Misdiagnosis of Somatoform Disorder

Figure 1. Front of car. There was airbag deployment in the front seat. This patient was a second row passenger. No head impact was reported.

A 14-year-old girl was a rear seat passenger involved in a frontal motor vehicle crash (MVC).

Amongst her symptoms was a sensation of weakness and paresthesias (abnormal sensations) in her right arm and hand. Because her neck MRI failed to explain her arm symptoms and the distribution of abnormal sensation did not follow a typical pattern, her neurosurgeon diagnosed her with a somatoform disorder, a psychological diagnosis meaning that her symptoms were manufactured from within, and she lacked any real or “organic” problem. Other terms that carry similar meaning include psychogenic or functional overlay. In the milieu of medico-legal cases it may be referred to as “secondary gain” meaning the patient may have other psychological reasons for what they report such as attention-seeking or for money.

Fortunately, this patient and her mother came in for a second opinion to see if there was a better explanation for the arm symptoms. Within minutes of talking it became quite apparent that there were many other symptoms that were being overlooked, including headaches that were mostly in the back of the head (suboccipital) and would radiate to the side of her head. She also had considerable neck pain, neck stiffness, and neck tightness. She reported decreased sensation in her right arm and hand, fatigue, and abnormal weakness with numbness and tingling from the wrist on.

She also complained of dizziness and lightheadedness, her balance was “terrible,” and she had fallen a couple of times since the crash. She was struggling with fine motor skills, blurred vision, double vision, and significant sensitivity to light and noise. She felt like her hearing had diminished since the crash and she had word finding difficulties, swallowing difficulties, stuttering, and prominent fatigue.

This prompted a different line of questioning which quickly revealed that her symptoms were better in the mornings, and would worsen toward the afternoon and evening. It was difficult for her to make it through a normal school day, and she would lie down the minute she got home. Further workup revealed that her symptoms were incompatible with a somatoform disorder or a concussion. Those suspicions were confirmed when she underwent imaging that showed a spinal fluid leak in her neck.

Figure 2. Axial image from CT myelogram of the cervical spine performed nearly 2 years after the crash. The image supported the suspicion of a spinal CSF leak.

The patient was referred for an epidural blood patch and within days had near resolution of all symptoms. Her only complaints at the time of follow up were headaches rated 1 out of 10 that would occur on rare occasions. Her arm symptoms fully resolved despite having them for over 20 months.

The misdiagnosis of somatoform disorder can be very damaging to patients, especially when it comes from a seasoned medical professional to a young child. It can cause them to question their own sanity and blame themselves for symptoms that are out of their control.

Case specific symptoms associated with her CSF leak:

Chronic daily headaches^1-3

Neck pain and tightness^2-11

Fatigue^{12, 13}

Numbness, tingling, and weakness in the arm and hand^{5, 10}

Dizziness^{2, 8, 9, 12}

Blurred vision, double vision^{2, 5, 8, 10}

Sensitivity to light and noise^{3, 5, 8}

Stuttering, word finding difficulties^{2, 5}

Spinal CSF leaks can be misdiagnosed as somatoform disorder.⁵

If you’ve been injured in a crash and are suffering from headaches, neck, back pain, or think you’ve been misdiagnosed, please give our clinic a call at 503-774-3778.

References:

1. Ranganathan, P., et al., Chronic headache and backache are long-term sequelae of unintentional dural puncture in the obstetric population. J Clin Anesth, 2015. 27(3): p. 201-6.
2. Ishikawa, S., et al., Epidural blood patch therapy for chronic whiplash-associated disorder. Anesth Analg, 2007. 105(3): p. 809-14.
3. Morgan, J.T., et al., Case report: spontaneous intracranial hypotension in association with the presence of a false localizing C1-C2 cerebrospinal fluid leak. Surgical neurology, 2008. 70(5): p. 539-543.
4. Renowden, S., et al., Spontaneous intracranial hypotension. Journal of neurology, neurosurgery, and psychiatry, 1995. 59: p. 511-5.
5. Schievink, W.I., Misdiagnosis of spontaneous intracranial hypotension. Archives of Neurology, 2003. 60(12): p. 1713-1718.
6. Davies, M.J., et al., Epidural blood patch as a diagnostic and therapeutic intervention in spontaneous intracranial hypotension: a novel approach to management. World neurosurgery, 2020. 137: p. e242-e250.
7. Akiba, C., et al., Cerebrospinal fluid leak presented with the C1-C2 sign caused by spinal canal stenosis: a case report. BMC neurology, 2020. 20(1): p. 1-5.
8. Fishman, R.A. and W.P. Dillon, Dural enhancement and cerebral displacement secondary to intracranial hypotension. Neurology, 1993. 43(3 Part 1): p. 609-609.
9. Clarot, F., et al., Giant cervical epidural veins after lumbar puncture in a case of intracranial hypotension. American journal of neuroradiology, 2000. 21(4): p. 787-789.
10. Mokri, B. and J.B. Posner, Spontaneous intracranial hypotension: the broadening clinical and imaging spectrum of CSF leaks. 2000, AAN Enterprises. p. 1771-1772.
11. Mokri, B., Spontaneous CSF leaks mimicking benign exertional headaches. Cephalalgia, 2002. 22(10): p. 780-783.
12. Graf, N., et al., Clinical symptoms and results of autonomic function testing overlap in spontaneous intracranial hypotension and postural tachycardia syndrome:A retrospective study. Cephalalgia Reports, 2018. 1: p. 2515816318773774.
13. Inamo, Y., A boy with growth disturbance caused by hypothalamic damage associated with intracranial hypotension syndrome following a motor vehicle accident: case report. Endocr J, 2008. 55(6): p. 1113-6.