The treatment of somatisation - reattribution skills

The model that we propose for the consultation has three distinct stages. These are outlined below:

1. Feeling understood

Take a full history of the pain:
It is essential to start from where the patient is at, but a the same time ask questions that may reveal key cues relating to mood. Useful techniques here are to a) go through a "typical day" and b) ask about associated symptoms.
Respond to mood cues:
Cues can then be responded to by clarification, the use of empathic comments and questions that probe mood state. it is important to remember to ask about biological symptoms. Also important at this stage are questions that:
Explore social and family factors:
Explore health beliefs:
what does the patient think may be causing the symptoms?
Finally in this first stage of the interview it is essential to carry out a brief focused physical examination. Unless this is carried out it may be very difficult to move on to the next stage.

 

2. Broadening the agenda

When all the information has been gathered, the stage is set for changing the agenda from one where the problem is seen essentially as physical to one where both physical and psychological problems can be acknowledged. The key elements in this stage are as follows:
Summarise the physical findings:
If any abnormality has been found but it does not (as is commonly the case) fully explain the patient's symptoms it should be mentioned and discussed honestly with the patient.
Acknowledge the reality of the patient's pain or other symptoms:
This is essential and must be sensitively done. many doctors find this difficult if they have not found anything abnormal on physical examination
Reframe the patient's complaint:
Remind them of other symptoms (especially the affective) and link them to life events if this is possible.

 

3. Making the link

There are a range of techniques that may be then used for making the link between the patient's physical and psychological symptoms. Only one or two will be appropriate for each patient and different techniques may be useful at different times.

a) Simple explanation

It not is sufficient to say that "anxiety causes headaches". A three stage explanation in which anxiety is linked to muscle tension which then causes pain is required. A similar approach can be used to explain how depression causes lowering of the pain threshold which results in pain being felt more severely than it would in a euthymic state.

b) Demonstration

Practical demonstration could involve for example asking a patient to hold out a heavy book on an outstretched hand to show how tension causes pain, however, simply reminding the patient of when something similar has happened eg: carrying heavy luggage, is usually sufficient. Information from the "typical day" can be used to link pain with stressful life events. Information about how the patient is feeling, both in terms of mood and pain/physical symptoms in the "here and now" during the interview can be used to link mood state with symptomatology. Two final techniques involve exploration of illness in other family members.

c) Identification

Other members of a patient's family may have experienced similar symptoms at the time of life threatening illness and the significance of the present symptoms can be explored in terms of their "special meaning" to the patient.

d) Projection

It is often easier to understand psychological mechanisms which occur in others and if other members of the patient's family have experienced physical symptoms when clearly under stress, the significance of this link may be used to draw helpful parallels with their own situation.

Clearly this is not a totally comprehensive model as further techniques are now required to help in the management of the symptoms themselves eg: cognitive techniques to cope with pain, anxiety management etc.

 

4. Negotiating treatment


Detection skills

Patients come with problems, not diagnoses.

Beginning the interview.

NB:

Sources of information

Management skills


Summary: the structure of problem based interviewing

Feeling understood
  1. Take a full history
    • elicit other associated symptoms
    • ask about a typical pain day
  2. Respond to mood cues
  3. Clarification
    • empathic comments
    • probe mood state/thought content
  4. Explore social and family factors
  5. Check for biological symptoms
  6. Explore patients health beliefs
  7. Specific example
  8. Scale
  9. Carry out focussed physical examination
Changing the agenda
  1. Feed back results of physical examination
  2. Acknowledge reality of pain
  3. Reframe the patient's complaint
  4. summarise psychological symptoms
    • remind them of mood symptoms and link to life events
    • negotiate: "I wonder if..."
Making the link

Mood/pathogenesis/symptoms

  1. Between anxiety and physical symptoms
    • "uptight" and muscle tension
  2. Between depression and physical symptoms
    • how depression can lower pain threshold
  3. How symptoms can make you feel more depressed - the vicious cycle
  4. By practical demonstration - how tension can cause physical pain
    • holding a book
    • carrying heavy luggage
  5. To life events - how symptoms related to life events 
    • link with mood or stressful events
    • "typical day"
  6. Linking in the "here and now"
    • "how are things today/now/at this moment?"
  7. With illness in other family members or significant others
    • by explaining shared symptoms (identification) - symptoms may be learned from significant others
    • by explaining shared illness behaviours (projection) - special significance of symptoms in relation to the history of significant others
  8. How symptoms might have occurred before during stress

Keeping a record

Microsoft Word document PBI symptom record sheet


Teaching problem based interviewing

Assessment and management of medically unexplained symptoms

When no diagnostic label is applied (2010)