patients with pituitary diseases present with many psychiatric symptoms such as body image disturbances , depression and adjustment disorders . due to hormonal dysregulation , diabetes mellitus ( dm ) , hyper or hypothyroidism , acromegaly , hyperprolactinemia are common . in these patients , diagnostic and management problems may ensue due to difficulty in distinguishing symptoms of endocrine and associated physical disorders from those of psychogenic origin . r. , a 17-year - old , unmarried girl from lower socioeconomic status , hindu nuclear family with no past or family history of psychiatric illness was referred from endocrinology ward with complaints of repeated demands for injectable analgesics for last 2 weeks . history revealed that around 4 years back , she started gaining height rapidly , developed masculine features and developed continuous , throbbing headache . a magnetic resonance imaging ( mri ) ( brain ) revealed a pituitary macroadenoma ; which was surgically resected and thyroxin 150 g / day and prednisolone 7.5 mg / day was started . after 2 months , she had also developed dm and was started on oral hypoglycemic drugs . she had stopped going to school because of embarrassment due to change in her physical appearance . about 1 year back , headache reappeared ; repeat mri revealed a residual tumor which was treated with radiotherapy for 25 days . however , there was no relief in her symptoms ; rather she reported an increase in severity and frequency of headache . simultaneously , family members noticed that she would remain sad , feel frustrated and ascribe her suffering to past sinful deeds . her interest in previously pleasurable activities like watching tv and interaction with friends and family members decreased . she had lost hope of getting cured and repeatedly expressed wishes to die ; would ask for  poison injection  so as to get relief from her suffering . she was started on injection octreotide , a somatostatin analog , for acromegaly ( not for a headache ) with which she felt relief in headache . she started demanding injection frequently and would get 5 - 6 injections of octreotide / day for headache . about a month after the hospitalization , she was reoperated and was shifted back to endocrinology ward after a week . however , she continued to complain of headache and was advised sos injection tramadol with which she reported instantaneous relief and slept off . next day she would tie a cloth around her head to get relief from headache , would ask her mother to thump her head , or she would do that herself . if denied , she would become aggressive , abusive and sometimes assaultive . within 4 days , she started receiving 5 - 6 injections of tramadol / day in addition to other oral analgesics . her psychiatric diagnoses were severe depressive episode without psychotic symptoms ( f32.2 ) , elaboration of physical symptoms for psychological reasons ( f68.0 ) and mental and behavioural disorders due to use of opioids , harmful use ( f11.1 ) . she was detoxified with tapering dosage of oral tramadol starting from an equivalent dose of 600 mg / day . regular sessions were held in which she was encouraged to verbalize and discuss feelings and concerns about her illness . a structured daily routine was prepared , which included performing activities of daily living at scheduled time , engaging in group and recreational activities . during these discussions , positive reinforcers like access to the computer for internet surfing were used to increase her compliance with a structured routine by making them contingent with same . her depressive symptoms improved significantly by 6 weeks and tramadol was tapered and stopped in about 3 weeks . over next 2 - 3 weeks , she gradually stopped demanding injections , started taking interest in recreational activities in the ward . her demand for injections and attention - seeking behaviour associated with pain had significantly reduced . her endocrine and intracranial diseases , started in early adolescence , had manifested in several physical symptoms , and significant masculine changes in body , and facial appearance in the form of acromegaly . she was unable to feel and verbalized her psychological distress , and instead she somatized same as pain symptoms like headache and repeated demands for injections for its relief . the irreversibility of associated bodily changes is known to induce highly individualized affective responses , body image disturbances and lowered self - esteem that may persist or even worsen upon proper endocrine treatment . in a series of 17 patients with acromegaly , ( 33.33% ) subjects exhibited psychiatric morbidity on the general health questionnaire a review of studies conducted in tertiary care pain clinics noted that the prevalence of such behavior ranged from 3% to 19% or more . the characteristics of patients more prone to develop dependence on prescribed opioids are extremes of age , past maladjustment or legal problems and history of comorbid psychiatric illness . in view of the presence of poor premorbid this case highlights that long - standing endocrine disorders , presenting with multiple physical diseases are often associated with varied psychiatric symptoms . careful selection of patients while prescribing opioid for pain management is important due to the possibility of developing abuse and dependence . while managing such patients , both pharmacological and psychological interventions play a significant role . a pragmatic approach comprising of interdisciplinary collaboration
we report a case of pituitary macroadenoma with multiple physical and psychiatric complications , which posed a significant diagnostic dilemma and management challenge for the treating teams of neurosurgery , endocrinology and psychiatry . a pragmatic approach comprising of interdisciplinary collaboration resulted in satisfactory management of the case .