Somatic symptoms: A form of grandiose delusions in manic disorder?

To the Editor

A broad English language definition of somatic symptoms refers to them as bodily sensations or physical dysfunctions that are perceived as worrying or unpleasant. Although somatic symptoms are commonly associated with unipolar depression (International Classification of Diseases, Tenth Revision [ICD-10]), individuals with bipolar affective disorder (BPAD) experience somatic symptoms at double the rate than the general population (Edgcomb et al., 2016).

Mrs D was a 63-year-old married mother of two adult children with a 22-year history of BPAD who presented to hospital with manic symptoms secondary to self-ceasing sodium valproate. She had been impulsively shopping, experienced elevated mood, irritability and pressure of speech. In the weeks prior to hospitalisation, Mrs D attended several hospitals with concerns about her kidneys, back pain, peripheral oedema, nausea, cough and shortness of breath. Mrs D fixated on her physical symptoms, although she was actually physically healthy.

Mrs D insisted that her back pain was due to kidney pathology and a ‘super-ureter’. She also believed that she had bilateral leg cellulitis causing peripheral oedema. In addition, Mrs D said that her nausea was due to ‘latent amoebiasis’. Investigations excluded any infective, renal, respiratory and cardiac pathologies. Her somatic and manic symptoms subsided quickly after she was restabilised on her mood stabiliser, sodium valproate.

Differential diagnoses include the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM 5) somatic symptom disorder, but this patient’s somatisation occurred exclusively during manic episodes. There were no depressive or psychosis symptoms to warrant a diagnosis of delusional disorder or schizophrenia.

Somatisation and hypochondria can be associated with untreated bipolar disorder (Pan et al., 2018) but is more common in unipolar depression. Manic episodes commonly include delusions with a grandiose theme, and perhaps over-valuation of somatic symptoms is actually ‘grandiose’ in theme. Hence, we contend that ‘grandiosity’ relating to the manic phase of BPAD has many interpretations, including somatisation.