1 Trauma and Pain in the Difficult PatientPresenter: Christina Jagielski, M.A., M.P.H. Discussant: Royce Lee, M.D.
2 Learning Objectives To understand the role of trauma in the experience of chronic pelvic pain To learn how to manage the difficult patient with past sexual trauma encountered in the medical context
3 History of Present IllnessPatient: 29 yo Caucasian Female CC: Abdominal Pain TAB on 1/30/2017 via D&C at an outside hospital Patient states that the abortion was painful and was done without anesthetic Patient stated she developed bacterial vaginosis after the abortion and believes this gave her PID One week prior to UCM admission, patient saw PCP who treated her for PID via Zofran and oxycodone 10 mg 4 days later, pain severity increased and PCP encouraged her to come to the ER Initial concern for endometriosis. Patient was initially treated with hydromorphone, oxycodone, and ketorolac for pain control, but narcotics were stopped due to lack of medical causation for pain. Psych consult: Concern for contribution of anxiety to pain
4 Social History Born in CaliforniaRaised by mother and father. Parents divorced at age 11 Moved to Chicagoland area as a teenager Has one sister 1.5 years younger Behavioral problems in childhood. Was sent to military/Mormon school as teen for 6 months after being caught with “weed pipe,” which patient states was placed there by a friend. Mother took her out because of concerns about Mormon teachings. Education: Completed GED. Attended several high schools due to behavioral problems and dropped out because she was told she would need to remain in school until age 20 to graduate. Has now completed prerequisites for nursing school. Not currently working Sexual molestation at age 15 Patient reports 2 previous abusive relationships. Has a restraining order on most recent ex-boyfriend who threatened to kill her. Currently in a romantic relationship with boyfriend of 6 weeks, who patient describes as supportive. No domestic violence in current relationship. Currently living with mother. Planning to move in with boyfriend within next two months
5 Psychiatric History History of PTSD related to molestation and rape. anxiety, ADHD (dx age 14) and probable Oppositional Defiant Disorder Rec’d rape counseling and has been seen by a psychiatrist “off and on” since age 23 Prior psychotropic medications : sertraline, fluoxetine, clonazepam, alprazolam, lithium, Depakote, venlafaxine, Adderall, Ritalin Current: feeling anxious for the last few weeks after termination of her pregnancy. Prior to termination, anxiety well controlled with clonazepam 1 mg QD PRN Patient reported frequent panic attacks in the last few weeks where she feels like she is dying, feels like her chest is caving in, she is unable to breath, and she has muscle tension and shakes. She states that it can last up to 1 hour and that they have been occurring multiple times a day. Denies history of depression Sleep worsened due to pain Guilt related to becoming pregnant with ex-boyfriend’s child Patient denies suicidal thoughts or intent. History of cutting at age 16 Denies symptoms of mania or psychosis Flashbacks triggered by sex or thoughts that remind of her past trauma Reexperiencing symptoms Nightmares or bad dreams, but states she does not find them distressing Hypervigilance and startles easily Denied depersonalization or derealization experiences. Denies anhedonia She reports feels of guilt related to become pregnant with her ex-boyfriend who was physically and emotionally abusive. She states that they had already broken up and she returned to his place to pick up some belongings. They had some glasses of wine and she reports they had sex which resulted in this recent pregnancy. She reports feeling that she did not have much of a choice with regards to her decision to terminate her pregnancy as she was terrified that her ex-boyfriend would try to find the child (even if she placed it up for adoption) and would be abusive to him/her Clonazepam which she reports using less than once a day.
6 Substance Use Alcohol - about 1-2 glasses once a week. Denies DUIs.Tobacco – Smokes 1-3 cigarettes per day. Trying to cut down tobacco use. Cannabis – several days a week Pt stated she was "shot up" with heroine by her boyfriend at age 15. Prescribed Norco by her outpatient gynecologist for her pain 1-2 weeks ago, but denies other pain medications. Prescribed clonazepam by her psychiatrist, 1 mg daily, but states that she does not need it daily. However, she took more than 1 per day the last 2 weeks prior to this hospitalization. Previously tried cocaine, mushrooms, LSD, and ecstasy. Denies use of amphetamines Family History: Mother - alcohol use disorder (in remission 17 years), Father - alcohol use disorder ("functional alcoholic" per pt)
7 Hospital Course Patient report: Hospital report:Becomes irritable due to multiple physical exams Feels “doctors aren’t taking what I say seriously” and stated that OB used “maybe a drop of lube” Stated exam triggered flashbacks At discharge patient stated she believed the treatment team thought she was “drug seeking”, had told her she “might have endometriosis” and was sending her away because there was nothing else they could do. Patient stated she was told she had “30 minutes to leave” and was distressed because she had no where to go, due to limited financial resources and inability to get to her mother’s home Hospital report: Patient insisted on oxycodone for pain control as she was provided this from her PCP on diagnosis of PID therefore on admission she was provided with oxycodone, ibuprofen, dilaudid, clonazepam for management and during hospital day 2. Day 3: No signs of infection and pain considered to be inconsistent with gynecologic etiology. Decision made to stop pain regimen, replaced with ibuprofen and acetaminophen Patient reported frustration and stated “I want to go to another hospital where I can get help” but would also state she has no where to go Patient states she does not expect to reach pain level of 0, but does not feel pain is dropping below a 7. Wishes to bring pain down to a 4 and then wean herself off medication. Day 4: Treating team meets with patient for one hour to discuss results and etiology of pelvic pain. Patient upset about discharged, guarded about providing provider contact information and refused to sign release of information forms
8 Suspicion of malingeringReview of Illinois Prescription Monitoring Suboxone (patient did not mention use of this drug), Benzodiazepines Norco Prescription drug monitoring showed up to monthly prescribing of these drugs. Patient was last prescribed medication as recently as Jan 19, 2017 although she previously noted that she was not currently under psychiatric care and was not chronically taking pain meds and denied drug dependency. She was not provided with this information, as decision was made to not aggravate her more. Chart states possible malingering for diagnosis vs endometriosis vs chronic pelvic pain syndrome.
9 Questions What role did the patient’s psychopathology play in the course of her medical stay and treatment? What role did the medical team play?
10 Pelvic Pain Nearly one half of women seeking treatment for chronic pelvic pain have sexual, physical, or emotional trauma (Randolph & Reddy, 2006) Women with chronic pelvic pain or gastrointestinal disorders who also had histories of childhood sexual abuse generally report lower quality of physical health and greater impairment of functioning than women with no history of sexual abuse (Drossman et al., 2000; Leserman et al., 1996; Walker et al., 1992). Women who have been multiply sexually victimized have poorer physical and sexual health outcomes then victims of a single instance of sexual violence, including pain and gynecologic problems. (Campbell, 2008)
11 Role of Trauma in Pain Violence triggers both acute and chronic stress response, leading to increased sensitivity of negative feedback systems in the HPA axis and lowered cortisol levels. This shift in cortisol levels creates an autoimmune/inflammatory response. If cellular immunity is depressed or inflammation is unchecked, chronic inflammatory disorders, chronic pain syndromes and recurrent pain symptoms may result. (Campbell, Greeson, Bybee, & Raja, 2008)