A 25-year-old woman presents because of extreme fatigue and loss of energy, sleep disturbances where she is unable to sleep at night but sleeps most of the day, lack of concentration, and difficulty making decisions. She is unable to hold down a job for more than a few weeks because she calls in sick to work multiple days per week. She is not interested in seeing friends or in engaging in activities she used to enjoy. She also reports loss of appetite and weight loss of 20 lb in the past 4 months.

In the past 6 months, she has made eight trips to the emergency department, convinced that she was having a heart attack. After a complete cardiac workup each time, results were negative.

Physical examination reveals that the patient appears pale, thin, and tired. Blood pressure is 125/85 mm Hg, and resting heart rate is 75 beats/min. She is 5 ft 5 in and 120 lb (BMI, 20). Heart, lung, and gastrointestinal sounds are normal on auscultation. Liver and spleen are normal on palpation. There is no lymphadenopathy.

Further questioning reveals that in addition to somatic delusions, the patient exhibits strong feelings of inadequacy, guilt, and a sense of deserved punishment. Her father was physically and emotionally abusive when she was a child; her parents divorced when she was 12. Her mother died a year and a half ago of COVID. The patient was living with her mother at the time. She got COVID when she went to a party with friends and experienced only mild symptoms. Her mother became sick shortly after that and died in the hospital 2 weeks later.

The patient has an unremarkable past medical history with no other comorbidities, no known substance misuse, no significant family history, and no previous history of mental illness of any kind. She takes no medication and does not report consuming alcohol.