School of Medicine, Health Policy and Practice, INSTITUTE OF HEALTH 15th international Course, Slovenia EURACT Somatisation Amanda Howe MA MEd MD FRCGP Professor of Primary Care Medical Course Director, UEA

Psychological aspects of ill health Psychological disturbance common when unwell - resolution of distress with understanding and time Tendency to somatise varies with culture, emotional expressiveness and insight Medically unexplained symptoms and ‘functional disorders’ – no disease, disorder of function ‘Facultative’ somatisation – patient is aware of psychological issues but presents physically ‘True’ somatisation and somatoform disorders – patient has little or no insight into psychological antecedents Emerging knowledge of the mind- body links makes explanation of symptoms more acceptable Still varies with cultural awareness and acceptance of the mind – body continuum Biomedical bias makes this a difficult area for clinicians 15th international Course, Slovenia EURACT

How to recognise somatisation in a patient with co-morbidities Consulting pattern – attendances are patient – initiated and appear too numerous for clinical need * this may be difficult to detect in systems where patient can initiate contact with multiple providers Patient has atypical symptoms in multiple systems Patient is difficult to reassure and pushes for multiple investigations or other intervention Patient is withdrawn, or others have noted a change in personality and usual level of function for them Patient has ceased to comply with usual management Examination and investigation reveals no changes School of Medicine, Health Policy and Practice, INSTITUTE OF HEALTH 15th international Course, Slovenia EURACT

Somatisation – the patient’s perspective I am an ill person and I don’t know what these symptoms mean I feel terrible, things must be getting worse How can the doctor know that I’m OK? Last time I was really seriously ill and they said I should have come earlier I couldn’t see Dr K who knows my case so shall try to go again I wonder if my problems are due to the new tablets My neighbour thinks I look worse The new nurse told me to come if anything worried me School of Medicine, Health Policy and Practice, INSTITUTE OF HEALTH 15th international Course, Slovenia EURACT

Managing the mind – body interface Four crucial stages in the consultation process: 1.Feeling understood: The general practitioner elicits a clear history of the symptoms, explores the patient’s ideas and concerns about these symptoms, is interested in associated psychosocial and personal context, and makes a brief focussed physical examination 2.Broadening the agenda: beyond the presenting physical symptoms. The doctor feeds back the results of the examination and any recent investigations, and explains the apparent lack of definite pathology. The doctor explicitly acknowledges the reality of the patient’s physical symptoms, and explores the extent of the patient’s acceptance that psychosocial or lifestyle factors may be linked to these symptoms 3.Making the link: The doctor shows how the physical symptoms could be linked with psychosocial or lifestyle explanations, using physiological and/or context links that fit with the patient’s given history and beliefs. School of Medicine, Health Policy and Practice, INSTITUTE OF HEALTH 15th international Course, Slovenia EURACT

Specific management strategies 4. Negotiation over further management. Various:- exploring patient’s views about referral & treatment appropriate use of relaxation & anxiety minimisation promoting problem solving and coping strategies setting lifestyle goals that patient thinks they can achieve appropriate treatment for depression cognitive approaches to negative thinking agreeing specific plans for follow-up physician commits themselves to ongoing care. School of Medicine, Health Policy and Practice, INSTITUTE OF HEALTH 15th international Course, Slovenia EURACT

Limits and difficulties Time available Ability to retain trust Keeping the mind-body explanations active especially if referred or other clinicians involved Accepting lack of progress / resolution Patient’s psychological attributes can undermine Co-morbidities! Abnormalities exist and patient will attribute problems to these Dealing with the problems at a non-medical level (spiritual, psychological, relational) School of Medicine, Health Policy and Practice, INSTITUTE OF HEALTH 15th international Course, Slovenia EURACT

Advantages and privileges Insight can develop over time Families may be supported to support the patient Patients usually grateful for your efforts and accept the commitment made, regardless of explanation Can experience relative empowerment even if symptoms remain active and function is limited New treatments may produce improvement, as can selfhelp and complementary therapies Training others in a patient – centred method mean that chronicity is minimised School of Medicine, Health Policy and Practice, INSTITUTE OF HEALTH 15th international Course, Slovenia EURACT

Issues for GP training and CPD Greater emphasis should be placed upon the assessment and management of patients with a combination of psychological and physical problems during undergraduate training. Medical students should be taught to incorporate brief psychological assessment into routine history taking. GP trainees require better supervision and training in the assessment and management of patients with medically unexplained symptoms. There should be good channels of communication within the general hospital and with community services with regard to psychiatric as well as physical health. School of Medicine, Health Policy and Practice, INSTITUTE OF HEALTH 15th international Course, Slovenia EURACT

Further reading Watkins A. Mind body medicine. Churchill Livingstone 1997 Bass C. Somatisation. Blackwell Pubs The psychological care of medical patients. RCP/RCPsych 2 nd ed Psychological care of patients with physical and psychological problems in primary care. RCGP/RCPsych 2005 (in press) Gask L, Goldberg D, Usherwood T…. Dowrick C. School of Medicine, Health Policy and Practice, INSTITUTE OF HEALTH 15th international Course, Slovenia EURACT

School of Medicine, Health Policy and Practice, INSTITUTE OF HEALTH 15th international Course, Slovenia EURACT Somatisation Amanda Howe MA MEd MD FRCGP Professor of Primary Care Medical Course Director, UEA