoms that recording 82 seconds on the EEG. After the were, according to her, due to nystatine use. first treatment her physical symptoms were Introduction She was diagnosed with hypochondriasis that markedly improved, her appetite and sleep pat- was considered to lead to lack of appetite and tern recovered in the following two weeks. Medically unexplained symptoms are fre- disturbed sleep, which were present as well. After 13 sessions of unilateral ECT she recov- quent, 20-50% of symptoms presented to a gen- Since she had severe trouble sleeping the anti- ered completely and maintenance pharma- eral practitioner remain without a physical depressant mirtazapine was started. Notably cotherapy was started with nortriptyline. The diagnosis.1 Most symptoms vanishNon-commercial over time there were no complaints of depressed mood or following 2.5 years she was in complete remis- but a small percentage persists without a anhedonia and there were no psychomotor sion and functioning well. Than she experi- somatic explanation despite extensive addi- symptoms; however she was very limited in enced a relapse and again she quickly recov- tional tests. Epidemiologic research shows her daily activities because of her physical ered with ECT. Four years after the initial com- that 2.5% of the general population suffers complaints. plaints of gastrointestinal discomfort she was from chronic somatic unexplained symptoms She remained preoccupied with her physical diagnosed with colon carcinoma. and in the elderly this is 3.8%.2 A systematic condition and was convinced that there was a review of the literature showed that approxi- not yet identified somatic cause for her symp- mately 50-75% of patients with medically unex- toms. A year after the use of nystatine she plained symptoms improve, whereas 10-30% of feared that her gastric mucosa would dry out Discussion and Conclusions patients deteriorate.3 Especially in the elderly completely and that she had a rotten tube in unexplained somatic symptoms are problemat- her throat. These ideas were diagnosed as The DSM IV-TR defines strict criteria to iden- ic since minor abnormalities in physical exam- delusional. She was referred to the psychia- tify medically unexplained symptoms as psychi- ination and work-up are frequently found with- trists as a patient with somatization and a atric somatoform disorders. Somatiza-tion dis- out explaining the symptoms in a satisfying hypochondriac delusion. Evaluation of her order requires a combination of gastro-intestin- way. This may lead to underscoring of psychi- depressive symptoms revealed a MADRS score al and pseudo neurological symptoms, sexual atric diagnoses such as somatization disorder of 25/60 without the patient reporting and pain complaints. Whereas in hypochondria and hypochondriasis in elderly patients. depressed mood or anhedonia. She com- the fear of being ill is central and patients real- [Clinics and Practice 2012; 2:e11] [page 21] Case Report izes that their anxiety is exaggerated and that that are most prominent.14 Severe depression 5. Munro A. Monosymptomatic hypochondria- no major physical condition is present. with hypochondriacal delusion was described cal psychosis. Br J Psychiatry Suppl 1988; The syndrome of monosymptomatic hypo- by Cotard in 1880 as du delire hypochondriaque (2):37-40. chondriacal psychosis (MHP) is a form of and in 1957 by Schneider as depressio sine 6. Koo J, Gambla C. Delusions of parasitosis DSM-IV delusional disorder, somatic subtype, depressione. In the English literature the term and other forms of monosymptomatic characterized by the delusional belief that one masked depression was popular, however in hypochondriacal psychosis. General discus- is afflicted with a medical disorder of defect. most cases it appeared to concern the differen- sion and case illustrations. Dermatol Clin Such patients often present to dermatologists tial diagnostic considerations: somatoform or 1996;14:429-38. with delusions of parasitosis. The literature somatization disorder. There is limited 7. Cetin M, Ebrinc S, Agargun MY, Yigit S. describes case studies and 1 double-blind cross research on depressive disorder with Risperidone for the treatment of monosymp- over study indicating the benefit from several hypochondriacal delusions. As a subtype it tomatic hypochondriacal psychosis. J Clin typical neuroleptics, especially pimozide for would be more frequent in women15 and Psychiatry 1999;60:554. 5,6 7-11 this disorder, atypical neuroleptics or anti- accompanied with a high risk for suicide.16 In 8. Chand PK, Anand S, Murthy P. Mono- 12 depressants. Our patient is crossing the bor- a multivariate analysis of 187 patients with symptomatic hypochondriacal psychosis: ders of the DSM IV criteria. Although she did- severe depression a subtype with hypochondri- atypical presentation and response to olan- n’t fulfill the criteria for a delusional disorder acal delusions could not be defined by specific zapine. J Clin Psychiatry 2005;66: 800-1. because since she didn’t believe she had a spe- characteristics, despite the number of vari- 9. Elmer KB, George RM, Peterson K. The- cific serious illness or defect and moreover her 17 ables that was analyzed. There are two case rapeutic update: use of risperidone for the daily functioning was restricted, she was con- reports describing a patient with hypochondri- treatment of monosymptomatic hypo-chon- sidered as a delusional disorder of the somatic 18 acal delusion
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