Functional Dysphagia in a Patient with Severe Weight Loss and Multiple Psychiatric Diagnoses: A Case Report

Functional Dysphagia in a Patient with Severe Weight Loss and Multiple Psychiatric Diagnoses: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Functional Dysphagia in a Patient with Severe Weight Loss and Multiple Psychiatric Diagnoses: A Case Report Daniel Fu, Cathy Daichang, Eric Jarmon This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5363196/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Functional dysphagia is a rare and complex disorder that presents diagnostic difficulties, particularly when psychiatric comorbidities are involved. This report discusses a unique case that underscores the importance of a thorough, multidisciplinary approach to the diagnosis of this disorder. Case Presentation: A 45-year-old female with a history of major depressive disorder, generalized anxiety disorder, and prolonged grief disorder experienced five years of vomiting shortly after eating or drinking, along with the sensation of something stuck in her throat. She also reported significant weight loss. After an extensive gastrointestinal evaluation failed to reveal an organic cause, supportive psychotherapy led to a better understanding of her symptoms. Functional dysphagia was identified as the most probable diagnosis, and the patient’s receptiveness to treatment increased with therapeutic support. Conclusions This case illustrates the challenges of diagnosing functional dysphagia, especially in patients with coexisting psychiatric conditions. A multidisciplinary approach, integrating both psychological and medical evaluations, is crucial to achieving an accurate diagnosis and optimizing patient care. Psychiatry Functional dysphagia psychogenic dysphagia major depressive disorder generalized anxiety disorder prolonged grief psychosomatic disorders unexplained vomiting BACKGROUND Functional dysphagia is a rare and poorly understood disorder that often presents diagnostic challenges, especially when compounded by psychiatric conditions. Existing literature suggests that functional dysphagia may be associated with psychosocial factors such as somatic obsessions in obsessive-compulsive disorder (OCD), unresolved grief, and post-infection complications like those from COVID-19 (1–3), though data on these associations remain limited. Further research is needed to better understand the underlying mechanisms and improve diagnostic approaches for functional dysphagia, particularly in complex cases with psychiatric comorbidities. The aim of this report is to highlight a rare and unusual case of functional dysphagia, with a focus on the initial diagnosis and workup for a patient with overlapping psychological and functional gastrointestinal symptoms. CASE PRESENTATION A 45-year-old female with a history of chronic feeding intolerance, percutaneous endoscopic gastrostomy (PEG) tube placement, major depressive disorder, generalized anxiety disorder, and prolonged grief disorder presented with a primary complaint of “vomiting after I eat or drink and feel like there is something stuck in my left neck” for 5 years. The patient reported daily vomiting occurring 5–10 minutes after eating or drinking, accompanied by a sensation of something stuck in her throat. This was followed by gagging and vomiting, as well as insertion of fingers into her throat to clear perceived phlegm. As a result of these symptoms, the patient reported a significant unintentional weight loss leading to placement of a PEG tube. The patient was admitted for management of nutritional deficiencies and received extensive workup gastrointestinal workup for vomiting which was unable to identify an organic cause. At this point, the psychiatry service was consulted for workup of psychogenic or functional causes of the patient’s vomiting. Prior to 2020, the patient’s medical history was notable for a non-displaced fracture of lateral malleolus of right fibula with delayed healing, tobacco use disorder (0.5 packs/day for 16 years), and chronic marijuana use (1–2 uses/day). The patient states that the feeling of something “stuck in my throat” started in December of 2020, during which time she reported having COVID-19 infection and financial stressors. She stated that her symptoms began as excess phlegm and mucus that she would “spit up”. The patient was evaluated by both ear-nose-throat (ENT) and gastrointestinal (GI) specialists at the end of 2021, at which point she reported an unintentional 50 pound weight loss in 1 year (initial weight 168 pounds), intermittent dysphonia that improved with throat clearing, and anxiety. Flexible laryngoscopy done at that time found erythematous arytenoid, copious nasopharyngeal secretions, mild edema of the bilateral vocal folds, and decreased amplitude of the bilateral vocal folds. Esophagogastroduodenoscopy (EGD) found evidence of laryngopharyngeal reflux. A double contrast esophagram found oropharyngeal phase dysphagia. The patient was encouraged to quit smoking and was given medications for symptomatic relief of suspected allergic rhinitis. The patient had multiple hospitalizations starting in March of 2022. During her initial hospitalization, lab results were notable for marked hypokalemia (2.8), imaging revealed thyroid gland enlargement, mild diffuse pulmonary emphysema, and hyperinflated lungs. Repeat EGD with biopsy was performed, which revealed reactive gastropathy that was negative for H. pylori and mild reflux esophagitis. At that point, the patient was on a liquid diet with no relief in symptoms and was prescribed oral esomeprazole 20 mg daily and oral dicyclomine 10 mg as needed. The patient was continuously followed by ENT and GI, who repeated a double contrast esophagram with similar results. The patient then obtained esophageal manometry and EGD with Botox injection procedures at an outside hospital system. The patient also received a colonoscopy with no notable abnormalities. The patient was next seen in May 2023 by GI surgery for rectal prolapse for one year in setting of diagnosis of chronic idiopathic constipation, in which she reported intermittent suicidal ideation without intent or plan. The patient agreed to follow up with a psychiatry and therapist, but was next seen in June 2023 after being hospitalized for hypokalemia and suicidal ideation, stating “I will go home and kill myself if no answer found today”. The patient was evaluated by psychiatry at this time, in which she stated she was frustrated with the situation but stated her statements were figures of speech and that she had no intention of committing suicide; the patient did not meet criteria for major depressive disorder. The patient was not interested in outpatient follow up at that point and was not deemed a danger to herself. The patient was seen by GI in July of 2023, who recommended small intestinal bacterial overgrowth breath test (SIBO), trial of oral gabapentin 200 mg twice daily, and consideration of selective serotonin reuptake inhibitor in the future. After SIBO breath test resulted as negative, GI recommended rheumatology workup for possible scleroderma, video esophagram/swallow study, gapabentin 300 mg twice daily, and recommended marijuana cessation for suspected cannabinoid hyperemesis syndrome and regurgitation. The patient continued to have little symptom relief and presented to the emergency department in November 2023 for epigastric and left lower quadrant abdominal pain. The patient was prescribed oral amitriptyline 20 mg at bedtime, metoclopramide 10 mg thrice daily, oral omeprazole 40 mg capsule once daily, oral gabapentin 300 mg capsule twice daily, and oral sertraline 25 mg tablet once daily. The patient had a repeat EGD in January 2024 with possible diminished contractility and a possible high pressure band at around the aortic arch, an esophageal web was disrupted at the lower third of the esophagus. The patient was also prescribed alprazolam 0.25 mg twice daily for anxiety. ENT recommended a computed tomography (CT) soft tissue of the neck, CT cervical spine without contrast, and CT chest with contrast in March 2024, which was notable for anterior osteophytes spanning C4-6. The patient had a repeat EGD with biopsy with no acute abnormalities. The patient was referred to general surgery for evaluation for PEG tube placement and started on nasogastric tube feeding trial. The patient was evaluated by endocrinology for her thyroid nodules, rheumatology for possible scleroderma, and neurosurgery for possible shaving of anterior osteophytes, all of which turned out negative. At this point, the patient was severely malnourished, and a PEG tube was placed in April 2024. The patient continued to have trouble tolerating feeds even through her PEG tube and presented in the following instance due to hypokalemia and dehydration. At her most recent presentation, the patient insisted that there was a structural cause to her vomiting and expressed distrust with the medical system who were initially unable to identify a diagnosis consistent with the patient’s expectations. The lack of clear progress left the patient frustrated that her doctors had been unable to identify a cause for her vomiting which lead the patient to become increasingly defensive about the “realness” of her symptoms. The psychiatry team approached this patient by conducting supportive psychotherapy, including validating her symptoms and listening to her concerns. Through a long conversation about the patient’s history of psychosocial stressors, it was revealed that the patient had symptoms consistent with major depressive disorder (MDD), generalized anxiety disorder (GAD), and prolonged grief disorder which were previously undiagnosed, manifesting as preoccupation with feelings of worthlessness and guilt, constant worries about her family and finances, intense sorrow and loneliness related to the death of her mother in 2009. The patient stated that contracting COVID-19 in 2020 was huge stressor in her life, during which time she began to have issues sleeping due to constant anxiety, increased social withdrawal from her family and friends, and began her restrictive eating pattern. It was during this time that her vomiting symptoms appeared, and following this time the patient felt that her vomiting became habitual. Through the course of these therapeutic sessions, the patient began to show improved insight into her condition, stating that her symptoms could be originating from her mind. Despite initial insistence on a structural cause, she admitted that her vomiting symptoms may have been an unconscious way of dealing with her immense psychological stress by converting her mental trauma into a physical response, supporting a diagnosis of functional dysphagia. Addressing the patient’s functional dysphagia involved supportive psychotherapy to validate the patient’s concerns and discuss the underlying cause of her symptoms. Diaphragmatic breathing exercises were recommended to manage her vomiting triggers although the patient stated it was not effective. Incremental increases in tube feedings were made to manage her nutritional needs. Outpatient psychiatric follow-up was arranged to continue providing therapy for the patient, and a switch to mirtazapine was suggested due to potential benefits to mood and appetite. DISCUSSION Functional gastrointestinal disorders often pose diagnostic and therapeutic challenges, particularly when intertwined with significant psychiatric comorbidities. This case report discusses a patient with functional dysphagia compounded by MDD, GAD, and prolonged grief disorder. The interplay between psychological stressors and physical symptoms necessitates a holistic, multidisciplinary approach. This patient was initially frustrated that her doctors had been unable to find any cause for her symptoms – perhaps because her “cry for help” was not validated by a medical diagnosis. As a reaction to her lack of validation, the patient became irritable, guarded, and distrustful of her care team. Hence, a compassionate approach involving validation of the patient’s symptoms was essential to help address this patient’s concerns. In the inpatient setting, the ability to manage diseases related to chronic psychosocial stressors is often limited by time and resources available. However, providing supportive psychotherapy can be invaluable to patient with psychogenic symptoms, conversion disorders, or functional dysphagia as likely in this patient’s case. This approach can strengthen the patient-physician therapeutic alliance, reduce patient frustration and anxiety, foster mutual trust, improve the quality and reliability of history obtained, lead to increased adherence to proposed treatment plans, augment the patient’s insight into their condition, and ultimately improve long-term patient outcomes by empowering them to understand their diagnosis and seek out care for their condition. When diagnosing functional dysphagia, it is important to identify comorbid psychosocial factors that are often intertwined with the development and course of functional dysphagia. One case study found that somatic obsessions in OCD with poor insight, such as the inability to swallow, could be mistaken for psychotic symptoms, complicating the diagnosis of functional dysphagia and highlighting the necessity of maintaining a broad differential diagnosis (3). Similarly, another case study linked unresolved grief to functional dysphagia, where emotional trauma manifested as swallowing difficulties despite no structural causes (1). These examples highlight the need to consider mental health conditions in specific cases of functional dysphagia. Early identification and a multidisciplinary approach remain crucial for effective treatment. The underlying mechanism of functional dysphagia is poorly understood, which complicates its diagnosis. While some studies suggest abnormalities in the distension phase of esophageal peristalsis, the limited data and rarity of the condition make it difficult to draw definitive conclusions (4). This uncertainty affects the workup, as tests like esophageal manometry may show distension issues, but physicians currently lack clear guidance on how to use that information in treatment. As a result, interpreting these findings remains challenging and may not lead to effective interventions. A significant consideration in this patient’s case is the potential impact of her COVID-19 infection, which may have played a role in the onset and exacerbation of her symptoms. COVID-19 has been linked to post-infection dysphagia, possibly due to cranial nerve dysfunction and neuromuscular complications. While the direct relationship between COVID-19 and functional dysphagia is still being explored, case studies suggest the virus can worsen preexisting swallowing issues (2). This highlights the need to consider COVID-19 in patients with unexplained dysphagia, even when structural causes are absent. CONCLUSION This case highlights the diagnostic challenges in managing a patient with functional dysphagia complicated by MDD, GAD, and prolonged grief disorder. A holistic, multidisciplinary approach is essential for accurate diagnosis and improving patient outcomes. Identifying the psychosocial factors contributing to functional dysphagia, such as unresolved grief and psychiatric comorbidities, is crucial for establishing a correct diagnosis and avoiding unnecessary investigations. Early identification of both psychosocial and medical factors, supported by collaboration among medical, psychiatric, and rehabilitative services, is key to optimizing diagnostic accuracy in complex functional disorders like this one. Abbreviations PEG Percutaneous Endoscopic Gastrostomy OCD Obsessive-Compulsive Disorder ENT Ear, Nose, and Throat GI Gastrointestinal EGD Esophagogastroduodenoscopy SIBO Small Intestinal Bacterial Overgrowth CT Computed Tomography MDD Major Depressive Disorder GAD Generalized Anxiety Disorder Declarations Methods The study design, data collection, and analysis were conducted in accordance with institutional guidelines at University Hospital in Newark. All patient data were anonymized to maintain confidentiality, and verbal and written consent was obtained from the patient in this report. Financial Disclosures and Conflicts of Interest None Ethics approval and consent to participate Not applicable Clinical trial number Not applicable Consent for publication Written and verbal informed consent was obtained from the patient for publication of this case report. Availability of data and materials All data generated or analyzed during this study are included in this published article. Competing interests The authors declare that they have no competing interests. Funding No funding was received for this case report. Authors' Contributions DF analyzed and interpreted the patient data and was a major contributor in writing the manuscript. CD analyzed and interpreted the patient data and was a major contributor in writing the manuscript. EJ supervised the clinical management, reviewed the manuscript, and was responsible for final approval of the manuscript. All authors read and approved the final manuscript. Acknowledgements We acknowledge the primary medical team and nursing staff at University Hospital in Newark, NJ for their contributions to patient care. References 1. Alzuabi HA, Altamimi AA, Al Harbi A, Al Shahrani SM, Al Faris A. Psychogenic Dysphagia in an Elderly: A Case of Eating Disorder Due to Trauma and Grief. Cureus [Internet]. 2023 Oct 16 [cited 2024 Sep 18]; Available from: https://www.cureus.com/articles/173660-psychogenic-dysphagia-in-an-elderly-a-case-of-eating-disorder-due-to-trauma-and-grief 2. Lin TY, Shen PC, Lee SA, Yeh SM, Chang KV, Wang TG. Case report: Dysphagia after COVID-19 infection in a stroke patient—Is neurostimulation a potential management? Front Neurol. 2023 Mar 6;14:1126390. 3. Sultan S. Obsessive-compulsive disorder presenting as chronic dysphagia—a case report. Middle East Curr Psychiatry. 2020 Dec;27(1):68. 4. Zifan A, Lin J, Peng Z, Bo Y, Mittal RK. Unraveling Functional Dysphagia: A Game-Changing Automated Machine-Learning Diagnostic Approach. Appl Sci. 2023 Sep 8;13(18):10116. Additional Declarations The authors declare no competing interests. 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Existing literature suggests that functional dysphagia may be associated with psychosocial factors such as somatic obsessions in obsessive-compulsive disorder (OCD), unresolved grief, and post-infection complications like those from COVID-19 (1\u0026ndash;3), though data on these associations remain limited. Further research is needed to better understand the underlying mechanisms and improve diagnostic approaches for functional dysphagia, particularly in complex cases with psychiatric comorbidities.\u003c/p\u003e \u003cp\u003eThe aim of this report is to highlight a rare and unusual case of functional dysphagia, with a focus on the initial diagnosis and workup for a patient with overlapping psychological and functional gastrointestinal symptoms.\u003c/p\u003e"},{"header":"CASE PRESENTATION","content":"\u003cp\u003eA 45-year-old female with a history of chronic feeding intolerance, percutaneous endoscopic gastrostomy (PEG) tube placement, major depressive disorder, generalized anxiety disorder, and prolonged grief disorder presented with a primary complaint of \u0026ldquo;vomiting after I eat or drink and feel like there is something stuck in my left neck\u0026rdquo; for 5 years. The patient reported daily vomiting occurring 5\u0026ndash;10 minutes after eating or drinking, accompanied by a sensation of something stuck in her throat. This was followed by gagging and vomiting, as well as insertion of fingers into her throat to clear perceived phlegm. As a result of these symptoms, the patient reported a significant unintentional weight loss leading to placement of a PEG tube. The patient was admitted for management of nutritional deficiencies and received extensive workup gastrointestinal workup for vomiting which was unable to identify an organic cause. At this point, the psychiatry service was consulted for workup of psychogenic or functional causes of the patient\u0026rsquo;s vomiting.\u003c/p\u003e \u003cp\u003ePrior to 2020, the patient\u0026rsquo;s medical history was notable for a non-displaced fracture of lateral malleolus of right fibula with delayed healing, tobacco use disorder (0.5 packs/day for 16 years), and chronic marijuana use (1\u0026ndash;2 uses/day). The patient states that the feeling of something \u0026ldquo;stuck in my throat\u0026rdquo; started in December of 2020, during which time she reported having COVID-19 infection and financial stressors. She stated that her symptoms began as excess phlegm and mucus that she would \u0026ldquo;spit up\u0026rdquo;. The patient was evaluated by both ear-nose-throat (ENT) and gastrointestinal (GI) specialists at the end of 2021, at which point she reported an unintentional 50 pound weight loss in 1 year (initial weight 168 pounds), intermittent dysphonia that improved with throat clearing, and anxiety. Flexible laryngoscopy done at that time found erythematous arytenoid, copious nasopharyngeal secretions, mild edema of the bilateral vocal folds, and decreased amplitude of the bilateral vocal folds. Esophagogastroduodenoscopy (EGD) found evidence of laryngopharyngeal reflux. A double contrast esophagram found oropharyngeal phase dysphagia. The patient was encouraged to quit smoking and was given medications for symptomatic relief of suspected allergic rhinitis.\u003c/p\u003e \u003cp\u003eThe patient had multiple hospitalizations starting in March of 2022. During her initial hospitalization, lab results were notable for marked hypokalemia (2.8), imaging revealed thyroid gland enlargement, mild diffuse pulmonary emphysema, and hyperinflated lungs. Repeat EGD with biopsy was performed, which revealed reactive gastropathy that was negative for H. pylori and mild reflux esophagitis. At that point, the patient was on a liquid diet with no relief in symptoms and was prescribed oral esomeprazole 20 mg daily and oral dicyclomine 10 mg as needed. The patient was continuously followed by ENT and GI, who repeated a double contrast esophagram with similar results. The patient then obtained esophageal manometry and EGD with Botox injection procedures at an outside hospital system. The patient also received a colonoscopy with no notable abnormalities.\u003c/p\u003e \u003cp\u003eThe patient was next seen in May 2023 by GI surgery for rectal prolapse for one year in setting of diagnosis of chronic idiopathic constipation, in which she reported intermittent suicidal ideation without intent or plan. The patient agreed to follow up with a psychiatry and therapist, but was next seen in June 2023 after being hospitalized for hypokalemia and suicidal ideation, stating \u0026ldquo;I will go home and kill myself if no answer found today\u0026rdquo;. The patient was evaluated by psychiatry at this time, in which she stated she was frustrated with the situation but stated her statements were figures of speech and that she had no intention of committing suicide; the patient did not meet criteria for major depressive disorder. The patient was not interested in outpatient follow up at that point and was not deemed a danger to herself. The patient was seen by GI in July of 2023, who recommended small intestinal bacterial overgrowth breath test (SIBO), trial of oral gabapentin 200 mg twice daily, and consideration of selective serotonin reuptake inhibitor in the future. After SIBO breath test resulted as negative, GI recommended rheumatology workup for possible scleroderma, video esophagram/swallow study, gapabentin 300 mg twice daily, and recommended marijuana cessation for suspected cannabinoid hyperemesis syndrome and regurgitation. The patient continued to have little symptom relief and presented to the emergency department in November 2023 for epigastric and left lower quadrant abdominal pain. The patient was prescribed oral amitriptyline 20 mg at bedtime, metoclopramide 10 mg thrice daily, oral omeprazole 40 mg capsule once daily, oral gabapentin 300 mg capsule twice daily, and oral sertraline 25 mg tablet once daily.\u003c/p\u003e \u003cp\u003eThe patient had a repeat EGD in January 2024 with possible diminished contractility and a possible high pressure band at around the aortic arch, an esophageal web was disrupted at the lower third of the esophagus. The patient was also prescribed alprazolam 0.25 mg twice daily for anxiety. ENT recommended a computed tomography (CT) soft tissue of the neck, CT cervical spine without contrast, and CT chest with contrast in March 2024, which was notable for anterior osteophytes spanning C4-6. The patient had a repeat EGD with biopsy with no acute abnormalities. The patient was referred to general surgery for evaluation for PEG tube placement and started on nasogastric tube feeding trial. The patient was evaluated by endocrinology for her thyroid nodules, rheumatology for possible scleroderma, and neurosurgery for possible shaving of anterior osteophytes, all of which turned out negative. At this point, the patient was severely malnourished, and a PEG tube was placed in April 2024. The patient continued to have trouble tolerating feeds even through her PEG tube and presented in the following instance due to hypokalemia and dehydration.\u003c/p\u003e \u003cp\u003eAt her most recent presentation, the patient insisted that there was a structural cause to her vomiting and expressed distrust with the medical system who were initially unable to identify a diagnosis consistent with the patient\u0026rsquo;s expectations. The lack of clear progress left the patient frustrated that her doctors had been unable to identify a cause for her vomiting which lead the patient to become increasingly defensive about the \u0026ldquo;realness\u0026rdquo; of her symptoms.\u003c/p\u003e \u003cp\u003eThe psychiatry team approached this patient by conducting supportive psychotherapy, including validating her symptoms and listening to her concerns. Through a long conversation about the patient\u0026rsquo;s history of psychosocial stressors, it was revealed that the patient had symptoms consistent with major depressive disorder (MDD), generalized anxiety disorder (GAD), and prolonged grief disorder which were previously undiagnosed, manifesting as preoccupation with feelings of worthlessness and guilt, constant worries about her family and finances, intense sorrow and loneliness related to the death of her mother in 2009. The patient stated that contracting COVID-19 in 2020 was huge stressor in her life, during which time she began to have issues sleeping due to constant anxiety, increased social withdrawal from her family and friends, and began her restrictive eating pattern. It was during this time that her vomiting symptoms appeared, and following this time the patient felt that her vomiting became habitual. Through the course of these therapeutic sessions, the patient began to show improved insight into her condition, stating that her symptoms could be originating from her mind. Despite initial insistence on a structural cause, she admitted that her vomiting symptoms may have been an unconscious way of dealing with her immense psychological stress by converting her mental trauma into a physical response, supporting a diagnosis of functional dysphagia.\u003c/p\u003e \u003cp\u003eAddressing the patient\u0026rsquo;s functional dysphagia involved supportive psychotherapy to validate the patient\u0026rsquo;s concerns and discuss the underlying cause of her symptoms. Diaphragmatic breathing exercises were recommended to manage her vomiting triggers although the patient stated it was not effective. Incremental increases in tube feedings were made to manage her nutritional needs. Outpatient psychiatric follow-up was arranged to continue providing therapy for the patient, and a switch to mirtazapine was suggested due to potential benefits to mood and appetite.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eFunctional gastrointestinal disorders often pose diagnostic and therapeutic challenges, particularly when intertwined with significant psychiatric comorbidities. This case report discusses a patient with functional dysphagia compounded by MDD, GAD, and prolonged grief disorder. The interplay between psychological stressors and physical symptoms necessitates a holistic, multidisciplinary approach.\u003c/p\u003e \u003cp\u003eThis patient was initially frustrated that her doctors had been unable to find any cause for her symptoms \u0026ndash; perhaps because her \u0026ldquo;cry for help\u0026rdquo; was not validated by a medical diagnosis. As a reaction to her lack of validation, the patient became irritable, guarded, and distrustful of her care team. Hence, a compassionate approach involving validation of the patient\u0026rsquo;s symptoms was essential to help address this patient\u0026rsquo;s concerns.\u003c/p\u003e \u003cp\u003eIn the inpatient setting, the ability to manage diseases related to chronic psychosocial stressors is often limited by time and resources available. However, providing supportive psychotherapy can be invaluable to patient with psychogenic symptoms, conversion disorders, or functional dysphagia as likely in this patient\u0026rsquo;s case. This approach can strengthen the patient-physician therapeutic alliance, reduce patient frustration and anxiety, foster mutual trust, improve the quality and reliability of history obtained, lead to increased adherence to proposed treatment plans, augment the patient\u0026rsquo;s insight into their condition, and ultimately improve long-term patient outcomes by empowering them to understand their diagnosis and seek out care for their condition.\u003c/p\u003e \u003cp\u003eWhen diagnosing functional dysphagia, it is important to identify comorbid psychosocial factors that are often intertwined with the development and course of functional dysphagia. One case study found that somatic obsessions in OCD with poor insight, such as the inability to swallow, could be mistaken for psychotic symptoms, complicating the diagnosis of functional dysphagia and highlighting the necessity of maintaining a broad differential diagnosis (3). Similarly, another case study linked unresolved grief to functional dysphagia, where emotional trauma manifested as swallowing difficulties despite no structural causes (1). These examples highlight the need to consider mental health conditions in specific cases of functional dysphagia. Early identification and a multidisciplinary approach remain crucial for effective treatment.\u003c/p\u003e \u003cp\u003eThe underlying mechanism of functional dysphagia is poorly understood, which complicates its diagnosis. While some studies suggest abnormalities in the distension phase of esophageal peristalsis, the limited data and rarity of the condition make it difficult to draw definitive conclusions (4). This uncertainty affects the workup, as tests like esophageal manometry may show distension issues, but physicians currently lack clear guidance on how to use that information in treatment. As a result, interpreting these findings remains challenging and may not lead to effective interventions.\u003c/p\u003e \u003cp\u003eA significant consideration in this patient\u0026rsquo;s case is the potential impact of her COVID-19 infection, which may have played a role in the onset and exacerbation of her symptoms. COVID-19 has been linked to post-infection dysphagia, possibly due to cranial nerve dysfunction and neuromuscular complications. While the direct relationship between COVID-19 and functional dysphagia is still being explored, case studies suggest the virus can worsen preexisting swallowing issues (2). This highlights the need to consider COVID-19 in patients with unexplained dysphagia, even when structural causes are absent.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis case highlights the diagnostic challenges in managing a patient with functional dysphagia complicated by MDD, GAD, and prolonged grief disorder. A holistic, multidisciplinary approach is essential for accurate diagnosis and improving patient outcomes. Identifying the psychosocial factors contributing to functional dysphagia, such as unresolved grief and psychiatric comorbidities, is crucial for establishing a correct diagnosis and avoiding unnecessary investigations. Early identification of both psychosocial and medical factors, supported by collaboration among medical, psychiatric, and rehabilitative services, is key to optimizing diagnostic accuracy in complex functional disorders like this one.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePEG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePercutaneous Endoscopic Gastrostomy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOCD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eObsessive-Compulsive Disorder\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eENT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEar, Nose, and Throat\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGastrointestinal\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEGD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEsophagogastroduodenoscopy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSIBO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSmall Intestinal Bacterial Overgrowth\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComputed Tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMDD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMajor Depressive Disorder\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGAD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGeneralized Anxiety Disorder\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eMethods\u003cbr\u003e\u003c/strong\u003eThe study design, data collection, and analysis were conducted in accordance with institutional guidelines at University Hospital in Newark. All patient data were anonymized to maintain confidentiality, and verbal and written consent was obtained from the patient in this report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFinancial Disclosures and Conflicts of Interest\u003cbr\u003e\u003c/strong\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten and verbal informed consent was obtained from the patient for publication of this case report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for this case report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDF analyzed and interpreted the patient data and was a major contributor in writing the manuscript. CD analyzed and interpreted the patient data and was a major contributor in writing the manuscript. EJ supervised the clinical management, reviewed the manuscript, and was responsible for final approval of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe acknowledge the primary medical team and nursing staff at University Hospital in Newark, NJ for their contributions to patient care.\u003c/p\u003e"},{"header":"References","content":"\u003cp\u003e\u003ca href=\"https://www.zotero.org/google-docs/?jY7Xdg\"\u003e1.\u0026nbsp;\u0026nbsp;Alzuabi HA, Altamimi AA, Al Harbi A, Al Shahrani SM, Al Faris A. Psychogenic Dysphagia in an Elderly: A Case of Eating Disorder Due to Trauma and Grief. Cureus [Internet]. 2023 Oct 16 [cited 2024 Sep 18]; Available from: https://www.cureus.com/articles/173660-psychogenic-dysphagia-in-an-elderly-a-case-of-eating-disorder-due-to-trauma-and-grief\u003c/a\u003e\u003c/p\u003e\n\u003cp\u003e\u003ca href=\"https://www.zotero.org/google-docs/?jY7Xdg\"\u003e2.\u0026nbsp;\u0026nbsp;Lin TY, Shen PC, Lee SA, Yeh SM, Chang KV, Wang TG. Case report: Dysphagia after COVID-19 infection in a stroke patient\u0026mdash;Is neurostimulation a potential management? Front Neurol. 2023 Mar 6;14:1126390.\u003c/a\u003e\u003c/p\u003e\n\u003cp\u003e\u003ca href=\"https://www.zotero.org/google-docs/?jY7Xdg\"\u003e3.\u0026nbsp;\u0026nbsp;Sultan S. Obsessive-compulsive disorder presenting as chronic dysphagia\u0026mdash;a case report. Middle East Curr Psychiatry. 2020 Dec;27(1):68.\u003c/a\u003e\u003c/p\u003e\n\u003cp\u003e\u003ca href=\"https://www.zotero.org/google-docs/?jY7Xdg\"\u003e4.\u0026nbsp;\u0026nbsp;Zifan A, Lin J, Peng Z, Bo Y, Mittal RK. Unraveling Functional Dysphagia: A Game-Changing Automated Machine-Learning Diagnostic Approach. Appl Sci. 2023 Sep 8;13(18):10116.\u003c/a\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Rutgers New Jersey Medical School","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Functional dysphagia, psychogenic dysphagia, major depressive disorder, generalized anxiety disorder, prolonged grief, psychosomatic disorders, unexplained vomiting","lastPublishedDoi":"10.21203/rs.3.rs-5363196/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5363196/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eFunctional dysphagia is a rare and complex disorder that presents diagnostic difficulties, particularly when psychiatric comorbidities are involved. This report discusses a unique case that underscores the importance of a thorough, multidisciplinary approach to the diagnosis of this disorder.\u003c/p\u003e\u003ch2\u003eCase Presentation:\u003c/h2\u003e \u003cp\u003eA 45-year-old female with a history of major depressive disorder, generalized anxiety disorder, and prolonged grief disorder experienced five years of vomiting shortly after eating or drinking, along with the sensation of something stuck in her throat. She also reported significant weight loss. After an extensive gastrointestinal evaluation failed to reveal an organic cause, supportive psychotherapy led to a better understanding of her symptoms. Functional dysphagia was identified as the most probable diagnosis, and the patient\u0026rsquo;s receptiveness to treatment increased with therapeutic support.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis case illustrates the challenges of diagnosing functional dysphagia, especially in patients with coexisting psychiatric conditions. A multidisciplinary approach, integrating both psychological and medical evaluations, is crucial to achieving an accurate diagnosis and optimizing patient care.\u003c/p\u003e","manuscriptTitle":"Functional Dysphagia in a Patient with Severe Weight Loss and Multiple Psychiatric Diagnoses: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-13 15:08:01","doi":"10.21203/rs.3.rs-5363196/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"392b2b61-b9e7-4782-9f18-56c4640b376a","owner":[],"postedDate":"December 13th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":39636444,"name":"Psychiatry"}],"tags":[],"updatedAt":"2024-12-13T15:08:02+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-13 15:08:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5363196","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5363196","identity":"rs-5363196","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}