Successful Resolution of Prominent Somatic Delusions Following Bi-temporal Electroconvulsive Therapy in a patient with Treatment-Resistant Schizoaffective Disorder

Abstract

Somatic delusions occur in a variety of psychiatric disorders including schizophrenia, major depressive disorder, and bipolar disorder. Somatization is associated with lower quality of life and greater risk for suicide. Treatment of somatic delusions is extremely challenging. Here we report an interesting case of severe somatic delusions in a 48-year-old African-American female with a long history of treatment resistant schizoaffective disorder, with multiple somatic complaints surrounding constipation, pregnancy, jaw pain, body aches, vaginal itch, malodorous urine, and neck pain, despite normal clinical examinations and negative medical work up. Additionally, she endorsed persistent auditory and visual hallucinations. Her symptoms remained resistant to several trials of psychotropic medications, including clozapine. Chart review of past hospitalizations revealed significant improvement with Electroconvulsive Therapy (ECT), so the team decided to perform a course of six bi-temporal ECT treatments administered over two weeks. Stimulation was applied at a current of 800 mA for 4.5s, with a pulse width of 1 ms and frequency of 60 Hz. This case illustrates the successful use of ECT in treating prominent somatic delusions in a patient with treatment-resistant schizoaffective disorder.

Introduction

Somatic delusions, in which the individual believes something is wrong with part or all of their body, may occur in variety of mental illnesses, including psychotic disorders such as schizophrenia and schizophreniform disorder,¹ and mood disorders, such as major depression and bipolar disorder.²,³ In a large sample of first-episode psychosis patients, 18% displayed somatic delusions.⁴ When somatization is a component of a mental illness it is associated with lower quality of life and overall health,⁵ and greater risk for suicide.⁶ While somatic preoccupations influence clinical outcomes, treatment can be difficult and there are no clear practice guidelines. Here we report an interesting case of severe somatic delusions in a 48-year-old African-American female with a long-standing history of treatment-resistant schizoaffective disorder, whose symptoms remitted only following treatment with bilateral electroconvulsive therapy (ECT).

Case Presentation

Ms. H, a 48-year-old African-American female, presented to us for the primary complaint of “I’m pregnant” after medical verification that she was not pregnant. In addition, she also had auditory and visual hallucinations. She was reportedly compliant on her psychotropic medications. She remained psychiatrically stable but not without somatic delusions while being monitored outpatient by her psychiatrist for 1.5 yrs. Per EMR review of her ER and clinic visits, Ms. H had a history of multiple somatic complaints such as constipation, pregnancy, jaw pain, body aches, vaginal itch, malodorous urine, neck pain, concern for STI despite denying unprotected sexual contact, cough, dysphagia, asthma/wheezing, and bladder pain all of which resulted in negative medical work up and lacked clinical evidence on physical examinations.

ECT was first introduced to Ms. H at our facility in the context of acute catatonia, persistent depression, and psychosis. Her catatonia was being treated with benzodiazepines and antipsychotic medications were held due to her catatonia. While her somatic complaints improved after 4 ECT treatments, she was unable to continue maintenance ECT due to social and financial reasons. Somatic delusions, depression, and psychosis persisted despite multiple trials of psychotropic medications (both mono and combo therapy) leading to psychiatric readmissions, state psychiatric hospitalization, and numerous visits to specialists for her somatic complaints. Over several more hospitalizations unilateral and bilateral ECT were utilized, with bilateral ECT resulting in greater improvement in disorganization due to somatic complaints (i.e. she became calmer, less anxious, and more easily redirected/reassured).

At the time of her latest admission, Ms. H scored a 93 on a 24 item Brief Psychiatric Rating Scale (BPRS; each item scored 1–7), displaying severe disturbances in items related to depression, thought disorganization, and hallucinations/somatic delusions. Six bilateral ECT treatments were administered over two weeks. Stimulation was applied at a current of 800 mA for 4.5s, with a pulse width of 1 ms and frequency of 60 Hz. Ms. H continued to display signs of depression and perseverate on her somatic delusions through the first ECT treatment. However, on the day following the second ECT treatment Ms. H appeared less withdrawn, irritable, and guarded. When asked about her somatic symptoms she only replied “yeah, my body hurts just a bit” but did not perseverate and was able to be redirected. When retested on the BPRS 24 hrs following the third ECT treatment, Ms. H had a 30% reduction in her total score. While there were significant reductions in items related to depression, Ms. H still displayed severe symptoms related to thought disturbances and somatic delusions. Over the course of ECT, Ms. H’s mood and somatic symptoms continued to improve. On the morning of her discharge, the day after her sixth treatment, she appeared well groomed and smiling, and reported her mood was “great”. On final BPRS evaluation, Ms. H scored a 48% reduction in her total score, displaying only minimal symptoms of depression, hallucinations, or delusions.

Discussion and Conclusion

Schizophrenia and schizoaffective disorder are heterogeneous disorders with a wide variety in disease course and prognosis. Much work has been done in an attempt to classify or identify variables that predict treatment response and disease course. A recent study of patients with schizophrenia identified those with a combination of prominent delusional symptoms and negative symptoms as least likely to achieve remission.⁷ Indeed, current pharmacologic treatments seem to be more efficacious at reducing hallucinatory behavior than delusions.⁶ Patients with somatic delusions pose a particular challenge to treatment as these delusions are associated with lower quality of life and overall health,⁵ and greater risk for suicide.⁸

While ECT is most often used for refractory major depressive disorder, the therapy was originally developed for use in schizophrenia, psychosis, and catatonia.⁹ A large retrospective study of Canadian inpatient psychiatry patients found overall rate of ECT use was highest in patients diagnosed with a mood disorder (7.2%), however 3.1% patients with schizophrenia or other psychotic disorder also received ECT.¹⁰ Meta-analyses have shown that ECT is effective for reducing symptoms and preventing relapse in schizophrenia and other psychotic disorders, at least in the short-term.¹¹ An important goal in psychiatry is now to identify the types of patients with psychotic disorders that would most likely benefit from ECT. Reviews of case reports and series have identified catatonia, confusional states, predominant positive symptoms, and shorter duration of the exacerbating episode as factors associated with positive ECT outcome.¹² There are also reports of the successful use of ECT for major depressive disorder with somatic symptoms¹³ and in a case of somatic type delusional disorder.¹⁴

A great deal of work is still needed to determine the appropriate use of ECT in psychotic disorders and in elucidating the physiologic mechanisms of ECT’s therapeutic effects. Patients suffering with psychotic symptoms must be treated on a case-by-case basis. ECT should be considered by clinicians treating patients with severe, transient, psychotic episodes with prominent positive symptoms. It should be especially considered in treatment-resistant cases given the limited risk of harm and possible clinical benefit. Here we report a case of an exacerbation of treatment resistant schizoaffective disorder with prominent somatic delusions that was successfully treated with a course of bilateral ECT. Clinicians could consider ECT as treatment option in patients with diagnosis of schizophrenia or schizoaffective disorder who have prominent somatic delusions.