Cases That Test Your Skills

The patient who couldn’t stop vomiting

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How was the diagnosis of Addison’s disease missed in this patient? What symptoms mask adrenal insufficiency to the point that it mimics psychogenic vomiting?

Dr. Wiseman’s and Dr. Dunlop’s observations

As this case demonstrates, physiologic vomiting may be misclassified as a conversion disorder because symbolic meaning is given to the emesis, psychological gain is inferred from the symptoms, and clinicians cannot find the true cause of the vomiting. (See Box for DSM-IV guidelines for diagnosing conversion disorder.)

Several case reports describe various psychiatric manifestations of Addison’s disease as components of presenting symptoms of anorexia nervosa, self-mutilation, bereavement, and schizophrenia.6-9 Often specialists from several disciplines see patients with chronic adrenal insufficiency before an accurate diagnosis is established.10 The presentation is so diverse and insidious that when unexplained emesis is a symptom, psychogenic vomiting may mistakenly be considered the etiology.

In our patient’s case, the correct diagnosis was initially obscured for two reasons:

  • First, the lack of definitive medical results led to multiple diagnoses. Ms. M was diagnosed with conversion disorder, eating disorder NOS, hypervitaminosis, and hypothyroidism, when only one disorder—Schmidt’s syndrome—was present.
  • Second, conversion disorder was mistaken for the etiology when significant physical signs and symptoms and laboratory abnormalities—including weight loss, severe debilitation, dehydration, hyperpigmentation, hyponatremia, and hyperkalemia—were present.
This case illustrates the imperative to rule out adrenal insufficiency in cases of persistent unexplained vomiting. Gastrointestinal symptoms are present in more than one-half of all cases of Addison’s disease.11 Intestinal cramps, diarrhea, anorexia, and vomiting are nonspecific abdominal symptoms that may delay appropriate diagnosis and treatment. In a study by Tobin et al, eight cases of Addison’s disease with significant GI disturbance had a mean duration of 7.6 months before an accurate diagnosis was made.10

Box

DIAGNOSING CONVERSION DISORDER

Conversion disorder is not a diagnosis of exclusion but has both negative and positive diagnostic criteria. The DSM-IV guidelines for conversion disorder include:

Positive criteria:

  • A change in physical functioning suggests a physical abnormality
  • A psychosocial stressor produces a psychological conflict that is believed to help initiate or exacerbate the illness

Negative criteria:

  • The symptom is not under conscious control
  • The symptom has no cultural sanction and cannot be explained by a discernable physical abnormality
  • Isolated chronic pain or sexual dysfunction are excluded.

While functional disabilities are common with conversion disorders, physical and laboratory abnormalities are absent or minor in comparison with the patient’s subjective complaints.

Source: DSM-IV. Washington, DC: American Psychiatric Association, 2000.

Related resourcesDrug brand names
  • Fludrocortisone acetate • Florineff
Author affiliations

William J. Wiseman, MD, Psychiatrist, Stress Center, St. Vincent Hospital, Indianapolis, IN

Stephen Dunlop, MD, Director of Behavioral Care, Saint Francis Hospital Center, Indianapolis, IN

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

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