“It's All in the Head” Well! Not Always: Mental Health Patients Are Not Immune to Physical Pain

AIMS: Emotionally unstable personality disorder (EUPD) patients are known to frequently present to acute hospitals with pain symptoms. Multiple pain syndromes like fibromyalgia, chronic fatigue syndrome etc. are also commonly diagnosed in this group of population. It can be difficult to differentiate psychosomatic pain from physical pain during these hospital presentations. Failure to exclude physical causes of pain can lead to inadequate pain relief and missed serious diagnosis. METHODS: We describe a 29-year-old lady known to have Type 1 Diabetes, chronic pancreatitis and past history of several overdoses. She was being supported by Home Treatment Team (HTT) before coming to the hospital. She presented to the Emergency Department (ED) after ingesting 40 tablets of Pregabalin. She was referred to mental health liaison service for ongoing suicidal thoughts. On assessment, she admitted taking multiple overdoses to relieve her of severe abdominal pain. Her pain symptoms had been attributed as attention seeking behaviour. She disclosed feelings of rejection and abandonment by hospital staff. Liaison team negotiated with emergency department staff to complete a physical health examination that revealed tenderness and guarding in the abdomen. She was booked for elective cholecystectomy after surgical review. However, she had to be admitted from ED for laparoscopic cholecystectomy because of worsening of pain and vomiting. She was referred to Pain Management Team after surgery. The team was cautious in providing her with pain medications considering past history of overdoses. She was unable to tolerate pain and voiced thoughts of overdose. We liaised with Pain Management Team to optimise her analgesics and arranged daily supervision of pain medications with HTT RESULTS: Our patient's physical symptoms of acute cholecystitis and frequent overdoses with pain medications were attributed to her personality disorder that resulted in dismissal of her real pain that “Its is all in the head”. This led to persistent pain affecting her mental health. CONCLUSION: Patients diagnosed with EUPD should be carefully assessed to exclude organic causes of pain before attributing their symptoms to mental health disorders. A thorough assessment and treatment of physical symptoms can improve their mental health as well as reduce attendance in health facilities.