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Somatic complaints in psychiatric elderly patients: Three clinical cases
European Geriatric Medicine 2 (2011) 31–34
Clinical cases
Somatic complaints in psychiatric elderly patients: Three clinical cases E. Frangos a,*, D. Zekry a, V. Rudhard-Thomazic b, U. Giardini b, J.J. Perrenoud a a b
Department of Rehabilitation and Geriatrics, Thoˆnex, Switzerland Department of Psychiatry, Geneva University Hospitals, Thoˆnex, Switzerland
A R T I C L E I N F O
A B S T R A C T
Article history: Received 10 November 2010 Accepted 15 November 2010 Available online 9 December 2010
Psychiatric elderly patients have often poor physical health and a higher mortality in comparison to the general population. However, it is sometimes difficult to identify the somatic origin of complaints, as illustrated in these three clinical cases. ß 2010 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.
Keywords: Somatic complaints Psychiatric elderly patients Mortality Somatization
1. Introduction Mental disorders have often a chronic course associated with a high risk of developing comorbid somatic illnesses [1]. Mortality is two to three-fold higher in patients suffering of depression, bipolar disorder and schizophrenia in comparison with the general population, especially regarding the cardiovascular mortality [2]. However, the psychiatric patient is often considered as a ‘‘difficult’’ patient, impeding the clinician’s ability to establish a therapeutic relationship or causing the caregiver to self-doubt, making medical diagnosis sometimes difficult to identify [3,4]. The differentiation between a somatic, functional somatic versus psychiatric origin of some complaints is hard to establish, and the overlap of these pathologies render this difficulty even more significant [5].
2. Case reports A 71-year-old woman known for a recurrent depressive disorder and cognitive impairment was admitted to the psychiatric clinic. During hospitalization, the only symptom was a fluctuating anxiety, without any pure somatic other complaints, especially no dyspnea or retrosternal pain. The routine electrocardiogram has shown diffuse negative T waves in the lateral territory (Fig. 1). The echocardiography reported a severe left ventricular dysfunction (Fig. 2) and the myocardial scintigraphy confirmed a transient hypocaptation in the antero-apical territory. The coronarography * Corresponding author. E-mail address: [email protected] (E. Frangos).
showed a subocclusion of the left main coronary artery ostium and an intermediate lesion of the anterior median interventricular artery. An angioplasty was successful, with a spectacular recovery of the left ventricular function (Fig. 3), and a significant improvement of the anxiety. A 76-year-old female was admitted to the intensive unit care after a suicidal attempt by drowning. She was known for a borderline personality and a chronically analgesic and benzodiazepine dependence. She complained of thoracic constriction episodes during anxiety crisis, resolving spontaneously, which she attributed to anxiety and recent changes in her treatment. The control electrocardiogram showed negative T waves in lateral and inferior derivations (Fig. 4). The troponin dosage was slightly elevated (1.22 mcg/l). The echocardiography showed an apical ballonization of left ventricle, and the coronarography excluded any coronary lesions (Figs. 5 and 6), evoking the diagnosis of Tako-Tsubo, suicidal attempt having been the triggering stress factor. A 70-year-old woman hospitalized 21 times in psychiatric clinics for a paranoid schizophrenia and an anxio-depressive disorder went by herself to the clinic, asking for a voluntary hospitalization for depressive symptoms and suicidal ideation. She complained spontaneously of an unusual asthenia. The chest radiography showed a voluminous peri-hilar left opacity (10.5 7.8 9.2 cm) with a pleural effusion (Fig. 7). The CT-scan confirms the mass, a mediastinal invasion, multiple adenopathies, compression on the brachiocephalic vessels and carcinomateous lymphangitis (Fig. 8). The biopsy confirmed a small cell tumor, with a fulminant evolution, an emerging dyspnea and death 2 weeks after the diagnosis. She also had an unrecognized severe obstructive syndrome (chronical tabagism).
1878-7649/$ – see front matter ß 2010 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved. doi:10.1016/j.eurger.2010.11.004
[()TD$FIG]
32
E. Frangos et al. / European Geriatric Medicine 2 (2011) 31–34
Fig. 1. Twelve lead ECG: negative T waves in leads I, avF, V4-V6.
particular strong association between somatization, anxiety and depression [5], but also because some symptoms (dyspnea, thoracic pain and palpitations) can be the alone manifestation of somatic as well as psychiatric pathology. In addition, the presence of psychiatric disorder is now recognized as an independent factor for the omission of prescriptions [10] and the high prevalence of cognitive impairment render the evaluation even harder.
3. Discussion Patients with severe mental illness have often poor physical health and a shorter life expectancy in comparison to the general population [6,7]. The prevalence of obesity, hypertension, diabetes, dyslipidemia is high, with a significant risk of developing cardiovascular disease [2,6,8,9]. The recognition of the somatic origin of some complaints is, however, difficult because of a
[()TD$FIG] [()TD$FIG]
Fig. 2. 2D echocardiography, apical four-chamber view: dilatation and severe hypokinesis of antero-septal wall of the left ventricle (LV) (LA: left atrium).
Fig. 3. 2D echocardiography, apical four-chamber view: normal contractility (DIA: diastole, SYS: systole, LV: left ventricle, LA: left atrium).
[()TD$FIG]
E. Frangos et al. / European Geriatric Medicine 2 (2011) 31–34
33
Fig. 4. Twelve lead ECG: inverted T waves in leads II, III, avF and V4-V6.
even if the limit for further investigations could be difficult to determine. A close collaboration between geriatricians and psychogeriatricians is recommended, as routinely performed in Geneva.
Recent recognition of the high-risk for comorbid illnesses and premature mortality in psychiatric settings should lead to a better physical health management routine [1,11], especially in the elderly. Somatic complaints should not be underestimated,
[()TD$FIG]
[()TD$FIG]
Fig. 5. Left coronary arteriogram (CX: circumflex, LAD: left anterior descending).
Fig. 6. Right coronary arteriogram (RC: right coronary).
[()TD$FIG]
[()TD$FIG]
E. Frangos et al. / European Geriatric Medicine 2 (2011) 31–34
34
Fig. 8. Thoracic CT scanner: voluminous left sus-hilar tumoral mass (right arrow) with pleural effusion (left arrow).
Fig. 7. Chest X-Ray: voluminous peri-hilar left opacity with pleural effusion (arrow).
Conflict of interest statement There is no conflict of interest. References [1] De Hert M, Van Winkel R, Silic A, Van Eyck D, Peuskens J. Physical health management in psychiatric settings. Eur Psychiatry 2010;25(Suppl. 2):S22–8. [2] Mu¨ller B, Baciu D, Saner U. Gestion du risque cardiovasculaire en cas de troubles mentaux graves. Forum Med Suisse 2010;10(40):679–83. [3] Simon JR, Dwyer J, Goldfrank LR. The difficult patient. Emerg Med Clin North Am 1999;17:353.
[4] MacDonald M. Seeing the cage: stigma and its potential to inform the concept of the difficult patient. Clin Nurse Spec 2003;17:305. [5] Lo¨we B, Spitzer RL, Williams JBW, Mussell M, Schellberg D, Kroenke K. Depression, anxiety and somatization in primary care: syndrome overlap and functional impairment. Gen Hosp Psychiatry 2008;30(3):191–9. [6] Citrome L, Yeomans D. Do guidelines for severe mental illness promote physical health and well-being? J Psychopharmacol 2005;19(Suppl. 6):102–9. [7] Fleischhacker WW, Cetkovich-Bakmas M, De Hert M, Hennekens CH, Lambert M, Leucht S, et al. Comorbid somatic illnesses in patients with severe mental disorders: clinical, policy, and research challenges. J Clin Psychiatry 2009;70(8):1191–2. [8] Dickerson FB, Brown CH, Daumit GL, Fang L, Goldberg RW, Wohlheiter K, et al. Health status of individuals with serious mental illness. Schizophr Bull 2007;33(5):1257. [9] Dixon L, Postrado L, Delahanty J, Fischer PJ, Lehman A. The association of medical comorbidity in schizophrenia with poor physical and mental health. J Nerv Ment Dis 1999;187(8):496–502. [10] Lang PO, Hasso Y, Drame´ M, Vogt-Ferrier N, Prudent M, Gold G, et al. Potentially inappropriate prescribing including under-use amongst older patients with cognitive or psychiatric co-morbidities. Age Ageing 2010;39(3):373–81. [11] Montejo AL. The need for routine physical health care in schizophrenia. Eur Psychiatry 2010;25(Suppl. 2):S3–5.
Clinical cases
Somatic complaints in psychiatric elderly patients: Three clinical cases E. Frangos a,*, D. Zekry a, V. Rudhard-Thomazic b, U. Giardini b, J.J. Perrenoud a a b
Department of Rehabilitation and Geriatrics, Thoˆnex, Switzerland Department of Psychiatry, Geneva University Hospitals, Thoˆnex, Switzerland
A R T I C L E I N F O
A B S T R A C T
Article history: Received 10 November 2010 Accepted 15 November 2010 Available online 9 December 2010
Psychiatric elderly patients have often poor physical health and a higher mortality in comparison to the general population. However, it is sometimes difficult to identify the somatic origin of complaints, as illustrated in these three clinical cases. ß 2010 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.
Keywords: Somatic complaints Psychiatric elderly patients Mortality Somatization
1. Introduction Mental disorders have often a chronic course associated with a high risk of developing comorbid somatic illnesses [1]. Mortality is two to three-fold higher in patients suffering of depression, bipolar disorder and schizophrenia in comparison with the general population, especially regarding the cardiovascular mortality [2]. However, the psychiatric patient is often considered as a ‘‘difficult’’ patient, impeding the clinician’s ability to establish a therapeutic relationship or causing the caregiver to self-doubt, making medical diagnosis sometimes difficult to identify [3,4]. The differentiation between a somatic, functional somatic versus psychiatric origin of some complaints is hard to establish, and the overlap of these pathologies render this difficulty even more significant [5].
2. Case reports A 71-year-old woman known for a recurrent depressive disorder and cognitive impairment was admitted to the psychiatric clinic. During hospitalization, the only symptom was a fluctuating anxiety, without any pure somatic other complaints, especially no dyspnea or retrosternal pain. The routine electrocardiogram has shown diffuse negative T waves in the lateral territory (Fig. 1). The echocardiography reported a severe left ventricular dysfunction (Fig. 2) and the myocardial scintigraphy confirmed a transient hypocaptation in the antero-apical territory. The coronarography * Corresponding author. E-mail address: [email protected] (E. Frangos).
showed a subocclusion of the left main coronary artery ostium and an intermediate lesion of the anterior median interventricular artery. An angioplasty was successful, with a spectacular recovery of the left ventricular function (Fig. 3), and a significant improvement of the anxiety. A 76-year-old female was admitted to the intensive unit care after a suicidal attempt by drowning. She was known for a borderline personality and a chronically analgesic and benzodiazepine dependence. She complained of thoracic constriction episodes during anxiety crisis, resolving spontaneously, which she attributed to anxiety and recent changes in her treatment. The control electrocardiogram showed negative T waves in lateral and inferior derivations (Fig. 4). The troponin dosage was slightly elevated (1.22 mcg/l). The echocardiography showed an apical ballonization of left ventricle, and the coronarography excluded any coronary lesions (Figs. 5 and 6), evoking the diagnosis of Tako-Tsubo, suicidal attempt having been the triggering stress factor. A 70-year-old woman hospitalized 21 times in psychiatric clinics for a paranoid schizophrenia and an anxio-depressive disorder went by herself to the clinic, asking for a voluntary hospitalization for depressive symptoms and suicidal ideation. She complained spontaneously of an unusual asthenia. The chest radiography showed a voluminous peri-hilar left opacity (10.5 7.8 9.2 cm) with a pleural effusion (Fig. 7). The CT-scan confirms the mass, a mediastinal invasion, multiple adenopathies, compression on the brachiocephalic vessels and carcinomateous lymphangitis (Fig. 8). The biopsy confirmed a small cell tumor, with a fulminant evolution, an emerging dyspnea and death 2 weeks after the diagnosis. She also had an unrecognized severe obstructive syndrome (chronical tabagism).
1878-7649/$ – see front matter ß 2010 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved. doi:10.1016/j.eurger.2010.11.004
[()TD$FIG]
32
E. Frangos et al. / European Geriatric Medicine 2 (2011) 31–34
Fig. 1. Twelve lead ECG: negative T waves in leads I, avF, V4-V6.
particular strong association between somatization, anxiety and depression [5], but also because some symptoms (dyspnea, thoracic pain and palpitations) can be the alone manifestation of somatic as well as psychiatric pathology. In addition, the presence of psychiatric disorder is now recognized as an independent factor for the omission of prescriptions [10] and the high prevalence of cognitive impairment render the evaluation even harder.
3. Discussion Patients with severe mental illness have often poor physical health and a shorter life expectancy in comparison to the general population [6,7]. The prevalence of obesity, hypertension, diabetes, dyslipidemia is high, with a significant risk of developing cardiovascular disease [2,6,8,9]. The recognition of the somatic origin of some complaints is, however, difficult because of a
[()TD$FIG] [()TD$FIG]
Fig. 2. 2D echocardiography, apical four-chamber view: dilatation and severe hypokinesis of antero-septal wall of the left ventricle (LV) (LA: left atrium).
Fig. 3. 2D echocardiography, apical four-chamber view: normal contractility (DIA: diastole, SYS: systole, LV: left ventricle, LA: left atrium).
[()TD$FIG]
E. Frangos et al. / European Geriatric Medicine 2 (2011) 31–34
33
Fig. 4. Twelve lead ECG: inverted T waves in leads II, III, avF and V4-V6.
even if the limit for further investigations could be difficult to determine. A close collaboration between geriatricians and psychogeriatricians is recommended, as routinely performed in Geneva.
Recent recognition of the high-risk for comorbid illnesses and premature mortality in psychiatric settings should lead to a better physical health management routine [1,11], especially in the elderly. Somatic complaints should not be underestimated,
[()TD$FIG]
[()TD$FIG]
Fig. 5. Left coronary arteriogram (CX: circumflex, LAD: left anterior descending).
Fig. 6. Right coronary arteriogram (RC: right coronary).
[()TD$FIG]
[()TD$FIG]
E. Frangos et al. / European Geriatric Medicine 2 (2011) 31–34
34
Fig. 8. Thoracic CT scanner: voluminous left sus-hilar tumoral mass (right arrow) with pleural effusion (left arrow).
Fig. 7. Chest X-Ray: voluminous peri-hilar left opacity with pleural effusion (arrow).
Conflict of interest statement There is no conflict of interest. References [1] De Hert M, Van Winkel R, Silic A, Van Eyck D, Peuskens J. Physical health management in psychiatric settings. Eur Psychiatry 2010;25(Suppl. 2):S22–8. [2] Mu¨ller B, Baciu D, Saner U. Gestion du risque cardiovasculaire en cas de troubles mentaux graves. Forum Med Suisse 2010;10(40):679–83. [3] Simon JR, Dwyer J, Goldfrank LR. The difficult patient. Emerg Med Clin North Am 1999;17:353.
[4] MacDonald M. Seeing the cage: stigma and its potential to inform the concept of the difficult patient. Clin Nurse Spec 2003;17:305. [5] Lo¨we B, Spitzer RL, Williams JBW, Mussell M, Schellberg D, Kroenke K. Depression, anxiety and somatization in primary care: syndrome overlap and functional impairment. Gen Hosp Psychiatry 2008;30(3):191–9. [6] Citrome L, Yeomans D. Do guidelines for severe mental illness promote physical health and well-being? J Psychopharmacol 2005;19(Suppl. 6):102–9. [7] Fleischhacker WW, Cetkovich-Bakmas M, De Hert M, Hennekens CH, Lambert M, Leucht S, et al. Comorbid somatic illnesses in patients with severe mental disorders: clinical, policy, and research challenges. J Clin Psychiatry 2009;70(8):1191–2. [8] Dickerson FB, Brown CH, Daumit GL, Fang L, Goldberg RW, Wohlheiter K, et al. Health status of individuals with serious mental illness. Schizophr Bull 2007;33(5):1257. [9] Dixon L, Postrado L, Delahanty J, Fischer PJ, Lehman A. The association of medical comorbidity in schizophrenia with poor physical and mental health. J Nerv Ment Dis 1999;187(8):496–502. [10] Lang PO, Hasso Y, Drame´ M, Vogt-Ferrier N, Prudent M, Gold G, et al. Potentially inappropriate prescribing including under-use amongst older patients with cognitive or psychiatric co-morbidities. Age Ageing 2010;39(3):373–81. [11] Montejo AL. The need for routine physical health care in schizophrenia. Eur Psychiatry 2010;25(Suppl. 2):S3–5.