I feel like I should add an addendum to the last post about my patient with delusional parasitosis. Part of the reason that the case is so frustrating to me is that the patient is really suffering. Every day he thinks that he is crawling with bugs and infecting other people and that no one believes him or helps him, and it’s really intolerable for him. It’s really hard to watch someone suffer, and to have a treatment that can help (in this case, psych meds) but to be unable to help the person access that treatment. 😦
This case has gotten under my skin June 29, 2010
A patient of mine came in several weeks ago with a complaint of “bugs under my skin.” During the course of the visit, it became clear to me that his symptoms did not match any known human bug infestation. Simply put, I thought he was having psychotic symptoms. As is so often the case with patients who have delusions, he does not believe that his mental health is playing any part in his symptoms. He is convinced that he has bugs burrowing under his teeth, into his eyeballs and under his nails. He saw them there in the exam room, but I didn’t. I tried to offer support in the best way I knew how (which, in the case of delusional parasitosis, is not much). When my reality testing and basic interventions did not appear to be sufficient, I encouraged him to go the the emergency room for an evaluation. Surely, I thought, someone there will call a psych consult when they listen to his story. Much to my dismay, no one has called a psych consult. The patient has been to several ER’s in the past month. He’s been treated for various skin conditions, without success. He told me he was seen by Dermatology and they did a skin biopsy. None of this has helped his symptoms. He’s currently convinced that he has an exotic parasitic illness that is not found in our state (or, in fact, our country). His symptoms are not consistent with this illness, nor has he recently traveled to any tropical locales, and yet still he hasn’t had a psych consult. WTF, emergency room staff? How does this not set off any red flags?
My fear is that he is going to harm himself trying to dig out the bugs. He has already made several statements about having to get them out. Of course I advised him not to try to remove the bugs himself, but he feels desperate, and desperate people do desperate things.
I’m so frustrated with this case. I can’t convince the patient that he doesn’t have a bug infestation, and he can’t entertain the idea that this might not be real. The ER–for whatever reason–has missed several opportunities to call in a consult, and the patient doesn’t want to go see psych as an outpatient. What are we supposed to do, wait until he seriously injures himself? Argh.
(And in case anyone is wondering “Maybe he really does have some kind of infestation?”…I’ve thoroughly entertained the idea and there just isn’t any singular infestation that would explain his symptoms. It is possible that he has some other underlying condition that is causing skin itching and he is interpreting that as bugs under the skin, but I am almost 100% positive that it’s not actually bugs)
Is that how it was for you? June 23, 2010
I walked into the exam room to see a patient who hadn’t seen me since I became visibly pregnant. After the initial “Oh, are you pregnant?” questions were out of the way, we went on to discuss her back pain. She was not happy with my proposed plan of care, and became quite irate. At one point she exclaimed, “You don’t understand! I have pain! You don’t feel anything because you’re pregnant! How would you know?!” Uh huh…I don’t feel anything because I’m pregnant. Right. Someone please tell that to my lower back!
A little problem I like to call… June 10, 2010
“Incongruent desire.” It’s a phrase I made up for my documentation to describe the situation when one person in a couple wants to have sex more than the other person. For example, I recently saw a woman with a complaint of vaginal dryness and decreased libido. At the initial appointment, we talked about her physical symptoms and I inquired into the state of her relationship and her general mood. She assured me that her mood was good, her partner was a nice guy, and that she was happy with his sexual technique. We checked a few labs, talked about using lube and made an appointment to discuss the results. The lab results were normal. I delved a little deeper into her sex life. It turns out that my patient is a nighttime sex person who says that she would be happy to have sex 2 times a week. Her partner is a morning person. Like, an early morning person. Early as in 5 a.m. every day before he goes to work. Every. Day. At. 5 a.m. My patient didn’t find this as bothersome as I would. She just felt bad that she wasn’t wet and ready every day at 5 a.m. when her partner was horny. I gave her the speech about how there are different types of normal for people, and that her level of sexual desire sounded perfectly healthy to me. I encouraged her to talk to her partner about ways that they can compromise on the timing of sexual activity. I informed her that contrary to her hopes, there is not a pill that can turn her into a horny morning person. What I didn’t say was that my partner would be getting nothing but an angry elbow in the ribs if I was being woken up at 5 a.m. for some lovin’.
Back Home June 7, 2010
Just got back from the annual Trans Health Conference in Philadelphia. Just like in previous years, the content was interesting, the youth attendees were adorable and I really, really needed the break from work. This year was made slightly more uncomfortable by the fact that I am 5 months pregnant and no longer enjoying sitting in a straight-backed chair for 8 hours a day. Although on second thought, I have never really enjoyed sitting in a chair for 8 hours at a stretch under any circumstances. That’s part of the reason why I entered a career that requires me to walk briskly in circles around a clinic for 8-10 hours a day.
I’m a little too tired to write much, but I wanted to post an update on my patient with post-partum psychosis. She was taken to the ER by ambulance, where she was evaluated and then placed on a 72-hour hold. They started her on medication and discharged her at the end of the 3 days. Per the discharge summary, she was no longer feeling suicidal and the voices were starting to go away. I haven’t seen her since, but I am hopeful that she’s staying on her meds and feeling a little more like herself.