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<p class="ltrs-br-ltr-br-title">Medically Self-Sabotaging Behavior and Multiple Symptoms on the Review of Systems</p>
<p class="ltrs-br-ltr-br-body-text"><span class="bold">To the Editor:</span> A minority of primary care patients report multiple symptoms during routine reviews of systems. We explored any correlation between intentionally sabotaging one’s own medical care (ie, an overall psychological need to maintain numerous physical symptoms, authentic or not) and multiple somatic symptoms as reported on a review of symptoms.</p>
<p class="ltrs-br-ltr-br-body-text"> </p>
<p class="ltrs-br-ltr-br-body-text"><span class="bold-italic">Method.</span> Participants were men and women, aged 18 years or older, in an outpatient internal medicine clinic staffed predominantly by residents. We excluded individuals with medical, intellectual, cognitive, or psychiatric symptoms that would preclude the ability to complete a survey.</p>
<p class="ltrs-br-ltr-br-body-text">One of the authors (C.L.) remained in the lobby, approached incoming patients, and informally assessed exclusion criteria. With potential candidates, she reviewed the project and invited each to complete a survey.</p>
<p class="ltrs-br-ltr-br-body-text">The survey consisted of 3 sections: (1) a demographic query; (2) the Self-Harm Inventory,<span class="htm-cite"><a href="#ref1">1</a></span> from which we selected 3 items related to medical sabotage: “Have you ever intentionally, or on purpose, prevented wounds from healing,” “made medical situations worse on purpose,” or “abused prescription medication?”; and (3) a symptom checklist of 35 items, adapted from a preappointment questionnaire by Sinsky,<span class="htm-cite"><a href="#ref2">2</a></span> which were preceded by the question, “Have you experienced any of the following symptoms in the past week?” with yes/no response options.</p>
<p class="ltrs-br-ltr-br-body-text"><span class="bold-italic">Results.</span> At the outset, 417 of 471 individuals approached agreed to participate, for a participation rate of 88.5%. Of these, 367 completed all study measures—124 men and 243 women, aged 19–97 years (mean<span class="thinspace"> </span>=<span class="thinspace"> </span>50.13, SD<span class="thinspace"> </span>=<span class="thinspace"> </span>15.46). Most (88.0%) were white (African American, 7.9%; other, 2.2%; Hispanic, 1.1%; Asian, 0.8%). All but 6.6% reported having attained at least a high school diploma, with 28.7% of the sample reporting a bachelor’s degree or higher.</p>
<p class="ltrs-br-ltr-br-body-text">Nineteen (5.2%) indicated ever having prevented wounds from healing, 25 (6.8%) indicated ever having made a medical situation worse on purpose, and 36 (9.8%) indicated ever having abused prescription medication. The number of endorsed symptoms in the review of systems ranged from 0 to 32 (mean<span class="thinspace"> </span>=<span class="thinspace"> </span>6.87, SD<span class="thinspace"> </span>=<span class="thinspace"> </span>5.95), with 89.9% endorsing at least 1 symptom. The mean number of such symptoms was greater for respondents who indicated a history of preventing wounds from healing (mean<span class="thinspace"> </span>=<span class="thinspace"> </span>12.68, SD<span class="thinspace"> </span>=<span class="thinspace"> </span>6.01) than for those who denied such a history (mean<span class="thinspace"> </span>=<span class="thinspace"> </span>6.56, SD<span class="thinspace"> </span>=<span class="thinspace"> </span>5.79; <span class="italic">F</span><span class="subscript">1,365</span><span class="thinspace"> </span>=<span class="thinspace"> </span>20.07, <span class="italic">P</span><span class="thinspace"> </span><<span class="thinspace"> </span>.001). Similarly, the mean number of such symptoms was greater for respondents who indicated a history of having made medical situations worse (mean<span class="thinspace"> </span>=<span class="thinspace"> </span>11.12, SD<span class="thinspace"> </span>=<span class="thinspace"> </span>7.65) than for those who denied such a history (mean<span class="thinspace"> </span>=<span class="thinspace"> </span>6.56, SD<span class="thinspace"> </span>=<span class="thinspace"> </span>5.70; <span class="italic">F</span><span class="subscript">1,365</span><span class="thinspace"> </span>=<span class="thinspace"> </span>14.13, <span class="italic">P</span><span class="thinspace"> </span><<span class="thinspace"> </span>.001). However, the mean number of endorsed symptoms was <span class="italic">not</span> greater for those who indicated a history of abusing prescription medication (mean<span class="thinspace"> </span>=<span class="thinspace"> </span>8.43, SD<span class="thinspace"> </span>=<span class="thinspace"> </span>6.25) than for those who denied such a history (mean<span class="thinspace"> </span>=<span class="thinspace"> </span>6.71, SD<span class="thinspace"> </span>=<span class="thinspace"> </span>5.91; <span class="italic">F</span><span class="subscript">1,365</span><span class="thinspace"> </span>=<span class="thinspace"> </span>2.69, <span class="italic">P</span><span class="thinspace"> </span><<span class="thinspace"> </span>.12).</p>
<p class="ltrs-br-ltr-br-body-text"> </p>
<p class="ltrs-br-ltr-br-body-text">These findings suggest that 2 forms of volitional medical self-sabotage—preventing wounds from healing and making medical situations worse on purpose—may be associated with and contribute to numerous physical symptoms on a review of systems. They also broach the deeper question of whether, in some patients, medical self-sabotaging symptoms and multiple self-reported symptoms in the review of systems purposefully function to engage health care professionals, maintain an illness identity, and/or self-sabotage a healthy lifestyle by promoting a sense of disability. Only further research will tease out the underlying psychological functions of these patient behaviors.</p>
<p class="ltrs-br-ltr-br-references-head"><span class="smallcaps">References</span></p>
<p class="references-references-text-1-9"><a name="ref1"></a>1. Sansone RA, Wiederman MW, Sansone LA. The Self-Harm Inventory (SHI): development of a scale for identifying self-destructive behaviors and borderline personality disorder. <span class="italic">J Clin Psychol</span>. 1998;54(7):973–983. <span class="pubmed-crossref"><a href="
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9811134&dopt=Abstract">PubMed</a> <a href="
http://dx.doi.org/10.1002/(SICI)1097-4679(199811)54:7%3C973::AID-JCLP11%3E3.0.CO;2-H">doi:10.1002/(SICI)1097-4679(199811)54:7<973::AID-JCLP11>3.0.CO;2-H</a></span></p>
<p class="references-references-text-1-9"><a name="ref2"></a>2. Sinsky CA. Improving office practice: working smarter, not harder. <span class="italic">Fam Pract Manag</span>. 2006;13(10):28–34. <span class="pubmed-crossref"><a href="
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=17139937&dopt=Abstract">PubMed</a></span></p>
<p class="ltrs-br-ltr-br-author"><span class="bold">Randy A. Sansone, MD</span></p>
<p class="ltrs-br-ltr-br-author"><a href="
mailto:Randy.sansone@khnetwork.org" target="_blank">
Randy.sansone@khnetwork.org</a></p>
<p class="ltrs-br-ltr-br-author"><span class="bold">Charlene Lam, MD, MPH</span></p>
<p class="ltrs-br-ltr-br-author"><span class="bold">Michael W. Wiederman, PhD</span></p>
<p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="bold-italic">Author affiliations:</span> Departments of Psychiatry and Internal Medicine, Wright State University School of Medicine, Dayton (Dr Sansone); Kettering Medical Center, Kettering (Drs Sansone and Lam), Ohio; and Department of Human Relations, Columbia College, Columbia, South Carolina (Dr Wiederman).</p>
<p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="bold-italic">Potential conflicts of interest: </span>None reported.</p>
<p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="bold-italic">Funding/support:</span> None reported.</p>
<p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="bold-italic">Published online:</span> July 7, 2011 (<span class="doi">doi:10.4088/PCC.10l01128</span>).</p>
<p class="ltrs-br-ltr-br-copyright-doi"><span class="italic">Prim Care Companion CNS Disord 2011;13(4):e1</span></p>
<p class="ltrs-br-ltr-br-copyright-doi"><span class="italic">© Copyright 2011 Physicians Postgraduate Press, Inc.</span></p>
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