SOMATIC PRESENTATIONS THE ART OF REATTRIBUTION Dr Ramesh

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

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

What is Somatisation? physical symptoms patient Emotional Distress

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.

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 to contain her with infrequent symptomatic treatments and simple investigations.

This case says it all. . 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, 4 th Ed, Barraclough & Gill (1996)

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)

Why Deal With Somatisation Work out some reasons in groups – flip chart Patient reasons • best interests of patient: unnecessary Ix, Rx, Tx, ↓iatrogenesis, ↓anxiety , disability and distress, awareness and thus empowerment, Doctor reasons • Hopelessness; “heartsink” emotions → framework, dr shopping/hopping, suing, maintain doctor-patient relationship Family • coping with patient, other dynamics Practice/NHS/Society reasons • More appointments, inappropriate Ix & Tx: cost savings (>£ 200 million per year!)

Why somatic symptoms are so difficult to pick up? (optional) Think for a moment in terms of patients and doctors. 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

Why somatic symptoms are 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

REATTRIBUTION

What doesn’t work. . 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

So, if u offer a bad explanation 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

Key Slide: Explanations that help 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 relationship and makes sure you’re both on the same wavelength

The exercise where you were allowed to say what you wanted to the ‘heart sink’…. provides an approach that might work or at least make you feel you are doing something positive.

DOCTOR’S POINT OF VIEW 1. Negative feelings from heart sink patients in general 2. Difficulty in trying to negotiate agendas. I know it is depression – why won’t they just accept it? 3. I don’t believe them - “Haven’t they got anything better to do? ” They don’t really have pain! SKILLS THAT MAY HELP NEUTRALISE FEELINGS MAKE THE LINK BROADEN THE AGENDA (=Acknowledging reality of symptoms) PATIENT’S POV • • “I know what they all think of me!” Not feeling understood Doctor doesn’t believe me! Doctor decides for me without consulting me FEELING UNDERSTOOD NEGOTIATE

The Art of Reattribution 4 stages 1. Feeling Understood (walk a mile. . ) Builds Rapport 2. Broadening the Agenda 3. Making the link 4. Negotiating the treatment EXPLANATION Done over several consultations (may take months) (1 a) Neutralise your (Dr. ) feelings then:

Key Essence of Reattribution Physical symptoms are linked to psychological issues in a way that patient and doctor find acceptable Approach is one of collaboration. To work collaboratively, neutralise your feelings. Work with the patient, not against them. Dance, not fight good for you, good for them

LET’S GO THROUGH THE STAGES

1 a How to Neutralise Negative Feelings Recognise your feelings Inner dialogue vs knee-jerk response Remind yourself: you’re a GP & this is the essence of your job. CBT yourself Actively turning your negative around into a positive ‘Oh no, not him again, but I suppose I am reducing anxiety and wastage of resources’ Get to know the patient as a person. Focus on something that you like about that person. Practise reattribution It will get you to a different state of mind. From Shark, Turtle or Teddy Bear to perhaps Owl? (conflict styles on Google)

1. Feeling Understood The most important stage. You need to peel enough ‘layers of the onion’ to give you a flavour of what it is like to “walk a mile” in the patient’s shoes. Without it you can’t do the other stages. Two parts to it 1. 2. Dr-centred bit: gets you enough information to make a reliable diagnosis so that you don’t get things wrong Pt-centred bit: makes the patient feel that you really feel what they are feeling rapport.

1. Feeling Understood THE DOCTOR-CENTRED BIT 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” 1 -10 scale 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” Assess mood and exclude depression/anxiety – not all have anxiety or depression. Brief focussed physical examination For doctor reasons – to exclude physical causes For patient reasons – to show them that you have taken their symptoms seriously.

1. Feeling Understood THE PATIENT-CENTRED BIT Whilst taking Hx, respond to emotional cues Assess mood: “you seem a bit down in yourself” Assess severity of any depression (biological features) Pick up on emotional cues. Perhaps an empathetic statement: “so, what’s made you really worried is that…. ” Explore patients view of the problem The patient’s health belief system - clarify extent of the worry Explore social, occupational, family and past factors Really try to understand the problem in a wide holistic way Ask what happened when the symptoms first started to appear Brief focussed physical examination

Video clips (5 mins) Specific example Health beliefs

2. Broadening the Agenda 3 parts 1. Feedback results of Ex/Ix State any abnormalities (even tenderness) and what you think it is Instead of “all the tests were normal” “we looked at several things: your thyroid and blood count were normal, as was your…. . ” 2. Acknowledge reality of symptoms Even if no physical reason for their pain. 3. Reframing the complaint The aim is to get them to see their symptoms in a different perspective. Start by summarising all their symptoms – physically, psychologically & 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 – gives the patient the opportunity to discuss further (rather than you being dictatorial).

Video clips (5 mins) Examination Tentative explanation (reframing)

Making the Link ……. . between physical complaints and psychosocial problems Toolbox of Techniques How the symptoms might have occurred before during stress How depression cause pain or lower the pain threshold How the symptoms can make you more depressed: “the vicious cycle” How tension 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!

Video clips (5 mins) Relating symptoms to life events How depression lowers the pain threshold The here and now How tension causes pain

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

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 Don’t forget to offer suggestions TENTATIVELY – ‘I wonder if xxx might help. What do you think? ’

Video clips (5 mins) Reassuring, offering suggestions

Does it work? Yes and no Remember, you may be trying to change abnormal health behaviour that’s been there for 20+ years. Probably essential first step in engaging the patient Much better than an unstructured approach like most GPs do Stops you from feeling helpless and hopeless.

Have a go yourself Practice patient scenario One trainee to do each of the four stages

Blacker’s Classification (1991) optional Grouped somatisers into three categories: 1. 2. 3. disguisers deniers don’t knows

Blacker’s Classification (1991) optional 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.

Blacker’s Classification (1991) optional 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.

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

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

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)

Recent Paper on Reattribution, 2008 (optional) 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 study Christopher 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 Morriss 7 BMC Fam Pract. 2008; 9: 46.

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