Patient X was a 45-year-old female. She presented to the emergency department with complaints of being sexually abused and requested to file a formal sexual abuse complaint.
The sexual abuse she described began 2 years before presentation, after she was fired from her job. Shortly after being fired, she developed what she described as a “hot feeling like a running microwave and a force of energy” in her abdominal area, in addition to feelings of a pricking sensation in her vagina. She also reported sensations of a foreign object being inserted into her vagina and anus. The “pricking” feeling and the sensations of anal and vaginal penetration intensified when she sat down, and on initial interview, she refused to sit and remained standing.
The patient believed that her symptoms were being caused by an individual whom she had never seen nor encountered and didn’t know but who had the ability to cause these sensations from a distance without ever being in physical contact with her. She was unable to specify whom she believed was responsible, stating only that “someone” may be causing it. She, therefore, considered herself the victim of sexual abuse and wanted to “speak out against it like a woman who was raped.” She was admitted to inpatient psychiatry with a provisional diagnosis of psychosis not otherwise specified.
On further interview, the patient relayed that she had been raped as a teenager by an acquaintance. At that time, she had informed several of her friends about the assault, but she said they stated that they had not believed her. The patient also reported that she had been sexually assaulted on several other occasions but was extremely vague, refusing to elaborate.
The patient denied any personal or family history of mental illness or illicit drug or alcohol use. She denied any history of medical illnesses or the use of any medications. There was no past history of closed head injury or seizures and no documented medical allergies. Laboratory studies and toxicology screen were within normal limits. Serum and urine pregnancy tests were negative.
On review of the patient’s medical records, there was documentation of three previous emergency department visits within the past 18 months for isolated vaginal pain and combined vaginal and gluteal pain. A transvaginal ultrasound obtained during one of these ED visits demonstrated uterine fibroids measuring up to 10 cm, a 3.5-cm simple ovarian cyst, a 2.5-cm endometrial polyp, a 6.3-cm tubular adnexal mass compatible with hematosalpinx, and adhesions in the cul-de-sac. At the time of these findings, the patient had been referred to gynecology for outpatient follow-up but did not seek further treatment.
During her hospitalization, the patient became increasingly guarded in her interactions with the treatment team and suspicious of the motives of the staff. This was largely caused by her rejection of her diagnosis of delusional disorder. The patient frequently commented that she found the diagnosis to be insulting, a minimization of her somatic complaints, and a dismissal of her sexual abuse allegations. Attempts at educating the patient on her psychiatric illness did not yield any notable gains in her acceptance of her diagnosis, nor did it improve her perceptions of the treatment team. Her suspiciousness did not extend to the other patients, as she was observed interacting normally with her peers, fully participating in group activities, and even offering assistance to the elderly patients.
The obstetrics and gynecology service was consulted for further evaluation of the patient’s documented gynecological pathology. On physical examination, they noted significant guarding and abdominal rebound tenderness, as well as a grossly enlarged uterus. A transvaginal ultrasound was recommended; however, because of her growing mistrust of the treatment team, the patient refused any further intervention by the gynecological service.
She was started on risperidone, with clonazepam later added to her regimen. The anal and vaginal sensations she described subsided within the first 7 days of her hospitalization. However, her belief that the sensations had been akin to sexual abuse persisted. Her anal and vaginal symptoms did not return, and the patient became less suspicious of the treatment team, although was still guarded.
Delusional Disorder, Somatic Type
The patient was discharged home with a diagnosis of delusional disorder, somatic type. Arrangements were made for outpatient psychiatric follow-up. It was also recommended that she follow up with obstetrics and gynecology as an outpatient.
Delusional disorders are among the rarer psychiatric conditions. Their rarity can be attributed to several factors, including lack of reporting by patients, who typically do not have insight into the condition, as well as a historically fluctuating definition of the disorder.1 Despite a relatively low prevalence, general practitioners often encounter these patients first because patients attribute their complaints to a medical, rather than psychiatric, disorder. Therefore, it is important for all clinicians to have a general understanding of delusional disorders, particularly those of the somatic nature.
In the United States, delusional disorders are rarer than mood disorders or schizophrenia. Their prevalence is around 0.03%, with an annual incidence of one to three new cases per 100,000.1 As in this patient, age of symptom onset is typically later than in schizophrenia. A retrospective analysis of 86 patients with delusional disorder presenting in an outpatient setting had an average age of symptom onset of 42.4 +/− 15.4 years.2 Serretti et al. noted an average age of delusional disorder onset of 39.57 +/− 12.10 years.3 Among 64 patients with delusional disorder, the average age of onset was 37.9 +/− 10.5, with an age of first psychiatric consultation of 44.2 +/−13.5.4
Delusional disorders are slightly more prominent in women, but among the disorder subtypes, men more commonly have paranoid delusions, whereas women more frequently have delusions with an erotomanic theme.1 In 467 patients diagnosed with delusional disorder, there was a greater male-to-female predominance of delusional disorder, jealous type (57.4% vs. 42.6%, respectively, P = 0.015).5 In this same study population, women accounted for 71.4% of patients with delusional disorder, somatic type, whereas men represented only 28.6%.5 Some association has been noted between delusional disorders and depressed socioeconomic status, and immigration.1
In patients who are eventually referred for psychiatric evaluation, the diagnosis of a delusional disorder can be compounded by the presence of other comorbid psychiatric disorders. Maina et al. noted 31.3% of patients with a comorbid Axis I diagnosis in their study sample of 64 patients with delusional disorder.4 The persecutory, somatic, and mixed subtypes represented 54.4%, 17.4%, and 15.2%, respectively, of sample patients with a comorbid psychiatric disorder.4 Additionally, delusional themes can have a polymorphic symptomatology and may occur alongside depressive symptoms and irritability.3
Somatic Delusional Disorder
Patients with somatic delusional disorder pose unique diagnostic and treatment challenges. These individuals rarely voluntarily seek psychiatric consultation and are often referred for evaluation by frustrated families and non-mental health practitioners after an exhaustive and non-revealing medical workup. Those with delusions of a somatic nature more often frequent surgical subspecialty, ob-gyn, dermatology, and primary care clinics.6 Eighty-five percent of 100 surveyed dermatologists identified at least one case of delusional parasitosis among their clinical practice.7,8
Diagnosing delusional disorder somatic type is especially challenging when the delusion coincides with a body system that is diseased, as evidenced in our patient. In these circumstances, it is difficult not only to differentiate between the delusion and the physical disease process, but also to convince the patient that the delusion is not explained solely by medical illness. This was strikingly evident in our patient, who had a gynecologic ailment in addition to delusions with a gynecologic theme.
The diagnosis is further complicated in patients who, as a result of their delusion, mutilate themselves, and subsequently present with physical signs and symptoms that could feasibly be explained by medical illness. This scenario is prominent among patients with dermatologic delusions, such as delusional parasitosis, in which patients often present with self-inflicted excoriations, nodules, and ulcerations.7
Mental Illness in the Medically Ill Patient
Delusional disorders constitute only a small fragment of psychiatric illnesses in patients with underlying medical conditions. The prevalence of mental disorders was 38.7% in a study group of 294 internal medical inpatients, with a higher prevalence among women and younger patients.9 Somatoform disorders accounted for 17.6% of total mental illnesses; phobias 12.9%; substance disorders 10.9%; and depression 8.3%.9 In this same group, only approximately 20% of patients were receiving mental health treatment.9 Among a study population of 86 cardiology outpatients, 40% had a coexisting mental disorder.10
Patients with mental illness can present in a variety of health care settings. The severity of psychiatric symptoms can influence whether a psychiatric or medical course of treatment predominates. An analysis of Medicaid claims for physical health services revealed that the use of medical services by people with severe mental illness depends heavily on the setting of the delivered care. Mentally ill patients accounted for 28% of all emergency room and ambulance-related claims, compared with only 11% in patients without mental illness.11 Among the same study population, mentally ill patients accounted for 14% of Medicaid claims in outpatient hospital and outpatient surgical settings, compared with 26% in non-mentally ill people.11 Fogarty et al. found that among those with posttraumatic stress disorder (PTSD), generalized anxiety disorder, and panic disorder, there was a statistically significant increased use of primary care services.12
Among medically ill patients, mental illness is often underdiagnosed, and the reverse holds true for the mentally ill. This phenomenon could be attributed to several factors. As previously discussed, certain populations of mentally ill patients have documented decreased use of outpatient health services, which means they would be less likely to receive routine medical care.
Another reason medical illness is underdiagnosed among those with psychiatric illness is that they may not recognize, or may ignore, the signs and symptoms of medical illness. There is some documentation that patients with bipolar and schizophrenia may have higher pain tolerances and therefore may be less aware of the painful symptoms indicating a disease process.13
Further complicating the medical management of the mentally ill patient is the fragmentation of their health care. Mentally ill patients often receive uncoordinated mental health and physical health services, with often infrequent to no communication between their primary care provider and mental health practitioner. This may lead to less than ideal scenarios in which each clinician assumes the other is aware of the medical or psychiatric plan for the patient.
Delusional disorder is an uncommon psychiatric condition characterized by a minimum 1 month of non-bizarre delusions, although distinguishing the bizarre from the non-bizarre can be difficult.14,15 Outside of the delusion and the resulting effects it can have on behavior, these patients often function fairly normally. Patients with delusional disorder rarely seek psychiatric evaluation voluntarily. General practitioners are more likely to first encounter these patients in their clinical practice.
We have presented a case of delusional disorder somatic type in a middle-age woman with no documented psychiatric history. This case was of particular interest to us, given the overall rarity of delusional disorders, particularly of the somatic type, and also because her somatic delusions coincided with an ongoing physical disease process. Because of this unique presentation, for several years before our intervention, her somatic complaints had been attributed to her medical illness and not to a psychiatric condition. This underscores the difficulty of diagnosing psychiatric illness in the medically ill patient, as there can often be a great deal of overlap between physical and psychiatric symptoms.
Our case highlights the importance of obtaining a detailed and thorough history, including evaluation for possible mental illness, in any patient who repeatedly presents with a recurrent complaint that cannot be entirely accounted for from a medical perspective. A multidisciplinary team approach is best when managing such cases. The same approach will also be beneficial to all patients with mental illness and will help defragment their health care.
- Delusional disorder and shared psychotic disorder. In: Kaplan BJ, Sadock VA. Synopsis of Psychiatry. 10th ed. Philadelphia: Williams & Wilkins; 2007:504–514.
- Hsiao MC, Liu CY, Yang YY, Yeh EK. Delusional disorder: retrospective analysis of 86 Chinese outpatients. Psychiatry Clin Neurosci. 1999;53(6):673–676. doi:10.1046/j.1440-1819.1999.00624.x [CrossRef]
- Serretti A, Lattuada E, Cusin C, Smeraldi E. Factor analysis of delusional disorder symptomatology. Compr Psychiatry. 1999;40(2):143–147. doi:10.1016/S0010-440X(99)90118-9 [CrossRef]
- Maina G, Albert U, Badà A, Bogetto F. Occurrence and clinical correlates of psychiatric comorbidity in delusional disorder. Eur Psychiatry. 2001;16(4):222–228. doi:10.1016/S0924-9338(01)00568-5 [CrossRef]
- de Portugal E, González N, Haro JM, Autonell J, Cervilla JA. A descriptive case-register study of delusional disorder. Eur Psychiatry. 2008;23(2):125–133. doi:10.1016/j.eurpsy.2007.10.001 [CrossRef]
- Qureshi NA, Al-Habeeb TA, Al-Ghamdy YS. Making psychiatric sense of sand: a case of delusional disorder in Saudi Arabia. Transcult Psychiatry. 2004;41(2):271–280. doi:10.1177/1363461504043568 [CrossRef]
- Robles DT, Romm S, Combs H, Olson J, Kirby P. Delusional disorders in dermatology: a brief review. Dermatol Online J. 2008;14(6):2.
- Szepietowski JC, Salomon J, Hrehorów E, Pacan P, Zalewska A, Sysa-Jedrzejowska A. Delusional parasitosis in dermatological practice. J Eur Acad Dermatol Venereol. 2007;21(4):462–465.
- Hansen MS, Fink P, Frydenberg M, de Jonge P, Huyse FJ. Complexity of care and mental illness in medical inpatients. Gen Hosp Psychiatry. 2001;23(6):319–325. doi:10.1016/S0163-8343(01)00162-1 [CrossRef]
- Birket-Smith M, Rasmussen A. Screening for mental disorders in cardiology outpatients. Nord J Psychiatry. 2008;62(2):147–150. doi:10.1080/08039480801983562 [CrossRef]
- Berren MR, Santiago JM, Zent MR, Carbone CP. Health care utilization by persons with severe and persistent mental illness. Psychiatr Serv. 1999;50(4):559–561.
- Fogarty CT, Sharma S, Chetty VK, Culpepper L. Mental health conditions are associated with increased health care utilization among urban family medicine patients. J Am Board Fam Med. 2008;21(5):398–407. doi:10.3122/jabfm.2008.05.070082 [CrossRef]
- Cradock-O’Leary J, Young AS, Yano EM, Wang M, Lee ML. Use of general medical services by VA patients with psychiatric disorders. Psychiatr Serv. 2002;53(7):874–878. doi:10.1176/appi.ps.53.7.874 [CrossRef]
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Publishing; 2000.
- Sammons MT. Pharmacotherapy for delusional disorder and associated conditions. Professional Psychology: Research and Practice. 2005; 36(5),476–479. doi:10.1037/0735-7028.36.5.476 [CrossRef]