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 understood
One 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 investigations
For 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 resistance
You 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.
Fluoxetine has been shown to be effective in MUS Fluoxetine has been shown to be effective in MUS
