"Managing Medically Unexplained Symptoms" (advice to GPs/PCPs)

Dolphin

Senior Member
Messages
17,555
Likes
28,239
Somebody posted this on another forum. I understand it is on a UK website for doctors.

Warning, you may find it infuriating! :(

Managing medically unexplained symptoms

07 Apr 10

Dr Mark Morris on how a psychological model for dealing with somatoform disorder can be used in primary care

It can seem burdensome when a patient repeatedly presents with physical symptoms and requests for investigations, despite repeated negative findings and reassurances that the symptoms have no physical basis.

Somatisation disorder is a form of this state of affairs where the main features are multiple, recurrent and frequently changing physical symptoms – as opposed to hypochondriacal disorder where the essential feature is a persistent preoccupation with the possibility of having one or more serious and progressive physical disorders.

Dissociative (conversion) disorder is a less common presentation, presumed to be psychogenic in origin, being associated closely in time with traumatic events, insoluble and intolerable problems, or disturbed relationships.
There is little evidence-based treatment of conversion disorder.

The approach

The Extended Reattribution and Management Model was developed for managing somatoform disorders (1) and I have adapted the model to complement my experience as a GP.Make the patient feel heard and understoodOne of the most important psychological aspects of the programme is to make the patient feel heard and understood – using the OARS approach.

• Open questions – what, where, how, why... Closed questions lead to the doctor overcontrolling the conversation. Balance open questioning with keeping focused. Such patients typically elaborate greatly on how severe an impact symptoms are having on their lives and often go off topic.

• Affirmations – such as saying: `Yes, clearly this has been taking its toll on your relationship, so how does . . .?'

• Reflective listening

• Summarising – such as: `If I have understood you correctly, you are saying...'Working like this will reduce patient resistance to the idea there is nothing seriously wrong and that investigations and treatment are unnecessary.


Explore life events, stress and other external factors Ask the patient:

• What else is happening in your life in general?

• How do you feel about this?

• What causes you the most trouble?

Ask about depression and anxiety

Ask about psychosocial circumstances and relationships at the beginning, otherwise the patient may feel that you are trying to dismiss the symptoms as being `all in the mind' as you cannot find anything else wrong. We need to help our patients accept that we are psychobiological in nature. They have symptoms that are real and have a need to deal with them whatever the cause. Somatisers may actually be biologically different.

Research suggests that somatising patients lack a normal filter function, resulting in the patients being unable to ignore irrelevant stimuli. Be clear about the patient's ideas, concerns and expectations. Remember to ask what the patient thinks might be going on, what they are worried about and what they think should be done and why.

Brief, focused physical examination and indicated investigationsFor example, listening to heart sounds if the patient complains of `heart trouble' – saying: `Nothing in your description makes me think there may be something wrong with your heart, but I would like to listen anyway.'This reassures the patient that they are being taken seriously and you are being careful and meticulous.

Be clear about the diagnosis – if you have one – and that there is nothing medically serious or sinister going on. A patient is most likely to accept this if you show that you have an understanding of the condition they are worried about and have discussed the absence of related symptoms and signs. Never tell the patient there is nothing wrong with them.

Acknowledge the reality of the symptoms and communicate empathic understanding of the patient's emotional problems or statements.For example, tell the patient: `I can see you are very troubled by your symptoms. Fortunately, for your reassurance, I can tell you that nothing indicates a serious physical disease. Perhaps we could try together to look for other possible explanations for your pain.'

Discuss the limitations of medicine

Explain we are unable to diagnose a large number of the problems people bring to the surgery. We can exclude serious pathology.

Many of these undiagnosed problems then just get better. When the problem does not completely go away, it is possible to learn to manage them better.Roll with resistanceYou may find in the more severe cases that there is a long way to go before the patient can begin accepting that there is nothing seriously wrong. Maintain the empathic, firm-but-friendly approach. For instance:`I can see you are convinced you have heart trouble but I can find no signs of changes to your heart, which is why we cannot offer surgical or medical treatment that will make the symptoms go away.

On the other hand, there are several things you can do to feel better, which would also be the case if you did suffer from an actual heart condition.

Would it be okay to take a closer look at these?'

Address the mind-body link

Try to explain that tension or mental stress is commonly accompanied by physical symptoms and/or that it may worsen existing physical symptoms. Examples you could use include:
• palpitations, breathlessness, and other physical symptoms when frightened or nervous
• increased sensitivity to physical symptoms when depressed
• tightening of muscles when frightened or stressed.


The chronic, entrenched patient

It may be helpful to tell the patient: `Many people feel like you do. It is in no way a rare condition – in fact we have a name for it, somatisation.'

Explain that the fundamental cause is unknown, as is also the case for many other illnesses, such as essential hypertension.

Assist the patient's understanding by using well-known examples such as when you think about fleas and lice, you start itching. Furthermore, it could also be mentioned that it can run in the family.Explain to the patient that how they act and react to symptoms is important for their future well-being.

The patient must learn how to cope with illness, that is, to function as well as possible in spite of the trouble he or she is experiencing and that it is important not to become physically unfit, which will just make things worse. It is also important for the patient to understand that he or she should not expose him or herself to unnecessary tests or treatments because this may cause harm.

Future involvement for the chronic, entrenched

• Be proactive not reactive.

• Promote continuity; become the named practitioner for the patient and inform other medical colleagues.

• Book regular scheduled appointments. You may not want to see them again, but this is an investment as you will see them less and save time in the long run.

• Acknowledge symptoms and their impact.

• Explore provoking and relieving factors; encourage more elaboration of relieving factors and influences and summarise with emphasis on what is working.

• Explore and encourage elaboration of how the patient is coping despite the symptoms.

• Consider antidepressants – there is evidence that SSRIs can be effective.

Source: Dr Mark Morris is a GP in Falmouth, Cornwall

References: This is an extract from Mental Health for Primary Care; a Practical Guide for Non-Specialists.

Pulse readers can buy this book at the specially reduced price of 20.00 + P&P (full price 24.95 + P&P). To claim the discount, visit www.radcliffepublishing.com and enter the discount code DX35 at the checkout when purchasing, or order via 01235 528820 quoting the same code. Offer ends 30 June 2010.
 

Mark

Senior Member
Messages
5,238
Likes
6,199
Location
Sofa, UK
Perhaps Adam should get to work on this piece of foul excrement! Although it should be handled with care: it is clearly designed to induce dangerous levels of enragement. But I couldn't bring myself to ask anyone else to wade through this, so here's my abridged and de-Newspeaked version.

"Mental Advice for Criminal Neglect: Top Tips for Non-Experts"

Part 94: What You Don't Know Can't Hurt You

Patients you can't figure out can be a right pain in the arse, especially when you keep telling them there's nothing wrong with them and they won't believe you. Somatisation disorder, hypochondriacal disorder, and dissociative (conversion) disorder are a suite of labels you can use to chuck any such person over to Mental Health for further processing.

There is little evidence. There is no proven treatment. (To be strictly accurate, there logically can't be any evidence, but don't worry, this can actually be quite useful).

Try my Extended Reattribution and Management Model (ermm): whatever they say, let them waffle on, then simply reply "You say that x...", and when the time's up, make another appointment.


ERMMs and OARS

OARS: How to convince a patient that you are understanding and sympathetic.
(Note: It is very important that they believe this).

1. Open Questions: Encourage them to waffle on about whatever they like (but not too much obviously, they will probably want to whinge) and don't ask detailed questions.

2. Affirmations: Imply you are listening sympathetically by saying things like "Oooh that must be horrible".

3. Reflective listening: Free Time/Verbal Ping-Pong.

4. Summarising: Repeat back what they have described using wording that subtly suggests it might not be real.



Further things you can try:

* Chat about depression and anxiety;

* Muse about the mind/body problem;

* Explain that we don't know everything and then confidently tell them there's definitely nothing seriously wrong with them;

* Latch on to them and make sure you become their doctor, then warn all the local doctors that the patient is only imagining they are ill;

* Book regular appointments as a cunning way to actually see less of them (obviously desirable);

* And - as always - if all else fails, stick 'em on Prozac.



REFERENCES
----------------

Dishonesty \Dis*hon"es*ty\, n. [Cf. OF. deshonest['e], F. d['e]shonn[^e]tet['e].]

1.Dishonor; dishonorableness; shame. [Obs.]
``The hidden things of dishonesty.'' --2 Cor. iv.
2.[1913 Webster]

2.Want of honesty, probity, or integrity in principle; want of fairness and straightforwardness; a disposition to defraud, deceive, or betray; faithlessness.
[1913 Webster]

3.Violation of trust or of justice; fraud; any deviation from probity; a dishonest act.
[1913 Webster]



Dr Mark Morris is a GP in Falmouth, Cornwall

Unlike Dr Sarah Myhill (currently under investigation for offering such people effective, evidence-based advice and treatments) may I presume his licence is not currently in question?
 

xrayspex

Senior Member
Messages
1,097
Likes
388
Location
u.s.a.
lmao thanks mark

ugh, I work parttime as a social worker and those OARS which is part of motivational interviewing (MI) is all the rage right now in certain parts of the states. the techniques can be useful to help facilitate conversation and William Miller is a big researcher and trainer of it in NM, Carl Rogers was the grandfather, forefather of some of these ideas but I don't think he intended them to be misused like this. I have had mixed feelings about it as a trainer I know is so passionate about it he wants all counselors trained in it rigorously and their sessions taped and then coded, yes they have a way of coding it to make sure the therapist or doctor or whoever is saying it exactly right in their reflection back to client, there is a "science" to it and its considered evidenced based (EB) supposedly, lots of research behind it. I havent heard of them using it in midwest to try to get out of treating cfs or fm patients but they are teaching it to clinicians in university hospitals and I have wondered how long until it does become sort of 1984ish way to manage costs. Where I see it used more is with people who need counseling for alcohol and drug problems to not make them defensive. But my concern is that it seems to me that it could be used to try to manipulate people to the therapists goals and not their own but make it seem like the client came up with the idea on their own. Its very irritating to me when I can tell my coworkers are doing it to me or other peers, feels condescending. We have had arguments about it at work and the funny thing is the top guy trainer proponent of it was trying to use it on me to talk me into how great it was and after a couple hours of that and he wasnt making headway he threw a tantrum and threatened me haha it was such poetic justice to watch......
 

Dolphin

Senior Member
Messages
17,555
Likes
28,239
Thanks Mark.

* Explain that we don't know everything and then confidently tell them there's definitely nothing seriously wrong with them;

* Latch on to them and make sure you become their doctor, then warn all the local doctors that the patient is only imagining they are ill;
Love it!
 

Mark

Senior Member
Messages
5,238
Likes
6,199
Location
Sofa, UK
Hi xrayspex, I liked your post, it provoked some very interesting thoughts which I then lost in posting my reply. :(. Try again...

No, it's gone. :( Damn, it was really good stuff too :D

Anyway: I loved your account of the therapist blowing up when you stood your ground: says it all for me. I totally agree that I find the approach condescending and irritating - I'll add patronising, insulting, dishonest. I have to say I'm coming round to the view that all these dishonest distortions of psychology are the root of so many problems in the world. It seems to me that any form of psychology that doesn't manage to be completely neutral in the model it projects on the individual, runs the risk of distorting that patient's reality with its own pet theory. In this case, if you go in with the idea that somebody is not really sick - of which you have no proof - and that they are somatising - of which there can be no proof that this happens - then these are the results you create. Even the very idea that this stuff exists means that I go in to see a doctor being completely unable to trust him/her, and that's the most insidious thing of all IMO. Our whole story may all be as simple as that: the errors of psychology and psychiatry. I think it's all probably an honest human error, in signing up to a seductive but wrong idea, but it's a catastrophic one. The latest moves on the horizon though, to expand all this movement, are really frightening and we must resist them. i wonder if our best strategy is to simply turn away from the system and not feed the beast, rather than taking it on directly. But I suspect we have to do both. This illness gave us a really good insight into how the world works though, I find myself taking some comfort in all that I've learned from this experience, even though that's small consolation really, but perhaps that depends on how we use that knowledge.

Welcome to the forums, see you around!

Mark



lmao thanks mark

ugh, I work parttime as a social worker and those OARS which is part of motivational interviewing (MI) is all the rage right now in certain parts of the states. the techniques can be useful to help facilitate conversation and William Miller is a big researcher and trainer of it in NM, Carl Rogers was the grandfather, forefather of some of these ideas but I don't think he intended them to be misused like this. I have had mixed feelings about it as a trainer I know is so passionate about it he wants all counselors trained in it rigorously and their sessions taped and then coded, yes they have a way of coding it to make sure the therapist or doctor or whoever is saying it exactly right in their reflection back to client, there is a "science" to it and its considered evidenced based (EB) supposedly, lots of research behind it. I havent heard of them using it in midwest to try to get out of treating cfs or fm patients but they are teaching it to clinicians in university hospitals and I have wondered how long until it does become sort of 1984ish way to manage costs. Where I see it used more is with people who need counseling for alcohol and drug problems to not make them defensive. But my concern is that it seems to me that it could be used to try to manipulate people to the therapists goals and not their own but make it seem like the client came up with the idea on their own. Its very irritating to me when I can tell my coworkers are doing it to me or other peers, feels condescending. We have had arguments about it at work and the funny thing is the top guy trainer proponent of it was trying to use it on me to talk me into how great it was and after a couple hours of that and he wasnt making headway he threw a tantrum and threatened me haha it was such poetic justice to watch......