SOMATIC PRESENTATIONS

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SOMATIC PRESENTATIONS THE ART OF REATTRIBUTION

• Dr. Ramesh Mehay
• Programme Director, Bradford VTS

based on the work of Dr. Linda Gask,
Psychiatrist, Manchester
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A Os

• Aims
• To help you
• gain a deeper understanding of patients who
  somatise and
• feel better about dealing with them
• Objectives
• At the end of this session, you will be able to
• define somatisation
• list the 4 key stages in managing patients who
  somatise
• list some practical techniques in each stage
  which may aid the consultation

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What is Somatisation?
patient
physical symptoms
Emotional Distress
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Did you know.

• Unexplained physical symptoms occur
• General population 80 per week
• Primary Care 25
• Secondary Care 50
• So you cant have a diagnosis all the time!
• But wont patients think youre stupid?
• Surely thats what patients want to know?
• Dont worry..... Youll feel better by the end of
  todays presentation.

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This case says it all....

• A 27 year old woman had been looked after by one
  GP throughout her life.
• Her patents had separated, her father being an
  alcoholic, and there was some suggestion that she
  had been sexually abused by her step-father.
• She herself tended to form abusive relationships
  with a succession of violent males, her main
  outlet being frequent consultations with her
  doctor with bitter complaints of symptoms in a
  variety of body systems.
• Although the GP viewed her as one of her heart
  sink patients, and never felt that she was
  achieving much progress, she managed o contain
  her with only infrequent symptomatic treatments
  and simple investigations.
•  

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• While her usual GP was on holiday she consulted a
  locum, complained of pelvic pain and in great
  distress. She was referred to the local
  gynaecologist.
• At the hospital, where she saw a succession of
  junior doctors, various medications were tried to
  no effect and eventually a hysterectomy was
  performed.
• The patient then complained that her pain had
  actually got worse.
• A psychiatric referral followed, and a diagnosis
  of somatisation disorder was made, but the
  patient was entirely unwilling to engage in any
  form of psychological treatment and spoke of
  suing the gynaecologist.
• Taken from chapter 9, Somatic Presentations of
  Psychiatric Disorder, Hughes Outline of Modern
  Psychiatry, 4th Ed, Barraclough Gill (1996)

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The usual things GPs do

• Reassure
• Advise
• Prescribe
• -eg analgesia, abx, antideps (symptomatic Rx)
• Refer (to secondary care)
• - 30-70 no physical pathology (Bass, 1990)
• Investigate
• -eg blood tests, scans, xrays, endosc.,
  laparosc.
• Operate
• -proportion of appendicectomies with normal
  histology (Fink, 1992)

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Why Deal With Somatisation

• Work out some reasons in groups flip chart

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Lets get stuck in....

• Consultation 1 lady with abdo pain, 27 y old,
  recurrent presentations with the same thing!
• Have a go.... lets see how you get on

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Three Questions (optional)

• In groups
• How did you get on with this patient?
• Try also to think of a dysfunctional consultation
  you have had with a patient with medically
  unexplainable symptoms.
• What did you do?
• Why was it bad from your point of view? (DOCTOR)
• Why do you think it was bad from the patients
  point of view? (PATIENT)
• Discuss Flipchart views

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SKILLS THAT MAY HELP NEUTRALISE FEELINGS MAKING
THE LINK BROADENING THE AGENDA (Acknowledging
reality of symptoms) FEELING UNDERSTOOD NEGOTIA
TING THE TREATMENT

• DOCTOR REASONS
• Negative feelings from heart sink patients in
  general
• Difficulty in trying to negotiate agendas. I
  know it is depression why wont they just
  accept it?
• I dont believe them - Havent they got anything
  better to do? They dont really have pain!
• PATIENT REASONS
• I know what they all think of me!
• Not feeling understood
• Doctor doesnt believe me!
• Doctor decides for me without consulting me

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GROUP TASK (optional)

• Why are emotional problems presenting as MUS not
  always recognised or treated as such?
• Might be helpful to think in terms of doctor
  reasons and patient reasons

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Why are somatic symptoms so difficult to pick up?
(optional)

• Doctor reasons
• Skill in detecting cues varies
• Medical training ? organic approach and single
  diagnosis
• Concern about missing an organic cause
• Clouding by the presence of other organic disease

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Why are somatic symptoms so difficult to pick up?
(optional)

• Patient reasons
• Patients give little indication that there is
  anything psychologically wrong
• Patients may be unaware of psychological basis
  for symptoms
• Patients want their physical symptoms to be taken
  seriously
• Patients may feel it is inappropriate to discuss
  psychological difficulties
• Stigma of mental illness remains very powerful

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What doesnt work.... (optional)

• Denying the reality of the symptom
• Implying imaginary disorder/psychological
  stigmatisation
• they dont know, but they cant tell you that.
  So they say its nothing
• its not bloody psychological. Im not off my
  trolley. She thinks its all in the mind
• Unresolved explanatory conflict

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So, if u offer a bad explanation (optional)

• to tell them its nothing doesnt wash!
• they simply lose faith in you and go elsewhere.
• I dont tell her now. I think shell just
  laugh
• Ill only see him now if its an emergency like
  the kids or something.
• Remember, patients are experts in their own
  bodies

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Key Slide Explanations that do help (optional)

• Legitimising the patients suffering
• Removing blame from the patient
• Helping the patient to understand the problem
• GP sanctions patients own explanation
• its interesting that you thought it might be
  irritable bowel when you looked stuff up on the
  internet. I was think that too.
• Tangible mechanism
• he explained about tensing myself up so the
  neck muscles stiffened resulting in the pain
• Good explanations maintain the dr and patient
  link and makes sure youre both on the same
  wavelength

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SKILLS THAT MAY HELP NEUTRALISE FEELINGS MAKING
THE LINK BROADENING THE AGENDA (Acknowledging
reality of symptoms) FEELING UNDERSTOOD NEGOTIA
TING THE TREATMENT

• DOCTOR REASONS
• Negative feelings from heart sink patients in
  general
• Difficulty in trying to negotiate agendas. I
  know it is depression why wont they just
  accept it?
• I dont believe them - Havent they got anything
  better to do? They dont really have pain!
• PATIENT REASONS
• I know what they all think of me!
• Not feeling understood
• Doctor doesnt believe me!
• Doctor decides for me without consulting me

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The Art of Reattribution

• 4 stages
• (1a) Neutralise your (Dr.) feelings then

EXPLANATION
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The Key Essence of Reattribution

• Physical symptoms are linked to psychological
  issues in a way that patient and doctor find
  acceptable
• Approach is patient-led in the sense that
  explanations fit with the needs of the patient
  and their beliefs

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LETS GO THROUGH THE STAGES
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How to Neutralise Negative Feelings

• Recognise your feelings
• Inner dialogue vs knee-jerk response
• CBT approach
• Actively turning your negative around into a
  positive
• Get to know the patient as a person.
• Focus on something that you like about that
  person
• Practising reattribution
• Shark vs. teddy bear vs. owl Angry vs. hugs n
  kisses vs. wise intellectual process

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Feeling Understood

• History of the PC
• Clarification can you tell me a bit more about
  the diarrhoea
• Associated symptoms any other symptoms when you
  got it yesterday morning eg sob, shakey hands
• typical day
• Specific example could you just take me through
  the last time you had it. What you were doing and
  where you were so it gives me a sense of what was
  happening and how it felt
• Respond to emotional cues
• Assess mood you seem a bit down in yourself
• Assess severity of any depression (biological
  features)
• picks up emotional cues ?empathetic statement
  so, whats made you really worried is that.

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Feeling Understood

• Explore patient health beliefs/ patients view of
  the problem
• Clarify extent of the worry eg 1-10 scale about
  the cause of the symptoms
• Does that scale increase when you have the pain?
• ?previous episodes of other symptoms
• Explore social and family factors
• Brief focussed physical examination
• For dr reasons to exclude physical causes
• For pt reasons to show them that you have taken
  their symptoms seriously
• Summarise what you find

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Broadening the Agenda

• Go through the three stages of broadening the
  agenda
• Feedback results of Ex/Ix
• It is important to state the abnormalities (eg
  tenderness) and what you think it is
• Rather and all the tests were normal say
  well, we look at several things your thyroid
  and blood count were normal. Your liver and
  sugar tests were okay too
• Acknowledge reality of symptoms
• Even if no physical reason for their pain.
• Reframing the complaint
• ie getting them to see their symptoms in a
  different perspective.
• Start off by summarizing all their symptoms
  physically, psychologically and socially.
• Then tentatively link them to the life events
  theyve told you about.
• I wonder whether What do you think?
• Remember, all suggestions should be TENTATIVE
  hypotheses

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Making the Link

• ..between physical complaints and psychosocial
  problems
• Toolbox of Techniques
• How the symptoms might have occurred before
  during stress
• How depression can cause pain or lower the pain
  threshold
• How the symptoms can make you more depressed
  the vicious cycle
• How tension can cause physical pain (good for
  neck/back pain or headaches)
• How symptoms can be related to life events
• Keeping a Record
• Linking in the here and now
• Significant others
• ALWAYS Explain to have physical complaints when
  you are actually suffering from emotional
  problems is quite common.
• These are a compendium of explanations use these
  tools appropriately not all at once!

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CRUCIAL POINT Making the Link

• GOOD EXPLANATIONS ARE CRUCIAL TO MAKING THE
  LINK
• they need to be contextualised to the specific
  case.
• Match what you say to what the patient has
  already offered to you in the consultation
• Use their own words as a starting point
• eg pressure rather than stress, mood rather than
  anxiety

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Negotiating Treatment

• Explore pts views (of what is needed)
• Acknowledge pt worries and concerns
• Amenability to
• -Antidepressant medication
• -CBT or other psychological therapies
• Problem solving coping strategies
• Relaxation techniques/Physical Exercise
• Specific plans for follow up

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Does it work?

• Yes and no
• Probably essential first step in engaging the
  patient
• Much better than an unstructured approach like
  most GPs do

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Blackers Classification (1991)

• Grouped somatisers into three categories
• disguisers
• deniers
• dont knows

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Blackers Classification (1991)

• Disguisers recognise that they have a
  psychological complaint but present to the doctor
  with a physical complaint as a ticket of
  admission.
• Deniers tend to resist exploration of
  psychological issues and often develop chronic
  somatic illnesses.
• Dont knows are aware of emotional or
  psychological issues, but present with physical
  symptoms because they are worried they reflect
  physical disease.

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Blackers Classification (1991)

• Whilst reattribution may help with disguisers
  and dont knows dealing with the deniers might
  prove more difficult.
• Deniers need empathy and full attention given
  to the possible physical reasons for their
  symptoms. Usually a long period of building up
  the relationship with the patient will be
  necessary, with regular appointments.

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Managing the fat-file patient (optional)

• What doesnt help
• Blanket reassurance that nothing is wrong
• Patients dont want symptom relief, but
  understanding
• Challenging the patient try and agree there is
  a problem
• Premature explanation that symptoms are emotional
• Positive organic diagnosis wont cure the patient

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What else can help (optional)

• One doctor dealing with the patient
• Clarifying areas you and the pt agree/disagree on
• Regular scheduled appointments
• Clear agenda setting during the consultation
• Limit diagnostic tests
• Provide clear model for the pt
• Involve the patients family
• Dont expect a cure

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Dealing with family (optional)

• Can be central in maintaining symptoms what do
  the family want?
• Involve family members who come with the patient
  by
• -Reinforcing explanations
• -Limiting further investigations
• -Explore their needs (the effect the pt has on
  the family eg demanding etc)

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Recent Paper on Reattribution, 2008

• Reattribution training increases practitioners'
  sense of competence in managing patients with
  medically unexplained symptoms.
• However, barriers to its implementation are
  considerable, and frequently lie outside the
  control of a group of practitioners generally
  sympathetic to patients with medically
  unexplained symptoms and the purpose of
  reattribution.
• These findings add further to the evidence of the
  difficulty of implementing reattribution in
  routine general practice.
• General practitioners' views on reattribution for
  patients with medically unexplained symptoms a
  questionnaire and qualitative studyChristopher
  Dowrick,1 Linda Gask,2 John G Hughes,1 Huw
  Charles-Jones,3 Judith A Hogg,4 Sarah Peters,5
  Peter Salmon,6 Anne R Rogers,2 and Richard K
  Morriss7 BMC Fam Pract. 2008 9 46.

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Final Note

• Practise will real patients and videotape
  yourself
• Look at what you do
• Look at them with colleagues and get some
  feedback
• this is the best way to acquire new skills
• EVALUATION