A 60-year-old woman comes to the office for follow-up of chronic tension-type headaches. Her headaches have not improved after several trials of medications, including those recommended by a neurologist specializing in the management of headaches. The patient says, "I'm really not surprised that this last medication didn't work either. All these drug companies just want to make money. I doubt that anything will help." When asked if she would consider pursuing biofeedback, relaxation training, or stress management therapy, she responds, "There's no point-how can I relax or do therapy when my head is pounding?" The patient's other medical problems include hypertension and hypercholesterolemia, which are well controlled with medication. She has a history of depression following her divorce in her 40s but was unwilling to take an antidepressant or see a counselor at that time. Which of the following statements is the most appropriate response to this patient's concerns?

Question

A 60-year-old woman comes to the office for follow-up of chronic tension-type headaches.  Her headaches have not improved after several trials of medications, including those recommended by a neurologist specializing in the management of headaches.  The patient says, "I'm really not surprised that this last medication didn't work either.  All these drug companies just want to make money.  I doubt that anything will help."  When asked if she would consider pursuing biofeedback, relaxation training, or stress management therapy, she responds, "There's no point-how can I relax or do therapy when my head is pounding?"  The patient's other medical problems include hypertension and hypercholesterolemia, which are well controlled with medication.  She has a history of depression following her divorce in her 40s but was unwilling to take an antidepressant or see a counselor at that time.  Which of the following statements is the most appropriate response to this patient's concerns?

Quizplus · Accepted Answer

This patient remains symptomatic despite the best efforts of the physician to treat her with multiple medication trials, and she rejects all recommended nonpharmacological approaches. Such patients believe that no treatment will help and appear not to want to improve. They are often frustrating to manage and can leave the physician feeling angry and manipulated. The understandable tendency to want to refer this patient to another provider or specialist should be avoided (Choice E). These patients often have underlying depression but will refuse referral to a psychiatrist. They are needy for attention and unconsciously wish to remain symptomatic so that they can continue to see a physician. The best approach is to empathize with them and attempt to engage them in a collaborative plan in which there is mutual agreement about realistic treatment approaches and limited expectations. Empathizing with the patient's frustration over disappointing outcomes and focusing on alleviation of symptoms rather than a cure is often helpful. (Choices A and C) There is insufficient information on this patient to diagnose depression, and she would likely reject this explanation of her poor response. She has previously rejected counseling and is currently resistant to other treatment approaches; therefore, she is unlikely to agree to counseling at this stage. (Choice B) This statement attempts to confront this patient by pointing out her help-rejecting pattern of behavior. This would likely be perceived as judgmental, resulting in loss of rapport and defensiveness. However, it could be useful as part of a therapeutic intervention by a skilled therapist in the context of structured psychotherapy. (Choice F) The physician has already encouraged the patient to consider nonpharmacological approaches. Rather than continuing to make treatment recommendations that will likely be rejected, the physician should develop a collaborative focus on a small goal that she identifies. Educational objective: Help-rejecting patients who are hopeless about treatment can lead the physician to become frustrated and confrontational and to desire to refer the patient to another provider. Clear expression of empathy and a collaborative approach with limited goals are the most effective approaches. References: Managing difficult encounters: understanding physician, patient, and situational factors. (http://www.ncbi.nlm.nih.gov/pubmed/23547575)

A 60-Year-Old Woman Comes to the Office for Follow-Up of Chronic