Odd behavior with psycosomatic symptoms

opossum · May 5, 2011

Sounds like it might be some kind of conversion disorder. Here's a link with some info about it: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001950/

I worked (briefly) in a psych hospital and saw this in some patients - and chest pain seemed to be a common symptom. It gets hairy because as nurses, when a pt complains of s/s of MI, we need to investigate it - however, in pts with psychosomatic disorders sometimes that assessment can "feed" their psychotic illness and exacerbate the symptoms of chest pain, anxiety, etc. So you really have to get to know your pts.

In being manipulative and trying to insult you, he actually gave you some very valuable information as to how to help him! Seems like you handled it well. It can be difficult to distinguish psychosomatic symptoms and malingering, but there is a difference and they have to be handled in different ways. I'm still learning...it certainly is challenging.

Psych nurses on this board will certainly have good advice for you.

neuroms · May 5, 2011

The patients refusal of most treatments sounds like a factitious behavior or, as you suggest, the pain is present and not exaggerated--we know that patients with high anxiety commonly experience associated chest pain--and there is an underlying cluster B personality disorder driving the patient's reactions in terms of need for control and validation. Did your doc order a psych consult?

neuroms · May 5, 2011

Sounds like it might be some kind of conversion disorder. Here's a link with some info about it: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001950/
I worked (briefly) in a psych hospital and saw this in some patients - and chest pain seemed to be a common symptom. It gets hairy because as nurses, when a pt complains of s/s of MI, we need to investigate it - however, in pts with psychosomatic disorders sometimes that assessment can "feed" their psychotic illness and exacerbate the symptoms of chest pain, anxiety, etc. So you really have to get to know your pts.
In being manipulative and trying to insult you, he actually gave you some very valuable information as to how to help him! Seems like you handled it well. It can be difficult to distinguish psychosomatic symptoms and malingering, but there is a difference and they have to be handled in different ways. I'm still learning...it certainly is challenging.
Psych nurses on this board will certainly have good advice for you.

I might be wrong, but I think conversion disorder, like somatization disorder, will involve multiple unverifiable pain symptoms as a pattern of coping. I guess an accurate history would help, huh?

Whispera, MSN, RN · May 5, 2011

Hello everyone! I've noticed something odd and I was wondering if this is an identified behavior and what the name would be. I recently had a patient that c/o chest pain intermittently with clear anxiety issues. He denied psych and anxiety issues, though he admitted he'd been sent to a psych hospital involuntarily. He was unknown to us, and his records were unavailable.
He would develop chest pain, usually when he was anxious, but wouldn't let me do much for him. The first time, he was worked up for cardiac problems, and ruled out. He was offered medication, and refused it all. He continued to c/o increasing pain, very theatrically, and asked for a warm pack because I had offered everything else. He accepted that and the pain went away almost immediately.
It was my opinion that this gentleman was really percieving pain, and believed that the warm pack would work, so it did. The then told me how much smarter he was than I because he could solve his pain and I couldn't. This seemed to be cyclic in nature with different things, always ending in an end that supported his hypothesis. I know this is manipulative behavior, but i was wondering if it is a specific behavior and how best to manage it. He wound up having a legitimate medical issue, but he clouded the facts so badly with this behavior. Any thoughts?

Anxiety can yield what a person defines as chest pain. His or her definition might or night not be our definition. Perhaps it's racing heartbeat, a jumping-out-of-the-chest feeling, or pressure in the cardiac area. Perhaps it's the pain of fear of what-in-the-world-is-going-on.

How do you know he had anxiety if he denied anxiety issues? Did you mean in his past? It would be interesting to know more about his past psychiatric diagnosis and treatment.

Did he tell you he knew more than you, as a way of condescending or was he jokingly saying it? Did his behavior around the chest pain get him attention? Did he seem a lonely sort of person who was craving human caring? Did his statements about him knowing more seem to help him feel important? Did he need that?

What was his legitimate medical issue? Could it in any way be related to chest discomfort?

I don't think his symptoms fit any particular diagnosis, but anxiety is surely involved. It's just difficult to see exactly how someone could help with that, in the short time we have with hospitalized patients. I believe the best way to try to deal with what I consider manipulative behavior is to talk about it with the person who's exhibiting it. Don't dance around it. Talk about what you see and think in a kind, caring way. Get the other person's input. See if you can come to a meeting of the minds. That doesn't mean you have to jump to the theatrical performance. Sometimes you have to set boundaries on what you can do and when you can do it.

It's also important to make sure the symptoms aren't related to a physical problem that could be deadly. I know that was done for this man. Sometimes people with psychiatric disorders don't get the medical attention they should get, just because their behavior is odd. Some can attribute the confusing symptoms to the psych disorder rather than a medical problem.

Sometimes all we can do is what we can do...and then go on and do it again...

Mrs. SnowStormRN, RN · May 5, 2011

Anxiety can yield what a person defines as chest pain. His or her definition might or night not be our definition. Perhaps it's racing heartbeat, a jumping-out-of-the-chest feeling, or pressure in the cardiac area. Perhaps it's the pain of fear of what-in-the-world-is-going-on.
How do you know he had anxiety if he denied anxiety issues? Did you mean in his past? It would be interesting to know more about his past psychiatric diagnosis and treatment.
Did he tell you he knew more than you, as a way of condescending or was he jokingly saying it? Did his behavior around the chest pain get him attention? Did he seem a lonely sort of person who was craving human caring? Did his statements about him knowing more seem to help him feel important? Did he need that?
What was his legitimate medical issue? Could it in any way be related to chest discomfort?
I don't think his symptoms fit any particular diagnosis, but anxiety is surely involved. It's just difficult to see exactly how someone could help with that, in the short time we have with hospitalized patients. I believe the best way to try to deal with what I consider manipulative behavior is to talk about it with the person who's exhibiting it. Don't dance around it. Talk about what you see and think in a kind, caring way. Get the other person's input. See if you can come to a meeting of the minds. That doesn't mean you have to jump to the theatrical performance. Sometimes you have to set boundaries on what you can do and when you can do it.
It's also important to make sure the symptoms aren't related to a physical problem that could be deadly. I know that was done for this man. Sometimes people with psychiatric disorders don't get the medical attention they should get, just because their behavior is odd. Some can attribute the confusing symptoms to the psych disorder rather than a medical problem.
Sometimes all we can do is what we can do...and then go on and do it again...

Very well said, I dont think there is any need to add to any of this. I will just reiterate, Anxiety is often associated with chest pain especially in Panic Disorders (and sometimes when Panic Disorder isnt there). Im very leary about using the term "manipulative" as the client could be delusional, and really believe his thoughts of grandeur. As Whispera said, there isnt enough history behind it. Setting boundaries may be the appropriate action in relation to behavior, but in relation to his complaints of chest pain, I say continue to treat him because we can only believe his chest pain is real and cannot say otherwise. See if you can get a psych consult for your patient. Good Luck to you! :)

mcleanl · May 5, 2011

Sounds like it might be some kind of conversion disorder. Here's a link with some info about it: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001950/
I worked (briefly) in a psych hospital and saw this in some patients - and chest pain seemed to be a common symptom. It gets hairy because as nurses, when a pt complains of s/s of MI, we need to investigate it - however, in pts with psychosomatic disorders sometimes that assessment can "feed" their psychotic illness and exacerbate the symptoms of chest pain, anxiety, etc. So you really have to get to know your pts.
In being manipulative and trying to insult you, he actually gave you some very valuable information as to how to help him! Seems like you handled it well. It can be difficult to distinguish psychosomatic symptoms and malingering, but there is a difference and they have to be handled in different ways. I'm still learning...it certainly is challenging.
Psych nurses on this board will certainly have good advice for you.

In my experience (in the ICU) conversion disorders are very extreme....not just odd behaviours.

alphabetsoup · May 5, 2011

Since he had an underlying medical condition, did it turn out to be GI related? It sounds to me that this patient must feel that he is always correct and superior over other people. I don't know what you can really do with that sort of personality other than to smile, bite your tongue, and leave it at that. The bright side is that eventually he will be discharged. Yes, there are people like that who must always be right, never accept that they are wrong, and will never sincerely apologize to anyone else. I don't think this is an official psychiatric disorder although Borderline Personality Disorder comes to mind.

ErinS, BSN, RN · May 6, 2011

I think you were taking care of my husband:yelclap:!

But seriously, he does have anxiety, and it is associated with chest pain. Perhaps the pain interventions distract him from his anxiety, and this works. My husband often uses distraction to manage it, and while your pt is not actively thinking he is using distraction, he is.

JeneraterRN · May 6, 2011

Thanks to all who responded! To answer some of the questions: he refused a psych consult because he's not "crazy," he did have GI issues which he told me I was completely wrong when I told him my suspicions. I say he clearly had anxiety issues because he'd fixate on a small detail and in five minutes, he was dying. There was mo joking with this man, I tried to which made him think I was more of an idiot. He was an intelligent enough person, but very difficult to deal with his personality.

The cyclic nature of his behavior was fascinating because it is self-reinforcing. I thought if there was some way to break the cycle, we could work more effectively with him and maybe eake out some compliance (I'm an optimist :)). I really couldn't think of a good way though. He'd have symptoms, we couldn't solve them, he could, therefore he was smarter because he reads webmd, and it happens again. He gets a huge payoff from the boost in his ego, giving him a short term solution to whatever he is trying to soothe inside. Smiling and nodding worked the best, not feeding into it. I finally told him, "when you figure out what you need, call me. I am not going to listen to you self diagnose needlessly.". He didn't like me so much after that. Thanks for the responses!