Adherence UtilizationReactions Interventions

Hypochondriasis—cont'd

Somatization Disorder

"Doctor shopping" Adhere to requests for medical testing, but highly resistant to psychosocial exploration, evaluation, or treatment.

Conversion Disorder

Adhere to medical recommendation. May accept psychosocial explanations.

Up to 9x the health care expenditures of typical primary care patients. Utilization increases depending on number of symptoms. Doctor seeking until patients can find a physician who believes them or will do what they seek.

Doctor seeking until patients can find one who believes them or will do what they seek.

Body Dysmorphic Disorder

Initially avoid medical care.

Once disorder is acknowledged by patient, can be intensely medical seeking to correct the defect.

Avoid doctors initially, but then may overuse medical care, seeking variety of surgical and medical treatments.

With more somatic complaints, perceives patient as more difficult. Frustrated, puzzled with inability to explain or diagnose problem. Wants patient to stop complaining.

Puzzled by patient's complaints of body defect that is not readily visible or apparent. Frustrated that reassurance does not work.

9. Foster more adaptive coping styles. 10. Provide additional treatment. Encourage regular office visits. With physical complaint, do a focused physical exam. Refer for consultation rather than hospitalization. Goal is preservation and restoration of function, not elimination of symptoms.

1. Empathize/understand involuntary nature of symptoms.

2. Screen for reasonable medical condition that could explain symptoms.

Use parallel diagnostic inquiry. (Suggest from start that symptoms have biopsycho-sociocultural components.) Workup proceeds simultaneously in all domains. Use emotion-focused interviewing (see above). Do not abandon the patient.

Correct reality distortions and unreasonable patient expectations. Elicit irrational thoughts and suggest more rational ones. Interpret specific defenses. Foster more adaptive coping styles.

Puzzled initially. Often feel helpless to address psychosocial or emotion conflict.

1. Empathize/understand involuntary nature of "symptoms.

2. Perform thorough neurologic and medical evaluation.

2. Make a timely diagnosis.

3. Give therapeutic reassurance that symptoms are not caused by a medical or neurologic condition but are secondary to underlying psychological conflict.

4. Combined medical model approach and psychological modalities best address physical needs and invite patient to engage in treatment without feeling humiliated (combined, if appropriate, with progressive physical therapy to promote sense of mastery and control).

5. Treat any comorbid psychiatric disorder.

6. Work through patient's defenses and help to develop more mature and adaptive defense mechanisms to prevent future conversion episodes.

7. Foster more adaptive coping styles.

1. Empathize; understand involuntary nature of symptoms.

2. Stepped care attempts to provide most effective but least intrusive treatments appropriate to a person's needs. Step 1: awareness and recognition

Step 2: recognition and assessment

Treatment options: exposure response; CBT or SSRI; or combined treatment.

3. NICE guidelines: SSRI or clomipramine, CBT (including exposure response prevention [ERP]), or combination of SSRI or clomipramine and CBT (including ERP); consider care coordination, augmentation strategies, admission, social care.

4. Do not abandon or threaten termination.

5. Correct unreasonable patients expectations.

6. Gently elicit irrational thoughts and suggest more rational thoughts.

7. Interprets specific defenses.

8. Foster more adaptive coping styles.

Continued

Table 46-2 Difficult Patients: Adherence, Utilization, Physician Reactions, and Interventions (DSM-IV-TR)—cont'd

Physician

Adherence

Utilization

Reactions

Interventions

Factitious Disorder

Patients will only adhere to medical recommendations when these support the patient's goal of assuming the sick role.

Extremely high use of inpatient medical hospitalization and occasionally psychiatric hospitalizations. Willing to undergo mutilating procedures.

Initial wish to help, then anger/rejection of patient's complaints. Wish to expose, retaliate, punish, or terminate care.

1. Empathize/explore with patient's history of trauma and painful early life experiences.

Clarify that you are being used to help patient seek dependent care.

Do not moralize. Explain that seeking care in a medical setting is fraught with iatrogenic injury.

4. Explain that there are other, more adaptive ways of receiving care, such as seeking psychiatric help.

5. Set limits on medical care; correct reality distortions.

6. Question irrational thoughts; suggest more rational ones.

7. Interpret defenses and maladaptive coping style.

8. Foster more adaptive coping styles.

Patients will only adhere to medical recommendations when these support the patient's goal of assuming the sick role.

Malingering

Only adhere to medical recommendations when these support patient's secondary goal.

Extremely high use of inpatient medical hospitalization and occasionally psychiatric hospitalizations. Willing to undergo mutilating procedures.

Exploit both inpatient but more often outpatient settings when needed. Symptoms abate or disappear as goals are obtained.

Initial wish to help, then anger/rejection of patient's complaints. Wish to expose, retaliate, punish, or terminate care.

Initial wish to help, then anger/rejection of patient's complaints. Wish to expose, retaliate, punish, or terminate care.

1. Empathize/explore with patient's history of trauma and painful early life experiences.

Clarify that you are being used to help patient seek dependent care.

Do not moralize. Explain that seeking care in a medical setting is fraught with iatrogenic injury.

4. Explain that there are other, more adaptive ways of receiving care, such as seeking psychiatric help.

5. Set limits on medical care; correct reality distortions.

6. Question irrational thoughts; suggest more rational ones.

7. Interpret defenses and maladaptive coping style.

8. Foster more adaptive coping styles.

1. Empathize with fear of being discovered in lying and exploiting other.

2. Determine the secondary gain that patient seeks. If dishonesty suspected, verify symptoms and illness progression with others.

3. Do not moralize. Direct patient to use of other, appropriate resources.

4. Correct reality distortions and unreasonable patient expectations.

5. Question irrational thoughts; suggest more rational ones.

6. Interpret defenses and maladaptive coping style.

7. Foster more adaptive coping styles.

CBT, Cognitive-behavioral therapy; SSRI, selective serotonin reuptake inhibitor.

*From American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 3rd ed revised. Washington, DC, APA, 1986.

of medical services are somewhat predictable based on the particular personality or somatoform disorder.

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