Je suis malade, donc je suis: Douze monographies de patients à forte consommation de soins

Abstract: Context. – Some patients, although they present no severe diseases, consult frequently, either for somatoform disorders, or for mild chronic diseases. A “Caisse Nationale d''Assurance Maladie” [National Health Insurance Fund] survey, built on care consumption criteria, has evaluated this sort of patient as constituting 3,6% of a vast sample of members of the national insurance scheme. They represent 8% of general practice acts and 14% of the whole care expenses. The aim of this survey is to describe, in general practice, the clinical reality of this category of patients recognised as high care consumers. Method. – Four urban or rural General Practitioners selected non-psychotic adult patients, consulting more than six times a year for more than two years, for at least two minor motives. Twelve of them accepted to meet the investigator for a detailed interview inspired by the method of “récit de vie” (life story) used in sociology. Interviews lasted between one and three hours, and were directed toward biography, complaints, pathologies, and care. Results. – The patients, ten women and two men, between 29 and 70-years-old, belonged to rather disadvantaged social categories. They had consulted their General Practitioner an average of 20.8 times over a period of a year. Pains, digestive or ORL disorders were the main motives for consultation. Objective diseases were rare and minor. Seven of them consumed psychotropic drugs in the absence of any well-argued psychiatric diagnosis as we found out afterwards in the files. Only one of them presented HARD scale depression criteria. Specialist consultations were rare; only three patients had consulted a psychiatrist. No actual addiction to alcohol or to illicit products was noted. They were all faithful to their General Practitioner; the link, solid in each case, could be of a submissive or aggressive nature. They all had known situations of lasting affective frustrations from childhood, such as abandonment or parental unavailability. Seven of them were also concerned by parental failures when they entered adulthood when, furthermore, they were already weakened by disease or pregnancy. For five patients, it was a complicated mourning which began the period of high care consumption. Nine patients had witnessed one parent''s serious disease during childhood. And six insisted on their own childhood diseases. The identification of a sick relative and the need for the support of a medical person were retained as an explanatory hypothesis for adopting the status of patient. Narcissistic weakness and the central role of an analytic relation with their General Practitioner, without any other psychological trouble, revealed a borderline condition. Conclusion. – High care consumption studied, as a “life situation” via these twelve stories seems to be characterized by an experience of past affective frustrations and more recent traumatisms of the patients. The survey permits, in the absence of located psychiatric pathologies, to assume as possible meaning a behaviour that is not socially adapted. It also put forward the modest but central role of the General Practitioner in receiving complaints. [Copyright &y& Elsevier]