(PO-044) (PO-044) Delayed Diagnosis of Metastatic Cancer in the setting of Psychoanalytically-Biased Weight Loss Attribution

Background

“Diagnostic overshadowing” occurs when physical symptoms are misattributed to mental illness or intellectual disability (Jones, 2008) and can lead to worse treatment outcomes for patients with mental illness (Barcella, 2019). Diagnostic overshadowing is more likely when a patient presents with a variety of symptoms, including functional symptoms. We present a patient with functional dysphagia and weight loss who attributed his weight loss to somatization, though was later demonstrated to have metastatic cancer.



Case

An 84-year-old male in psychoanalysis for over 60 years for treatment of PTSD, dissociative identity disorder, and mixed personality disorder presented with 56-lb weight loss over one year, which he attributed to somatization of repressed memories discovered during psychoanalysis.



He was hospitalized eight months prior with 1.5 weeks of abdominal pain, choking, alternating loose stools and constipation, but only 6lbs weight loss over the last year. Mental status exam was remarkable for circumstantiality, catastrophizations, psychoanalytic intellectualization, and passive aggression. He perceived lifelong somatization and attributed presenting physical symptoms as somatization from “breakthroughs” in psychoanalysis. Abdominal and chest X-rays were unremarkable, and cognitive screening was benign. He preferred psychoanalysis and clonazepam to engagement in cognitive behavioral therapy. The medical evaluation was unremarkable, and the medical discharge summary ultimately ascribed the patient’s symptoms to “decompensated psychiatric illness.” He was re-hospitalized eight months later with another 50-lb weight loss, intolerance of oral intake, and rectal pain. He ascribed his symptoms to a “Freudian breakthrough” regarding oral sexual abuse during infancy and forced stool consumption in childhood. Psychiatry recommended workup for indolent cancer and attempted exposure therapy using sour gummy candies with bodies lacking genitals. The patient terminated consult psychiatry involvement, preferring psychoanalyst telepsychology visits. Esophagram lacked structural abnormality and a nasogastric tube was placed without recommended cancer workup. Two weeks later, the patient developed shock, and CT abdomen demonstrated metastatic disease consistent with gallbladder or pancreaticobiliary adenocarcinoma. The patient was ultimately discharged to hospice and died 1 month later.



Discussion

Although this patient’s psychiatric presentation and esophagram were consistent with functional dysphagia, his significant weight loss and rectal pain were due to malignancy. His psychoanalytic interpretation delayed the diagnosis of cancer. When consult psychiatrists evaluate functional gastrointestinal disorders with significant weight loss, we must maintain vigilance for malignancy evaluation, even if a functional process is evidenced.



Conclusion

Diagnostic overshadowing can delay the identification of serious disease and psychiatrists play an important role in alerting medicine colleagues to this phenomenon.



References

1 Jones et al.; Diagnostic overshadowing: Worse physical health care for people with mental illness. Acta Psychiatr Scand 2008;118(3):169-71.

2 Barcella et al.; Out-of-Hospital Cardiac Arrest in Patients with and without Psychiatric Disorders: Differences in Use of Coronary Angiography, Coronary Revascularization, and Implantable Cardioverter-Defibrillator and Survival. JAHA 2019;8(16):e012708.