Upload
grace-bolton
View
216
Download
0
Tags:
Embed Size (px)
Citation preview
Dr. Ramesh MehayProgramme Director, Bradford VTS
based on the work of Dr. Linda Gask, Psychiatrist, Manchester
AimsTo help you: gain a deeper understanding of patients who
somatise and feel better about dealing with them
ObjectivesAt 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?
patientphysical symptoms Emotional Distress
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.
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.
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)
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)
Work out some reasons in groups – flip chart
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
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.
1. What did you do? 2. Why was it bad from your point of view? (DOCTOR)3. Why do you think it was bad from the patient’s
point of view? (PATIENT)
Discuss & Flipchart views
DOCTOR REASONS1. 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!
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
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
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
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
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
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
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
DOCTOR REASONS1. 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!
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
4 stages (1a) Neutralise your (Dr.) feelings then:
EXPLANATION
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
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
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….”
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
Go through the three stages of broadening the agenda
1. Feedback results of Ex/Ix It is important to state the abnormalities (eg tenderness) and what you think it isRather 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”
2. Acknowledge reality of symptoms Even if no physical reason for their pain.
3. 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
……..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!
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
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
Yes and noProbably essential first step in
engaging the patientMuch better than an unstructured
approach like most GPs do
Grouped somatisers into three categories:
1. disguisers2. deniers3. don’t knows
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.
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.
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
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
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)
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.
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