Case Study: Samuel

The patient, named “Samuel,” is a 28-year-old, final year medical student from the south-eastern region of Nigeria in sub-Saharan Africa. He was declared missing for 10 days then later seen in a city in south-western Nigeria, a distance of about 634 km from south-eastern Nigeria where he lived and schooled. Ten days before his presentation, while studying in his room alone at night, Samuel suddenly saw a full human skeleton reading at the same table with him, sitting at the opposite side. At the same time, he claimed he felt uneasy and quite uncomfortable. He saw the whole room turning with everything inside becoming unstable and unreal. After this experience, Samuel had overwhelming fears and did not know when he left the room. Two days later, he discovered he was with his younger sibling in south-western Nigeria. Samuel had no knowledge of how he made the journey that takes approximately eight hours by road. He equally could not remember where he slept the night he left his room, how he raised money for the journey, or the buses and routes he took. Samuel denied all memory of events for the two days from when he left his room at the university to the time he suddenly realized he was at his brother’s house, hours away. The brother, however, reported that Samuel appeared unkempt, looked exhausted but was fully conscious and alert on arrival at his house without any assistance.

Prior to this episode, Samuel had been under severe economic and academic pressures. The younger brother, who paid the patient’s bills, had threatened to withdraw his sponsorship because of Samuel’s prolonged stay in school beyond the stipulated duration of training due to his repeats of examinations and classes. Samuel had been worried that he might also fail in his final qualifying examinations scheduled to be held in three months. He subsequently became involved in several religious activities to obviate his perception of impending doom.

Samuel admitted to having a low mood, loss of interest in usually pleasurable activities, and poor appetite. He had lost weight and most often preferred being alone. He had also been feeling weak, especially in the morning hours, but had managed to grudgingly carry on with the day’s activities. He had suicidal ideation but never attempted suicide. Samuel slept poorly at night. His sleep had been marked by early morning wakefulness and waking up not feeling refreshed.

There were no symptoms suggestive of seizure, manic episode, schizophrenia, anxiety, or organic disorders. Samuel never drank alcohol or abused any psychoactive substances. He denied a history of head trauma or loss of consciousness in the past. Past medical, psychiatric, family, and personal histories revealed no significant findings.

Examination of his mental state revealed a young man who was clean, appropriately dressed, and mildly emaciated with poor eye contact. His mood was depressed. He had no thought disorders. Samuel was oriented in time, place, and person but had impaired attention and concentration at the time of the examination. Immediate recall, short- and long-term memory were intact. However, there was amnesia for the two days he wandered away from school. Judgment and insight were not impaired.

His physical examination was unremarkable. Neurological assessment and basic laboratory testing revealed no significant abnormalities.[/footnote]Igwe, M.N. Dissociative fugue symptoms in a 28-year-old male Nigerian medical student: a case report. J Med Case Reports 7, 143 (2013). https://doi.org/10.1186/1752-1947-7-143[/footnote]

Treatment

In regards to the case study about Samuel written above, the patient engaged in psychotherapy by clinical psychologists, and his depression was treated with paroxetine. He responded very well and was able to write his final qualifying examinations three months later. He, however, did not pass either of the two subjects examined. At a six-month follow up, Samuel could still not recall events for the two days from when he left school to the time he was seen in his brother’s house, 634 km away. He reported no further periods of amnesia or wandering away from his place of residence.[/footnote]Igwe, M.N. Dissociative fugue symptoms in a 28-year-old male Nigerian medical student: a case report. J Med Case Reports 7, 143 (2013). https://doi.org/10.1186/1752-1947-7-143[/footnote]

Case Study: Ali

A 73-year-old Saudi man, “Ali” started visiting the primary health care center in our institution 25 years ago. He was concerned with having cancer that would give him only a few days to live. In the beginning, Ali was evaluated medically through a detailed history and documentation of his symptoms and then a management plan was created accordingly to exclude cancer. Full history, physical examinations, and radiological and pathological investigations were ordered and the results were all negative for cancer. The physician explained the results of the investigations to Ali, but he refused them and continued to insist that he had cancer regardless of the results. He was then referred to the Psychiatry Department to be evaluated but he could not realize that his symptoms might be of a nonorganic cause, either psychological or mental.

Ali continued to visit the general hospital, emergency department, and the primary health care in the institution and was still occupied with the idea of cancer. Although he was seen by many physicians, Ali was never satisfied with their conclusions. Eventually, a physician reported the case to the department of medical eligibility, addressing the issue of continuous primary health care center visits with very variable symptoms, nonconclusive diagnosis, and an unconvinced patient. The department of medical eligibility in the hospital administration decided to temporarily limit Ali’s file to the psychiatry department to drive Ali to visit the psychiatrist to be evaluated psychologically in order to make his file eligible again. Ali was unhappy at the beginning but he had to visit the psychiatrist. So, an appointment with the psychiatrist was booked and a full psychological and social evaluation was performed by taking a thorough history from Ali. The family and social history evaluation revealed Ali’s very low SES and similar conditions in the family. Following this extensive detailed history and evaluation, the treating psychiatrist contacted the department of medical eligibility to make Ali’s file eligible again as promised by them with unlimited eligibility to all specialties and the primary care center. For the past 25 years of continuous hospital visiting, Ali had almost weekly and even daily visits to the primary care facility. Ali kept complaining of variable symptoms every week and specifically asking for certain lab tests and radiological studies. Also, he successfully convinced some physicians to order a biopsy for him.

Over the years, Ali’s investigations cost approximately $178,200. His most requested investigations were mainly invasive radiological studies specifically abdomen and pelvis CT (18 times) and a wide range of other invasive and noninvasive studies like chest CT (11 times), brain CT (seven times), chest MRI (four times), lumbar spine MRI (six times), and other studies. In addition, he asked for a variety of lab tests and underwent several biopsies.^[1]

Treatment

Ali was treated as follows:

Five years ago, an experienced board-certified family physician was shocked when he looked at Ali’s file and decided to take some action to stop Ali’s costly visits. First, they limited Ali’s primary care visits to only one clinic where he would be referred to the supervising physician himself. Then, they worked to build strong and effective patient rapport based on trust and honesty. After negotiations, the patient agreed to enroll in CBT for six sessions at 90 minutes each. The patient was advised to have a scheduled sleeping time, ensure healthy eating habits with regular physical exercise, be involved in social activities, stay away from stressors like searching the web for symptoms, and avoid TV health shows and health magazines during active cycles of the disorder. After that, there was an agreement with the patient not to disturb the clinic and he would get to see the physician regularly for checkups every three months.

After five years of implementing the new rules, Ali is still visiting the clinic for regular follow-up and sometimes he breaks the rules and comes regularly to the clinic, especially in active cycles of the disorder, though there is a dramatic decrease in the total financial cost due to the relative decreasing number of visits, less time spent on arguing with the patient, and the filtration of his requests. Moreover, there is a remarkable improvement in the patient’s condition because of CBT and relative compliance to health advice.^[2]

Case Study: Mia

A 15-year-old white female, “Mia” presented with flu-like symptoms that progressed two days later to throwing up blood. She was sent to the emergency room where she was diagnosed with possible appendicitis and was discharged the next day. That weekend, she was still vomiting, unable to hold food down, and nauseated. Mia was admitted to Arkansas Children’s Hospital (ACH) for one to two weeks where she received extensive workup including MRI, CT scan, gastrointestinal imaging, and a spinal tap, and all the results came back normal. She was also evaluated by an ophthalmologist and a cardiologist, and no organic etiology was found for her symptoms. Mia was discharged home with an unknown diagnosis and started on symptomatic medical management to help relieve some of the symptoms. Soon after she was discharged from ACH, her legs started getting weak, and it was discussed that she may be having some neurological disorders and would need to be evaluated further. Presenting with symptoms of throwing up, unable to keep food down, leg numbness, and a constant migraine, Mia was readmitted at ACH for another two weeks where even more extensive workup was done again, including CT and MRI scans of the brain. All results came back normal, and she was sent home without a true diagnosis and was treated for depression and anxiety.

Mia was referred to a neurologist at the University of Arkansas for Medical Sciences (UAMS) two to three weeks later where she was evaluated and admitted to the hospital for one day to treat a migraine. The therapist uncovered that from the age of six to 12 years, Mia experienced two active addicted parents, and she received physical and mental abuse from her father. During that time, she was required to become the head of the household to ensure bills were being paid and that her parents were being taken care of. At the age of 12, her mom received de-addiction treatment for three to four months and has been clean and sober for the past five years. Between the ages of 12 and 13, her parents got divorced, and she moved with her mom. Mia attended high school for one year but then transferred to another city.^[3]

Treatment

With no evidence of any organic etiology found on the extensive workup and no sign of relief with continued treatment, Mia was diagnosed with functional neurological symptom disorder (conversion disorder). She was discharged to receive physical therapy (three times a week) and CBT (once a week) and also seen by a therapist. Seven months later, she was referred and accepted into the Mayo Clinic as an outpatient for further management. At Mayo Clinic, she went to group therapy every day from 8 a.m. to 4 p.m. for four weeks with people who were experiencing other neurological disorders, not just functional neurological symptom disorder. During the group therapy at Mayo Clinic, she not only went through physical therapy and occupational therapy but also learned how to stay on a schedule, how to live a normal life with functional neurological symptom disorder, and how to manage and tolerate the pain. She believes that the group therapy at Mayo helped her the best in her recovery.

Mia states that there were no real triggers that caused this disorder, but her history could have been an underlying cause. She is now still in recovery, all symptoms have improved but not completely gone away. She still experiences numbness and weakness on the right side, headaches, nausea, and pain in the right leg. She learned, at Mayo Clinic, how to tolerate and deal with the pain, which she believes helps her. Mia is currently on Topamax, iron, vitamin D3, and calcium. She plans to graduate high school this year and plans to attend college as a premedical student.^[4]