Case 5: A woman sure she has stomach cancer despite a normal gastroscopy

01The case

A 42-year-old woman does not understand why her GP has referred her to a psychiatrist. For some months she has felt tired all the time and cannot sleep deeply. In the interview she looks downcast and speaks very quietly. She is convinced that her trouble is a bodily one: food has lost its taste, so she suspects stomach cancer. She hears with indifference that her gastroscopy was normal, and replies that one test cannot rule out the cancer or its spread.

02Summary

Diagnosis

A severe depressive episode with psychotic symptoms (psychotic depression): the psychotic feature is a hypochondriacal delusion.

What points to it

• Low mood with a shade of indifference, a sense of doom, poor sleep, lack of energy, slowness and fatigue.
• Food has lost its taste: part of the loss of pleasure (anhedonia). She eats because she must, even though her appetite is not much reduced.
• No sense that her trouble is mental: she puts it all down to a grave bodily illness.
• A firm belief in cancer that a normal test does not shake. An overvalued idea leaves room for argument; a delusion does not. Hers fits her mood (mood-congruent), which marks the depression as psychotic.

What else it could be

• Hypochondriasis (in ICD-11, hypochondriasis or health anxiety disorder), where the fear of illness is the main problem and mood is not lowered in this way.
• A delusional disorder of the somatic type, where mood is not low.
• A real physical illness: tiredness and loss of taste in a woman of 42 deserve a full examination and blood tests before the doctors stop looking.

Management

• Ask about suicide: psychotic depression carries a high suicide risk, and admission is often needed.
• An antidepressant together with an antipsychotic.
• ECT if drugs do not work, or sooner if she stops eating and drinking or the risk is high. ECT works well in psychotic depression.
• Keep a working relationship with her and her GP, and do not order test after test to reassure her: it rarely shifts a delusion.

Outlook

Good for the episode with treatment, but the depression may come back, and psychotic depression tends to recur in psychotic form, so maintenance treatment matters.