SOMATIC PRESENTATIONS & THE ART OF REATTRIBUTION

1. Dr. Ramesh Mehay Programme Director, Bradford VTS SOMATIC PRESENTATIONS &THE ART OF REATTRIBUTION based on the work of Dr. Linda Gask, Psychiatrist, Manchester

2. 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

3. What is Somatisation? physical symptoms patient EmotionalDistress

4. Did you know…. Unexplained physical symptoms occur: • General population 80% per week • Primary Care 25% • Secondary Care 50% • So you can’t have a diagnosis all the time! • But won’t patients think you’re stupid? • Surely that’s what patients want to know? • Don’t worry..... You’ll feel better by the end of today’s presentation.

5. 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.

6. 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)

7. 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)

8. Why Deal With Somatisation Work out some reasons in groups – flip chart

9. Let’s get stuck in.... • Consultation 1 – lady with abdo pain, 27 y old, recurrent presentations with the same thing! • Have a go.... let’s see how you get on

10. 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 patient’s point of view? (PATIENT) Discuss & Flipchart views

11. SKILLS THAT MAY HELP NEUTRALISE FEELINGS MAKING THE LINK BROADENING THE AGENDA (=Acknowledging reality of symptoms) FEELING UNDERSTOOD NEGOTIATING THE TREATMENT DOCTOR REASONS • Negative feelings from heart sink patients in general • Difficulty in trying to negotiate agendas. I know it is depression – why won’t they just accept it? • I don’t believe them - “Haven’t they got anything better to do?” They don’t really have pain! PATIENT REASONS • “I know what they all think of me!” • Not feeling understood • Doctor doesn’t believe me! • Doctor decides for me without consulting me

12. 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

13. 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

14. 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

15. What doesn’t work.... (optional) • Denying the reality of the symptom • Implying imaginary disorder/psychological stigmatisation • “they don’t know, but they can’t tell you that. So they say it’s nothing” • “it’s not bloody psychological. I’m not off my trolley. She thinks it’s all in the mind” • Unresolved explanatory conflict

16. So, if u offer a bad explanation (optional) • to tell them it’s nothing doesn’t wash! • they simply lose faith in you and go elsewhere. • “I don’t tell her now. I think she’ll just laugh” • “I’ll only see him now if it’s an emergency; like the kids or something.” • Remember, patients are experts in their own bodies

17. Key Slide: Explanations that do help (optional) • Legitimising the patient’s suffering • Removing blame from the patient • Helping the patient to understand the problem • GP sanctions patient’s own explanation “it’s 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 you’re both on the same wavelength

18. DOCTOR REASONS Negative feelings from heart sink patients in general Difficulty in trying to negotiate agendas. I know it is depression – why won’t they just accept it? I don’t believe them - “Haven’t they got anything better to do?” They don’t really have pain! PATIENT REASONS “I know what they all think of me!” Not feeling understood Doctor doesn’t believe me! Doctor decides for me without consulting me SKILLS THAT MAY HELP NEUTRALISE FEELINGS MAKING THE LINK BROADENING THE AGENDA (=Acknowledging reality of symptoms) FEELING UNDERSTOOD NEGOTIATING THE TREATMENT

19. The Art of Reattribution 4 stages (1a) Neutralise your (Dr.) feelings then: EXPLANATION

20. 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

21. LET’S GO THROUGH THE STAGES

22. 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

23. 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, what’s made you really worried is that….”

24. 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

25. 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 they’ve told you about. “I wonder whether………” “What do you think?” Remember, all suggestions should be TENTATIVE hypotheses

26. ……..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 ALWAYSExplain: 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! Making the Link

27. 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

28. Negotiating Treatment • Explore pt’s 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

29. Does it work? • Yes and no • Probably essential first step in engaging the patient • Much better than an unstructured approach like most GPs do

30. Blacker’s Classification (1991) Grouped somatisers into three categories: • disguisers • deniers • don’t knows

31. Blacker’s 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. • Don’t knows are aware of emotional or psychological issues, but present with physical symptoms because they are worried they reflect physical disease.

32. Blacker’s Classification (1991) • Whilst reattribution may help with “disguisers” and “don’t 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.

33. Managing the “fat-file patient” (optional) What doesn’t help • Blanket reassurance that nothing is wrong • Patients don’t want symptom relief, but understanding • Challenging the patient – try and agree there is a problem • Premature explanation that symptoms are emotional • Positive organic diagnosis won’t cure the patient

34. 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 patient’s family • Don’t expect a cure

35. 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)

36. 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.

37. 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