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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 • • • • • • 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 • • • • • • 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