The psychology of symptom embellishment or fictionalization

[jmj11]

I know that this is a multi-factorial problem. For some patients it is a means to get opioids. For others it is a part of a general somatization disorder.  However, as I sat and listened to two patients yesterday, obviously totally fictionalizing their symptoms, I sat and pondered what makes these people tick? I also pondered how much I hate this situation, that is usually a lose-lose for the provider.

 

One them, a upper middle class man (engineer), took one dose of a very benign drug (propranolol 20 MG) and then how, over the subsequent hours became disoriented, vomited, had diarrhea, and then slowly he could not feel or move his legs. Eventually it (total paralysis) marched (bilaterally) all the way up to his neck. His wife, siting and listening with concern, said she wanted to call 911 but her husband is so brave and stoic that he kept insisting that she not, unless he "went into a complete coma."  Then he added how he was paralyzed for almost 48 hours.  Really? Damn! I would be in the back of an ambulance within ten minutes of being "total paralyzed."

 

Then they start voicing how disappointed they were in me for prescribing such a toxic drug. 

 

Later in the day I saw a women and I just sat and let her weave just a convoluted nonsensical story about her symptoms (too unbelievable to even get into here).

 

I know that in neurology you see this stuff more often than say . . . dermatology. Neither of these patients were seeking pain meds. They were just wanted to be disease princesses and princes. The lady had 71 radiological exams in the past three years . . . and she has no serious illnesses.  But don't these stories complicate your days? 

[ajnelson]

I'd say I see at least one patient like this a day in the ER. It's painful to say the least, because we have to try to sift through all of these symptoms and decide if there is any real pathology hidden in any of it or not. And sadly, this is how your lady ended up with these 71 radiological exams [emoji53]

 

 

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[Joelseff]

I see 1-2 a day in IM. I get the unfortunate job of establishing pts in the practice and of course the overflow cases.

 

Saw one lady yesterday who is transferring care from one of the many private offices who were closed up and joined Kaiser. Her cc was "ear pain" but when I walked in.... It was "I have a hole in my heart and I have bad blood pressure and COPD and asthma. I need my meds but I don't know what they are." I call her pharmacy and she has not been on any maintenance meds since 2013. BP is 120/80. No murmur, lungs CTAB etc. I RX Albuterol and send her on her way with a F/U with a PCP in 2 weeks. I watch her from my office window as she fires up a Newport on her way to her car.

 

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[jmj11]

I see 1-2 a day in IM. I get the unfortunate job of establishing pts in the practice and of course the overflow cases.

 

Saw one lady yesterday who is transferring care from one of the many private offices who were closed up and joined Kaiser. Her cc was "ear pain" but when I walked in.... It was "I have a hole in my heart and I have bad blood pressure and COPD and asthma. I need my meds but I don't know what they are." I call her pharmacy and she has not been on any maintenance meds since 2013. BP is 120/80. No murmur, lungs CTAB etc. I RX Albuterol and send her on her way with a F/U with a PCP in 2 weeks. I watch her from my office window as she fires up a Newport on her way to her car.

 

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So what was that all about?  Socially isolated and seeing a visit to you as her only contact with the outside world?  I don't get it.

[Joelseff]

I don't get it either. Some people need a friend

 

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[Reality Check 2]

My bias was being raised in a medical family full of nurses.

You had to be bleeding out the eyes or have a limb hanging to be taken in.

 

Lots of common sense - you barfed - don't eat, rest, ice chips, ginger ale ---- you have a cold - sudafed, triaminic back in the day and blow your nose and wash your hands. 

 

It actually took me 3 months to convince my Mom my knee was in trouble when I was in high school - high level soccer player back then. I ended up having meniscus surgery. It took a whole lot to convince my mom I wasn't doing it for kicks or attention and walking up and down stairs with locking wasn't fun.

 

I am not sure how some of my patients were raised or what got attention in their families. I am not sure how much Dr Oz and TV have done to damage our patients. Lots of folks think they are unique, dying, untreatable or need STAT high level attention. Somehow folks on TV have seriously unusual illnesses that are miraculously cured in 30-60 minutes on TV by multispecialty residents operating well out of their realms.

 

Some folks sort of dare me to figure them out - statements like "nothing has ever worked before", "no one has ever figured this out", "I know this isn't the typical" -- my stomach sort of flips when I hear those - exams are usually completely benign and unhelpful yet the patient is experiencing death defying symptoms with normal blood pressure and pulse in the 60s.

 

I don't think folks understand common illness anymore. Can't use a thermometer and don't understand tylenol and ibuprofen or sudafed or nasal saline. They drink milk and eat enchiladas after barfing. Less than 12 hours of symptoms is a crisis.

 

I don't get it either. Somehow we have trained folks to think that weird gets attention and is special and that every thing we do is fraught with complications.

 

Maybe we should put Home Ec back in schools and teach basic health 101 - again

[Joelseff]

^ so right! Amen!

 

I just love seeing on my schedule a pt for urgent visits cc: "same day fever of 99.2" my call center is partly to blame. Can't triage worth a lick.

 

I get countless blank stares from parents when I tell them "it's just a cold..." and they ask "so what can he/she take to make it go away?" and I say "nothing..."

 

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[jb5158]

I see this at least twice a day. I am in neurology and even more so, specialize somewhat in epilepsy so I see all the psychogenic spell patients. I had two people in the last two days who have seen 4+ neurologists/neurosurgeons in the past couple years who are convinced that they have some progressive neurologic disease that everyone is missing. When someone gets to that point, there's really no reassuring them. I've had people beg for referral to Mayo Clinic, get told that it's anxiety or functional, and then continue to blame everyone for not figuring out what's wrong with them. All while not working on other health conditions, going to counseling, trying to be more active, etc. I do think shows like House contribute....while we learn in school to think of horses, not zebras, shows like that glorify the zebras and make it seem like they happen way more than they actually do.

 

Although some patients truly are toxic and will cling to any sympathy/coddling because they want the attention/sick role, I think most people are just scared and misled. I have been told that even though I didn't get them "answers," they're appreciative of the time I take to go over everything with them. I think a lot of people feel like they're in an assembly line when they see some doctors and worry that things are being missed because no one takes the time to actually listen. 

[Reality Check 2]

Even when I can't pinpoint a diagnosis - I try to tell the patient what I KNOW THEY DON'T HAVE.

Sometimes that reassurance helps.

 

I have to remember that a lot of employers are turds and folks feel like they can't miss work or risk losing their jobs.

It sucks that our society is a 24/7 always working environment with little respect for the common cold or people getting sick - or their kids.

The bad apples have made it hard for normal people to call in sick.

 

People look at me like I am the crazy one when I tell them that what they need is just a few days to recover and allow themselves to be sick.

Geez - what a concept.

[DogLovingPA]

I am still continually shocked by these patients.  I was raised similar to reality check 2 - I honestly can't recall EVER going to the doctor.  My dad walked around with a broken scaphoid for 6 weeks this summer, I worked for 3 days with pneumonia before I bothered to get seen, I had abdominal surgery and took only 1 day off before going back (my surgeon recommended 7 days - I looked at her like she was crazy).....     I simply can't relate to these patients.  I agree with all above - we have lost touch with what it means to be sick (and don't even get me started on Dr. Oz).  Everything is a crisis and must be fixed now.  Most of my patients are anxious about fairly benign problems (3 red bumps is a "spreading rash", my jaw aches and I cut myself last week so I must have tetanus, etc).  Patients like JMJ11 describes - that's a whole different level - there has to be some underlying psychological pathology. 

[jb5158]

One them, a upper middle class man (engineer), took one dose of a very benign drug (propranolol 20 MG) and then how, over the subsequent hours became disoriented, vomited, had diarrhea, and then slowly he could not feel or move his legs. Eventually it (total paralysis) marched (bilaterally) all the way up to his neck. His wife, siting and listening with concern, said she wanted to call 911 but her husband is so brave and stoic that he kept insisting that she not, unless he "went into a complete coma."  Then he added how he was paralyzed for almost 48 hours.  Really? Damn! I would be in the back of an ambulance within ten minutes of being "total paralyzed."

 

Your comment makes me laugh because there's so many people with psychogenic spells that say they were unconscious and shaking for 5+ hours....if I lost consciousness for more than a few seconds (outside of fainting), my husband would be freaking out. But these people's family members just watch their loved ones convulse for multiple hours? Seems fishy.  Or the ones that swear up and down that they haven't had a single bowel movement in 2 months...not even passing gas....but amazingly their appetite is just fine and they're eating like normal....where is it all going then?!

 

While sometimes amusing, it is so hard to know who is BSing you for disability or something or who truly believes that these things are going on and needs psychiatric help. Plus I think many people embellish so that people take them seriously (10 out of 10 pain when sitting comfortably on their phone playing candy crush). 

[jmj11]

Here is one on the flip side. In our neck of the woods, the PCP is more likely to be a ND than a MD/PA/NP. Even many of the NPs are practicing "natural medicine."

 

So, just saw a patient whose PCP is an ND. Her blood pressure consistently runs 180-215/98-115.  She says, her ND has warned her not to take prescription drugs because she has "medication hypersensitivity syndrome."  I see this quite frequently where the ND warns against vaccines or hypertension treatment. I told her she was going to die from a stroke or CAD and that is really what should keep her up at night.  I am sure she will never come back.

[Reality Check 2]

I tell the patient they are stroke bound but might not die - they have the chance to become incontinent, drooling and aphasic - forever............................

 

My patient with a HUGE family hx of CAD and the patient has an LDL of 185 and an HDL of 32 but doesn't want to take Lipitor because it is "poison" as per her ND. She won't even take aspirin.

 

Today's special on the menu - IBS................................

[Reality Check 2]

Just got a call for a refill of codeine cough medicine.

Given 75 ml 48 hours ago.....

 

Said the bottle was only "half full" when he got it and only lasted 2 nights.

 

I am 10000% sure this guy did not read the label at all and just took the lid off and chugged it to his content - more has to be better. He doesn't have time to be sick or cough and there has to be a cure somewhere. 

 

My refill answer - no.

 

He has the flu by the way. I was giving him a few nights of comfort care. Max 10 ml po at qhs - should have lasted 7 NIGHTS.

 

Oy!! Here's your sign....................................

[EMEDPA]

I've seen numerous patients with similar BS stories, but my favorites involve supposed traumas.

Me: "so you were hit by a bus traveling at high speed while in a crosswalk and it dragged you for 50 yards under the back tires but left you without a scratch" ?

them: "yup, I was lucky, but it really hurts. can I have 60 2 mg dilaudid tabs to get me through the week"

Me: " No. not just no, hell no. please leave now, you are wasting my time and putting patients with real problems at risk by being here".

[Reality Check 2]

I have one currently who gets "migraine pain" in her knee but only at night and it wakes her. Doesn't happen if she falls asleep on the couch or in the car.

Absolutely not reproducible.

Normal MRI.

 

No evidence of RLS or vit D deficiency. Nothing in the other knee. Exam stone cold normal.

 

She had a loss of family member to drug overdose last year and I find it weird that she will take hydrocodone willingly and copiously. She will not, however, take SSRIs due to the "side effects I read about".

 

I inherited her.

 

Gave her 90 days to wean off narcotics. Gave her ortho offer. She cried and pleaded with me to not take her off. 

I said no - has to come off of them. She can't continue without anything diagnosable and without anything reproducible. 

My halo has rust now.............................

[ohiovolffemtp]

On the other hand, I remember a patient with a sudden onset of unilateral leg "paralysis" and retention of both urine & stool.  Patient could lift the other leg off the bed, but no muscle tensing on "paralyzed" leg.  Hmmm.... Patient had a psyche hx so did DRE - wow - no anal sphincter tone.  MRI showed a small amount of cord compression which the spine surgeon said wouldn't account for the reported symptoms.  Neurology ultimately confirmed it was conversion disorder.  I was impressed - I wear size 8 gloves and didn't think conversion disorder would prevent a reaction on DRE.