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

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.

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.