What is the diagnosis and treatment for a 1-year history of unexplained symptoms including sensations of air bubbles in the skin, throat, and body, muscle twitches, high blood pressure (hypertension), edema, gastrointestinal issues, and neurological symptoms, in a patient with a history of depression, anxiety, and sleeping disorder, who has been experiencing significant distress and impairment in daily life?

Functional Neurological Disorder (FND) with Somatic Symptom Features

This presentation is most consistent with a functional neurological disorder (FND) with prominent somatic symptom features, requiring immediate referral to a neurologist with FND expertise and concurrent psychiatric/psychological support, not further medical testing. 1

Diagnostic Reasoning

Your symptom constellation—sensations of air/bubbles moving through body, visible muscle twitching synchronized with sensations, voice changes without infection, throat sensations without structural pathology, and the characteristic pattern of symptoms worsening when attention is focused on them (sitting/lying down) but improving with distraction (walking/driving)—represents classic positive clinical features of FND. 1

Key Diagnostic Features Present

• Internal inconsistency: Symptoms resolve or reduce during distraction (walking, driving, spontaneous conversation) but worsen with focused attention (sitting, lying down, when discussing symptoms). 1
• Suggestibility: The "air" sensation has evolved and spread over time as you've become more focused on it, and you can capture it on video when hypervigilant. 1
• Functional voice disorder: Complete voice loss for one day without infection, voice changes with breathing, throat sensations without structural pathology on examination by your heart doctor. 1
• Functional movement disorder: Visible muscle twitching synchronized with sensations, whole body movements you can observe and record. 1

Why This Is NOT Primarily Psychiatric

Psychiatric care correctly determined you are not psychotic—these are real neurological symptoms, not hallucinations or delusions. 1 FND represents altered nervous system functioning where the hardware (structure) is intact but the software (processing) is disrupted. 1 The DSM-5 classification has moved away from "psychogenic" terminology because functional imaging shows actual cerebral correlates for these disorders. 1

Secondary Medical Issues Requiring Management

New-Onset Hypertension

Your new hypertension at one year requires evaluation for secondary causes given the temporal relationship with symptom onset. 1 Screen for:

• Renal parenchymal disease: Obtain renal ultrasound, urinalysis, serum creatinine. 1
• Sleep-disordered breathing: Your loud snoring without documented apnea still warrants formal polysomnography, as 25-50% of resistant hypertension cases have obstructive sleep apnea. 1
• Medication/substance effects: Ensure no contributing medications or substances. 1

Edema and Weight Fluctuations

The lower extremity edema with weight fluctuations requires basic evaluation: serum albumin, liver function tests, thyroid function, and echocardiogram if not recently performed. 1 However, edema can also be perpetuated by immobility from FND symptoms.

Sleep Disorder

Your pre-existing sleep disorder with loud snoring requires polysomnography if not previously completed, as untreated sleep disorders are perpetuating factors for FND. 1

Treatment Algorithm

Immediate Actions (Week 1-2)

1. Referral to neurologist with FND expertise: This is the single most important step. General neurologists may not recognize FND; you need someone specifically trained in functional disorders. 1

2. Concurrent mental health referral: Not because this is "psychological," but because cognitive behavioral therapy specifically designed for FND addresses the perpetuating factors (fear-avoidance, hypervigilance, catastrophic thinking about symptoms). 1

3. Speech-language pathology evaluation: For functional voice disorder assessment and treatment. 1

Addressing Perpetuating Factors (Ongoing)

Your symptoms are maintained by several perpetuating factors that must be addressed simultaneously: 1

• Hypervigilance and self-monitoring: You are constantly scanning for the "air" sensation, which amplifies perception. 1
• Fear-avoidance: Difficulty sitting/lying down because symptoms worsen creates a cycle of avoidance. 1
• Belief that symptoms indicate damage: Your fear that your larynx or esophagus could "break" represents catastrophic thinking that perpetuates symptoms. 1
• Symptom has become part of identity: After one year of suffering, the symptoms have become central to how you experience yourself. 1

Specific Therapeutic Interventions

Cognitive behavioral therapy for FND: Addresses dysfunctional thoughts ("something will break"), reduces hypervigilance, and retrains attention away from symptoms. 1

Physiotherapy/physical therapy: Retrains normal movement patterns and reduces struggle behaviors (the excessive effort you describe). 1

Speech therapy for functional voice disorder: Uses techniques to restore normal voice production and reduce throat tension. 1

What NOT to Do

Do not pursue further medical testing unless new, distinct symptoms emerge that are inconsistent with FND. 1 You have already had cardiac evaluation showing your heart is fine. Further testing will:

• Reinforce the belief that something structural is wrong 1
• Delay appropriate FND treatment 1
• Potentially cause iatrogenic harm from unnecessary procedures 1

The medical literature shows that in alert patients with unexplained symptoms, extensive testing rarely identifies organic pathology (only 16% in one large study), costs are extremely high, and outcomes are poor without addressing the functional component. 2

Prognosis and Expectations

With appropriate FND-specific treatment, many patients experience significant improvement. 1 However, success requires:

• Accepting the diagnosis (which is a real neurological condition, not "all in your head") 1
• Engaging actively in FND-specific therapy 1
• Addressing perpetuating factors like hypervigilance and fear-avoidance 1
• Managing comorbid conditions (sleep disorder, hypertension) 1

Your depression history and current suicidal ideation require immediate psychiatric attention, but this should occur alongside—not instead of—FND treatment. Depression is both a predisposing factor and a consequence of living with undiagnosed FND. 1

Critical Next Step

Request referral to a neurologist specializing in functional neurological disorders. If your location lacks this expertise, major academic medical centers typically have FND clinics. The FND Hope website (fndhope.org) maintains a directory of FND-knowledgeable clinicians worldwide. 1

Your symptoms are real, disabling, and treatable—but only with the correct diagnosis and FND-specific interventions, not more medical testing.