ある患者(シェーグレン症候群)をめぐる治療関係の混乱について(問題症例をめぐって第30回日本心身医学会総会)

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We encounter indeed those patients who are called "problem patients" in our clinical practice at general hospitals; they manifest such characteristics as, 1) a discrepancy between complaints and the severity of the disease, 2) chronic complaints, 3) a clinging, demanding or aggressive attitude towards the doctor and nursing staff, etc. However, I don't think that they are by nature problem patients. The "problem" should be understood in the context of the doctor-patient relationship. The clinical case presented is a 53 year old female worker, who is also a housewife. She was referred to the psychiatrist, because her frequent abdominal pain was easily alleviated by a placebo injection, and her complaint of vomiting didn't seem to be real. In the first session, the patient told the psychiatrist that she had been suffering from abdominal pains for almost 30 years. No doctor could find the origin of those pains ; she expressed negative feelings towards the former internist in charge (Dr.A), but she idealized the current internist in charge (Dr.B) and the professor internist in the university hospital (Dr.C) with whom she sometimes consulted. She further told the psychiatrist about her stressors which consisted of problems caused by her family members (her son, her daughters and her husband). She also expressed negative feelings towards the nursing staff. During the 2 years when the psychiatrist saw her, Dr.B and his nursing staff encountered many troubles caused by the patient. Although she was hospitalized for 4-5 times and also received outpatient treatment, there were many exaggerated somatic complaints, frequent demands to stay out at home or to be discharged, along with her clinging, demanding and aggressive attitudes towards the hospital staff : there was also no cooperative attitude on the part of family members. Indeed, the very internist-patient relationship was in crisis and being broken. On the other hand, the psychiatrist couldn't play the expected role of arranging the troubled relationship, although he tried to listen to the patient and successfully empathized with her traumatic experiences. Eventually, only after the patient's psychological stressors had been almost all resolved, was the relationship re-established and the patient's panicky state diminished. However, I don't think the favourable result was brought about only through the improvement on the patient's part, but also through the re-stabilization of the internist's feelings towards the situation. In the "problem patient" phenomenon, it is crucial, I believe, that the doctor in charge should work through any negative feelings he may have towards his patient or the patient's characteristics mentioned above.
日本心身医学会の論文
1990-06-01

ある患者(シェーグレン症候群)をめぐる治療関係の混乱について(問題症例をめぐって第30回日本心身医学会総会)

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