Severe headache as a presenting complaint in sigmoid sinus thrombosis complicated by functional overlay.

An otherwise serious and potentially fatal organic condition may present with a co-existing strong functional component. We encountered a female patient who presented with bouts of severe headache over the occipital region, associated with blurring of vision. Initially, non-contrast computed tomography (CT) scan (Brain) showed normal study, and she was deemed as having functional symptoms. Later, magnetic resonance imaging (MRI) (Brain) showed filling defect in right sigmoid sinus and magnetic resonance (MR) venography confirmed right sigmoid sinus thrombosis. On adequate anticoagulation, she did not improve and still had bouts of severe headache, although no longer associated with impaired vision. The treating neurophysician concluded that symptoms could no longer be accounted for by the organic condition. Overt and covert psychosocial stressors were found to be present in a detailed psychological exploration. Psychological intervention effectively controlled the headache. Thus, functional overlay can complicate the clinical picture in a severe organic condition and may require active psychiatric intervention over and above medical treatment.

Functional overlay in presence of an otherwise serious and life-threatening medical condition may not be a recognized as a legitimate entity as per the existing diagnostic schedules; but physicians and psychiatrists do encounter it in their routine practice.[1] The presence of a “neurological” component in the presentation of symptoms may usually be undermined when the onset is attributed to and immediately preceded by a clear psychosocial stressor and the patient appears to “dramatize” or “catastrophize” the symptoms. Likewise, the presence of a “functional” or “psychiatric” component may be obscured when the patient has a co-existing medical condition that is grave and potentially fatal. In absence of any definite testing methods, the extent of functional overlay cannot be confirmed or quantified objectively.[1]

Co-occurrence of neurological and functional symptoms is more common than expected. In fact, experience of bodily dysfunction rendered by a neurological illness is one of the most powerful risk factors for developing functional symptoms.[2] Many patients have two diagnoses, e.g., epilepsy and psychogenic non-epileptic seizures; multiple sclerosis and functional limb weakness; idiopathic intracranial hypertension and functional visual symptoms; etc.[2] Here, we report a case of a female patient presenting with acute onset severe headaches diagnosed as having sigmoid sinus thrombosis with strong functional overlay, not improving with medical treatment (adequate anticoagulation) alone but finding relief in the symptom after psychiatric intervention.

CASE REPORT

Mrs. A, a 30-year-old female, presented in psychiatry outpatient department (OPD) with complaint of recurrent bouts of severe headache over the occipital region on a background of continuous generalized dull aching headache which had set in over a period of 5 days. The severe bouts were not preceded by any sensory or motor changes; neither were they associated with nausea, vomiting, lacrimation, photophobia, phonophobia, giddiness, or visual disturbance. There was no relief reported with the multiple analgesics taken, which included Nonsteroidal anti-inflammatory drugs, caffeine, and ergots. Her primary consultation was with a physician at a tertiary care center where she underwent complete blood counts, thyroid, renal and hepatic function tests, random blood sugar test, and non-contrast computed tomography (CT) scan (Brain) [Figure 1], all of which were within the normal range. Also, an apparent excess of facial grimacing gave the impression that she was exaggerating the symptom. Hence, a psychiatric referral was made considering the headaches to be psychogenic in origin.

Figure 1

Non-contrast CT scan (Brain) showing normal study

On exploring the history, the patient reported that her father had died in a road traffic accident while she was still 7 years of age. She could not complete her schooling due to the family's poor financial condition. Later, she was forcibly married off to her paternal aunt's son after death for her mother. Despite being married for 8 years and having two children, she admitted that the marital relationship had always lacked intimacy. Since the husband frequently abused her verbally and occasionally, physically as well, the dislike for the husband had grown over time. In retaliation, she was staunchly resisting the husband's advances for sexual intercourse since 1 year. Just before the onset of headaches 5 days back, her husband forcefully had intercourse with her against her wish. She felt completely victimized and helpless, and started yelling loudly. She attributed the onset of the headaches to this incident and her excessive yelling. She was admitted under psychiatric care.

On the day of admission, she received 2 mg clonazepam in divided doses and felt better symptomatically. At midnight, she suddenly woke up complaining of severe headache associated with blurring of vision in both eyes, which she experienced for the first time in the 5 days of being ill. Ophthalmological examination showed bilateral papilledema. Magnetic resonance imaging (MRI) (Brain) done on an urgent basis showed filling defect in the right sigmoid sinus. Magnetic resonance (MR) venography confirmed right sigmoid sinus thrombosis [Figure 2]. She was transferred to neuromedical care for further management. Immediate intervention with mannitol infusion and subcutaneous low molecular weight heparin helped her recover her vision. Then, on an oral anticoagulant agent, she still had bouts of severe headache, although no longer associated with impaired vision. As concluded by the treating neurophysician, symptoms could no longer be accounted for by the organic brain condition. Consequently, she was transferred back to the psychiatry ward. She was predominantly helped with a supportive psychotherapeutic approach. Her husband was psycho-educated about the nature of the illness and the functional overlay, and the need for marital harmony. Psychological intervention and husband's considerate demeanor effectively controlled the headache along with clonazepam 2 mg/day in divided doses, while the oral anticoagulant was continued. She virtually was free of the headaches at the time of discharge after 5 days of admission.

Figure 2

Filling defect in right sigmoid sinus on MR venography confirming thrombosis

DISCUSSION

Rare organic diseases or those with vague or unusual presentations or those that may have prominent psychological symptoms may be misdiagnosed as functional if the physician does not have an appropriate index of suspicion.[3] If the physician carefully listens to and briefly examines the patient, a significant organic disease seldom is overlooked.[4] Medical services are traditionally organized into distinct medical/surgical and psychiatric services, wherein the medical/surgical sector offers treatment for “organic” illnesses and the psychiatric for “functional” problems.[5] This “black or white” approach of diagnosing and dealing with disorders as either being “organic” or “functional” is fraught with limitations, as it fails to acknowledge the coexistence of medical and psychiatric conditions. Medical and psychological conditions may have overlapping symptom presentations. Presence of a medical condition does not preclude the possibility of functionality and vice versa, as both may not be mutually exclusive essentially. The fact remains that co-occurrence of neurological diseases and emotional disorders is fairly common,[5] and it is easy for the presence of a neurological disease to overshadow or mask the presence of functional symptoms.[2] It is worthwhile for a clinician to identify and appreciate the existence of both, whenever present and understand that patients with such co-morbidity would benefit only with a combined approach.

In conclusion, functional overlay, though common is poorly understood and hence probably frequently mismanaged or left unmanaged. Underestimating the need to address functional overlay in the setting of serious medical conditions may lead to incomplete care offered to patients, as is evident in our case. Similarly, overemphasis on patient's psychosocial history and histrionic clinical presentation may lead to missing out on a grave medical diagnosis.