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OMCR 2014 ;6 (3 pages) Pregnancy delusion hinders the diagnosis of achalasia in a patientwith life-threatening emaciation Rafael Dias Lopes, Claudio E. M. Banzato and Amilton Santos Jr* Department of Psychiatry, Faculty of Medical Sciences, University of Campinas (Unicamp), Campinas, SP, Brazil *Correspondence address. Department of Psychiatry, Faculty of Medical Sciences, University of Campinas (Unicamp),Campinas, SP 13083-970, Brazil. Tel: þ55-19-3521-7206; Fax: þ55-19-3521-7206;E-mail: amilton1983@yahoo.com.br Received 21 March 2014; revised 6 May 2014; accepted 13 May 2014 Abnormal eating behaviour among psychiatric patients is associated with several psychiatricconditions, but may also be caused by a comorbid physical condition. Clinical assessment of apsychiatric patient is often challenging, which contributes to an increased rate of undiagnosedmedical conditions and an increased mortality rate. We present the clinical case of a 46-year- old woman with a long-term delusion of triplet pregnancy, and recurrent vomiting. She experi-enced intense weight loss and eventually faced a life-threatening situation due to achalasia,which was incidentally discovered on a chest X-ray during her second psychiatric hospitaliza-tion, after several other tests, including upper digestive endoscopy, returned normal results.
After a successful laparoscopic Heller's myotomy, her digestive symptoms greatly improved.
This report illustrates the difficulty of establishing clinical-surgical diagnoses in psychoticpatients, as some delusions seem to explain clinical complaints, masking and delaying the diag-nosis of comorbid conditions.
People with psychotic disorders have a higher mortality rate A 46-year-old female patient was referred to the outpatient than the general population [Denial of symptoms, refusal psychiatric service of the University of Campinas, presenting to seek treatment, failure to establish differential diagnoses with a body mass index (BMI) of 13.88 kg/m2 (weight: and difficulties in detecting comorbid diseases contribute to 30.4 kg) and with the diagnosis of a delusional disorder and a this increased risk [Several clinical and surgical conditions suspected anorexia nervosa. She had experienced a structured may be associated with psychiatric symptoms, either as causal delusion of pregnancy with triplets for the previous 7 years, factors, as consequences of the symptoms, or co-occurring causing a severe impact on her quality of life, including a with primary psychiatric disorders [– ].
near-total absence of social relationships and abnormal behav- The presence of abnormal eating behaviour among psychotic iour. For example, she redecorated her house, at considerable patients, such as pica, gorging, rumination syndrome and refusal expense, for the sake of her ‘babies'.
to eat, due to negative or to positive symptoms, is well known in Despite many negative urinary pregnancy tests and pelvic the psychiatric literature. Positive symptoms such as delusions ultrasounds, her beliefs were unchanged: she felt pregnant, and hallucinations are the main reason for restrictive food intake argued that she was not menstruating, and claimed that she and weight loss among psychotic patients []. In this report, we could see the babies' faces in the ultrasounds. She demanded describe the case of a woman with severe weight loss, whose medical explanations for the non-birth of the babies, and com- psychotic symptoms were not the cause of, but represented an plained that the triplets were pressing her stomach, thus block- obstacle to, the diagnosis of a life-threatening clinical-surgical ing the passage of food. She felt as if the food were lodging in her stomach, causing gastric discomfort. To attenuate this # The Author 2014. Published by Oxford University Press.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License which permits non-commercial re-use, distribution, and reproduction in any medium,provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Pregnancy delusion hinders the diagnosis of achalasia Figure 1: Computed tomography, at the level of the tracheal carina, showingesophageal dilatation. The patient had a nasoenteric feeding tube.
symptom, she had, a year previously, begun to self-inducevomiting and to decrease food intake, leading to a 20 kg lossin 9 months. She denied using any other purgative methodsor being afraid of gaining weight. Previous examinations,including upper digestive endoscopies, were normal. At the beginning of her follow-up, the only positive laboratory find-ings were subclinical hypothyroidism and iron-deficiencyanemia. She had no hallucinations, her affect was partially Figure 2: Barium swallow study with continuous fluoroscopy confirming theacute narrowing at the gastro-esophageal junction.
blunted and she had no insight whatsoever. Owing to herlow weight and very intense psychotic symptoms, she wasadmitted to a psychiatric ward and submitted to a broad clin- ical evaluation, without any other positive findings. She didnot meet the criteria for anorexia nervosa. Instead she was This report describes a patient with a delusional disorder and diagnosed with a delusional disorder and hypothyroidism.
comorbid primary achalasia, in which digestive symptoms Both food refusal and vomiting were considered secondary were given a delusional interpretation. This delusional mis- to her intense delusional beliefs. She was prescribed olanza- attribution contributed to the delay of the diagnosis of the pine 10 mg/day and levothyroxine 25 mg/day and gained esophageal disease, notwithstanding the several clinical exami- 2 kg in 2 weeks. After 20 days of involuntary hospitalization, nations, laboratory and imaging tests and hospitalization.
she absconded from the ward and abandoned the course of Association between achalasia and psychiatric symptoms is not rare: indeed, achalasia is a differential diagnosis to anorexia One year later, she voluntarily returned to the outpatient nervosa. There have also been reports that these conditions can psychiatric service. She continued to hold delusional beliefs, occur simultaneously , – In such cases, the initial diagno- including the delusion that unborn triplets were pressing sis of anorexia nervosa may mask and delay the diagnosis of against her stomach. She had experienced additional weight achalasia, potentially leading to worse clinical outcomes.
loss, and now weighed 25.1 kg (BMI: 10.8 kg/m2). She was This was not the first case of a psychotic patient with a very readmitted to the psychiatric ward and prescribed clozapine.
low BMI (10) presenting to the outpatient psychiatric After 45 days of hospitalization, she had developed a fever service of the University of Campinas. A young male patient and a cough. A plain chest X-ray revealed considerable refused to eat because his delusion forbade him to take the esophageal dilation. She was then submitted to a chest tomog- lives of other living beings, including plants. Another patient raphy (Fig. an esophageal manometry and a barium was so absorbed by her delusions that she repeatedly forgot to swallow study (Fig. which confirmed the delayed esopha- eat. Fawzi and Fawzi [] showed that unusual eating attitudes geal emptying and enabled are more common in schizophrenic patients than in the the diagnosis of esophageal achalasia. A successful laparo- general population, especially in those with more active scopic Heller's myotomy was performed, which greatly im- psychotic symptoms. Moga et al. [describe a 42-year-old proved her digestive symptoms. She was discharged after 73 woman with a long-standing history of anorexia nervosa who days of hospitalization, weighing 30.9 kg (BMI: 13.37 kg/m2) developed religious delusions, including the conviction that and taking clozapine 200 mg/day. At present, she remains de- God prohibited her from eating. However, these patients did lusional, but her weight has increased to 49.150 kg (BMI: not present a co-occurring physical disease explaining their 21.27), with no gastric complaints.
weight loss.
R.D. Lopes et al.
Renca et al. describe a 68-year-old patient who insidiously developed hypochondriac delusions followed by food refusal, In memory of Alexandre Laner Cardoso, a dear friend and persistent hypoglycemia and neuroglycopenic symptoms. The patient was treated as psychotic for 2 years until a diagnosis ofinsulinoma was made [].
To the best of our knowledge, however, our report is the first description of a psychiatric patient with life-threateningweight loss, without anorexia nervosa, in which a complex de- lusion hindered the diagnosis of a co-occurring achalasia.
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may occur. Among psychotic patients, medical complaints can 3. Garcia JC, Arau´jo OFG, Murro ALB, Traballi ALM, Andreollo NA.
become the raw material for delusional elaboration, to the extent Idiopathic achalasia mistakenly diagnosed as anorexia nervosa. Rev BrasPsiquiatr 2008;30:168.
that the delusion may appear to explain the reported symptoms.
4. Marshall JB, Russell JL. Achalasia mistakenly diagnosed as eating The impact of clinical comorbidities (and perhaps the mortality disorder and prompting prolonged psychiatric hospitalization. South Med rate itself) among these patients might decrease if psychiatrists J 1993;86:1405 – 7.
and general clinicians alike became more attentive to the physical 5. Duane PD, Magee TM, Alexander MS, Heatley RV, Lososky MS.
Oesophageal achalasia in adolescent women mistaken for anorexia health of patients with mental disorders, combining efforts to nervosa. BMJ 1992;305:43.
prevent, promptly diagnose and treat their somatic diseases, in 6. Yum S, Caracci G, Hwang M. Schizophrenia and eating disorders.
addition to their mental disorders. Written informed consent was Psychiatr Clin North Am 2009;32:809– 19.
7. Fawzi MH, Fawzi MB. Disordered eating attitudes in Egyptian obtained from the patient for publication of this case report.
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8. Moga D, Cabaniss DL, Marcus ER, Walsh BT, Kahn DA. Religious delusions in an evangelical Christian woman with anorexia nervosa. J SUPPLEMENTARY MATERIAL Psychiatr Pract 2009;15:477 – 83.
9. Renca S, Santos G, Cerejeira J. An insulinoma presenting with hypochondriac delusions and food refusal. Int Psychogeriatr 2013; 25:1909 – 11.

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