Case study 9: A case of abdominal pain

Index clinical situation

Depression

  • Abdominal distension,
  • Constipation,
  • Dysuria,
  • Frequency of micturition.

Synopsis

The problem is presented using a sheaf of letters between the general practitioner and hospital. It is advised that these be distributed prior to the first case discussion. The problem is about a 35 year old woman with abdominal symptoms and a history consistent with depression. She is seen by a number of different specialists who do find any cause for her symptoms. The patient is unwilling to accept the diagnosis of her depression.

This lady has had a series of referrals to a number of hospital based consultants (+/- numerous investigative procedures). These have not identified a cause for her symptoms but she has been given a diagnosis of depression, which she is unwilling to accept.

Diagnosis

What is the most likely diagnosis?

Functional disorders are those of unknown aetiology which can give rise to the symptoms described in this lady's case. For example, irritable bowel syndrome is the most common disorder of the GI tract and may affect one third of the general population (although only approximately 20% of sufferers seek medical advice).

Referrals for functional disorders account for about 50% of gastroenterology out-patient work and about twice as many women as men are referred. Symptoms are usually noticed between late adolescence and late 30s in women and slightly later in men. Many doctors do not appreciate the wide range of clinical features associated with functional disorders and this may lead to inappropriate referrals and treatment (both medical and surgical). In two thirds of cases the onset of these symptoms is preceded by episodes of anxiety or depression.

Effects

What effects could the symptoms have on the patient's lifestyle (including employment)?

The unpredictability of symptoms could lead to poor performance at home and at work and also in absences from work.

At the symptomatic level, the lead symptoms of gut and urinary discomfort and low mood make for a difficult work colleague or subordinate. This is particularly so if the patient is struggling through a prolonged diagnostic process (see 3 below) which is likely to be frustrating and unfulfilling. You need to reflect for a while on what other factors should be considered in relation to the interaction between the patient’s health and performance:

  • Physical tasks (e.g. moving and carrying objects, stretching, bending, etc.) - do these exacerbate her symptoms?
  • Psychological factors (e.g. relationships) - are these a significant factor in this lady's case?
  • Oganisational factors (e.g. worries about permanency of employment, inherent job duties such as dealing with general public, etc.) - does she perceive these factors as "stressful"?

Response to treatment is often transient or variable. Treatment options may include increased fibre intake, osmotic laxatives (e.g. lactulose), prokinetic drugs which increase small bowel and colonic transit (e.g. cisapride), antidepressants which can be used to treat coexisting depression or for their central analgesic effect. Would treatment affect an individual at home and/or at work? The patient may need to have easy (rapid!) access to toilet facilities in response to treatment. In addition, antidepressants may affect the person's ability to concentrate, their memory and their sleeping patterns - these effects should be taken into account by the clinician and also be discussed with the patient.

At the end of this section jot down the advice you might offer the managers and colleagues of your patient if you were dealing with that patient in an occupational setting. (Remember that they don't understand medical words or ideas but will be resentful if they feel your advice is peremptory or patronising).

Physical vs psychological

In pursuing the physical route did the clinicians imply that a physical cause might be identified? If a more "holistic" approach had been taken (i.e. explaining that physical causes for her symptoms were being looked at perhaps to exclude rather than to identify a physical cause) would this lady have been more prepared to accept the diagnosis of psychological illness (depression)?

Many patients describe their symptoms in physical terms, as they think that it is more acceptable to have physical symptoms rather than psychological ones. Why is this when about 5% of the population will experience an episode of moderate to severe depression at some point in their lives? Between 15 and 30% of workers will experience mental health problems each year and depression alone accounts for almost 20% of all sickness absence from work. Is this because patients think that doctors will be more attentive to a physical complaint, or that the stigma of having psychological illness is still too great, or because patients believe that the symptoms they experience must have a physical cause?

What can the doctor do to help the patient accept a diagnosis that they may not feel is appropriate?

Set down a half dozen ideas about how you would try and persuade your patient. Acceptance, or fear of non-acceptance of a diagnosis by family, friends and colleagues is often a big stumbling block.

Acceptance

If the patient accepts the diagnosis of depression, then the clinician can offer advice +/- treatment to the patient.

Depression is 2-3 times as common in women as men and most episodes remit within 6 months. Some cases may become chronic (especially if undertreated) and a proportion will have further episodes of depression.

About 80% of patients can be treated successfully with medication (antidepressants), cognitive therapy or a combination of the two. Side effects from medication should be taken into account including the patient’s lifestyle including both home and work activities. An individual is unlikely to commence or continue treatment which they do not find "acceptable", and it is especially important to take this into consideration for treatment of depression which is likely to last for months rather than weeks.

Tricyclic antidepressants, for example, may cause drowsiness, tremors and blurred vision. If this means that the patient is unable to function on a day to day basis, then the individual may discontinue treatment. More modern antidepressants (for example SSRIs) may have fewer side effects and allow an individual to pursue their normal activities (both at home and at work) including household chores, driving, concentrating on tasks, operating machinery and equipment and undertaking computer work.

Note down the main classes of antidepressants and their side effects. Which of these might impact on your patient's job if they were:

  • An officer worker?
  • A lorry driver?
  • A doctor?

Treatment options may also have to be more "holistic" in nature. As well as treating symptoms, the doctor and patient may need to look for cause(s) of this lady's problem including financial worries, interpersonal relationship issues, family problems and work related causes. It is more common for psychological problems to have multiple causative factors than a single one. Obviously the doctor and patient and may not be able to rectify the causal factors (especially not immediately).

If work related problems are identified, then the employer has a duty to look into these and deal with them in the same way as physical, chemical and biological hazards. In law this comes under the UK regulations for Control of Substances Hazardous to Health (COSHH) which aim to assess risks, to try to minimise their effects and look after mental well-being as well as physical health and safety.

An employer may have the following services, which have some expertise to help in these sorts of matters:

  • An occupational health service with specially trained doctors and nurses,
  • An employee assistance programme (EAP) - usually operated by counsellors and/or psychologists,
  • HR/personnel department - some personnel in these functions have training or knowledge of psychosomatic conditions.

Think about the correspondence you might send them to persuade them to help you treat your patient successfully. Try one or two different approaches.

Useful references