What is the diagnosis and appropriate treatment for a middle-aged adult with a history of depression, anxiety, and sleeping disorders, presenting with a year-long history of unusual sensations of air bubbles under the skin, voice changes, breathing difficulties, muscle twitches, edema, newly developed high blood pressure, and significant impairment in daily life?

Diagnosis: Somatic Symptom Disorder with Psychiatric Evaluation Required

This patient requires urgent psychiatric evaluation for somatic symptom disorder (or related condition), not further medical workup, as the extensive bizarre sensory phenomena without objective findings, combined with psychiatric history and the patient's own insight that symptoms are "not real," strongly indicates a primary psychiatric etiology.

Immediate Clinical Assessment

Rule Out Medical Emergencies First

• Measure blood pressure in both arms immediately to evaluate the newly developed hypertension and assess for secondary causes 1.
• Perform focused neurological examination looking specifically for objective weakness, sensory deficits, or coordination abnormalities—not subjective sensations 2.
• The muscle twitches (fasciculations) throughout the body warrant evaluation for neuromuscular disorders, though the diffuse nature and association with other psychiatric symptoms suggests benign fasciculation syndrome or anxiety-related phenomena 1.

Essential Laboratory Workup for New Hypertension

• Initial laboratory evaluation should include TSH, comprehensive metabolic panel, serum potassium, and calcium to screen for secondary hypertension causes 1, 3.
• The combination of new-onset hypertension, edema, weight fluctuations, and gastrointestinal symptoms requires screening for hypothyroidism (TSH), which can cause weight gain and hypertension 1, 3.
• Check plasma aldosterone/renin ratio if hypokalemia is present, as primary aldosteronism presents with hypertension and muscle cramps/weakness in 8-20% of hypertensive patients 1.

Why This is Somatic Symptom Disorder

Key Diagnostic Features Present

• The bizarre quality of symptoms (air bubbles moving through skin, separation of fat from muscle, "tough air" outside the body) without objective physical findings is pathognomonic for somatic symptom disorder 4.
• The patient demonstrates insight that symptoms are "not real" and states "I'm certain this is psychological"—this paradoxically supports the diagnosis, as true psychosis would lack this insight 4.
• Extensive medical evaluations have been negative despite year-long symptoms affecting multiple organ systems 4.
• The temporal pattern—symptoms worse when sitting/lying down, better when walking/driving—suggests anxiety-mediated hypervigilance rather than organic pathology 1, 5.

Associated Psychiatric Features

• History of depression and anxiety disorders from 2014-2018, with recent recurrence 1.
• Sleep disturbance with loud snoring (though sleep apnea ruled out) and insomnia—both associated with hypertension development 1, 6, 7.
• Auditory hallucinations occurred once (hearing voices upon waking), which the patient recognized as not real—this represents hypnagogic hallucinations, not psychosis 4.
• Suicidal ideation with detailed planning, though currently resolved, indicates severe psychiatric distress requiring ongoing monitoring 1.

The Hypertension Connection

Depression and Sleep as Mediators

• Depression increases hypertension risk by 44% in middle-aged adults, with insomnia and sleep disturbance acting as mediators of this relationship 6.
• The patient's loss of normal bodily signals (hunger, thirst, fatigue) combined with sleep disturbance creates a physiological stress state that elevates blood pressure 6, 7.
• Daytime sleepiness and sleep disturbance predict hypertension development and are associated with increased systolic blood pressure and diastolic variability 7.

Anxiety and Stress Effects

• Anxiety and stress-related factors directly elevate blood pressure through hypothalamic-pituitary-adrenal axis activation, even in young adults 5.
• The patient's hyperventilation episodes lasting hours represent panic-equivalent symptoms that acutely raise blood pressure 1, 5.

Critical Pitfalls to Avoid

Do Not Order Extensive Imaging or Specialty Referrals

• In alert patients with new psychiatric symptoms, 63% have organic etiology—but this patient has already had cardiac evaluation, and symptoms do not fit any organic pattern 4.
• The "air bubbles" and movement sensations are not consistent with subcutaneous emphysema, neurological disease, or any medical condition 1.
• Pursuing further medical workup reinforces illness behavior and delays appropriate psychiatric treatment 1, 4.

Do Not Attribute Everything to Anxiety Without Treating Hypertension

• The new hypertension requires treatment regardless of etiology, as untreated hypertension causes end-organ damage 1.
• Initiate combination antihypertensive therapy with RAS blocker plus calcium channel blocker, targeting systolic 120-129 mmHg 2.
• Avoid beta-blockers as monotherapy if pheochromocytoma has not been definitively excluded, though the symptom pattern makes this diagnosis extremely unlikely 8.

Medication Selection Considerations

• SSRIs are first-line for comorbid depression and anxiety in patients with cardiovascular concerns, with sertraline having the best safety profile 1, 9.
• Avoid SNRIs (particularly venlafaxine) as they carry greater risk of hypertension, potentially worsening blood pressure 9.
• Mirtazapine offers benefits for sleep and appetite stimulation with minimal blood pressure effects, though orthostatic hypotension is possible 1, 9.

Recommended Management Algorithm

Step 1: Psychiatric Referral (Urgent)

• Refer immediately to psychiatry for comprehensive evaluation and treatment of somatic symptom disorder 1, 4.
• Cognitive behavioral therapy is the evidence-based treatment for somatic symptom disorder and anxiety 1.
• The patient's insight and motivation ("I really wants to live") are favorable prognostic factors 1.

Step 2: Initiate Hypertension Treatment

• Start combination antihypertensive therapy (ACE inhibitor or ARB plus amlodipine) 2.
• Monitor blood pressure response over 2-4 weeks 1.

Step 3: Address Sleep Disturbance

• Cognitive behavioral therapy for insomnia is first-line treatment before pharmacotherapy 1.
• If medication needed, consider trazodone or mirtazapine rather than hypnotics (zolpidem), which increase fall risk 1.
• Polysomnography should be performed given loud snoring, sleep disturbance, and hypertension, even though sleep apnea was reportedly ruled out—obstructive sleep apnea affects 25-50% of hypertensive patients 1.

Step 4: Antidepressant Therapy

• Initiate sertraline as it has been extensively studied in patients with cardiovascular disease and has lower risk of QTc prolongation than other SSRIs 1, 9.
• Effects may take 4-6 weeks; reassess symptoms and blood pressure at that time 1.

Step 5: Safety Planning

• Given history of suicidal ideation with planning, establish crisis plan and regular follow-up 1.
• Involve family/support system as patient has strong protective factors (children) 1.

What This Patient Does NOT Need

• CT or MRI imaging of any body region 4
• Neurology consultation for fasciculations 1
• Pheochromocytoma workup (symptoms do not fit classic triad, and prevalence is only 0.1-0.6%) 8
• Cushing's syndrome evaluation (lacks physical findings of central obesity, moon facies, or striae) 1
• Additional cardiac testing beyond what has been completed 4