Lam, CLK

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Title Cases of anxiety and depressive disorders in general practiceAuthor(s) Lam, CLKCitation Hong Kong Practitioner, 1995, v. 17 n. 2, p. 77-81Issued Date 1995URL http://hdl.handle.net/10722/45125Rights Creative Commons: Attribution 3.0 Hong Kong LicenseDISCUSSION PAPERCases Of Anxiety And Depressive Disorders In GeneralPractice*Cindy L K Lam**, FRCGPGeneral Practice UnitDepartment of MedicineThe University of Hong KongIntroductionI want to share with you my clinicalexperience with anxiety and depressive disordersin general practice. I found that a lot of times,patients presenting to me don't really fall into thecategory of either a pure physical or psychologicalproblem but a mixture of both. I shall illustratewith some real patient examples how patients withpsychological problems present, some of thedifficulties in their diagnoses, the interactionbetween physical, social and psychologicalproblems and some management issues.How Do Psychological Problems Presentin General Practice?A Lady Complaining of Runny NoseMrs. A, a 40 year old housewife, came to seeme complaining of runny nose. After describingher runny nose, she also softly uttered that shehad problems sleeping. We can choose to explorethe runny nose or the insomnia. The resultingdiagnosis will be very different - we can label it asa simple upper respiratory infection or it may bedepression.Patients often somatise their psychologicalproblems in order to legitimise the consultation.On the other hand, most patients are able totell us and want to tell us about theirpsychological problems if we are interested.The tendency to somatisation is common in theChinese culture. According to Goldberg andBridges: 'somatisation is the most commonreason why psychiatric illness goes undetectedIn ancient Buddhist scripturepsychologisation was regarded as the originaland most primitive response somatisationwas regarded as an adaptive achievement ofmankind, lessening the psychic pain andexchanging it for physical pains for which therehave always been treatments".Probably we doctors reinforce this belief inwhat we do by paying a lot of attention andoffering endless treatment to physical symptomsbut tending to ignore and do very little otherthan give blanket reassurance to help patients'psychological problems. The time has come forus to change our attitudes and approach to ourpatients. We need to show our patients that weare prepared to help their mind as well as bodyand it is alright for them to present theirpsychological symptoms directly to us.Until our patients have learned that it issafe and acceptable to present psychologicalproblems directly, we have to rely on certaincues to help us pick up the psychologicalproblems behind the physical complaint:* This article was based on a presentation at the Workshop on Depression and Anxiety organized by the HKCGP on January 9, 1994.** Address for correspondence: Dr. Cindy L KLam, G.P.U. 3/F, Ap Lei Chau Clinic, 161 Main Street, Ap Lei Chau, Hong Kong.77Anxiety and Depressive Disorders1. The look of the patient - one looks anxiouswhen one is anxious, depressed when one isdepressed.2. The nature of the complaint - somesymptoms are frequently psychosomatic andwe have to be more aware of the possibleunderlying psychological problem in patientspresenting with them (Table 1). IncreasinglyI discover that much chronic pain ispsychological in origin. If you have a patientcomplaining of some intractable pain forwhich no cause can be found despitecomplete 'physical' examination, multipleinvestigations and referrals, and it does notrespond to any physical or drug treatment,think about depression and look forpsychological symptoms, do a psychologicalexamination!Table 1: Clues to DiagnosisPatient's appearancePsychosomatic symptoms:* insomnia* dizziness* headache* tiredness & gen. aches* dyspepsia* breathlessness* chronic painPsychological symptomsFrequent consulters / fat foldersDoctor's feelings3. The mood and feelings of the patient - if youask the right question, the patient will tell youthe right answer. I do not mean askingleading questions but quite the opposite, askan open question like: 'What is your moodlike? How do you feel?' Try to encouragepatients to talk about how they feel and whatthey think. It is a bit more difficult toexpress emotions and describe one's mood inCantonese but most people can tell you howthey feel and what they think. On the otherhand, most Chinese react very negatively tothe question, 'Are you worried?' Beingworried is often regarded as a stigma ofpsychic weakness.4. The frequent attender - one clue is the "fat"folder. The patient with psychologicalproblems often consults frequently as a cryfor help and the record becomes thicker andthicker as more and more investigations,referrals, and treatments are given butwithout success.5, The doctor's own emotional reaction - askyourself and reflect on how you feel after orduring the consultation. Very often I findmyself feeling depressed after talking to apatient who is depressed. I feel anxious whentalking to a patient who is anxious. We get alot of useful information on the patient'semotional state by reflecting on our own.How to Share the Diagnosis with thePatient?A Lady Complaining of Shortness of BreathMrs. B aged 32, complained of recurrentepisodes of breathlessness for about 2 years. Shealso had chronic right sided shoulder pain whichshe attributed to overwork. When I asked her indetail what the breathlessness really was like, shesaid that she had pins and needles sensations inher fingers and around her mouth, and she feltlike dying. Sometimes the discomfort was so greatthat she thought she was going to die. Thebreathlessness was relieved by rebreathing into abag.78Hong Kong Practitioner 17 (2) February 1995This patient was suffering from panicdisorder and a lot of her symptoms were causedby hyperventilation. I tried to explain to herthat she had a psychological problem but shesaid that she had no worries (rememberChinese are very defensive about worries).After a period of silence, the patient told methat she thought she had 'neurasthenia'.What is "neurasthenia"? A lot of literaturehas been written on neurasthenia in Chinese;the term is used much more loosely than itsoriginal meaning. About 80% of the patientswith neurasthenia were found to havedepressive disorders2"1. Chinese seem to acceptand relate to this term very well. Should weuse this term as a convenient label for anyanxiety or depressive disorder in our Chinesepatients?The problem is often not so much ofmaking the diagnosis but of sharing it with thepatient. What are the Cantonese names for"panic disorder" and "hyperventilation"? I don'tthink there are any, and even if there are, theyprobably mean very little to an averageCantonese. While 'depression', 'panic' and'obsession' are commonly used terms inconversational English, there is not even aneasily understood Cantonese translation fordepression, let alone the more complicatedobsessive compulsive disorders.In sharing the diagnosis of a psychologicalproblem, it is important to tell the patient thatwe do not mean that he/she is malingering.Patients may feel upset and rejected when theythink the doctor does not believe them.Acceptance of their symptoms is very important.Try to empathize with them by telling them thatwe understand psychological problems are muchmore unbearable and could cause more sufferingthan physical illnesses. We often have to helppatients express their symptoms in psychologicalterms. This may be more difficult in Cantonesethan in English but it is not impossible.We have to gradually educate our patientsthat it is very acceptable to present psychologicalproblems directly to us. Patients will keep onsomatizing their psychological problems ifdoctors reinforce this behaviour by payingattention to only pain, headache, or shortness ofbreath, but taking it very lightly when they saythat they are unhappy. It is not difficult toidentify the clues of psychological problems, butwe sometimes, consciously or subconsciously,pretend that we have not seen them because weare not sure how to explain and manage the realproblem. So we just go on playing the physicalgame with the patient over and over again untilour hearts sink. I think the time has come forus to break this vicious cycle by facing thechallenge.Is It A Physical, Social or PsychologicalProblem?A Man Complaining of Blurring of VisionMr. C, aged 50 complained of blurring ofvision and dizziness for about a year. One yearago, he had an episode of loss of consciousnessdue to a minor stroke which caused residual leftupper quadrianopia. He was found to behypertensive at that time and was givenmetoprolol (which may cause depression). Heused to be a watchman and was quite happythough he was not well-off. Since this episode ofillness he was unable to work because of blurringof vision and dizziness. He was afraid to go outbecause of his dizziness. He lived with his brotheron whom he was now dependent, but his sister-in-law did not like him at all. He came to ask me tocure his blurring of vision and dizziness so that hecould get back to work. On physical examination,his visual acuity was good but there was left upperquadranopia. There was no ataxia or diplopia.The most striking examination finding wasthat he looked very very depressed. On furtherenquiry, he thought he was going to be blind like79Anxiety and Depressive Disordershis mother. He felt inferior and useless at home,and had lost all interests. He had strong suicidalthoughts, planning to jump from a height. Thephysical disability was not severe in objectiveterms but subjectively he felt he could not doanything. I tried to counsel the patient and inview of his suicidal intention, I referred him to apsychiatrist. The psychiatrist admitted him toKwai Chung Psychiatric Hospital but hedischarged himself the next day because hethought he was not mad. He came to see me thenext day after his discharge complaining about myreferring him to a psychiatric hospital. He felteven worse in Kwai Chung because theenvironment was very disturbing.He went to see anther doctor because hethought I was not helping him. The doctoradvised him to have a CT scan and told him thatthere was an infarct in his brain which wasincurable. He was found unconscious the nextmorning by his brother who took him to QueenMary Hospital. The initial diagnose was anotherstroke, but his signs were hard to explain. He hadtaken an overdose of metoprolol and prothiaden.Luckily he survived, but is still incapacitated withhis dizziness and blurring of vision.Was this a physical, psychological, or socialproblem? The interaction between these threeaspects of a person's health is so close thattreating one aspect and not the other will probablydo more harm than good. Gentle and gradualcounselling is required to make the patient accepthis/her illness, otherwise he will reject your helpand go doctor shopping.Have We Cured The Problem?An Old Man with Severe Chest PainMr. D, aged 75, complained of chest pain for3 months. The pain became progressively moresevere to the point that he could not carry out anyof his daily activities. It even disturbed his sleep.He had pain even at rest, and his family took himto the hospital. He was diagnosed to haveunstable angina due to ischaemic heart disease.He was discharged one week later with fourcardiac drugs and nitroderm.His wife brought him to see me because hischest pain was not improved despite the drugtreatment. I did not find anything on physicalexamination except an old gentleman in agony anda wife in distress. I told the couple that he wasalready taking all types of anti-anginal drug, therewas really nothing that I could offer except re-admission to the hospital, but the patient refusedto go. When the patient was dressing, the wifesaid to me in tears that something must be donebecause she could not bear it any longer. Thediagnosis became clear when the wife told me thather husband would cry in pain and asked her toput a rope on the ceiling so that he could hanghimself. As a matter of fact, this man is afraidthat his wife will desect him now he is getting old.I gave him an antidepressant and his chest painstarted to improve after two weeks and subsidedone month later.Have I really cured this man? When can westop the antidepressant? How about the wife?Who was the real patient? Why did he becomedepressed? The antidepressants might havehelped him symptomatically, but counselling isrequired to solve the problems in this family.ConclusionWe, as general practitioners, can stop theprocess of somatic fixation by picking up the cuesof psychological problems, being brave in makingthe diagnosis, sharing our understanding of theproblem with the patients in terms that they canunderstand, adopting a whole person approach inour management, and providing the necessarycounselling and support. We need to show ourpatients that we are ready to help them with theirpsychological problems and that they do not need-Hong Kong Practitioner 17 (2) February 1995to somatise in order to gain the ticket ofadmission.I would like to end this discussion by quotingProfessor Richard Grol's saying:'The general practitioner has important rolesin the prevention of somatic fixation butthe general practitioner's behaviour can alsopromote processes of somatic fixation5'. HReferencesGoldberg DP, Bridges K, Somatic presentations of psychiatric illness inprimary care setting. J Psychosom Res 1988; 32: 137-144.Kleinman A, Neuraesthenia and depression: a study of somatisation andculture lu China. Culture, Medicine & Psychiatry 1982; 6:117-190.Tseng WS, The nature of somatic complaints among psychiatric patients:the Chinese case. Comprehensive Psychiatry 1975; 16: 237-245.Cheung FM, The indignization of neuraesthenia in Hong Kong. Culture,Medicine & Psychiatry 1989; 13: 227-241.Grol R. (ed), To heal or to harm - the prevention of somatic fixation ingeneral practice. 2nd ed, London: RCGP.**** **** ****Department of Community Medicine&Hong Kong College of CommunityMedicineInvites your participation in anintensive preparatory course forPart I, MFPHM & FHKCCMJoint ExaminationMock Examination March 25th and 26thtutorialApril 8th - 13th (excl 9th)9 am to 5 p.m.Local and overseas tutors, rehearsal of examinationtechnique, in depth study of examination paperstyle and content.Course fee $5000 (inclusive of tuition and materials)Address inquiries to Mrs. J. Johnston,Departmentof Community Medicine, Patrick Manson BuildingSouth Wing, 5 Sassoon Road, Pokfulam. Tel 28199199 Fax 2855 952881

Cases of anxiety and depressive disorders in general practice

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Cases of anxiety and depressive disorders in general practice

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