What is the diagnosis and treatment for a patient with a 1-year history of unusual sensations, including feeling like air bubbles in the skin, throat, and body, accompanied by muscle twitches, high blood pressure (hypertension), edema, and a history of depression, anxiety, and sleeping disorders?

Functional Neurological Disorder (Conversion Disorder) with Somatic Symptom Presentation

This patient requires urgent psychiatric evaluation and treatment for a functional neurological disorder (conversion disorder), as the constellation of bizarre, inconsistent sensory phenomena ("air bubbles" moving through the body, visible pulsations, voice changes without infection, muscle twitches), loss of normal bodily signals (hunger, thirst, fatigue), and auditory hallucinations—all occurring without structural pathology despite extensive medical workup—represents classic positive clinical features of functional communication, swallowing, and sensory disorders. 1

Diagnostic Framework

Positive Clinical Features Supporting Functional Disorder

The presentation demonstrates multiple hallmark features of functional neurological disorder (FND):

• Internal inconsistency of symptoms: The sensations resolve or change dramatically with distraction (symptoms improve when walking or driving), which is pathognomonic for functional disorders 1
• Symptoms inconsistent with anatomical/physiological patterns: "Air bubbles" moving through skin, separating fat from muscle, and synchronizing with visible twitches defies any known neurological or medical pathology 1
• Inefficient movement patterns: The hyperventilation episodes lasting hours, voice changes during breathing, and struggle behaviors represent non-ergonomic patterns typical of functional disorders 1
• Suggestibility: Symptoms intensify when attention is focused on them (worse when sitting/lying down and thinking about them) 1

Predisposing and Perpetuating Factors Present

The biopsychosocial model identifies clear risk factors in this case:

• Predisposing vulnerabilities: History of depression (2014-2018), previous psychiatric illness, and personality traits suggesting stress reactivity 1
• Precipitating mechanisms: The sudden onset one year ago suggests a triggering event, with subsequent severe fatigue and altered physiological arousal 1
• Perpetuating factors: Hypervigilance and excessive self-monitoring (recording videos, counting seconds until sleep), catastrophic thinking (believing she would die or become severely handicapped), fear-avoidance behaviors, and belief that symptoms represent physical damage 1

Critical Differential Diagnoses to Exclude

Ruled Out by Clinical Features

• Psychotic disorder: Psychiatric evaluation already determined the patient is not psychotic; the single episode of auditory hallucinations with intact insight ("knew they didn't exist") does not meet criteria for psychosis 1
• Panic disorder: Despite medical records documenting "anxiety and panic attacks," the patient explicitly denies anxiety and panic symptoms—this discrepancy itself suggests misattribution of somatic symptoms 1
• Seizure disorder: The muscle twitches lack the characteristic features of seizures (no prolonged tonic-clonic movements coinciding with loss of consciousness, no postictal confusion, no tongue biting) 1

Medical Conditions Requiring Evaluation

Despite the overwhelming evidence for functional disorder, certain organic conditions must be systematically excluded:

• Pheochromocytoma: The new-onset hypertension, episodic symptoms, and autonomic dysfunction warrant screening with plasma free metanephrines or 24-hour urinary fractionated metanephrines 2
• Adrenal insufficiency: Orthostatic symptoms, edema, and hypertension changes could suggest adrenal pathology; check morning cortisol and ACTH 3
• Medication-induced symptoms: Review all current medications, as antihypertensives (particularly beta-blockers and centrally-acting agents) can cause depression, fatigue, and altered sensory experiences 4

Management Algorithm

Step 1: Complete Medical Workup (If Not Already Done)

• Plasma free metanephrines to exclude pheochromocytoma (given new hypertension and episodic symptoms) 2
• Morning cortisol and ACTH if orthostatic symptoms persist 3
• Comprehensive medication review to identify potential contributors to depression or sensory symptoms 4
• Basic metabolic panel, thyroid function tests, vitamin B12 level 5

Step 2: Deliver Diagnosis with Therapeutic Explanation

The diagnosis must be communicated as a positive diagnosis of functional neurological disorder, not a diagnosis of exclusion:

• Explain that FND is a genuine neurological condition where the nervous system functions abnormally despite normal structure 1
• Emphasize that symptoms are real and not "imagined" or "made up" 1
• Use the biopsychosocial model to explain predisposing factors (previous depression), precipitating events (onset one year ago), and perpetuating factors (hypervigilance, fear-avoidance) 1

Step 3: Initiate Psychiatric Treatment

Cognitive-behavioral therapy (CBT) combined with selective serotonin reuptake inhibitors (SSRIs) is the evidence-based treatment for functional disorders with comorbid depression and should be initiated immediately 1:

• Start SSRI (e.g., sertraline 50mg daily, titrate to 100-200mg) for depression and anxiety symptoms 1
• Refer to psychologist/psychiatrist specializing in CBT for functional neurological disorders 1
• Address catastrophic thinking patterns and hypervigilance through structured therapy 1

Step 4: Manage Hypertension Appropriately

Given the association between depression/anxiety and hypertension in low-income populations 6:

• Choose antihypertensive agents with lowest depression risk: ACE inhibitors, calcium channel blockers, or diuretics 4
• Avoid beta-blockers and alpha-methyldopa, which have strong associations with depression 4
• Monitor for orthostatic hypotension if using diuretics 7

Step 5: Address Perpetuating Factors

• Reduce hypervigilance: Discourage video recording of symptoms and excessive self-monitoring 1
• Gradual exposure to feared activities (sitting, lying down) through graded activity programs 1
• Address sleep disorder with sleep hygiene and possible sleep study if snoring suggests sleep-disordered breathing 1

Critical Pitfalls to Avoid

• Do not order endless investigations: Further testing without clear indication reinforces illness beliefs and perpetuates symptoms 1
• Do not dismiss symptoms as "psychological": This alienates the patient and prevents engagement with treatment 1
• Do not attribute all symptoms to anxiety: The medical record's insistence on documenting "anxiety and panic attacks" against the patient's self-report represents poor clinical practice and damages therapeutic alliance 1
• Do not use beta-blockers for hypertension: Given depression history, choose ACE inhibitors or calcium channel blockers instead 4

Prognosis and Follow-Up

• Schedule follow-up within 2-4 weeks to assess response to SSRI and engagement with CBT 1
• Monitor for suicidal ideation given previous suicidal planning 1
• Reassess functional status and quality of life at each visit 1
• Consider cardiac rehabilitation/secondary prevention programs if cardiovascular deconditioning has occurred 1

The combination of CBT and SSRI treatment improves outcomes in terms of depression symptoms, social function, and functional neurological symptoms 1. Early intervention prevents chronicity and improves long-term prognosis 1.