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At the heart of general practice since 1960

Explaining the unexplained to patients

Somatic symptoms unexplained by an identifiable disease form a substantial proportion of all doctors' work. An estimated 20 per cent of new inceptions of illness in primary care ­ and as many as a third of all medical outpatients ­ have symptoms inadequately explained by relevant organic disease.

Existing terminology is unsatisfactory when describing the psychological process implying a transformation of psychological distress into somatic symptoms. Although the widely-used term for this is somatisation, 'functional symptoms' is more acceptable to patients.

In our culture patients often assume symptoms without organic basis are somehow 'unreal' or 'all in the mind'. Patients may also have a sense of blame and stigma ­ the price we pay for the unhelpful mind-body split (see box below). Patients often refer to 'stress' and this can provide an appealing metaphor for the interplay of psychosocial stressors and physical processes.

These issues of terminology and patient response have assessment and management implications, especially for the way a consultation is conducted and what the GP tells the patient.

It is also important to remember medically unexplained syndromes are not discrete entities. Studies show syndromes often overlap. For instance, 70 per cent of patients with debilitating fatigue lasting more than six months also have diffuse muscle pain (fibromyalgia or chronic widespread pain). Similar overlaps occur between irritable bowel syndrome, atypical non-cardiac chest pain, chronic fatigue and gynaecological syndromes.

Apparent differences between syndromes are usually the result of artificial distinctions made on the basis of presenting complaint, physician interest and service configuration.

The consultation

The key to detection (and preventing iatrogenic factors from prolonging the duration of disorders) lies in the GP consultation. Vital steps are to:

 · Summarise the case notes.

 · Identify illness attributions ­ 'What do you think is causing the symptoms? What is your worst fear when you have the pain?'

 · Elicit a detailed illness history, such as history of explained or unexplained physical illness, childhood illness or illness of parents and the impact on childhood development and schooling.

 · Ask about life events and difficulties ­ 'Have you had any recent setbacks in your life?' Sensitive wording will be needed for questions about issues such as divorce, work or family and childhood, especially quality of parental care and early experiences of abuse.

 · Ask about mood ­ 'Have you been feeling anxious or depressed recently?'

 · Compile a comprehensive list including physical, psychological and social problems.

 · With the patient's consent, involve a relative or key other in the assessment, asking questions such as: 'What impact is the patient's illness having on them?'

 · Inquire about disability ­ 'What impact have your symptoms had? Are you having problems at work?'

 · Take a thorough medication history including why medications are being taken.

 · Share a preliminary formulation with the patient of what you understand.

Physical examination

Each patient should be examined for new symptoms but if somatisation is suspected the purpose of the examination should be explained.

With established problems, patients may repeatedly request physical examinations. Try to avoid reinforcing health fears by initiating examinations yourself ­ only perform physical investigation when necessary and always give the patient an explanation.

Agree on the time when investigations for a particular symptom should stop.

Breaking the news

Research shows patients value explanations that:

lprovide a tangible basis for the symptoms

lexculpate the patients from any blame

lempower patients by indicating what they can do to help themselves ­ for instance by relaxation or exercise, or by just accepting or tolerating the symptoms.

Explanations must make sense to the patient. A good explanation will incorporate metaphors a patient understands rather than medical terms that are meaningless to them. Telling a patient 'nothing is wrong' will fail to satisfy their need for explanation and a patient is likely to escalate their presentation, presumably in an attempt to engage the GP.

When to refer

Patients with severe psychiatric disorder ­ features of a personality disorder or marked functional impairment ­ or who are at risk of suicide, are likely to need specialist psychiatric assessment. Patients with a persistent fear of illness, or an anxiety disorder or depression not responding to conventional treatment, may also benefit.

Some patients see their GP regularly with numerous, longstanding physical symptoms, often having consulted various specialists.

These patients may be demanding but can be managed effectively so physical functioning is improved and health care costs are reduced.

Assessment by a psychiatrist, followed by shared care with a family doctor, is recommended for the long-term management of patients with these chronic medically unexplained disorders.

Available treatments

Once patient and GP have agreed psychological distress is an important factor they can start to examine the management options. Even if the patient has significant disease it is important to identify and manage psychological co-morbidity.

Continuity of care is important as repeated physical examination and investigations during follow-up may only serve to reinforce abnormal illness behaviour and health fears.

Antidepressants

Randomised controlled trials suggest antidepressants can be useful in the treatment of patients with medically unexplained symptoms whether or not depression is present. Before starting antidepressants it is important to explain to the patient the drug is not being used primarily to treat depression but to help 'damp down' their awareness of physical symptoms.

Treatment should start with a low dose of the drug to be increased gradually (usually at weekly intervals) according to response. For instance amitriptyline could be increased in weekly increments from 10mg to a dose of up to 25mg that the patient can tolerate.

Benefit is usually seen within one to seven days of starting treatment ­ before any antidepressant effect would be expected to occur. Patients should be told about the importance of taking the treatment regularly.

Psychological treatments

Cognitive behavioural therapy is widely advocated for patients with medically unexplained symptoms. This form of psychotherapy is usually brief and is concerned mainly with helping the patient overcome identified problems and obtain specified goals.

The therapy encourages self-help techniques, such as relaxation and self-management of stress and anxiety.

Patients may keep a diary of symptoms, thoughts and evidence 'for' and 'against' the existence of a serious physical cause for their symptoms. 'Maintaining factors' such as repeated body checking are discouraged and patients' negative or false beliefs about symptoms challenged.

A large number of studies have shown physical symptoms improve to a greater extent in patients treated with cognitive behavioural therapy compared with patients in control groups.

Another form of psychotherapy is interpersonal therapy, but this may need to be carried out in a specialised centre.

Several trials have also shown the benefits of hypnosis in patients with medically unexplained symptoms. But patients with high levels of psychological distress are less likely to respond than those without overt symptoms.

Group hypnosis appears to be equally effective as individual hypnosis, provided patients agree to this kind of treatment.

Prognosis

The overall prognosis for the majority of patients with medically unexplained symptoms is very good. In approximately 70 per cent of patients symptoms spontaneously remit within a few months of presentation. Other patients will adapt and find ways to cope with their symptoms.

A poor prognosis is associated with the following factors:

 · History of somatic symptoms of two years or more

 · History of childhood physical or sexual abuse

 · History of psychiatric disorder

 · Ongoing severe psychosocial stressors.

In chronic fatigue syndrome, poor prognosis is associated with a belief the condition is

caused by a virus. In irritable bowel syndrome poor prognosis is associated with atypical symptoms, such as a focus on abdominal pain.

Managing chronic somatisation

 · Be proactive ­ see patient at regular, fixed intervals

 · Draw up list of psychosocial problems

 · Negotiate graded withdrawal of unnecessary drugs

 · Treat coexisting psychiatric disorders

 · Minimise contact with other specialists ­ too many practitioners makes care diffuse and risks iatrogenic harm.

 · Interview a close relative and try to involve them in the management plan

 · Try to reduce expectation of cure ­ aim for damage limitation and talk

in terms of 'coping'

During the consultation try to:

1 Use metaphors to explain to the patient

Contrast the ways two doctors, Dr X and Dr Y, told patients that, despite their menstrual symptoms, no disease was present. By indicating no tangible physical mechanism that might underlie the symptoms, Dr X risks the patient thinking he regards her symptoms as 'all in the mind'. Dr Y uses a physical metaphor that

will make sense to the patient to 'explain' how symptoms can arise in the absence of disease.

Dr X 'There's nothing wrong inside. We've had a look and your womb is perfectly normal.'

Dr Y 'The womb is like a finely-tuned machine, which means the problem with your periods is really a problem with the fine control of the way your womb is working. And we know there is a very fine hormonal control on how your womb is working and how heavy your periods are. Unfortunately, sometimes it tends to give up, and that's when your periods tend to get too heavy.'

2 Give meaningful reassurance

This GP thought the patients' symptoms were not caused by any physical disease. However, he gives reassurance that appears to reject the patient's symptoms and disregards the patient's cue to provide a better explanation. The patient then escalates her presentation. The GP offers to repeat the tests ­ even though the patient has not asked for this.

Patient So I've just come for my results for the scan and blood test.

GP Everything looks a mystery to me at first till I consult the

computer! Right, right....the blood tests are perhaps easier

because I think they are normal.

Patient That's strange.

GP A little bit of a rise in your ESR but it's not,

you know, it's not significant, ESR....

Patient I've been getting more problems.

GP Like what?

Patient Pains in my fingers, goes from my knuckles to the tips of my

fingers and then my knee and my wrist and my elbows.

GP Well I think we ought to.... redo the tests in an interval because

it might be that we've shot our bolt too early, pre any changes

....pre changes....ESR, erythrocyte sedimentation rate

3 Share a preliminary formulation of what you understand

'Let me see if I've got this right. You have experienced a lot of fatigue and muscle pain in the last six months and have had to give up your regular gym classes. But you also told me you've not been sleeping, had poor concentration and feel panicky in situations like shops and crowds.

All these symptoms have been worse since you took on more responsibility at work and became upset after you fell out with your line manager.

Have I got that right?'

Useful websites

for patients

National electronic Library for Health:

www.nelh.nhs.uk

Irritable bowel syndrome:

www.iffgd.org

Dysfunctional breathing and hyperventilation:

www.physiohypervent.org

Health worries:

www.healthanxiety.com

Chronic pain:

www.painsociety.org

Christopher Bass is consultant in psychiatry at the John Radcliffe Infirmary, Oxford

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