Dr. Szigethy and Colleagues Reply

To the Editor: We thank Dr. Wystanski and Dr. Fishbain for their thoughtful comments on our recent case report of an adolescent with complicated emotional and physical illness complaints. We wholeheartedly agree with Dr. Wystanski that it is not diagnoses we treat but the patient. He raises two additional important issues: 1) Was the diagnosis of depression accurate? 2) Would diagnosing Angela with either an anxiety or conversion disorder have changed the treatment algorithm used? Clearly, in all patients we identify target symptoms to guide our treatment approach. Angela had a symptom cluster most consistent with a depressive disorder. She did have additional symptoms in the realm of anxiety and even somatoform disorder. However, she only met full DSM-IV diagnostic criteria for depression, which provided us a framework around which to organize treatment. Having such a framework was important from two perspectives: 1) it allowed us to integrate empirically driven interventions for depression, such as paroxetine, cognitive behavior therapy, and family psychoeducation; and 2) it allowed us to organize the complex information for her family to help them develop a more cohesive illness narrative. Certainly, had Angela not shown progress in both physical and emotional symptom remission, we would have reformulated the case to consider other diagnostic possibilities and other treatment approaches. Using depression as the illness model allowed Angela’s family to recognize the early signs of a more clear-cut depressive episode 1 year after her hospital discharge and to reseek the appropriate treatment after they had self-terminated treatment. Although on the surface, similar medications and therapeutic approaches could be used to treat anxiety or somatoform symptoms, we argue that there would have been subtle differences in the interventions, such as the specific manual-based cognitive behavior therapy modality used, the psychoeducational approaches used with the family, and the target symptoms tracked to determine the medication algorithm used.

We agree with Dr. Fishbain that Angela’s chronic neck pain in the context of neck torticollis was essential to address as part of a comprehensive treatment, and we did. We are fortunate to have a first-rate inpatient pain service at our children’s hospital, and as stated in the case report, pain treatment staff were consulted and involved in treatment decisions. The pain management physician also helped medicate the patient with intravenous methohexital for neck brace adjustments so the patient could practice relaxation techniques without distraction from pain. The integration of the pain treatment with the psychiatric and medical care Angela received led to a full remission of her symptoms, and thus it was not necessary to refer her to an outside pain treatment facility, a reasonable option had her pain not remitted.