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 Features

This patient requires urgent psychiatric evaluation and treatment for a functional neurological disorder (FND), specifically functional sensory and motor symptoms, with consideration for underlying somatic symptom disorder. The constellation of bizarre, inconsistent sensory phenomena ("air bubbles" moving through the body), muscle twitches, voice changes, and breathing alterations without organic findings, combined with psychiatric care already ruling out psychosis, strongly indicates FND 1.

Diagnostic Reasoning

Positive Clinical Features Supporting FND Diagnosis

The presentation demonstrates multiple hallmark features of functional communication, swallowing, and sensory disorders 1:

• Internal inconsistency: Symptoms that vary dramatically with attention and context—worse when sitting/lying, better when walking or driving, and the ability to video-record visible manifestations suggests heightened self-monitoring 1

• Disproportionate severity: The extensive symptom burden (affecting throat, voice, breathing, multiple body regions) without corresponding structural findings on cardiac evaluation despite cardiologist concern for impending heart attack 1

• Inefficient movement patterns: The described "struggle behaviors" with breathing, hyperventilation for hours, voice changes synchronized with breathing, and sensation of airways being "pushed aside" represent non-ergonomic patterns typical of functional disorders 1

• Suggestibility and hypervigilance: The patient's detailed tracking and video documentation of symptoms, along with the spreading pattern of sensations throughout the body over time, reflects excessive self-monitoring—a perpetuating factor in FND 1

Biopsychosocial Predisposing and Perpetuating Factors

The patient's history reveals multiple risk factors for functional disorders 1:

Predisposing vulnerabilities:

• Previous depression and anxiety (2014-2018) 1
• Personality traits suggesting stress reactivity and emotional inhibition (the patient emphasizes not feeling anxiety despite severe symptoms) 1

Precipitating mechanisms:

• The sudden onset one year ago without clear medical trigger 1
• Ambivalence over expression of negative emotions—the patient repeatedly insists they don't feel anxiety despite catastrophic thoughts about dying and becoming handicapped 1
• Sense of entrapment in the medical system without diagnosis or validation 1

Perpetuating factors:

• Hypersensitivity to subtle bodily sensations (feeling "air" moving, separating fat from muscle) 1
• Fear-avoidance behaviors (difficulty eating/drinking, avoiding sitting/lying positions) 1
• Catastrophic thinking (believing airways could "break," planning suicide) 1
• Hypervigilance with video documentation of symptoms 1
• Belief that symptoms represent undiagnosed physical disease despite extensive negative workup 1
• Medical uncertainty and lack of diagnosis reinforcing symptom focus 1

Critical Differential Considerations

Ruled Out by Clinical Features

Cardiac pathology: Already evaluated by cardiology with normal findings despite initial concern 1

Neurological disease: The pattern of symptoms—bizarre sensory phenomena without anatomical distribution, inconsistent with any known neurological syndrome—argues against structural neurological disease 2. The muscle twitches (fasciculations) throughout the body without weakness or atrophy are benign 1

Psychosis: Psychiatric evaluation has already ruled this out, and the single episode of auditory hallucinations upon waking with immediate insight they weren't real is more consistent with hypnagogic phenomena than psychotic disorder 1

Medical Comorbidities Requiring Attention

New-onset hypertension: The development of hypertension coinciding with symptom onset warrants investigation 3, 4. However, anxiety and depression are strongly associated with hypertension in low-income populations, and the relationship may be bidirectional 3.

Important caveat: Diuretics used for hypertension management can cause electrolyte disturbances that may worsen or perpetuate some symptoms 5. If the patient is on furosemide or similar diuretics, monitor for hypokalemia, hypomagnesemia, and dehydration, which can cause muscle cramps, weakness, and dizziness 5. Additionally, some antihypertensive medications (particularly beta-blockers, methyldopa, and reserpine) are associated with depression 6, though diuretics, calcium channel blockers, and ACE inhibitors have the lowest association 6.

Edema and weight fluctuations: These could represent volume shifts from diuretic use if prescribed for hypertension 5, or may be part of the functional symptom complex 1

Sleep disorder with snoring: Requires evaluation for sleep apnea despite patient report of negative testing, as sleep disturbance perpetuates functional symptoms 1

Management Algorithm

Immediate Actions

1. Comprehensive psychiatric reassessment focusing specifically on FND diagnosis rather than just ruling out psychosis 1

   • The patient needs explicit explanation that FND is a real neurological condition with identifiable mechanisms, not "all in their head" 1
   • Address the patient's catastrophic thinking and suicidal ideation history 1

2. Medication review for hypertension management 6

   • If on beta-blockers, methyldopa, or reserpine, consider switching to ACE inhibitors, calcium channel blockers, or diuretics (if not already on them) due to lower depression risk 6
   • If on diuretics, check electrolytes (potassium, magnesium, sodium) to rule out contributing metabolic factors 5

3. Rule out remaining organic contributors 2

   • Thyroid function (can cause anxiety-like symptoms, tachycardia, and hypertension)
   • Basic metabolic panel (electrolytes, renal function)
   • Complete blood count (anemia can cause fatigue, palpitations)

Definitive Treatment Plan

Cognitive-behavioral therapy (CBT) is the primary treatment for functional neurological disorders 1. The patient requires:

1. Specialized FND-focused psychotherapy 1

   • CBT targeting illness beliefs, fear-avoidance, and catastrophic thinking 1
   • Graded exposure to avoided activities (sitting, lying down, eating) 1
   • Attention retraining to reduce hypervigilance and self-monitoring 1

2. Consider selective serotonin reuptake inhibitors (SSRIs) 1

   • Given history of depression and current somatic symptoms, combined CBT and SSRI treatment improves outcomes 1
   • SSRIs can address both depressive symptoms and reduce somatic symptom severity 1

3. Physical therapy/rehabilitation 1

   • For retraining normal movement patterns and reducing "struggle behaviors" 1
   • Graded exercise to address deconditioning from avoidance 1

4. Speech and language therapy 1

   • For functional voice disorder and dysphagia symptoms 1
   • Can help retrain normal swallowing and breathing patterns 1

Specialist Referral

Referral to a neurologist or psychiatrist with FND expertise is appropriate given:

• Complexity and severity of symptoms 1
• Lack of local resources and diagnostic clarity 1
• Suicidal ideation history requiring intensive intervention 1
• Need for coordinated multidisciplinary care 1

Critical Pitfalls to Avoid

1. Never tell the patient "it's just anxiety" or dismiss symptoms as "not real" 1. FND represents genuine neurological dysfunction in how the brain processes sensory and motor information 1

2. Avoid excessive medical testing once organic disease is reasonably excluded, as this reinforces illness beliefs and perpetuates symptoms 1

3. Do not attribute all symptoms to psychiatric causes without basic medical workup 2. The new hypertension, edema, and sleep disorder require appropriate medical management 5, 6

4. Address medication-induced contributions before concluding all symptoms are functional 5, 6. Antihypertensive medications and diuretics can cause or worsen depression, fatigue, and other symptoms 5, 6

5. Recognize that functional overlay can coexist with organic disease 1. The patient may have both hypertension requiring treatment AND functional sensory symptoms 1

Prognosis and Expectations

With appropriate FND-focused treatment, many patients experience significant improvement 1. However, the patient should understand:

• Recovery is gradual and requires active participation in therapy 1
• Symptoms may fluctuate, especially with stress 1
• The goal is improved function and quality of life, not necessarily complete symptom resolution 1
• Early intervention improves outcomes—the one-year delay in diagnosis may have allowed symptom entrenchment 1

The patient's preserved insight (knowing the voices weren't real, recognizing symptoms seem bizarre) and strong motivation to live for their children are positive prognostic factors 1.