This case study highlights the repeated presentations to a local
emergency department. The available data details at least 38 encounters
for acute MSK-related pain or injury, for a seven year period ending in
Feb 2021; remarkably, 28 of which were within one calendar year (2015).
Upper limb pain and persistent MSK pain involving an extremity were the
main reasons for ED presentation. However, no further mental health
presentations for the ED or specialist care were identified which may be
due to the type of data captured (or not) in the retrospective records.
The final mental health diagnosis provided in April 2017 reports a
first-time diagnosis of Anorexia Nervosa. It is important to note that
up to 40% of people diagnosed with Anorexia Nervosa have comorbid
personality disorders across the Cluster B traits, which are defined by
the DSM as including impulsive behavioural patterns along with
compulsive traits (13). Existing evidence
suggests that pain is implicated in higher rates of generalised anxiety
disorder (GAD), post-traumatic stress disorder (PTSD) substance misuse
and other comorbid disorders (14)
resulting in a further reduction in functionality, recalcitrant
treatment response and increased health care costs. It appears that
people living with mental health conditions receiving inadequate
treatment remain at risk of experiencing other comorbid health
conditions and it remains plausible that the repeated acute pain/ MSK
presentations observed may be due to an unrecognised eating disorder
phenotype. An improved understanding of pre-existing
vulnerabilities/resiliencies associated with repeated acute care
presentations and triage processes may inform healthcare redesign to
streamline more bespoke care pathways for people with acute MSK injury.
It is acknowledged that people living with a mental illness experiencing
concomitant physical symptoms, which in turn results in a shortened life
span, increased comorbidities, a lowering in their quality of life due
to a mix of disparity in healthcare access and utilisation
(15). Unfortunately, these physical
symptoms have been largely attributed to underlying psychiatric
conditions (16). It is our belief that
living with a mental illness may lead to a delay in establishing the
correct diagnosis and intervention required to adequately address the
physical and mental signs/symptoms, which could result in an
inappropriate plan of care on discharge from the ED.
Early onset mental health disorders have shown to increase risk for
lifelong adversity (17), contributing to
health inequity. There are several studies on the observations of, and
reporting on, an increasing number of young people presenting to the ED
with mental health disorders (18). The
intensely stimulating environment of the ED may prove a therapeutic
challenge for an acutely injured person with or without history of
previous mental health disorders. The trauma, distress, pain, and
expectations around recovery are complex for people living with a mental
illness. Adding to this complexity are pre-existing stress, pain, mental
ill-health, and early life adversity as all could influence the clinical
course on a patient-by-patient basis following acute injury. Such
complexity can, and likely does, place further demands on the resources
within an ED workforce and resources
(19).
Limitations
The retrospective data collection is limited over the time period
captured between 1 January 2015 to 31 July 2021 at the single ED
location looking for only acute MSK pain presentations with limited
information gathering about any triggers prior to presentation and
existing supports and services. We do not have further available
information on the young person attending other hospital EDs in addition
to the district hospital ED within the catchment area, largely, if not
completely, due to a lack of communication between hospital EMRs. Our
retrospective record review data interrogated set points in time and
does not capture all the information from specific presentations.
Further, a lack of information around the methods of classification of
the data obtained at the time of presentation also hampers the
interpretation of the data collected from the retrospective record
review. This is a case report based on the retrospective study of
de-identified data and it was not possible to provide the patient’s
perspective.
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