Challenging Cases: How Do We Intervene With Pediatric Med/Psych Issues?

Abstract

This article focuses on pediatric patients whose difficult medical presentation includes both physical and psychological components. These patients do not have a known psychiatric diagnosis and often have had previous hospitalizations for presumed organic illness. Results of diagnostic testing are generally uninformative, and management is time-intensive, involving multiple health care providers and significant medical resources. Antagonism in the relationship between the physician and parent frequently develops.1 Although diverse in presentation and outcome, conceptualization of these “med-psych” cases into general categories may result in early recognition of these patients, decreased hospital length of stay and expense, improved quality of the physician–parent relationship, and increased treatment effectiveness. We describe 2 different types of cases, outline effective and ineffective interventions, and discuss unresolved difficulties with management. Due to a paucity of relevant research, this article is based primarily on clinical experience. A 15-year-old male was hospitalized after 3 weeks of tachycardia, syncope, tingling in his hands, and subjective fevers. Medical history included an irregular heartbeat. His mother also has mitral valve prolapse and panic attacks. The family initially did not report school or behavioral difficulties. He and his parents indicated significant fear about something “being seriously wrong with him.” After results of initial diagnostic testing were unrevealing, further interviews elicited that the patient had recently been expelled from school due to a fight. He was assigned to an alternative school, which limited his school-related activities and eliminated contact with previous classmates. He also expressed sadness regarding the death of his grandmother ~18 months prior. His affect was generally flat, he cried easily when talking about his grandmother, and he had lost interest in previously satisfying activities. This case is typical of pediatric patients who present with medically unexplained somatic complaints such as fatigue, abdominal pain, musculoskeletal pain, syncope, and/or headache. Nausea and …