Should Somatoform Disorders only be diagnoses of exlcusion?

[masterofmonkeys]

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I have been increasingly horrified by the lengths some specialists go in diagnosis hunting when somatization seems rather likely in explaining at least some of the symptoms of patients. They'll order tests on 1 in a trillion diagnoses, perform nerve blocks and even neurolysis in absurd frequencies, and in general subject these patients to quite a bit of discomfort, pain, and not least, medical risk in treatment of pain issues. Even when

An example, girl with intractable pelvic pain treated with an absurd amount of PO as well as regular nerve blocks. Extensive gynecological workup is negative. Also 'passes out' from pain with no change in vitals. Now being worked up for primary autoimmune autonomic dysfunction as a cause of her pain. Despite...no change in vitals corresponding to pain, no vasoactive changes, and normal EMG... Oh, did I mention severe enmeshment, appearance of mother to relish the role of caregiver, and...drumroll please...rape history? They regularly make it to scheduled appointments with pain docs and neurologists, but miss 3/4 of scheduled appointments with counselor and pain psychologist.

Another, child with MS (very real) who has an essentially normal neurologic exam with the exception of vibratory sense dysfunction and no thalamic or sensory cortical lesions on MRI who presents with severe gait disturbance with narrow-based gait and 'collapses' which only happen while assisted with walking and never involve traumatic falls.

Now, don't get me wrong, we hardly want to miss diagnoses.

There was another kid I saw who had a likely spinal concussion. He clearly had some psychosocial issues and was engaging in pain behaviors as well. Injured on the job while working to help support family while dad was being treated for cancer, higher expectations than siblings, problems with peers, etc. Somatization was being floated around in him despite a classic physical exam for myelopathy with findings that a 17 year old wouldn't know how to fake. I was the only one not considering it seriously for a while, and was the only psych dude involved.

I've been where that kid was myself, except I don't actually have any psychosocial issues or pain behavior. So I know what it's like to have doubters around when there really is a bonafide somatic issue going on. And how it can delay diagnosis and intervention.

But it seems like there are many cases where psychiatric history and evaluation make it clear that there is a strong likelihood of somatoform disorder either as primary or as a comorbidity of somatic illness. To me it seems silly that we wait for the exhaustion of tests before we start to consider it. Whatever happened to clinical likelihood?

While I'm not denying the importance of a good medical workup for somatic complaints, regardless of how outlandish, it seems to me that proper care for these patients would involve concurrent psychiatric evaluation and treatment/management.

I don't see why intervention, pain medication, and extensive workups can't also go hand in hand with therapy, coping skills teaching, and/or psychiatric medication. Why would you delay what could be at worst helpful adjunctive treatment allowing these people to live as full lives as possible, and at best could be curative?

Granted I'm also in the minority in that I think all people with chronic debilitating medical conditions should have a psychiatrist as part of their primary management team (even though i don't and have never seen one lol). My mantra is there is no such thing as a chronic pain patient without psych issues.

 

[whopper]

In dealing with somatoform disorders there's a treacherous grey area between psychiatry and the other medical field where if the doctors from both (or more) disciplines don't work well together, it can lead to poor treatment and frustrating complications.

For example let's say an IM doctor rules out a physical medical disorder by the use of a test that's only 70% accurate, then turfs the patient to psychiatry believing the person has a somatoform disorder? What if you can tell the IM doctor didn't practice the standard of care in ruling out a disorder and was too hesitant to drop the patient to you? Then after examining and interviewing the patient yourself, you're not convinced the IM doctor did enough to rule out a physical disorder?

Then what if you call the IM doctor, and that doctor is not willing to cooperate in good faith? That attending puts up the wall and does everything to prevent himself from assisting you.

It's happened to me. It's not a good position to be in if you actually happen to care about your patient.

You can argue that perhaps the IM doctors in these situations may order too many tests. IMHO the best way to handle it is both doctors need to be in a zone where they are willing to work together, each handling the responsibilities that are needed from their fields without trying to dump it on the other.

That is not always the case.

 

[Sneezing]

So, whopper, what did you do? The workup yourself or just let the patient slide on by?

 

[masterofmonkeys]

In dealing with somatoform disorders there's a treacherous grey area between psychiatry and the other medical field where if the doctors from both (or more) disciplines don't work well together, it can lead to poor treatment and frustrating complications.

For example let's say an IM doctor rules out a physical medical disorder by the use of a test that's only 70% accurate, then turfs the patient to psychiatry believing the person has a somatoform disorder? What if you can tell the IM doctor didn't practice the standard of care in ruling out a disorder and was too hesitant to drop the patient to you? Then after examining and interviewing the patient yourself, you're not convinced the IM doctor did enough to rule out a physical disorder?

Then what if you call the IM doctor, and that doctor is not willing to cooperate in good faith? That attending puts up the wall and does everything to prevent himself from assisting you.

It's happened to me. It's not a good position to be in if you actually happen to care about your patient.

You can argue that perhaps the IM doctors in these situations may order too many tests. IMHO the best way to handle it is both doctors need to be in a zone where they are willing to work together, each handling the responsibilities that are needed from their fields without trying to dump it on the other.

That is not always the case.

I've had to do the medical workups myself on a couple of occasions. Once to rule in and once to rule out. Ive also gotten into umm...passionate discussions with specialists who won't stress the importance of psych workup and treatment with their patients.

 

[TX515]

But it seems like there are many cases where psychiatric history and evaluation make it clear that there is a strong likelihood of somatoform disorder either as primary or as a comorbidity of somatic illness. To me it seems silly that we wait for the exhaustion of tests before we start to consider it. Whatever happened to clinical likelihood?

While I'm not denying the importance of a good medical workup for somatic complaints, regardless of how outlandish, it seems to me that proper care for these patients would involve concurrent psychiatric evaluation and treatment/management.

I don't see why intervention, pain medication, and extensive workups can't also go hand in hand with therapy, coping skills teaching, and/or psychiatric medication. Why would you delay what could be at worst helpful adjunctive treatment allowing these people to live as full lives as possible, and at best could be curative?

For billing purposes

 

[whopper]

So, whopper, what did you do? The workup yourself or just let the patient slide on by?

My typical (the other doctor is ticking me off) situation usually occurred in emergency psychiatry. That occurred about 1-2x week. E.g. a guy who has hepatic encepholpathy is diagnosed as psychotic. The guy has obvious asterexis, no previous psychotic history (and he's 45 years old), and has a distended liver.

The ER doc wrote on his physical exam that everything was within normal limits despite that a medical student could tell what was wrong within a few seconds.

Somatofrm DOs are a different nature. They usually do not occur in the ER, and will not resolve immediately. It can last for months if not longer. The ER situation I mentioned above will resolve within a few hours and then the monkey is off your back.

If the situation is in the hospital, and there's a lack of good faith disagreement, you can go up to the higher ups, eventually the department heads. That usually fixes the problem.

As a resident, when these things occurred, I simply told the attending, and left it at that. A resident should not go to someone above the attending in this type of situation unless it's an acute emergency, and the attending cannot be obtained. It's up the attending from there, and the attending should keep the resident informed of what's going on for teaching and continuity of care purposes.

I've seen attendings that when in this situation IMHO didn't show the appropriate decorum, urgency and understanding. As a resident, this can be frustrating, but you have to respect the proper chain of command. A resident should not take on an attending from a different department unless you have the attending from your own department backing you up.

As an attending, now you have the power and responsibility to take over these things. I've had numerous turf wars with other units and hospitals. My 2 worst cases 1) a patient who had a heart rate go below 30, and the IM doctor on duty refused to show up. I found out about it after the fact--on a Monday when it happened on a Saturday night. That Monday morning I ordered a stat EKG, and told the IM doctor what happened. The patient was fine, but had she had a bad outcome, IMHO it would've met the definition of malpractice. No one with a HR below 30 should be ignored.

In this case I brought up the situation to my superiors.

2) I had a patient who I believed had a normal pressure hydrocephalus. She showed ataxia, urinary incontinence, and confusion. She was schizophrenic and the usual dosage of antipsychotic that always worked on her did not work. She was on a previous psychiatric unit for months and the other doctor thought she was psychotic.

(She was hospitalized several times, and each time Risperdal, a total of 4 mg a day stabilized her. I had her on 8mg, and she was tried on several psychotropic medications with no improvement.)

Since she showed atypical sx of psychosis, and the usual dosage didn't work for her, I had a lingering feeling she had a medical etiology to her presentation. I told the IM doctor that covered my unit that I thought it was an NPH. The IM doctor didn't remember what NPH was. I told her what it was, gave her a printout of it, and we both decided she needed to be sent to a medical hospital (she was in a psychiatric hospital with little medical coverage).

So, the patient was shipped to the medical hospital where the IM doctor refused to do an NPH work up, and just sent her back to us. We did not have the ability to do a CT scan or lumbar puncture in the psychiatric hospital.

I brought the situation up to my superiors. The 2nd highest doctor in the hospital got into a tense debate with another medical officer from the medical hospital. They agreed to take the patient back.

This time, I called up the other hospital and asked if I could speak to the attending about the patient. The nurse got me the resident covering the patient. I specifically asked for the attending, but they would not honor my request. I informed the resident that I believed it was NPH or perhaps another medical disorder causing the strange symptoms, and gave my reasoning.

A few days later, I was informed the medical hospital discharged the patient to a nursing home--without an NPH work-up. Her family wanted to know what was going on, but she never signed disclosure documents. I couldn't tell them what was going on, and if my hunch of NPH was right, well she wasn't going to get better anytime soon if at all.

I asked my superiors that I felt this case was badly handled, and I wanted to call the nursing home and let them know what happened. In several nursing homes the doctor covering the patients only sees them once a week if that (sometimes once every few months). I had a feeling the doctor wouldn't do an NPH workup. I imagined a nightmare scenario where this person never got better because the doctor at the nursing home didn't scratch the surface on the case. Such a situation can happen where a doctor is responsible for several patients in such a setting, and her atypical sx were labelled as psychosis. For a non-psychiatrist, that is often enough to prevent any further investigation.

I was told by the administration that my responsibility over the case was over. Maybe in a legal sense it was, but in an ethical sense I felt I had to inform that nursing home. I called them up and told them what happened.

That really was all I could do. I did hear that about 6 months later she got better, but I don't know if the nursing home doctor uncovered a medical etiology.

Getting back to the original question, if you have a patient with a somatoform disorder, you can only do what you can do. First you have to try to contact the other doctor. In several cases a face to face or a verbal talk on the phone will defuse any anger and frustration real or imagined against the other doctor. In most cases, after discussing the case, I've noticed the other doctor was working in good faith, just that I did not understand their line of thinking.

In outpatient- If the PCP is not cooperating, in my situation I would not order tests to confirm a medical disorder because my insurance will not cover my practice outside the scope of psychiatry. If a situation happened where I believed that the PCP was not cooperating in good faith, I would have to document that I felt I did everything I could do on my end and that the patient would have to seek a second opinion.

 

[nancysinatra]

But it seems like there are many cases where psychiatric history and evaluation make it clear that there is a strong likelihood of somatoform disorder either as primary or as a comorbidity of somatic illness. To me it seems silly that we wait for the exhaustion of tests before we start to consider it. Whatever happened to clinical likelihood?

While I'm not denying the importance of a good medical workup for somatic complaints, regardless of how outlandish, it seems to me that proper care for these patients would involve concurrent psychiatric evaluation and treatment/management.

I don't see why intervention, pain medication, and extensive workups can't also go hand in hand with therapy, coping skills teaching, and/or psychiatric medication. Why would you delay what could be at worst helpful adjunctive treatment allowing these people to live as full lives as possible, and at best could be curative?

I would tend to think these cases are outnumbered by cases where these specialists desperately want to get rid of somatizing patients, but don't have anywhere to send them. These patients are the bane of existence in many fields. There's no miracle cure for them. Just because therapy and coping skills teaching might help some patients doesn't mean these treatments are reimbursed by insurance or that therapists are lining up to take referrals from outside specialists, or that they even believe those specialists when they do make referrals. For example I have heard of psychiatrists questioning whether pseudoseizures are real seizures even after a neurologist has ruled real seizures out, and referring patients back to neurology for a better workup. So you have the medical uncertainty that psychiatrists feel contributing to the problem. Plus many of these patients are reluctant to present for psychiatric treatment. There might be an Axis II comorbidity which will make the patient even more of a pariah in all specialties. Or god forbid the dx turns out to be factitious d/o. I have yet to hear of anyone who "treats" that disorder. You mentioned a mother who relished the role of caregiver... My impression is, when factitious disorders come up, psychiatry is not very helpful. You can refer any disorder in the world for psychotherapy but not all will recover or even show up for appointments.

My own experience is that turfing, and trying to get rid of patients, is more the rule. In the ER, I cannot even count the times a patient with a psych history comes in, with what looks like a probable medical problem, but because they've got the "psych hx," the medical workup isn't done and whatever is wrong with them is labeled "psychosis." If they're mad, it's psychosis. If they're vomiting, it's "psychosis." If they're acidotic and breathing funny and have AMS, that can also nowadays be "psychosis" (I learned this in the past week!). Then are the delirium workups that the medical ER doctors hand straight to psych. If the patient has ever had a beer in his life, and now he has AMS of any kind, no matter what other things are going on, to some people that's simple alcohol withdrawal until proven otherwise (if not "psychosis"), meaning it is a "psych consult." Meaning end of all medical attention. Not every ER doctor is like that obviously, but I've seen this happen many times!