When a patient is admitted with puzzling or medically unexplained symptoms, hospitalists may have to separate fact from fiction.
On one side are patients with somatic symptom disorder. These patients experience genuine, distressing symptoms yet have normal results on physical examination and diagnostic testing, explained psychiatrist and internist Kimberly M. Stoner, MD, MS, FACP, during her talk at Hospital Medicine 2019. “These patients are often completely dissatisfied. . . . They've had 12 workups at multiple places, and they still don't have an explanation.”
On the other side are patients with deception disorders, such as factitious disorder (aka Munchausen syndrome) and malingering, who cause or feign their own illnesses and injuries.
Proper inpatient management of patients with somatic symptom disorder or deception disorder can help reduce iatrogenic harm and save health care costs, said Dr. Stoner, an associate professor in the departments of internal medicine and psychiatry and behavioral medicine at the Medical College of Wisconsin in Milwaukee.
The key is recognizing who is suffering and who is bluffing.
When symptoms are real
Somatic symptom disorder is highly prevalent (4% to 6% of the general population), most common in women, and associated with a history of childhood abuse, trauma, and exposure to chronic illness, Dr. Stoner noted. In the past, patients with the disorder have been described in the medical literature as “heartsink patients” because of physicians' feelings about them.
Somatization is highly comorbid with other functional disorders. “There are a lot of words we see in a past medical history, like fibromyalgia or chronic pelvic pain, that in our mind are ‘dirty’ words,” she said. However, for these patients, having a label for their symptoms makes them feel vindicated and improves their satisfaction with their care, said Dr. Stoner.
The disorder is also expensive, costing an estimated $256 billion per year and 20% of the U.S. medical budget, plus the additional costs to society of disability related to these symptoms, she said. While primary care is key, Dr. Stoner said proper treatment and management of somatic symptom disorder begin in the hospital.
To build rapport in the inpatient setting, the first steps are setting aside some time to let these patients tell their stories, then using every physical exam maneuver possible to try to reassure the patient that you are taking their symptoms seriously. If you suspect, based on your history and physical, that somatic symptom disorder may be the issue, excuse yourself by saying something like, “No one's been able to tell you what's going on, so I'm going to get to the bottom of this. Let me go do some record review,” Dr. Stoner recommended.
After you've settled on the diagnosis, return to the patient and say that somatic symptom disorder could explain why he or she has been suffering for so long. “I ask the patient, ‘Have you ever heard that term before? Do you know anything about that?’” Dr. Stoner said. “And oftentimes, they get kind of offended, like ‘Oh, that means you think it's all in my head.’”
If this happens, reassure the patient that the symptoms are absolutely real, she said. For example, Dr. Stoner explains that all humans have a connection between the brain and the body, such as how someone might get a tension headache after a stressful day of work. However, people with somatization are wired in such a way that these symptoms happen relentlessly.
“I say, ‘I'm not going to be able to cure your symptoms. This is how you're wired. This is how your nervous system is connected,’” she said. “‘But we can help you to manage your symptoms so that you're able to get back to your life and things that you're missing out on.’”
These patients come to the ED or hospital because they feel that they can't manage their symptoms on their own, so it's helpful to brainstorm a self-management toolkit with them, said Dr. Stoner.
After making the diagnosis, ask what strategies have ever improved the pain, headaches, or other symptoms. Compile a list of various ways the patient can try to self-manage symptoms to avoid hospitalization in the future, she said. “Hot bath, essential oil, downward-facing dog pose, going for a swing, reciting [a] psalm, whatever, it doesn't matter as long as it's helpful,” Dr. Stoner said.
Despite often lacking self-efficacy, patients with somatization tend to be hypervigilant and self-monitoring when it comes to their symptoms, she said. “They come in with their telephone-book stack of ‘Every day, here are my symptoms.’ I try and change that into more of a functional progress log with incremental goals,” from getting out of bed to washing the dishes to attending a child's soccer game, Dr. Stoner said.
These patients often benefit from discontinuation of unnecessary medications to cut down on side effects, she said, and hospitalists could also consider starting an antidepressant with a benign side-effect profile. While the number needed to treat for an antidepressant in somatic symptom disorder is only three, patients may be confused about or resistant to taking one, Dr. Stoner said.
“I tend to frame somatic symptom disorder as a nervous system disorder . . . [by saying], ‘We need to start this medication that's a neurotransmitter modifier, and it will help you.’ That usually improves the chance of the patient taking it,” she said.
Referral to cognitive behavioral therapy may also be beneficial. However, “Make sure that the therapist you're referring a patient to knows that the diagnosis is somatic symptom disorder,” said Dr. Stoner. “They're often a licensed social worker or someone who's not medical and . . . gets roped into hearing about medical problems every week and not redirecting the patient in terms of coping skills.”
Detecting deception and ‘duper's delight’
Unlike patients with somatic symptom disorder, who suffer in earnest, those with deception syndromes cause or fake their own symptoms.
Patients with factitious disorder, which has a prevalence of 1%, produce symptoms of an illness or injury to be in the “sick role” or to receive attention, Dr. Stoner said. “We also have patients that describe ‘duper's delight.’ They really enjoy fooling doctors. Doctors are smart, and it really makes them feel pretty clever when they can trick us,” she said.
Some common presentations of factitious disorder are diarrhea (abusing laxatives), hematuria (pricking a finger to put blood in one's urine), hyperthyroidism (abusing levothyroxine), hypoglycemia (taking insulin), and injuries that don't heal (manipulating wounds), Dr. Stoner noted. “Usually the presenting symptom will get better after they've been admitted to the hospital setting, but then if you're about to discharge them, there might be an exacerbation, or a new symptom that's unexplained will develop,” she said.
Often, these patients are younger, have worked in health care, and want to be in the patient role, Dr. Stoner said. In addition, it may become clear that they have been admitted to multiple different facilities and are very isolated. “Nobody's coming in to the hospital to see them because they've kind of burned every bridge,” she said.
In contrast with factitious disorder, malingering is motivated by secondary gain and often involves external rewards, such as receiving disability benefits, settling a lawsuit, or obtaining opioids, Dr. Stoner said. “But oftentimes, I find nowadays things overlap. I have patients I'm pretty sure were factitious, but someone in their church sets up a GoFundMe [donation website] to help them, and they end up getting financial rewards even though they originally just wanted to be in the sick role,” she said.
However, distinguishing between the two disorders isn't as important as distinguishing genuine medical disorders from deception, Dr. Stoner said. “If you can avoid invasive diagnostic tests and procedures that aren't clearly indicated based on your objective findings, that's ideal,” she said.
In addition, patients with deception syndromes need 1:1 or remote observation “because most hospital risk management [departments] don't want patients self-injuring while they're actually in the inpatient setting,” said Dr. Stoner.
Placing such an observation order may anger the patient and make it clearer that malingering is present. In that case, confront the patient (but not alone) and explain that the symptoms are medically unexplained, that the care team is concerned about self-injury, and that the team needs to ensure the patient's safety while in the hospital, Dr. Stoner recommended.
It can also be helpful to give the patient an opportunity to save face. For example, explain to the patient that the source of his bacteremia is uncertain: It may have happened while brushing his teeth or it's possible he caused it (Dr. Stoner recalled a nurse doing so by injecting feces into her own bloodstream). Either way, let the patient know that the fever is expected to resolve by the next day.
“That way, they have to get out of the hospital,” she said. “Most patients aren't going to admit it, even if you confront them, that they were causing their symptoms. But they will quickly leave your hospital and go elsewhere to seek treatment.”
One final strategy is offering an inpatient psychiatry consult, although patients may be reluctant to accept one, Dr. Stoner said. However, she said it's worth trying since factitious disorder has a substantial mortality rate (20%). “They usually won't go into therapy, which is sad because these patients end up dying. . . . They're willing to do so much self-harm in order to get into the hospital that it's pretty dangerous,” said Dr. Stoner.
Nonetheless, patients with deception disorders should be rapidly discharged without regret. “For patients who are truly factitious or malingering, discharge is very appropriate,” she said.