Womens Health 4 Patients who require psychiatric intervention

I brought this patient up already in my last blog, but as it was a different point, I felt it deserved its own blog/discussion. I found myself reflecting on what I could have done for my patient who refused a psychiatric review.

Just a bit of background: this patient was one of my 3 conversion disorder cases. She gave birth precipitately at home, retained her placenta, was brought to hospital and subsequently developed pelvic pain, lower limb weakness, what she describes as nerve pain down both legs, and lost her ability to balance in standing or walk. Oddly, she was happy as Larry about the situation. She had self-diagnosed herself as having a PMH of MS, ankylosing spondylosis, and vasculitis. She had been taking a corticosteroid without the medical’s team knowledge (don’t ask how she got them!) for the AS. She had a detailed FIVE PAGE birth plan, which obviously had not gone to plan at all.

I can certainly understand how confronting it is for someone to have very disturbing physical symptoms and to be told that a psychiatric review is indicated. And as it IS the patient’s choice, this was not pushed. But then what?? The person possibly best equipped to convince the patient that a psychiatric review may be beneficial is the psychiatrist or psychologist themselves… and the patient had just declined their services. I believe that when a situation like this presents, it may well fall on me to encourage the patient to consider the psychiatric services.

I didn’t do this for her. I believe I should have tried though. I could have explained to her what conversion disorder is. I believe the important take-home message in this situation is that just because the source of symptoms is in the head, it doesn’t mean that it is within the patient’s control or conscious processing. Feelings of shame or guilt may be responsible for a patient refusing psychological intervention. I think it is important for SOMEONE to point out to the patient that although conscious thoughts and cognitive processes are not necessarily responsible for this presentation, psychological intervention may in fact have very positive results. I realize that this is a bit of a fib, as I do believe that maladaptive thought processes were somehow involved in this patient’s situation. She had self-diagnosed herself a variety of disorders and was taking medication without the hospital’s knowledge. But she doesn’t need to realize that, whilst I’m encouraging her. I think that the next time I am presented with a similar scenario, I would give this approach a crack. I don’t know, does anyone disagree? Otherwise, who else will take on that role?