Which Problem Are We Addressing Today? The Utility of a Multifaceted Formulation Approach to a Complex Case

Treating patients with complex co-occurring serious psychiatric disorders is challenging and, with diagnostic advances, not uncommon (1, 2). According to the DSM-5, estimated prevalence rates in the general population are 8.7% for posttraumatic stress disorder (PTSD), about 1.6%–5.9% for borderline personality disorder, and 0.2% for delusional disorder (3). Although each of these rates is relatively low, once criteria are met for one disorder, the risk of having a co-occurring psychiatric disorder increases (4). A large epidemiologic study found high rates of co-occurring psychiatric morbidities in individuals with PTSD, including mood (47.1%), anxiety (49.5%), and personality disorders (32.5%) (4). Specifically, among individuals diagnosed as having PTSD, about 12.5% also met criteria for borderline personality disorder. Another large study found that traumatic life experiences were significantly associated with PTSD, borderline personality disorder, and attenuated positive psychotic symptoms, with psychotic symptoms associated with report of more than four traumas (5). Although multimodal treatments exist for patients with multiple conditions, the focus is often pharmacotherapy. However, when patients decline medications, we as their clinicians must pull from our full breadth of training and resources to return them to health. Before illustrating these concepts through a case presentation of a woman with PTSD, borderline personality disorder, and somatic delusions, we review standard pharmacological and evidence-based behavioral treatments for each disorder.

Selective serotonin reuptake inhibitors and prazosin have been shown to be efficacious in treatment of PTSD (6, 7). Systematic review of the psychotherapy literature indicates that cognitive-behavioral therapy (CBT) is the most efficacious treatment (8). Exposure therapy also is used, sometimes enhanced by virtual reality technology (9). Eye movement desensitization and reprocessing is another validated treatment for PTSD (10, 11). For those unable to tolerate trauma-focused therapy, interpersonal therapy has been shown to be effective (12).

Although no medication for the treatment of borderline personality disorder has been approved by the U.S. Food and Drug Administration, several classes of medications have been tried (e.g., second-generation antipsychotics, mood stabilizers, and opioid antagonists) and some are moderately efficacious (e.g., antipsychotics and lamotrigine) (13, 14). Among psychosocial approaches, dialectical behavior therapy and CBT have been the treatment mainstays for years (14, 15).

Somatic delusions have been treated following guidelines for most psychotic disorders, including antipsychotic medications such as pimozide (16). A recent review concluded that both first- and second-generation antipsychotics had a response rate of nearly 50% in the treatment of delusional disorder (17). However, despite growing interest in the use of CBT and other solution-focused approaches to treat delusional disorders, authors of a recent review concluded that more data are needed to recommend any particular therapeutic approach (18).

Although empirical research supports the efficacy of pharmacotherapy and evidence-based psychotherapy approaches for these disorders individually, few published studies are available to guide treatment of these disorders in co-occurring presentation, especially when patients decline pharmacotherapy. For example, research on theoretical models and clinical approaches to the treatment of somatic delusions related to trauma is limited. There is some evidence that dialectical behavior therapy plus prolonged exposure therapy can be beneficial in treating co-occurring PTSD and borderline personality disorder (14, 19). To the best of our knowledge, no published studies have addressed the treatment of co-occurring PTSD, borderline personality disorder, and somatic delusions.

The severity of somatic delusion within the context of trauma history and borderline personality disorder necessitates novel case conceptualization and clinical approaches. Below, we present the case of a 54-year-old woman who came to an urban Veterans Affairs (VA) hospital psychiatric clinic, presenting with PTSD, somatic delusions, and borderline personality disorder. In this case, we describe shifting symptomatology, which we addressed using a multifaceted formulation and treatment course, to illustrate how an integrated conceptual framework can facilitate treatment of a patient with serious mental illness.

CASE

Ms. K was a 54-year-old Caucasian veteran of the U.S. Air Force who originally sought treatment for PTSD related to military sexual trauma. Upon presentation, she also appeared to be struggling with depression, chronic passive suicidal thoughts, and somatic preoccupations with possible delusions. After Ms. K had made multiple visits to the emergency department, her primary care provider (PCP), and multiple medical specialists, it become evident that her somatic problems had a distinct delusional quality, and her mental health coordinator persuaded her to meet with a psychiatrist. During the initial meeting (and in subsequent ones, as well) with the psychiatrist, Ms. K refused medication, citing previous negative experiences with psychopharmacotherapy herself and among people she knew. She did agree to see the psychiatrist (hence forth referred to as the “therapist”) for psychotherapy.

One element of Ms. K’s presentation was her fixation on pop singer Michael Jackson and her involvement in a Michael Jackson fan club. She engaged in magical thinking that centered on her belief that he sent angels to protect her. She also identified with him in her conflicted feelings about race, in that she rejected her own racial identity, and with it her family of origin. For example, she stated that her freckles were a sign that she was really meant to be African American.

Psychodynamic Formulation

Ms. K and her four sisters were raised by their biological parents in the northeastern United States. Both parents misused alcohol, and her mother was verbally and physically abusive toward her. Ms. K believed her mother had suffered her own childhood trauma and distrusted men as a result, an idea supported by her mother’s disparaging comments about and suspicious attitudes toward men. Ms. K felt that her mother’s distrust of her father led to attempts to sabotage Ms. K’s relationship with him. She experienced her father as emotionally absent and continued to struggle with his death four years prior, because she was never able to address or repair this rift.

Trauma and neglect in Ms. K’s childhood led to development of social disinhibition that persisted into adulthood. Having lacked parental nurturing, Ms. K had a strong need to be taken care of that often led to disappointment in her relationships with others. For example, at age 20, she married a man who was both emotionally unavailable and verbally, physically, and sexually abusive. Of note, this man was Ms. K’s superior officer in the U.S. Air Force, and their relationship possibly represented a power dynamic related to Ms. K’s desire to connect with a father figure. Ms. K believed her conflicted relationship with her mother and her longing for an emotionally salient relationship with her father led her to choose this man as a partner. In her nonromantic relationships, she overextended herself emotionally and financially, oftentimes to casual acquaintances she had met through social media. When invariably these relationships fell short of her needs, she experienced disappointment and turned to the medical establishment for comfort. In fact, from June 2015 to August 2016, she went to the emergency department 17 documented times, generally concerned about infection and requesting antibiotics and antifungal medication. This behavior was considered curious by her therapist, given her stated distrust and avoidance of medications.

Ms. K’s systemic infection fears likely arose from the numerous severe infections she had contracted from her then-husband, who engaged in multiple extramarital affairs. This situation resulted in Ms. K’s contracting pelvic inflammatory disease on several occasions, necessitating intravenous antibiotics and hospitalizations and ultimately a complete hysterectomy at age 24. Interestingly, Ms. K rarely spoke of the hysterectomy and only in the context of her husband’s infidelity. It is possible that her inability to have children was too difficult for her to examine fully in therapy given her trauma history and abusive relationship with her own mother. Although Ms. K did not directly address her inability to have children, her desire to nurture and help others likely provided an alternative avenue to mothering behavior.

Trauma-Informed Formulation

As stated earlier, at age 20 Ms. K had married a noncommissioned Air Force officer, who was verbally, physically, and sexually abusive throughout their seven-year marriage. He threatened to harm her family if she reported the abuse, and 27 years after they divorced she remained fearful of what he might do if he found her or her family.

Following the hysterectomy, Ms. K continued to report abdominal pain. During times of emotional stress, she believed she was again systemically infected and inflamed and would seek medical attention. For example, Ms. K returned home from a family trip convinced she had contracted a sexually transmitted infection from hotel sheets or public toilets. Describing a burning feeling throughout her body along with the belief that fungus was coming out of her ears, she wanted to be hospitalized for treatment with intravenous antibiotics. Feeling her concerns were not being taken seriously, she changed PCPs, reported recent suicidal ideation to the new PCP, was hospitalized for psychiatric evaluation, and then was discharged less than 24 hours later.

The internalization of Ms. K’s traumatic history manifested in her somatization of distress and generally dysfunctional way of relating to others. The abuse from her mother compromised her self-esteem and demonstrated to her that caretakers were not to be trusted. This distrust was reinforced by her abusive ex-husband and was represented by abdominal pain, which she related to her surgical history but which also had an emotional component related to the trauma he had inflicted upon her. She coped with these traumas through magical thinking, where she depended on the protection and help of “angels” and Michael Jackson.

Cognitive-Behavioral Formulation

Ms. K navigated the world believing herself to be damaged and therefore unlovable. Her core belief that she did not deserve to be taken care of clashed with her simultaneous need for nurturing, and thus in relationships she assumed a caretaking role. She often gave people money that she could ill afford to give, hoping she would to get nurtured in return, a social interaction pattern that served several functions. It maintained her view that if she could take care of others, she must be okay herself. It also allowed her to avoid addressing her own problems as she distracted herself with others’ needs. However, people invariably took advantage of or disappointed her, reinforcing her belief that she was damaged and unlovable.

Ms. K’s cognitive style included all-or-none thinking. She described certain people in her life as “angels” and others as “monsters,” displaying her polar thinking of people as good or bad.

Integrated Formulation

Ms. K’s rigid cognitive style extended to her self-perception. The integrity of her body had been assaulted and violated at different stages of her life by people who should have been trustworthy. When she felt abandoned or hurt by these individuals, she internalized these feelings, and they manifested as ego-syntonic somatic complaints. Her sense of violation routinely manifested as a delusion of systemic infection, for which she would seek consistent care and safety provided by medical institutions, which served to reinforce her behavior.

Treatment Course

Ms. K came to treatment with a complex history. Initially, the plan was to establish a therapeutic alliance and encourage Ms. K to take antipsychotic medication for her somatic delusions. During the year-long course of psychotherapy, it became evident that her delusions were grounded in her traumatic past. Approaching her case from a combination of psychodynamic, trauma-informed, and cognitive-behavioral perspectives proved helpful, especially because she continued to refuse medications.

A significant treatment challenge was Ms. K’s varied presentation. In some sessions her somatic delusions were prominent, and in others they were not. She struggled to focus on serious topics, and she defended against painful affect by regressing to childlike giggling and covering her face with her hands or by returning to her preoccupation with Michael Jackson. When the latter occurred, she responded well to gentle redirection. A useful strategy was to empathize with the underlying affect without endorsing the delusion. The ability of the therapist to hold simultaneously the different formulations presented above was key to best meeting Ms. K where she was at any particular time in session. When relationships were her focus, examining psychodynamic issues represented in her relational patterns was beneficial. When she presented with concrete thoughts, discussing her unhelpful thinking patterns was useful. Maintaining overall awareness of and sensitivity to her trauma history was vital.

It was essential in treatment that Ms. K felt cared for and nurtured, which was demonstrated in several ways. Certainly a strong therapeutic alliance kept her in treatment (20). Another useful strategy involved functioning as treatment anchor, with the therapist coordinating different providers and settings (emergency department, inpatient, PCP) to arrange for the most appropriate level of care. For example, after Ms. K had an unnecessary psychiatric admission, her therapist arranged for a swift discharge. This action prevented both exacerbation of Ms. K’s psychiatric symptoms and any potential conflict with the treatment team stemming from her refusal to take medications. Arranging for discharge also strengthened the therapeutic relationship (21). By communicating with her PCP, the therapist helped decrease excessive referrals and procedures while helping the PCP learn how to effectively manage this patient’s complex needs. Additionally, a VA team social worker provided widened support for the patient.

DISCUSSION

Limited clinical literature addresses somatic delusions in the context of co-occurring PTSD and borderline personality disorder. We found only two cases from the last 15 years that addressed case formulation and treatment of somatic delusions. In a case report of a young man with olfactory hallucinations related to his somatic disease, Kimhy provided a formulation considering predisposing factors for the hallucinations and treatment using CBT principles (22). Another case report described a young woman’s fixed delusion of a little boy shining a light on her and physically exposing her to the world (23). Silva et al. explored how CBT and psychodynamic theories can be used to help formulate and treat such a case. Specifically, they discussed how CBT, using Socratic questioning within a safe therapeutic relationship, might help in addressing the patient’s self-perception and self-worth. According to the CBT model, early treatment may need to focus on alleviating distress associated with the delusion rather than on confronting the delusion itself, as was done with Ms. K. Within the psychodynamic framework, an early focus of therapy is conveying the therapist’s ability to tolerate components of the patient’s life and experiences. In the current case discussion, Ms. K informed her case manager early in treatment that she felt her therapist was too young and that she had not disclosed her full trauma history to protect the therapist. Slowly and over time, however, Ms. K was able to relate details of her traumatic history, perhaps showing how the therapeutic alliance was strengthened simply with the presence of the therapist, who became attuned to the patient through multiple sessions without showing overt distress.

From the psychotic-spectrum delusions and magical thinking to her mood and anxiety symptoms, Ms. K’s trauma experience appeared to form the basis of her overall pathology. Perhaps her most consistent presentation involved the magical thinking that Michael Jackson sent angels to protect her. In one study, Hausteiner-Wiehle and Sokollu found that, even after correcting for depression, anxiety, and gender, magical thinking was significantly higher in those with somatoform disorder than in those without it (24). The researchers theorized that these patients may use magical thinking to restore a sense of control in reaction to stress, trauma, or somatic symptoms they experience, which appeared to be consistent with Ms. K’s stated beliefs. Thus magical thinking along with somatic delusions served as a defense mechanism, as has been similarly described in another case report of a woman with schizophrenia and somatic delusions (20).

Ms. K’s presentation also included borderline personality disorder. Trimboli et al. cautioned that “reality testing in the low-level borderline category may be tenuous and may result in transient psychotic episodes during periods of decompensation” (25). This was certainly true of Ms. K as her thinking became increasingly delusional during periods of pronounced stress and crisis.

The diagnostic complexity of this case mirrors current prevalence data indicating that co-occurring serious psychiatric illness is either increasingly common, better recognized, or perhaps both. The current case was particularly challenging because one of Ms. K’s disorders was directly trauma-related (1, 2). In a cross-sectional study of 106 patients with delusional disorder, de Portugal et al. found that 46% had been diagnosed with at least one co-occurring psychiatric illness in their lifetime, most commonly a depressive disorder or an anxiety disorder (26). Thus Ms. K’s presentation illustrates the more common picture of comorbidities among serious psychiatric illnesses. While diagnosticians often strive to attribute symptoms to a single diagnosis, in a case like Ms. K’s shifting symptoms and presentations indicate multiple areas of concern, and addressing pathologies that present differently from visit to visit requires a nuanced understanding of the patient. An evolving grasp of the multiple formulations of the case was needed, in keeping with Silva et al.’s conclusion, “although (formulations) are essential as a kind of working model and as a structure for gathering information, they must be open to change, evolution, and even rejection as the patient’s ‘true self’ begins to emerge. . . .” (23).

Ultimately, integrating disparate theories into a multifaceted formulation was key to working with Ms. K through her different presentations and problems. Schiepek et al. similarly opined that use of multiple theoretical backgrounds can both inform case formulation and direct the therapy effectively (27). As Sledge et al. noted, integrated psychotherapy, clarified as good psychiatric management, should be the standard of care (28). When a patient repeatedly seeks attention and care within different medical fields, “a successful liaison between the psychiatrist and the somatic specialist is necessary to achieve improvement in the patient’s condition” (29). In the current case, the treating psychiatrist collaborated with Ms. K’s PCP to facilitate an understanding of Ms. K’s underlying pathology and reinforce the need for validation of her distress through thorough physical examinations while minimizing utilization of medical tests and invasive procedures.

CONCLUSIONS

The case presented in this article illustrates the importance of integrating theoretical formulations, and viewing them as fluid rather than fixed, to better understand and help the patient (see Box 1). While Ms. K may have benefited from medications, the work began with building trust within the therapeutic relationship to guide her toward considering this treatment option. Over the course of the year, despite decompensations secondary to interpersonal crises, Ms. K appeared stabilized to some extent, making medications and more in-depth therapy a possible future direction for her care. Our recommendations for Ms. K’s continuing care included strengthening and maintaining the therapeutic alliance, increasing her social support network, addressing delusions with gentle confrontation, and managing her use of medical resources appropriately whether through coordination with the PCP or presentation to the emergency department. In this way, the complex nature of her psychological distress was and can be managed through the understanding of a multifaceted formulation.