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At the heart of general practice since 1960

Clinical casebook

Solving the

puzzle

of chronic

somatisation

Dr Tanvir Jamil takes a candid view of diagnosis and management

Case history: 56-year-old Susan sees you for the third time this week. She has a history of depression, and of aches and pains all over. She refuses to take antidepressants as they may be addictive, but has been on diazepam 2mg every day to 'calm her nerves'. She reads Colonic Irrigation Weekly and thinks her problems may be caused by 'yeast'.

Tanvir Jamil is a GP in Burnham, Bucks

What can I do about Susan?

What do you think you should be doing?

No, please don't go into your Socratic questioning mode again. Can't you, just this once, tell me what to do? It's Christmas, after all.

That reminds me ­ where's my present? Anyway what makes you think I know what to do with her? It was me who suggested that she see you in the first place.

OK ­ you're not going to give me a straight answer, but where do I start?

What do you think about when you hear her name?

I'm not sure what you mean.

Let me give you an example. I know this very nice mother of two ­ she's bit of a rough diamond. She reminds me of the film My Fair Lady. What film does your patient remind you of?

Enter the Dragon?

Maybe we should think about how she makes you feel?

Pretty frustrated and a tiny bit guilty as well.

That's why patients like this are the ultimate test of your mettle. Chronic somatisation does not fit well with our acute illness model. You have to think about her problem as a chronic disability and a puzzle in mind-body linkage. So what's the key goal in treating her?

Apart from getting her out as soon as possible? Well, I think it would be relief of her suffering?

Yes. For that you need to get to know her feelings and values.

I wanted to sort her out quick, not keep her talking until New Year's Eve.

If you really want to help her, you'll have to discover the key features of her life.

I can see the problem already ­ her IQ. It's barely above room temperature.

Don't let that stop you asking about her ideas, concerns and expectations ­ ICE.

Why can't we ever have a tutorial without mentioning ICE?

Because ICE actually works. Calm down. Look, breathe into this paper bag and then tell me what you're going to do next.

I think I should empathise with her by saying something like: 'Feeling as bad as you do, still not knowing what to do about it, must be frustrating. I can understand how hard that must be.'

That's it. Take your time. Perhaps you should make a 'contract' to see her every week for 10 minutes, which may stop her shopping round the other GPs in the practice?

What about investigations and treatment goals?

Don't let her anxiety push you to request unnecessary tests. The pace of care for somatising patients is much slower than that for patients with other conditions. You might even want to invite her to observe with you the ways in which escalation of symptoms might link with mood. My main aim would be to try shifting treatment goals to rehabilitation and to regaining and maintaining function.

She keeps asking me for painkillers.

A good way to give medication is for a specified time only. Then judge its effectiveness by how well it improves her function, not by its ability to reduce her symptoms. If it does not improve her function, stop the medication. Remember to support her efforts.

She keeps waving the colonic irrigation magazine in my face and talking about toxins and yeasts. I don't believe in any of that, but I'm tempted to say something positive just to end the consultation.

Don't collude with her. You have to be honest. If you don't believe a treatment works or it may be harmful, you have to explain why you feel that way. But always have an initial curiosity towards patients' ideas about treatment, don't discount them straightaway. Sometimes they are excellent.

Actually, I was curious about the colonic irrigation until she showed me pictures of hose pipes. Here's another dilemma I have. What do I call Susan's problem? I don't want to use any 'wastebasket diagnoses' such as 'post-viral fatigue' or 'a little arthritis'.

You're right ­ those kind of labels often lead to misconceptions. What about something like 'heightened somatic awareness?'

Did I mention her IQ wasn't that high?

'Protracted fatigue?'

Er, never mind ­ maybe we'll just not use a label after all. I've heard that a positive mental attitude is also important.

Yes you should definitely try and keep positive when you see her.

I meant her positive mental attitude.

Absolutely. Get her to think about her condition from a different point of view. Help her become aware of the negative things she says and substitute new thoughts. For example, rather than 'I'll never be able to do that', she should start

to think 'I can do that if I take things slowly'.

I suppose it might help also if I had help from our in-house physiotherapist or even an occupational therapist?

Now you're sounding much more positive ­ remember suffering is a function of the person of the patient, not of her organs.

That's very sage-like ­ thanks. By the way I've thought of another film she reminds me of ­ Chitty Chitty Bang Bang.

You're thinking of colonic irrigation again. Merry Christmas. And a very happy new year.

Tanvir Jamil is a GP in Burnham, Bucks

Key points

· Somatisation needs to be viewed as a chronic disability

· Get to know the patient's feelings and values about their illness

· Avoid unnecessary medications, tests and referrals

· Concentrate on maintaining or regaining function

· Encourage a positive mental attitude

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