Beneath the symptoms - Oxleas NHS Foundation Trust

Beneath the symptoms…Dr Geoff Lawrence-Smith,Specialist Registrar, Heath Clinic, Bracton Centre,Oxleas NHS Foundation Trust

AIMS• To understand what is meant by“Somatic Presentation of Distress”• To appreciate what research has to sayabout this illness• To be familiar with some techniques formanaging somatic presentations–To want to try them out

Background• ‘Common-sense’ of ‘mind-body’ link– but dualism seems to persist• Stigma of ‘mental disorder/illness’• Easier to accept physical over emotional• Putting feelings/pain ‘into’ the body– unconscious

Examining Research Data• More than ¼ of primary carepatients in England haveMUS– 1/3 neurologicaloutpatients havesymptoms inconsistentwith disease• Parental illness & lack ofcare in childhoodpredispose women to MUS(OR – 2.9)• Significant co-morbidity– Often psychiatric– Use of screening tools• PHQ – 9• HADS• HRQoL

Debate

Management• Regular scheduled appointments– With a physical examination– Signs over symptoms• Antidepressants• Psychological therapies– CBT– Psychodynamic• Reattribution model• Future directions– Stepped care– Correspondence (Cochrane review)– Reclassification

Increasing Awareness inPrimary Care• Goldberg, Gask and Sartorius, 2001;“Training Physicians in Mental Health Skills”– Collaboration between Institute of Psychiatry,National Primary Care Research Centre and WorldPsychiatric Association– Seminars involving video and role-play todemonstrate and practice skills• The reattribution model– Recent skepticism (Morriss et al, 2007) but makespragmatic sense

4 - Stage Model• Understanding Symptoms• Broadening the Agenda• Making Links• Negotiating Treatment

Understanding Symptoms (1)• ‘Classical’ HPC– Onset– Duration– Previous experience– Improving/deteriorating– Aggravating/relieving factors– Associated features

Understanding Symptoms (2)• Typical Day• What do other’s think?– Introduction to allies• Health Beliefs– Experiences of illness in others– Worries about future– Worries about diagnosis• How much worry, generally?– Scale 0-100%

Understanding Symptoms (3)• Physical examination– Good practice– Take patient seriously– Increase patient satisfaction

Broadening the Agenda• Acknowledge that pain is ‘real’• Subtle introduction of Psycho-socialaspects in a summaryReframe the Complaint

Collaborative problem listPredisposingPrecipitating(trigger)MaintainingBio -Psycho -(thinking)Social(relationships)DoctorMusculoskeletal chest painAbdominal cramp and bloatingMusculoskeletal chest painAbdominal cramp and bloatingMusculoskeletal chest painAbdominal cramp and bloatingMusculoskeletal chest painAbdominal cramp and bloating

Making Links (1)• Propose links between pain/symptomand stress/feeling low• ‘Tension’• Vicious CyclePAIN/SYMPTOMSSTRESS/LOWSTRESS/LOWPain• Reduced pain thresholdPAIN/SYMPTOMSLOWPAIN

Making links (2)• Linking to the ‘Here-and-Now’– “…stressful just talking about it!”• Experience of similar illness in others– Easier to recognise emotional problems inour peers than ourselves

Making links (3)• Homework…for nextweekSymptomsWhenWhereWho withMood

• You can’t use themall in one session– Pick your favourite• Use patient’s ownwords• Avoid diagnosticlabels unlessobviously helpfulDon’t Worry…

Treatment options• Negotiation between doctor and patient• Clarifying what happened during consultation– Acknowledge patient’s concerns• Patients know their lives best– Ways to “reduce pressure”• Returning to Health Beliefs– Ways to “manage worry”• Relaxation• Plan for FOLLOW - UP

That’s all very well…• Patients want you to own theirsymptoms• Using provocative and disturbinglanguage– Ring et al, 2004• Pts’ allies can help you• Peer group supervision– ? with a CBT therapist

Cases from your experience

AIMS• To understand what is meant by“Somatic Presentation of Distress”• To appreciate what research has to sayabout this illness• To be familiar with some techniques formanaging somatic presentations–To want to try them out

Thank you for listening

References• Do patients with unexplained physical symptoms pressurisegeneral practitioners for somatic treatment? A qualitative study.Adele Ring, Christopher Dowrick, Gerry Humphris, Peter Salmon, BMJ,doi:10.1136/bmj.38057.622639.EE (published 31 March 2004)• ABC of psychological medicine: Chronic multiple functionalsomatic symptoms. Bass & May, BMJ VOLUME 325 10 AUGUST2002• ABC of psychological medicine: Functional somatic symptomsand syndromes. Mayou & Farmer, 2002;325;265-268 BMJ– www.medicine.manchester.ac.uk/psychiatrytrainingvideos/• Very useful videos and DVDs with accompanying lecture notes• Why do people get ill? Leader & Corfield, 2007. ISBN 978 – 0 – 241– 14316 - 2