Download Managing the Somatic Symptom Patient

Never Getting Better: Managing the
Somatic Symptom Patient
Mark Servis, MD
Senior Associate Dean for Medical Education
Roy Brophy Endowed Chair and Professor of Clinical Psychiatry
UC Davis School of Medicine
Objectives
• To recognize the major clinical presentations of
patients with somatic symptom, factitious and
malingering disorders
• To understand the challenges of working with these
patients
• To apply some of the principles of effective
management and treatment
No Disclosures
Why are somaticizing patients
so difficult?
Why are patients with somatic symptoms
so difficult?
 They don’t get better
 Confusing presentation
 Not a “real” problem
 Demanding of time and resources
Clinical Vignette 1
Lucy is a 31 year-old woman who was recently admitted to the
hospital by her family physician for evaluation of persistent nausea and
vomiting. She is will known to the hospital staff from her four
previous hospital admissions and multiple emergency and outpatient
visits over the last 10 years. Lucy has a long history of multiple
medical complaints that are characterized by their endurance and
resistance to treatment.
Her initial problems began at age 14 years when she achieved
menarche followed by several cycles of irregular and painful menses.
Her mother took her to a gynecologist for evaluation, but no obvious
cause was found for the problem. She continued to have problems
with menstruation for many years. At age 17 years her headaches
started and she periodically complained of difficulty swallowing and
blurred vision. Lucy was evaluated by a neurologist for multiple
sclerosis with no positive findings.
Her first hospital admission occurred at age 20 years when she
complained of acute abdominal pain and vomiting. Despite the
absence of any other signs or symptoms, she was taken to surgery and
a normal appendix was removed. Lucy was discharged after 1 week.
The abdominal pain and vomiting recurred periodically after that initial
episode.
Three additional hospitalizations followed over the next 10 years for
various physical complaints including pain in her joints and
extremities, chronic diarrhea, and excessive menstrual bleeding.
Lucy’s medical complaints seemed to increase in frequency and
intensity as she grew older. She quit her job at the age of 25 to devote
her energy to keeping track of her various medical symptoms and
seeking appropriate treatment.
Is Lucy faking it?
Somatic Symptom Disorder (SSD)
 Previously known as Briquet’s syndrome or
Hysteria in DSM I and II, and in DSM III and IV as
Somatization Disorder
 Multiple distressing somatic symptoms – pain, GI,
sexual dysfunction – with excessive thoughts,
feelings and behaviors in response to these
symptoms, beyond what appears medically
explainable by available findings
Somatic Symptom Disorder
 More common in women
 Usual onset before age 30
 Symptoms vary over time
 Chronic condition – associated with alexithymia
 Not intentional/conscious
Treatment of SSD
• Conservative medical management with regularly
scheduled visits
• Review records in front of patients to demonstrate you take
complaints seriously
• Acknowledge the severity of the patient’s distress
• Explain that they do not have life-threatening disease
• Assign jobs – such as journaling
• Pharmacotherapy for concurrent anxiety or affective
symptoms
• Supportive psychotherapy sometimes useful
• Opportunity for CAM interventions
Clinical Vignette 2
Walt is a 46-year-old man who has been chronically worried about his
health for several years. When he visited his internist for a general
physical examination last year, his blood pressure was mildly elevated
at 145/93 and his EKG was normal. The physician suggested that he
have his blood pressure taken every few months, but decided not to
start him on any medication. Despite the reassurance Walt became
convinced that he had hypertension. He also began to complain of
vague chest pains.
One night he awoke to feel his pulse throbbing in his forehead and
some discomfort in his chest. He became convinced that he was
having an episode of acute hypertension and a possible heart attack.
He became so agitated that his wife drove him to the local hospital
emergency room for an evaluation. The nurse took his blood pressure
and found it to be mildly elevated at 155/95. An EKG was normal.
The next day Walt made an appointment with his physician. The
examination in the doctor’s office again showed a mildly elevated
blood pressure of 145/90. The physician reassured Walt again,
prescribed a mild diuretic, and sent him home after telling him that his
chest discomfort was not an indication of a heart attack. Walt felt
somewhat better but began to worry again later in the evening when he
became aware of his heart beat while lying quietly in bed.
What is Walt’s problem?
Illness Anxiety Disorder
 Previously known as Hypochondriasis
 Excessive concern about disease, preoccupation
with health
 Aggressive and hostile overtones
 Magnification of physical symptoms
 2:1 male to female ratio
 Resistant to psychological explanation and treatment
Treatment of Hypochondriasis
• Tolerance of underlying aggression in patient
• Contentment with “doing nothing” – avoid iatrogenic
illness
• Reassurance and placebo
• Conservative medical management
• 5 minute supportive psychotherapy
Basic strategy for 5 minute Supportive
Psychotherapy
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Focus on feeling, not fixing
Focus on here and now
Emphasize options
Reinforce patient strengths
Get back to patient responsibility
Empathic stance - understanding and acceptance
10 Questions Every Therapist Should
Know
1. How do you feel about that?
2. What troubles you the most?
3. How are you handling that?
4. What are you feeling right now?
5. What do you want?
10 Questions Every Therapist Should
Know
6. What can you do about that?
7. What are your options?
8. What is the best thing that can happen?
9. What is the worst thing that can happen?
10. What does it mean to you?
5 Responses Every Therapist Should Know
1.
2. I can understand that you would feel that way
3. That must be very difficult for you
4. Under the circumstances I’m sure you did the best you
could
5. Tell me more
Clinical Vignette 3
Sadie, a 43-year-old woman, was brought into a hospital emergency
room by her family who reported that she experienced the sudden
onset of blindness. The family explained that Sadie had just
discovered that her husband had been having an affair with another
woman. She was arguing with her husband when she suddenly
stopped and announced that she could not see anything. The family
was concerned that the patient might have had a stroke because she
had hypertension. The patient’s husband and sister brought her to the
emergency room.
Sadie was examined by the emergency room physician and the
neurologist on call who found no evidence of neurological deficits.
The patient’s blood pressure was mildly elevated. A psychiatrist was
called to see the patient. When he entered the examining room he
found a concerned middle-aged woman, the sister, sitting next to the
patient and holding her hand. The physician asked Sadie to tell him
what had happened and she stated, “I was arguing with my husband
and suddenly I couldn’t see anymore, but that’s okay.”
Is Sadie really blind?
Conversion Disorder
 Neurologic symptom whose etiology is unconscious
psychological conflict
 Not intentional/conscious
 Presenting symptoms include paralysis, blindness,
mutism, psuedocyesis, parasthesias, seizures with
atypical presentation (i.e. pseudoseizures)
Conversion Disorder
 Can have symbolic relationship to unconscious
conflict, past or current stressor
 “La belle indifference”
 25:1 female to male ratio
Treatment of Conversion Disorder
• Patients are usually not resistant to psychological
explanation of illness, but puzzled since they don’t “feel”
stressed
• Respond well to positive reassurance and suggestion
• Emphasize rapid return to functional status
Clinical Vignette 4
Troy is a 32 year old man who was brought to the emergency room
one July evening after he vomited blood while eating dinner in a local
restaurant and complained of an intense burning pain in his stomach.
He reported that 10 years ago he first experienced a bleeding duodenal
ulcer while serving in the Marine Corps. He was rushed to the base
hospital and given three units of blood. A subsequent evaluation by
the psychiatrist led to a medical discharge. He was told that the stress
of Marine life caused his ulcer.
The physician listened quietly to Troy’s history while she examined
him. She asked about the two old surgical scars on his abdomen. Troy
explained that one scar was from his gall bladder operation and the
other was from a wound he received while in the Marine Corps. He
would not elaborate on the latter, stating only that it was a secret
mission. Troy asked the physician if she was going to pass a
nasogastric tube to drain the contents of his stomach. The procedure
showed bright red blood in Troy’s stomach.
An emergency gastroscopy was performed that evening to look for the
source of the bleeding. Blood was seen in his stomach, but no active
bleeding site was discovered. Troy continued to complain of burning
in his stomach and demanded pain medication. The following
morning he received an upper gastointestinal barium X ray that
showed no abnormalities. When the physician informed him of the
results Troy said, “What’s wrong with you doctors? I’m bleeding, my
stomach hurts, and you can’t find anything wrong. Don’t you know
what you’re doing?”
Later that afternoon he had another episode of vomiting blood.
Additional tests were unable to discover the site of the bleeding and
Troy again became abusive to the physician when she asked him for
more information about his past medical history. Troy was vague
about the details of his previous treatments. He suggested that the
doctor was incompetent and insisted on leaving the hospital against her
advice.
What is the cause of Troy’s bleeding?
Factitious Disorder
 Motivated by assumption of sick role
 Involves fabrication of symptoms and/or selfinflicted injury
 Conscious
 History vague and confusing
 Chronic with poor prognosis
 Munchausen’s and Munchausen’s by proxy
Detective Work
• Fevers - injecting contaminated material, false
thermometer readings
• Dermatitides - self-inflicted skin wounds
• Hematologic - self-inflicted phlebotomy or anticoagulants
• Hypoglycemia - insulin or oral hypoglycemics
• Endocrine - thyroid or epinephrine administration
• GI - laxative abuse or vomiting
Treatment of Factitious Disorder
• Patients respond with psychotic level of denial to
confrontation
• Document and discharge
• Coordinate and communicate with potential entry points
into the health care system
Clinical Vignette 5
Max is a disheveled 32 year old man who presents as a walk-in patient
at the VA hospital in the early morning hours complaining of “hearing
voices and seeing people.” He states that “the voices told me to come
to the VA and see the doctor” and that they are irresistible, continuous
and uncontrollable. Pressed to elaborate on the voices he reports that
some are barely audible, but “seem to be telling me to go to a school
and shoot some people.” He also reports seeing strange alien beings
visiting him when he is alone. There is no evidence of a thought
disorder. When confronted on the atypical nature of his symptoms
Max becomes increasingly agitated, demanding, and confrontational.
He wants to talk with another doctor and seems pleased whenever
there is discussion about possible admission. He does admit that he is
out of money and has nowhere to go.
Why is Max reporting hallucinations?
Malingering
 Intentionally causes or feigns symptoms
 Discrepancy between distress or disability and
objective findings
 Poor cooperation in evaluation and treatment
 Motivated by external gain
 Conscious
 Frequently comorbid with antisocial personality
disorder
 Strictly speaking not a psychiatric diagnosis
Malingering motivations
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Avoidance of criminal responsibility, trial and punishment
Avoidance of military or hazardous duty
Financial gain, disability or lawsuit damages
Facilitation of transfer from prison to hospital
Admission to hospital
Drug-seeking
Functional Medical Syndromes
 Irritable bowel syndrome
 Chronic fatigue syndrome
 Fibromyalgia
 Neuropathic pain
Conclusions
 Approach as a diagnostic challenge
 Beware premature diagnostic closure
 Often “doing nothing” is the best thing
 Avoid furor therapeuticus