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Iranian Rehabilitation Journal, Vol. 11, No. 17, April 2013 Case Report

A Case Report on Somatoform Disorder:
Colorful Visual Hallucinations
Susan Afghah1,MD.; Morteza Noorikhajavi, MD.; Jafar Babapour, Pharm.D University of Social Welfare and Rehabilitation Sciences, Tehran, Iran. Objective: To report a case of somatoform disorder (not otherwise specified-NOS).
Methods: The patient was an eight-year-old boy who complained of anxiety and seeing visual
hallucinations of colorful shapes. He was administered ant migraine and antiepileptic drugs. However, no
changes were observed. Psychotherapy was started, as well as fluoxetine (20 mg per day). Initial
assessments included a behavioral interview, charting of daily activities, and recording visual
hallucinations with a description of the patient’s emotional and situational condition during the
hallucinations.
Results: The patient’s visual hallucinations disappeared completely after two months of treatment.
Conclusion: Somatoform disorders may respond well to a combination of behavioral therapy and
antidepressant medication.
Keywords: Elementary visual hallucinations, Migraine aura, Occipital seizures, Somatoform disorders
Submitted: 11 Nov. 2012 Accepted: 20 Feb. 2013 Introduction
When a diagnosis is made, limiting morbidity from The term somatoform is derived from the Greek medical procedures is a major goal (2). term ‘soma’ for body. Somatoform disorders encompass mind-body interactions in which the Case Presentation brain, in ways still well not understood, sends The patient was an eight-year-old boy who was various signals that impinge on the patient’s admitted to a private psychiatric clinic for resistant awareness, indicating a serious problem in the body visual hallucinations for the past nine months. The (1). The somatoform disorders are a group of problem began with the sudden onset of visual conditions involving physical complaints that hallucinations, consisting of the appearance of high suggest a medical condition, but are not fully frequency colors and lights with geometric shapes, explained by a medical condition, a pharmacologic such as red, blue and yellow rectangles and circles. effect, or other psychiatric condition. The symptoms These visual hallucinations generally lasted for 15 are usually recurrent, involving multiple, clinically seconds, after which he had no other symptoms, significant complaints. In assessing somatoform such as headache or loss of consciousness. These complaints, the evidence for medical disorders hallucinations occurred few times a day following should be sought while evaluating the evidence for the initial event. Although he was not affected psychological disorders (2). Patients with academically, these symptoms led him to become somatoform disorders often undergo multiple moderately depressed. He was anxious while seeing medical procedures and tests without significant the colors and his immediate family members were findings. It is common for patients to come under greatly stressed during the diagnosis and treatment the care of many providers, often at the same time. of the problem. We held psycho-education sessions for the parents to The initial assessment, carried out by ophthalmologists, modify their parenting styles and the resultant revealed no ophthalmologic problems. An examination behaviors of their child. The contents of these by a neurologist was also recommended. EEG and sessions consisted of: brain MRI results were normal, as were CBC, FBS,  Explaining somatoform disorders, as well as Ca, Mg, TFTs and LFTs. Due to a positive family the etiology, symptoms and treatment plans. history of migraine and negative personal history of  Educating the parents about positive head trauma and substance abuse, his problem was reinforcement techniques, such as giving initially diagnosed as acephalgic migraine, although rare among children(3).For treatment, cyproheptadine and propranolol were prescribed. The two  Emphasizing that the parents should never tell medications were titrated to a maximum tolerable their child that he is lying or has no disease. dose of 12 mg/d and 30 mg/d respectively over 3 Rather, they should explain to him that he is weeks. The patient showed no improvement in visual symptoms over the three month period.  Encouraging parents to focus on returning to The next diagnosis was idiopathic occipital epilepsy everyday life and starting ordinary activities, with visual hallucinations (IOEVH) (4, 5, 6). The patient received carbamazepine (600 mg/d) for two  Asking the boy to talk about his thoughts and months, but no improvement was observed. In the emotions when he has visual hallucinations in next step, sodium valproate (800 mg/d) was added to order to identify the predisposing events that carbamazepine for three months. Once again clinical response was negative. Nine months after the  Identifying any stressful life event and using neurologic diagnosis, the patient was referred to a psychiatric clinic. The patient was diagnosed with Discussion
psychotherapy was started and fluoxetine was Visual hallucinations in children often include titrated to a target dose of 20 mg/d over four weeks. geometric shapes with bright colors. This disorder is The clinical response was significantly positive with seen more often in people with positive family a surprising decrease in the duration and frequency histories of migraine. In this patient, based on his of visual hallucinations. He recovered completely positive family history, migraine was the first diagnosis, followed by IOEVH. The combination of subsequent negative clinical responses to drugs, anxiety and parenting styles led us to the diagnosis During the analysis of the complex lifestyle of the of somatoform disorder NOS. The clinical response patient’s family, it was discovered that his mother to psychotherapy and fluoxetine was positive and the was quite obsessive about the patient and tried patient had significant emotional and behavioral aggressively to plan many activities, such as improvement, such that the frequency of the patient's swimming and English classes for him during the visual hallucinations decreased to only twice a day, weekends and summer time, with high expectations each lasting only few seconds. After two months, he of him in every activity. The father was passive, recovered completely and was very satisfied with the blaming the young boy most of the time. These therapy. His social relationships and academic kinds of behaviors made the boy anxious and left function improved remarkably, as well as his anxiety him with low self-esteem. Thus, his reaction to and depression. stress presented as an increased severity in visual Vol. 11, No. 17, April. 2013
Refrances:
4. Covanis A. Panayiotopoulos syndrome: a benign childhood 1. Hollifield MA. Somatoform disorders. In: Sadock BJ, autonomic epilepsy frequently imitating encephalitis, Sadock V.A. Kaplan & Sadock’s Comprehensive Textbook syncope, migraine, sleeps disorder, or gastroenteritis. of Psychiatry. 8th ed. Philadelphia: Lippincott Williams and 5. Lada C, Skiadas K, Theodorou V et al. A study of 43 2. Scheffer R. Psychiatric disorders. In: Kliegman RM, patients with panayiotopoulos syndrome: a common and Marcdante KG, Jenson HB, Behrman RE. Nelson Essentials benign childhood seizure suceptibility. Epilepsia. 2003; 44: of Pediatrics. 5th ed. Philadelphia: Elsevier Saunders; 6. Victoria PS, Grant LT .Visual hallucinations. Current 3. Shevell MI. Acephalgic migraines of childhood. Pediatric Treatment Options in Neurology. 2004; 6:75-83.

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