Psychosomatics 43:93-131, April 2002
© 2002 The Academy of Psychosomatic Medicine
Assessment and Treatment of Functional Disorders in General Practice: The Extended Reattribution and Management Model—An Advanced Educational Program for Nonpsychiatric Doctors
Per Fink, Dr.Med.Sc.,
Marianne Rosendal, M.D., and
Tomas Toft, M.D.
Accepted November 13, 2001. From the Research Unit for Functional Disorders, Psychosomatics and C-L Psychiatry; Research Unit for General Medicine, Aarhus University Hospital, Aarhus N, Denmark. Address correspondence and reprint requests to Per Fink, The Research Unit for Functional Disorders, Psychosomatics and C-L Psychiatry, Aarhus University Hospital, Barthsgade 5, 1, DK-8200 Aarhus N, Denmark; e-mail: flip{at}aaa.dk Translation: M.L. Pold.
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Introduction
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Physical symptoms with no organic basis should generally be regarded as a mechanism that allows humans to respond to stressors in the same way that anxiety and depression may reflect distress. Treatment of patients who present with such symptoms is often difficult, and some patients have even been conceived to be "troublesome." As a physician, one evidently wants this group of patients to share the treatment options and quality of care offered to patients without such symptoms. The objective of The Extended Reattribution and Management (TERM) model presented here is to assist the process of improving our treatment options for this group of patients and prevent inappropriate illness behavior.
The Research Unit for Functional Disorders, Psychosomatics and C-L Psychiatry, Aarhus University Hospital, Denmark, has developed an advanced educational program for assessment and treatment of functional disorders in general practice in cooperation with the Research Unit for General Practice, Aarhus University, Denmark. Associate Professor L. Gask, of Manchester University, United Kingdom, has provided important advice in the process of developing the program.
The program consists of this manual and an intensive course that joins the various elements in hands-on training. Course participants also receive separate training materials (see below).
The primary target group is physicians in primary care or general practice, but the program could probably also find good use in other areas. Hence, it has been recently used for physicians in social medicine. Furthermore, the training techniques can be used both in the everyday clinical practice and in the treatment of psychiatric disorders other than somatization.
The project is developed in connection with the Prevention of Functional Disorders and Abnormal Illness Behavior in General Practice study, which is an interdisciplinary cooperative effort that includes the participation of The Research Unit for Functional Disorders, Psychosomatics and C-L Psychiatry, Aarhus University Hospital; and The Research Unit for General Practice, The Department of Ethnography and Social Anthropology, and The Department of Psychology, University of Aarhus, Denmark. (The FIP study is financed through a governmental research council program set up to enhance interdisciplinary research: Sundhedsfremme og forebyggelsesforskning, which is a program under Tværrådsligt program for Sundhedsforskning (grant number 9801278) and the Quality Improvement Committee for General Practice in Aarhus County.) The program was developed in close cooperation with a second study, Somatizing Patients in General Practice, which originates from the Committee for Quality Improvement in General Practice in Vejle County and The Research Unit and Department for General Practice, University of Aarhus, Denmark. (The study was financed by the Quality Improvement Committee Q2 in Vejle County, Vejle Amts Lægevidenskabelige Forskningsfond, Fonden vedr. finansiering af forskning i almen praksis og sundhedsvæsenet i øvrigt, Praktiserende Lægers Uddannelses- og Udviklingsfond, and the Sara Kirstine Dalby Krabbes foundation.
We wish to express our gratitude to the professor in primary care, Frede Olesen; primary care physicians, Hans Kallerup, Jette Schjødt, Sven Ingerslev, Mogens Tuborgh, Annette Vibæk Lund, Marthin Holm, Kaj Sparle Christensen, and Jette Møller Nielsen; associate professor Laurits Ovesen (deceased); psychiatrists Emma Rehfeldt and Lene Søndergaard Nielsen; and psychologist Lisbeth Frostholm for reading, commenting, and actively participating in TERM model development, as well as Ph.D. of psychology Lisbeth Bindslev and senior lecturer Morten Pilegård for linguistic revision of the text.
The educational program is based on the Reattribution Model, developed by David Goldberg and L. Gask in Manchester during the early 1980s and later extended by L. Gask. The model has been tested in different studies,1–11 which have indicated that it may be instrumental in improving physicians' communication skills and reducing the use of health care services.
We have changed and modified the Reattribution Model somewhat, and we have also added new elements. The name has therefore been changed to TERM model. The most significant modifications are as follows:
- A general interview technique has been incorporated into the model.
- A clearer discrimination is made between the different principles. For example, we emphasize only the use of active listening and assessment during the first phase. Many physicians tend to be overly "efficient," to give advice and offer explanations too quickly, which is very inappropriate when dealing with somatizing patients.
- Questions about mental illness, functional level, and expectations of treatment, etc., have been added as independent items.
- The biological basis of somatoform disorders is now central to the explanatory model.
- We have added a guide for follow-up treatment.
- We have added a guide for treatment or management of subacute and chronic somatizing patients.
- The project and the educational program are described in detail for documentation purposes.
This educational program focuses on diagnosing and treating patients with functional disorders. However, quite a few of the methods taught are general and may be used to good effect in other mental disorders and in everyday clinical practice. Several comprehensive programs have been developed for the treatment of depression in primary care12 and of alcohol and substance abuse.13
The section below describes the aim and structure of the course. If you read the material as part of course participation, you may omit these sections and continue reading from Chapter 1.
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Aim
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The project's main aim is to offer physicians in general practice an advanced course in the diagnosis and treatment of somatizing patients in a form acceptable and practicable to a broad section of primary care physicians. The course will cater for the training needs of those physicians who are least experienced in these fields in particular, but all participants will be able to profit from the training, irrespective of their qualifications.
The practical limits were discussed and defined when developing the course. First, most physicians were assumed not to be able to spend more than 2 days for a residential course and three–four evening sessions during a month. Second, we presumed that the physicians would be compensated for the loss of earnings due to course participation. Finally, the model was designed to allow its implementation in everyday clinical practice without exceeding prevailing time and financial constraints.
However, it is hardly realistic within this framework to train physicians who are not psychiatrists to master the diagnosis and treatment of all aspects of functional disorders; therefore, we decided to focus the training on special themes and not to use techniques that involve the use of schedules, diaries, etc. Diagnosis and treatment of depression and anxiety disorders are briefly described. In other words, we decided to develop what we believe is a complete program for the treatment of somatizing patients in general practice. It is not the intention that all participants master all the elements of the model; it will be satisfactory if they learn to master parts of the program. We hope that this will inspire the participating physicians to keep working with the program and that some of them will become interested in continuing the process in other postgraduate courses. We also hope that the participants will appreciate the broader purpose the techniques may serve, including their potential use in the treatment of other than functional disorders, be they well-defined physical diseases or other psychiatric disorders.
The educational program has three main aims:
- Mediation of knowledge about functional disorders—etiology, epidemiology, diagnosis, and treatment.
- Giving physicians proficiency in (1) general interview technique and (2) specific principles for treatment of functional disorders. The main focus is on quite simple techniques, which all physicians, in principle, should be able to learn, and which most can master. Our focus is on cognitive, behavioral, and "administrative" techniques—we do not directly teach the use of traditional psychoanalytical techniques such as transference and countertransference. The techniques are mainly trained through specific microskills training.
- Change of attitude, because psychiatric disorders and especially functional disorders are still stigmatizing conditions. Some patients with functional disorders are severely disabled and in great emotional pain because of their illness. This involves great costs for society, not only due to increased health care costs but also through lost working years, early retirement pension, and other social expenses. Failure to diagnose and treat these conditions may have severe consequences for patients. This program seeks to initiate a change of attitude toward patients with functional disorders, to ensure that functional disorders are treated as seriously as other disorders and that the patients receive the same comprehensive treatment as other patients. The time constraints on the course made it necessary to strike a balance between, on one hand, reducing theory to a basic but sufficient level to allow physicians to feel confident and articulate about the nature of the psychiatric conditions while treating the patients and, on the other hand, focusing on practical case-driven exercises.
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Overall Structure
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The program consists of a 2-day residential course (16 hours) followed by three–four evening courses (2 hours' duration) with an interval of about 1 week, one booster meeting (2 hours) after 3 months, and, finally, a facilitator visit to the physician's practice (1 half-hour) after 6 months.
Instructional materials:
- The present manual describes in detail the latest research about functional disorders and the treatment model in theory and practice.
- A work folder for the participants with detailed instructions for each exercise, including concrete suggestions for the wording of questions, case notes, copies of overheads from all presentations, TERM model memory cards, advice on how to manage chronic conditions, and diagnostic guidance.
- A teacher folder with the same contents as the participant folder, overheads for each theoretical presentation, and the matching speaker's notes as well as a guide to group supervision.
- Instruction for actors (four case stories).
- A video with examples of the different techniques produced by L. Gask.
The materials can be ordered or downloaded from homepage: www.auh.dk/cl_psych/dk/index.htm.
Structure of the Residential Course
The residential course lasts 2 whole days. It consists of four 3-hour modules. The sequence of the modules can be seen in Figure 1. The first day starts with a general introduction and a 30-minute workshop about the participants' own experiences and expectations.
Round of Introduction and Workshop about Personal Experience
After the general introduction, the participants gather in training groups, which are organized in advance. The groups consist of 6–10 physicians, 8 being the ideal number. Each group has two supervisors (a physician and a psychiatrist). Group participants introduce themselves, and the participants are encouraged to formulate their own needs and expectations from the course. The supervisor's main focus is to create a relaxed environment to encourage confidence and good learning skills.
Introduction to Exercises and Theoretical Presentation
The participants meet for plenary sessions in which they are introduced to the exercises and theoretical presentations. The preliminary introduction is followed by a 5- to 10-minute introduction video designed to make participants feel more relaxed and comfortable. After each exercise has been introduced, participants watch a short instructive sequence from the video "The Reattribution Model" by L. Gask.
The theoretical presentations cover the following subjects:
- The somatization concept (definitions and clinic)
- The patient's illness beliefs
- Latrogenic factors
- Etiology and epidemiology
Each presentation comes with a set of overheads with matching speaker's notes and precise instructions about what information goes with each overhead and notes referring to relevant pages in the TERM folder as well as relevant articles. The teachers are encouraged to use their own words, to facilitate discussions, and to welcome comments from the audience.
Hands-On Exercise
Prior to the first exercise, the participants receive careful instruction, both verbally and in writing, about the principles of the exercises and rules for feedback. Seven minutes are allotted for the interview and 5 minutes for feedback for each of the four exercises in each module. Two participants are selected to take turns in interviewing an actor in a separate video room. The physician who is not conducting the interview will act as an observer. Only the first interview is recorded on video. The actor is instructed in advance and has received the patient presentation with which the other participants are working. If the participants are divided into more than one group, the actors will alternate between the groups for each exercise.
The other participants work in pairs, taking turns in being "doctor" and "patient." After each module, the participants pair up with new partners.
A written exercise instruction is handed out. The "doctor's" instructions contain an outline of the items to be given special attention and some suggestions for the wording of questions and answers. The "patient" receives a case story and instruction on how he or she should react in specific situations. The roles are reversed after 15 minutes and a new case story is handed out, although the "doctor's" instructions remain the same. Four case stories are used and extended as the exercises progress.
The supervisor is available during the exercises, and he or she may intervene to give advice. The groups are encouraged also to take time out when something is difficult. The time out may allow the "doctor" to discuss alternative approaches and wordings with the "patient" and the supervisor and to test these at once.
Group Supervision
A period of 30 minutes is allotted for supervision of each video in groups of eight participants. Group supervision is performed according to a set of rules designed to guide supervisors through the process. The exercise is based on the training of microskills or training of special skills and adopts a mainly cognitive approach that focuses on concrete wording.
Evening Meetings
The supervision groups formed during the residential course meet again for weekly evening meetings three–four times. For each meeting, the participants will bring a video recording of a consultation with one of their own patients. It is possible to supervise two recordings at each meeting, which allows each physician to have at least one recording/consultation subjected to joint supervision. The physicians are encouraged to focus on a specific TERM model theme.
Booster Meeting
The booster meeting, held 6 weeks after the last evening meeting, allows the group and the supervisors to discuss their clinical experience with TERM model use.
Facilitation
After 6 months the participating physicians receive a visit in their practice. The person who visits them is a colleague (facilitator), who has been introduced to the educational program but has not necessarily been a teacher. The visit takes about a half-hour and is designed in particular to assess with the physician the incentives, barriers, strengths, weaknesses, opportunities, and threats in connection with daily clinical TERM model use. Three months later, the physicians receive a letter describing the collective experience gained from the facilitator's practice visits.
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Training of Supervisors
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The project saw the formation of a team of teachers that consisted of six physicians and four psychiatrists. The physicians all had previous experience from teaching and supervision of colleagues. It was found inexpedient to use psychologists as teachers, because the target group was physicians and the subject demanded both general medical knowledge and knowledge of everyday clinical practice.
Three of four psychiatrists had received formalized psychoanalytic psychotherapeutic training, and all had extensive experience or had received formalized training in group therapy. Two of the psychiatrists had received cognitive therapeutic training.
The supervisors were trained at a 3-day workshop, during which all elements of the program were presented and trained. This allowed us to change some of the elements and to add or leave out minor themes during the practical testing. On the first day, L. Gask conducted training in the supervision of groups based on experience derived from training English physicians in the Reattribution Model.
The teacher group had primarily received analytically oriented psychotherapeutic training, and the focus was therefore primarily on the cognitive elements and practical aspects of the training on the basis of the rehearsal of microskills. In the supervision of the physicians, emphasis was given to avoiding some of the central themes in psychoanalytic theory, namely transference and countertransference, and to showing utmost caution when addressing the physician's own emotions toward patients. Furthermore, it was emphasized that the program primarily focuses on the cognitions of the patient and only secondarily on the patient's emotionality. Emphasis was given to this particular aspect to facilitate physician learning by relying on the classical skills training paradigm, avoiding the reluctance and anxiety that could otherwise result among participants who were not inclined or motivated toward analytical approaches.
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The Danish Health Care System
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The Danish Health Care System is almost entirely financed via taxes, and all medical treatment, including psychiatric treatment, is free of charge. All Danish inhabitants are covered by public health care and can choose to belong either to Group I or II. Everybody who belongs to Group I is part of a general practitioner listing system. People who belong to this group are registered with one general practitioner and cannot freely seek another. If it becomes necessary to receive specialized treatment, including admission to a hospital, the patient must usually obtain a referral from the general practitioner or the on-call physician. However, this rule does not apply to emergency situations and when patients wish to seek treatment by a general eye or ear, nose, and throat specialist. Physicians on an alternating schedule (on-call doctors) handle off-hours visitation and treatment. All medical treatment is free for persons who belong to Group I. People who belong to Group II are not registered with one physician and can freely choose among physicians. They can also receive treatment from specialists without a referral. However, they have to pay part of the costs of the consultation themselves; 98% of the population belongs to Group I. All patients must pay some of the costs of the medicine they may need, and they must also pay part of the costs for examination and treatment by dentists, chiropractors, physiotherapists, psychologists, etc.
Physicians are paid by the public health care service. They receive a fixed yearly amount for every person listed with their practice and an amount for every consultation and the associated services.
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Testing the Program
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The effect of TERM model training of physicians is being tested in two randomized controlled studies that include 80 physicians and approximately 4,000 patients from Aarhus and Vejle County. The patients and physicians will be followed for 1–2 years to evaluate the effect of the intervention on the patients' health and use of health care. The results are not yet available, but the participating physicians were very positive when evaluating the course both immediately after the course and during the practice visits 6 months later.
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Chapter 1: Background and Etiology
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Background
Epidemiology and Presentation of the Problem
Studies that have used standardized psychiatric interviews have shown that at least 20%–30% of consecutive patients who consult their family physician suffer from a psychiatric disorder.14–16 Furthermore, psychosocial factors are often more important for the course of a given physical disease and the use of health care than the severity of the disease itself when judged by biomedical data,17–24 and the physician only diagnosed a psychiatric disorder in about half the cases.24–25
The most frequent mental disturbances in general practice are somatoform disorders, depression and anxiety.14–16,19,24–27 These disorders have a significant comorbidity. Thus, approximately 50% of all patients who have a somatoform disorder (according to ICD-10 criteria) also have another mental disorder, usually depression and/or anxiety.28 The essential characteristics presented in somatizing conditions are functional symptoms, that is, physical symptoms that may indicate a physical disease but for which there are no adequate organ pathology or pathophysiological explanation.28
About one-fourth of all patients seeking treatment in primary care are reported to suffer from a somatoform disorder according to ICD-10 criteria, and many more seek treatment for medically unexplained physical symptoms.19 In a United States study of the 25 most prevalent physical symptoms among patients who sought treatment in an internal medical outpatient clinic, less than 10%–15% of the cases presented with symptoms that could be attributed to a genuine physical disorder.29 It would hence seem to be the exception rather than the rule in primary care for physical symptoms to be caused by organ pathology or pathophysiological disturbances. (See TERM model objectives and Definition of somatizing conditions and functioning disorders:.)
According to general population studies, most people experience physical sensations and symptoms every day. Physical sensations are therefore to be regarded as normal phenomena.30
Patients with somatoform disorders have an excessive use of health care services both in primary care and in the specialized health care sector.31 Chronically somatizing patients will, over time, often have gone through numerous hospitalizations, operations, and futile treatments with the impending risk of being exposed to iatrogenic harm. Somatoform disorders are thus very costly not only to society but also to the patients because of the suffering inflicted on them.
Classification of Patients Who Present with Functional Symptoms
Below, physical symptoms without organic basis will be referred to as "medically unexplained or functional symptoms." These terms are used synonymously with somatization.
The term is thus only used descriptively without inferring a causal relationship. Somatization is to be regarded as a continuum that ranges from mild conditions that are difficult to discern to serious conditions that cause the patient to suffer and make him or her seriously ill.
The Canadian psychiatrist McDaniel has suggested a broader and more apt definition of the overall somatization concept, "[a] process whereby a physician and/or a patient or family focuses exclusively and inappropriately on the somatic aspects of a complex problem."32
Somatoform disorders form the main class of psychiatric disorders of the ICD-10 and DSM-IV, and they include most somatizing conditions. Somatoform disorders are usually subdivided into somatization disorder, hypochondriasis, somatoform autonomic dysfunction, and somatoform pain disorder, etc. Other somatizing conditions are found among the group of dissociative disorders, neurasthenia, elaboration of physical symptoms, and factitious disorder, including Münchhausens' syndrome. According to the ICD-10 criteria, a somatoform diagnosis requires an illness period of at least 6 months, which makes the classification less useful in primary care.
A more simple classification more suitable for primary care is found in Table 1.
Acute functional symptoms are medically unexplained transient symptoms, and the patients are easy to reassure. Such reactions are frequent in strain and stress.
Subacute functional symptoms include conditions where symptoms have been present for less than 6 months but where it is difficult to reassure the patients or they can only be temporarily reassured. This program is designed such that patients who seek treatment more than once because of functional symptoms (lasting less than 6 months duration) will be classified as having subacute symptoms.
For a somatizing condition to be classified as chronic, the patients must have complained of medically unexplained symptoms for at least 6 months. The condition may be further subdivided according to whether the patient presents with multiple symptoms—most often from numerous bodily systems (multisymptomatic)—and patients with only few symptoms or with a symptom picture focused on a single organ system or symptom pattern (oligosymptomatic). A multisymptomatic illness picture should, however, be observed over a certain period of time, because the patient may focus his or her complaints first on one symptom pattern (e.g., "gastrointestinal disorder") and then later shift his or her focus to another pattern of symptoms (e.g., "cardiopulmonary disorder"), which at the time of the examination may present as oligosymptomatic.
The group of chronic somatizing conditions also includes the diagnoses of complex syndromes such as fibromyalgia and chronic fatigue syndrome. The nosologic status of these syndromes has not been settled yet, because some physicians hold the opinion that a specific organic basis of the symptoms has still to be found. However, existing scientific evidence strongly suggests that these syndromes are artificially created and the majority of the patients have to be regarded as chronically somatizing.
Physical symptoms related to other mental disorders (also called facultative or presenting somatization): In most mental disorders, the patients primarily present with physical rather than emotional symptoms36 as seen in 50%–90% of the cases of depression. Please refer to Table 2 and Table 3 for the most common physical symptoms in depression and anxiety.
The prominent physical symptoms in mental disorders make it only natural for patients to fear that they suffer from a physical disease. However, contrary to "true somatizers," facultative or presenting somatizing patients will accept the correct diagnosis of a mental disorder as opposed to a physical disease.
Illness worry, illness aggravation, and pathological illness behavior in physical disease: This group of symptoms is poorly defined, because we still lack thorough knowledge about the interaction between illness behavior and the emotional reactions to illness. Patients in this group suffer from a verifiable physical disease. However, there is a discrepancy among the subjective difficulty, the patient's worry, functional level, and treatment results, and the severity of the disease on the basis of biomedical data. It is often difficult to determine whether these patients are better classified as belonging to the group of somatoform disorder, because they may have incorporated their genuine physical disease into their somatization. In this case, it is not appropriate to use a rigid psychic versus nonpsychic dictum, because the problem is most often a combination of both, especially in more chronic cases of somatization. This rough classification includes three diagnoses that do not form an independent target in this treatment program.
Hypochondriasis is frequent and is characterized by excessive and inappropriate worry and with preoccupation with the fear of having or developing a serious physical disease. Patients are usually excessively preoccupied with bodily sensations and functions. They are often influenced by information about diseases reported in, for example, television or radio. The disorder has much in common with obsessive-compulsive disorder. Patients feel distressed by constant worrying but are unable to control it.
Factitious disorder: The patients feign illness or deliberately inflict a disease on themselves. In contrast to malingering, there is no apparent external incentive for producing the symptom(s), and the motive is unconscious and understandable only in a psychopathological context. Patients who have factitious disorder often have a severe personality disorder where the patient borders on psychotic breakdown.
Dissociative disorder: Patients usually present with pseudo neurological/physical symptoms, such as paralysis, blindness, and confusion. The onset is sudden and is closely associated in time with emotionally traumatic events, insoluble and intolerable problems, or disturbed relationships. Less severe cases are probably quite common, and even mentally stable and previously healthy individuals may react with dissociative symptoms when exposed to disaster. The condition is usually transient and with sudden spontaneous remission. A precondition for making a diagnosis of dissociative disorder is the identification of a provoking psychological trauma.
The Differential Diagnosis Between a Genuine Physical Disease and a Functional Disorder
Today, functional disorders are, by definition, exclusion diagnoses, because the diagnostic criteria demand the symptoms to be medically unexplained. This does not imply, however, that the diagnoses rest on the exclusion of organic disease alone. Today's plethora of diagnostic options would also simply make it less than reasonable not to give due consideration to the diagnosis of functional disorders. Different characteristics, symptoms, and features are available for diagnosing somatization, and these should be used in differential diagnosis. Please refer to Chapter 5.
The somatizing patient often (but not always!) presents with vague, atypical symptoms; that is, symptoms lying outside what is usually expected in authentic physical diseases, and they are unspecific, which gives the symptoms a low differential diagnostic value, because they can be encountered in many different mental and physical diseases (such as fatigue and headache). The patients therefore find it difficult to give further details about their symptoms; that is, describe their intensity, quality, chronology, etc. Patients who have a genuine physical disease do not have this problem. They are usually very precise in their description of the symptoms; for example, the pains are shooting, burning, or are like a toothache. Instead, the attention of a patient with functional disorders is directed toward the subjective suffering caused by the symptoms and the negative consequences the symptoms have on his or her life and quality of life.38
Etiology
The etiology of functional disorders is unknown, but it is probably multifactorial. Medically unexplained physical symptoms can generally be regarded as a basic mechanism that allows some people to respond to stressors in the same way that others may respond with anxiety or depression. It appears that different unspecific predisposing factors commonly seen in different mental disorders assume importance depending on the person's general vulnerability. Examples of unspecific factors could be the loss of a close relative, loss of job, or moving to a new area. Specific predisposing factors for somatoform disorders may include childhood physical or sexual abuse and parental somatization. However, neither parental nor childhood well-defined physical disease lead to somatization. The reported familiar transmission in somatization may be rooted in sociocultural variables, but there is also some support for a genetic transmission.28 (See Background and etiology of functional disorder.)
Predisposing factors may include, besides patient- and illness-related factors, iatrogenic factors embedded in the way physicians and the health care system manages and cares for the patients. This appears to be of great importance for the course of the disorder. Likewise, social factors, especially the family, may maintain the patient in the sick role. Finally, these are strong indications of the involvement of biological factors.
The next chapter will discuss the factors that precipitate, initiate, and maintain functional disorder. These factors must be known for proper treatment to be given.
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Chapter 2: The Interaction Between the Physician and the Somatizing Patient
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The Contribution of the Health Care System (Iatrogenic Factors)
The way the physician and the health care system react, handle, and manage the patient may increase both the number and severity of the symptoms. The patient may be kept in the role of the sick, and the illness may become chronic. In Figure 2, Sternbach39 and Quill40 illustrate very well this pathological cycle of examinations and interventions frequently found in somatizing patients. Figure 2 also illustrates the close, almost symbiotic interaction that may emerge between the physician and the somatizing patient.
It is often puzzling how chronically somatizing patients can go through numerous futile hospitalizations, examinations, interventions, and attempts at treatment without relief.31 What makes physicians continue to examine and "treat" the patient despite no evidence of an organ pathology? What makes physicians unable to stop it? Some of the reasons for this irrational pattern of reactions are stated in Table 4.
The Fear of Overlooking a Genuine Physical Disease
When physicians are asked why they continue examinations and tests for which there are no objective indications, the most frequent answer is the fear of overlooking a genuine physical disease. However, this is hardly a reasonable fear, because genuine physical disease is reported to be overlooked in less than 3%–4% of the cases.31,41,42 On the contrary, a physical disease is, it would seem, less often overlooked in patients who somatize, because their threshold for registering physical symptoms is lower than that of nonsomatizing patients and because they seek family physician care at an earlier stage than nonsomatizing patients.43 If the patients are not satisfied with their physician, they will consult the doctor on night duty or in the emergency room.
However, most physicians will probably agree that they cannot totally avoid overlooking physical diseases or making an erroneous diagnosis, no matter how careful they are. Serious consequences for the patient are believed to be rare, indeed, and in most cases they amount to little more than a delay in diagnosis and, by implication, treatment.
The argument for making unnecessary examinations on a doubtful indication is often that "you can never be absolutely sure." This is true, but it may also be the best argument for drawing the line and stopping the examinations. The wish for complete certainty is often rooted more in the physician's need or wish not to be blamed than in consideration for the patient.
The large group of somatizing patients is paying the price for this approach in terms of undue discomfort during unnecessary examinations and an increased risk of being exposed to iatrogenic harm. Furthermore, an exaggerated examination program may keep the patient in the sick role, and he or she may develop a chronic condition if sufficient treatment is not initiated or is delayed unnecessarily. Mental disorders should be regarded with the same seriousness as physical diseases because of the associated high mortality rates and the very significant consequences for patient functioning.
It may seem paradoxical that the fear of overlooking a physical disease is much stronger in the case of functional disorders than in physical disease. The etiology of many physical diseases; for example, essential hypertension, remains unknown. Yet, even if hypertension may be multifactorial, we do not relentlessly pursue its etiology but are satisfied that it is "essential," provided a reasonable examination program has been carried out.
The Fear of Complaints and Prosecution
The fear of being scorned by colleagues or the media or of being sued by the patient for having overlooked something may also be of importance.44 In order to avoid subsequent criticism, the physician may feel compelled to perform tests and examinations that may appear superfluous from a medical point of view. In the United States, defensive tests and examinations seem to be part of clinical practice, and we may fear that this approach will also gain ground in Europe. However, complaints associated with somatizing conditions remain rare in Denmark.31
No Other Treatment Option and Lack of Confidence in Psychiatric Treatment
Nonpsychiatric physicians may have a limited knowledge of state-of-the-art psychiatric principles and methods of treatment. They may still hold the belief that referrals to psychiatric care may imply long-term treatment during which patients do not improve significantly.
A physician with no confidence in psychiatric treatment may choose to "treat" the patients despite the lack of indication of a medical disease and to give a biomedical treatment the benefit of doubt, "because you can never be absolutely sure" that the treatment does not work. This attitude may have the effect that patients are not properly diagnosed and, hence, they may be denied effective psychiatric treatment.
Unfortunately, the attitudes of the nonpsychiatric physicians are not completely unfounded. Psychiatrists may have only limited knowledge of functional disorders and their treatment. Psychiatrists tend to regard somatoform disorders as less-severe mental illnesses that demand more time and capacity than are available in psychiatric care. This view may be rooted in psychiatrists' rather poor experience with such patients, who are primarily consulting nonpsychiatric physicians because they believe that they have a physical disease, not a mental disorder.
As a consequence of this attitude, a group of severely ill patients are denied appropriate treatment. Health care providers thus continue to leave these patients to their own devices.
Lack of Understanding of the Nature and Character of Mental Disorders
The somatizing patient often insists on further tests to rule out organ pathology. Some physicians may think that the patient is just being tested and treated at his or her own request and therefore, in other words, is assuming responsibility for the process himself or herself.40,44 However, this attitude expresses a lack of understanding of the nature of mental disorders. It is assumed that patients always act in their own best interest, and the existence of unconscious motives is rejected. The physician is thus reduced to an "organ mechanic," with no general concern for the well-being and interest of the patients.
Some physicians believe that humans in general act rationally, and they will examine patients with the sole purpose of convincing them that they are wrong to think that they are having a physical disease. In most cases, this will comfort psychologically healthy people but not mentally unstable patients. On the contrary, mentally unstable patients may interpret testing and examination as indicating that there is some truth in their illness after all. The patient may even believe that the physician is hiding the truth to prevent the patient from feeling hurt.45
Insufficient Knowledge about Handling Behavioral Dysfunctions and Mental Disorders
Physicians are primarily trained in a biomedical illness model and are often at a loss when this model turns out to be insufficient. The patient may put heavy pressure on the physician by saying things like, "I know my illness is for real and not a figment of my imagination." The physician may be frustrated when he or she cannot cure the patient and may therefore resort to the well-known practice of testing and repeated, but futile, attempts at treatment.
The physician may fall back on attributing the patient's complaints to random findings; for instance, back pains may be attributed to minor changes found on X rays. Such abnormal findings are frequent in symptom-free individuals, so the correlation may be highly speculative. Both physician and patient may be quite content to have found "the explanation" for the symptoms. Nevertheless, the symptoms almost always return after a short while.
Some physicians accede to the patient's request for examinations and tests, arguing that that the patient would otherwise go to another physician. This would lead to further examinations, tests, admissions, and treatment attempts before the new physician gets to know the patient (see Figure 2). This pattern may repeat itself. To protect the patient from unnecessary suffering, the physician may comply with the patient's desire for more tests. A strategy in which such tests are performed on an psychological indication may be appropriate in some cases, provided that the tests are conducted in a sober and carefully considered way and on safe indications.
The Physician's Personality and Understanding of the Medical Profession
The universal nature of most emotional problems makes it difficult for the physician to entirely avoid personal involvement when faced with the patient's emotional problems. Physicians may deal with their own problems in a less appropriate way, and the discussion of mental issues may therefore become an unpleasant experience to the physician.46 Some physicians try to solve this problem by avoiding "subjective" patient contact and maintaining an "objective" view of the presented symptoms.
Some physicians believe that they should only examine and treat physical problems and that an organic cause of the problem should always be excluded first. They do not feel qualified to explore psychosocial problems and may believe that this type of problem has nothing to do with physical disease.40,44
Physicians often join the profession with the idealistic belief that physicians should be nice, kind, knowing, self-sacrificing, and caring. Physicians have an inherent urge to prove to themselves and others that they are skilled and fulfil these ideals.46 Patients may put heavy pressure on physicians by appealing to the emotional part of his or her self-conception with statements such as, "I would do anything to get well, but I can't," "I can't take it anymore (so you must take over)," or "you're the doctor." When cornered in this way, the physician will be inclined to use the more familiar model, the biomedical one, which seems to be what the patients want.
Modesty
Some physicians may feel uncomfortable when asking about the patients' emotional well-being, in the same way that a gynecological examination or rectoscopy may be seen as an infringement of privacy.44,46 In some cases, the impression is that physicians find it easier to perform the above-mentioned examinations than to ask patients about their psychosocial well-being. To avoid offending the patients, it is important to ensure that they understand why a question is asked or an examination is performed.
Pandora's Box or the Fear of Loss of Control
Many physicians have experienced that patients, when asked about personal problems, reveal a pent-up need to discuss these problems. It may be overwhelming to physicians, who do not know how to stop or help patients cope with their apparently huge problems.47 Furthermore, physicians may fear the patient's reaction (walking out, anger, crying, etc.), and, to avoid this confrontation, they may order a test "just to be certain."
The Fear of Dependency
Physicians may avoid psychosocial subjects because they fear that patients may become dependent on them and will not be able to end the relationship.44,46 This should not usually be a problem if due attention is paid to the physician's as well as the patient's limits and if such limits are discussed with the patient. Raising this issue in an empathetic manner will only rarely cause the patient to feel offended. On the contrary, most patients will find it reassuring. Nevertheless, if this turns out to be a problem, it may be a good idea to discuss the case with a colleague or a psychiatrist.
Lack of Time
The physician may find that there is insufficient time to conduct a psychosocial interview and to deal with mental disturbances. This argument is based on the erroneous idea that it is more time-consuming to assess mental illness than to assess physical disease. Much may, however, be achieved in a short time if the efficiency and approach used for taking a medical history is also used in case of a mental disorder. Thus, in the long run, time can be saved if the physician conducts a careful assessment and thorough examination at the first contact, because the patient will not return with uncertainty and unanswered questions. Furthermore, studies have shown that it saves time to ask directly about mental problems and social conditions. Physicians may thereby avoid the so-called doorknob questions; for example, when the patient on the way out and with the hand on the doorknob says, as if an afterthought "by the way ...."48
The Patient's Symptom Perception and Illness Understanding
From Sensation to Symptom
People react in different ways to symptoms of illness, and they have different thresholds for seeking treatment. In other words, they differ in illness behavior. Illness behavior determines the use of health care services, whereas the severity and character of a physical disease often is of lesser importance.18
Illness behavior can be subdivided into treatment-seeking behavior and social illness behavior. Illness behavior is determined by our interpretation, evaluation, and perception of symptoms.49 Cognitive and emotional factors thus activate a given behavior, and the illness behavior in turn is influenced by individual upbringing, culture, social factors, etc.
A model of symptom and illness perception (Figure 3) shows how people perceive and evaluate physical sensations and symptoms.31,49–52 The outlined processes are universal (i.e., not pathological) and are continuous processes. The process ranges from the totally unconscious level to a level where all attention is focused on the symptoms and sensations. The latter is seen in hypochondriacs, who can think only of their prospective disease, and in patients who have just been given the diagnosis of a severe physical disease. The process may have different tonus or excitability from person to person, according to person-specific biological factors and acquired experience. Furthermore, the general tonus or level of arousal is influenced by moods or mental stress. A person who is depressed or anxious will, for instance, be more sensitive and worried, which will lower the symptom perception threshold. Also, expectations influence the tonus of the process.53
The model presupposes that all people experience nonpathological physical sensations or symptoms daily, which both the patient and the physician may misinterpret as being symptoms of a physical disease.54 The process of somatization can hence be seen as a tendency to misinterpret and/or intensify normal bodily sensations or even common diseases or minor injuries.
The process may be initiated by a number of different factors, internal as well as external. A good example of the suggestive element is the epidemic of allergic reactions to copy paper,55,56 which was given much attention in the Swedish media during l979. When the phenomenon was investigated, it turned out that only a certain type of copy paper caused an allergic reaction. The majority of those who complained about allergic reactions had never touched this particular type of copy paper. After the publication of the results and the removal of the concerned copy paper from the market, the number of cases quickly dropped to zero.
Previous Experience and Inner Evaluation
Everybody has a personal sensation/symptom panorama with which he or she is familiar. This knowledge accumulates throughout life in a continuous process. When girls reach puberty, they become familiar with new symptoms in connection with menstruation, which they add to their personal symptom picture. Also, in chronic diseases, patients add the new symptoms to their picture, and only when the intensity, type, or composition of the symptoms change will patients start considering whether there could be some other cause or the disease has deteriorated. Experiences with symptoms from various diseases will also form part of the individual's inner frame of reference.
Thus, each person primarily judges his or her condition through inner evaluation, that is, from subjective symptoms, experiences, and emotions that are tied to these. The type of sensation is affected by cultural and social factors, whereas its severity seems to be of minor importance. Even the most severe physical sensations can be quite normal, for example, severe dyspnea and palpitations after a run, and would therefore not be interpreted as signs of illness.
This can be illustrated by the illness behavior of a family with an unusually severe form of migraine in which the fits led to hemiplegia.57 The members of the family did not consult their physician to any major extent, because the symptoms were well known. They knew from the experience of other family members that the fits would cease by themselves and, so far, the physician and neurologists had been unable to help.
External Sources and External Evaluation
When the personal evaluation of the sensations/symptoms is no longer sufficient, individuals may seek information or help from external sources: family members, colleagues, books, medical encyclopaedia, weekly magazines, etc. As a last resort, individuals may consult physicians to be reassured or to receive treatment. The physicians' information and reaction will be crucial, so he or she must be acquainted with the patient's own perception of the problem. The physician's questions and responses can reinforce or reduce the patient's focus on special symptoms or organs. The patient will internalize this experience, which becomes part of the personal symptom panorama. (See The patient's sympton perception and illness understanding.)
External information may make an individual change the interpretation of personally well-known sensations; that is, they are suddenly misinterpreted as signs of illness. Most physicians have experienced this themselves during their medical training. External information can initiate the process, as outlined in Figure 3. The new information will cause focused attention on the body part that is suspected to harbor the disease. A cycle of worry and expectation of symptoms will ensue. Everybody knows this phenomenon: if you injure your foot, all your attention is directed toward the foot, which then is examined for symptoms and changes. This will cause new sensations/symptoms to surface and to be interpreted in the light of external or internal sources. Thus, you will either become reassured or more nervous that the sensations/symptoms may be signs of illness. The process can be cumulative, because the patient may wrongfully ascribe the physical arousal accompanying the nervousness or the anxiety to a disease.
The Patient's Illness Perception
The patient's illness perception and illness model are crucial to his or her morbidity and functional level. This also applies to severe physical diseases in which the patient's self-perception may be decisive for the prognosis for subjective well-being, functional level, and use of health care services.58
A patient's illness perception may be seen as consisting of at least five main elements:59
- The identity of the illness: What does the patient think is wrong?
- The cause: Is the patient convinced that the condition is caused only by organically founded problems, are psychosocial factors of any importance, or do other causes play a part?
- Time frame: Does the patient think it will be short lived or does he or she fear a chronic disorder?
- The consequences: Does the patient believe that he or she will be able to work again, that she will be troubled, or that he will depend on sickness benefit, etc.?
- Recovery and control: Does the patient believe he or she will recover and that treatment will help? Does the patient feel he can control the illness to a certain extent, or does she feel helpless?
Future research will most likely uncover further details of our illness perception.
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Chapter 3: Biological Basis of Somatization
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Together with other factors, the hereditary predisposition in somatoform disorders supports the existence of a biomedical component in the disorder.60,61 Some people subjected to severe stress—for example, in a combat situation or accident—can suppress even severe pain. In such cases, psychological factors alter the threshold of the individual's perception via biological mechanisms. In contrast, the multisymptomatic illness pattern encountered in somatizing patients may be caused by the patients' intensification of all bodily sensations; that is, afferent stimuli to the brain are not suppressed. The result is that all sensations or symptoms, which are continuously evaluated in the unconscious part of the mind, will suddenly surface to the conscious level. It could be said that the filter function is insufficient62 (Figure 4).
James et al.63 suggest the presence of a fundamental neuronal and physical dysfunction in the attention processes of somatizing patients. In EEG examinations with evoked potentials, they found that somatizing patients responded in the same way to both relevant and irrelevant stimuli. In other words, the somatizing patients were unable to ignore the irrelevant stimuli.
The results from a study that used PET scanning showed significant changes in the somatizing patients that closely matched the changes found in depressed patients (H. Karlsson, personal communication). Numerous other studies have indicated that biological mechanisms and pathophysiological changes may be contributing factors in somatizing conditions.31 (See The biological basis of somatizing.)
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Chapter 4: How the Physician Becomes More Comfortable With the Somatizing Patient
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When working with the somatizing patient, it is of foremost importance to structure and plan the treatment and to make clear agreements. This is done to secure that everything is open and above board. It is, moreover, imperative that the physician makes the diagnosis and knows and understands the nature of somatoform disorders in order not to be in constant doubt about the diagnosis.
Chronically somatizing patients can be particularly burdensome. In some cases, these patients would be better treated (or better managed) by the shared care of the family physician and specialized psychiatric health care. Unfortunately, this is rarely an option. Much frustration among physicians as well as patients may be avoided by adopting the advice on management and handling of somatizing patients outlined in Chapter 7.
Do Not Accept Responsibility that Is Not Yours
The doctor-patient relationship often fails because the physician accepts that somatizing patients hands him or her all the responsibility for their health, a responsibility that the doctor in no way can live up to. A British study on a gynecological ward analyzed consultations due to gynecological problems without organic basis by comparing the consultations that led to hysterectomy with those that did not. 38 It was characteristic that the patients focused on their subjective inconveniences and the consequences for their lives and their quality of lives. They were sometimes almost aggressive when demanding that the gynecologist should do something immediately. The patients were able to put pressure on the physician by referring to earlier unsuccessful treatment attempts and devaluating previous physicians and treatment implying, "if you do not help me you are just as bad," and "nothing has helped me; you must make an effort and help me." Consultations that led to hysterectomy in spite of lacking indications on the basis of biomedical facts were characterized by the fact that the gynecologist accepted that the consultation was conducted on the patient's terms. The topic of these consultations was the subjective consequences and inconveniences the disorder was causing. These are areas in which the patient is the absolute expert. Inversely, when consultation did not lead to hysterectomy, the gynecologist stood firm, maintaining that he or she had "looked inside the patient" and with his or her own eyes had seen that there was nothing wrong with the uterus and would therefore not perform a hysterectomy. The physician maintained his or her field of competence—that is, organic changes and physical diseases—and also that he or she had examined the patient and found no signs of organ changes. The gynecologist referred patients with psychosocial problems due to their symptoms to treatment elsewhere.
It is important to bear in mind that it is the patient and not the physician who has a problem, and the patient only can be helped through factual guidance. The patient cannot question the physician's field of expertise and expert decision that there is no organic problem to treat. The physician must therefore not accept it if the patient tries to make the physician responsible for the patient's health by demanding treatment that is not indicated but instead should offer the patient help in finding other possibilities, when the possibility they endorsed—that is, medical or surgical treatment—is not an option.
Communication
Patients with somatoform disorders often focus on their subjective illness story and its consequences. The patient's psychosocial communication may cause the partners to talk at cross-purposes—the physician talks about facts and the patient about feelings. Thus, the patient does not feel understood or the conversation will be one sided. If the patient is in charge, the communication will often be limited to emotions and demands for actions ("I hurt, do something!"). Recognizing the reality of the symptoms and communicating emphatic understanding of the patient's emotional problems/statements, combined with the insistence of diagnosing and appropriate treatment, will contribute to finding a common ground for communication.
If the patient tries to make the physician responsible for his or her problems by insisting that the problem is only physical and, as such, one the physician should be able to handle, it is important for the physician to maintain that this is his or her field of expertise. The physician must communicate that there are no organ pathological findings to indicate an organic disease or to perform surgical or medical interventions. It is important to insist on the mainly psychosocial nature of the problem, as when dealing with apoplectic patients disabled by paresis. Such patients can be offered neither medical nor surgical treatment but may be helped through psychosocial measures.
Accepting the Limits of Medicine
Somatizing patients seek treatment among others because they expect medicine to have a cure for their problems. Patients may believe they have an undiagnosed disease, because "the physicians cannot find out what is wrong." It is essential for the physician at an early stage to elucidate the patient's illness perception and any myths the patient may have and at the same time empathically inform the patient about what the evidence suggests is wrong and what may be the best and most effective treatment approach. It will often be advantageous to offer a physiological explanation for the patient's symptoms, and it is necessary to outline the limits of medical treatment.
If the physician has asked the patient about his or her expectations during the consultation, it will be easier to keep the allotted time and avoid being stressed by the knowledge of a full waiting room. If the patient's illness perception and reluctance to accept nonbiomedical explanations suggests that mutual understanding may be hard to reach, the physician should schedule a new appointment and allow for due preparation. (See Becoming more comfortable with the somatizing patient.)
Time pressure may often cause the physician to seek easy solutions. However, this approach will often, in the long run, turn out to be time consuming, because the untreated patient may return time and again with ongoing symptoms and renewed worries.
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Chapter 5: Assessment and Treatment
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Considerations Before the Consultation
The physician's familiarity with the patient will often give him or her a gut feeling in advance whether the patient will present with functional symptoms. The physician may find it useful to devote extra attention to this feeling in an effort to fully understand it before the consultation. Somatization should be considered if the patient previously has presented a vague or complicated illness story, if the patient has not responded as expected to treatment, if symptom patterns repeat themselves in an incomprehensible manner, or in cases where something does not really add up.
Patients with somatoform disorders often complain of grave subjective suffering and discomfort. The physician may feel forced to do something immediately, with the result that the consultation will focus solely on the most urgent problems, as defined by the patient. It can be very frustrating always to feel one step behind and feel manipulated by the patient's apparently severe and urgent symptoms. The physician may avoid this situation by being prepared for the consultation with a potentially somatizing patient (please refer to Table 5). Consideration of the listed questions will allow the physician to prepare a mental agenda before the consultation and to decide on a strategy, an approach that will be proactive rather than reactive.
Assessment and the Art of Making the Patient Feel Heard and Understood
General Techniques
One of the most important psychological aspects of the treatment program is to make the patient feel heard and understood. To achieve this, the physician must know a number of general rules of communication, which are listed in Table 6. Central to these rules is that the spirit matters more than the technique. It is more important to be attentive and to have eye contact with the patient than to remember a special technique. Avoid hiding behind instructions, lab-test forms, the patient's case notes, etc.
Socratic Questioning
The central element in Socratic questioning is curiosity. The task lies in coming to understand how the patient thinks, feels, and perceives the situation. At this stage, use active listening skills, show genuine interest in the patient's problems, be open, and do not attempt to find premature explanations or to make corrections and give advice. Interesting at this point is not the factual state of affairs but the patient's subjective perception of the situation. Exact knowledge of the patient's perceptions makes this much easier and may be a fundamental prerequisite to correcting misunderstandings and misinterpretations. In general, people are afraid to appear ignorant and to say something that will sound stupid to the expert. Advice offered at the wrong moment may cause the patient to feel stupid and, in the worst case, that he or she is ridiculed or loses face.
It is important to be neutral, because the patient may withdraw if the physician's opinion becomes known. The physician must refrain from giving advice and explanations, because no matter how well intended these may be, the patient is unable to use them unless they in agreement with the patient's own understanding. In the seventeenth century, Pascal Penesees wrote, "People are generally better persuaded by the reasons which they have themselves discovered, than by those which have come into the mind of others"—words that are still valid.
In the consultation, use open questions such as, "What do you think" or "What is going through your head when you feel like this?" By using closed questions, namely questions that can only be answered with yes or no, the physician controls the dialogue and takes on the responsibility. The physician may feel that this amounts to a burden, especially if he or she is insecure about what to do with the patient or which direction to take. The patient, too, may feel under pressure because of all the questions. Many patients describe that they feel more relaxed and reassured when they can use their own words. The patients will feel more satisfied to be able to discuss what they feel are important and are allowed to express their own understanding of a specific situation. Patients will feel that the physician is listening, and this will make them feel understood.
Physicians can encourage patients to express themselves by making supporting utterances or grunts (facilitation) such as, "Aha...," "really," "continue," and "tell me more about that."
The physician should not remain passive and let the patient control the whole dialogue. The patient rightly expects the physician to keep the time and to make sure that he or she receives the necessary information. However, it is also possible to control or focus the dialogue through the use of open questions and to clarify what the patient means by frequent summaries, perhaps combined with relevant closed questions. If the patient spends too much time on irrelevant information, try to keep the focus by asking, "it is fun to hear about the football match, but please tell me more about..."
Socratic questioning does not necessarily take more time than the use of closed questioning. Actually, quite the opposite may be true, because it may require many closed questions to reach the same answers. Furthermore, you are more certain that the patient has told what he or she really came for and thus avoid many of the so-called door knob questions.48 It may be important to use closed questions in some cases, for example if you want to be certain of the nature of a symptom.
Summaries
Summaries present a simple but very effective method of making the patient feel understood. Summaries can be classified into three types: repetition, in which the patient's own words are used; rephrasing, in which other words are used but with the same meaning; and interpretation, in which other words with another meaning are used as explanations.
Repetition of the patient's experiences and expressions affords the physician the possibility of checking that he or she has correctly understood the patient, and it hopefully gives the patient the feeling of having been heard and understood. Repetition also serves to clarify (or reinforce) the patient's experiences, and the patients may come to see the problem in a different light and to better understand the problem. An entirely different situation results when you hear your own experiences expressed by someone else, even if your own words and meanings are used. Just think of the comment, "it does sound strange when I hear you saying it."
Summaries will also serve to expose many of the paradoxes or inconsistencies in the patients' way of thinking. If the patient becomes aware of such contradictory thoughts and ambiguities, it will make him or her wonder and with great certainty make changes.
During summaries, the physician can use the following expressions, "did I understand you correctly; you mean...," "I want to be sure that I have understood you correctly," "you are saying (or mean) ...," "if I have understood you correctly, you are saying," "I hear you say...," or "on one side ... and on the other...."
Express Empathy (Emotional Feedback)
By the physicians' expressing empathy, the patient will feel heard and understood. Empathy could be expressed by saying, for example, "I can tell it has been hard on you (or caused you trouble)," "I understand that you find it unpleasant," or "I can see this is disagreeable." It is important to bear in mind that understanding and empathy do not equal agreeing with or accepting the patient's explanations and actions.
TERM Model Step 1: Understanding
The different steps in the assessment of patients who present with medical unexplained symptoms are illustrated in Table 7. This method of structured assessment may also be very useful when dealing with other patients. (See Assessment techniques.)
Assessment of Symptoms
The physician must insist on a clarification of symptoms as well as on the identification and description of specific symptoms, even in cases where it is obvious that the physical symptoms presented are not rooted in physical disease. This is not only fundamental to correct diagnosing; it will also give greater weight to the physician's words when he or she explains the absence of an organic basis of the symptoms to the patient. On the basis of the physician's knowledge as an expert, which cannot be disputed by the patient, it is easier later on to have a qualified discussion of the patient's health beliefs and fears.
Patients with functional disorders almost always focus on the their subjective suffering caused by the symptoms and on the negative consequences on their lives and quality of life. It is therefore often difficult for the patients to be specific when describing their symptoms. A thorough review of all the symptoms may help the patient get a general, overall view of the symptoms, something that may otherwise be difficult, and hence alleviate the fear that springs from their profusion. In some cases, this approach alone can be therapeutic. It may be of great value to have the patient describe a "typical pain/symptom day."
Explore Emotional Clues
Patients often tell about the emotional trouble their physical difficulty is causing them, as reflected in common statements such as "I am so depressed because it won't go away" or "if it doesn't improve soon, I'll kill myself." Without either disputing or confirming the causality, the physician may invite the patient to elaborate on how his or her feelings in the following way, "tell me more about this" or "you say that you feel everything is confusing (the patient's own words)—try to tell me more about that (about how you feel)." Be emphatic and do not be sparing with emotional feedback; reply, for example, by saying, "I do understand this is difficult for you." (See TERM Model.)
This will allow the discussion of other issues than physical symptoms and will change the focus of conversation while sending the signal that emotional factors are important. Also, the patients see it as a sign of genuine interest in their well-being. Attention should also be paid to nonverbal emotional clues that, if present, could be brought into the open by asking, "you look quite tense, is that how you feel?"
Ask Directly About Symptoms of Anxiety and Depression
The physician should use general and open questions and words such as "how is your general mood," "how do you feel about yourself," "are you able to relax," or "do you feel stressed?" This may be more acceptable than asking whether the patient is "depressed" or "anxious." If the patient confirms these screening questions, a more direct question may be asked about symptoms of depression and anxiety disorders, maybe by use of a questionnaire.
Explore Life Events, Stress, and Other External Factors (Social, Work-Related, and Family)
Functional physical symptoms are often a reaction to psychosocial distress. Likewise, a patient's problems caused by authentic physical diseases may be worsened by psychosocial distress and in stressed situations. Patients may be reluctant to tell about such problems, because they may erroneously believe that the physician deals only with physical matters. It is therefore advisable to screen for such stressors as a routine. Often the patients themselves have wondered whether there might be a connection, and the physician's questions might therefore confirm the patient's own hypothesis. Chronically somatizing patients may be particularly reluctant to reveal thoughts about the impact of psychosocial factors to the physician, fearing that the physician will focus exclusively on this and not take their physical problems seriously and not examine them properly.
Below are stated some short, generally valid screening questions to elucidate this situation:64 - Background: "What else is happening in your life (in general)?"
- Affect:"How do you feel about this?"
- Trouble: "What causes you the most trouble?"
- Coping: "How do you handle this?" "How did you cope with this?"
- Empathy: "It must be difficult for you." "I can tell...."
Some physicians are reluctant to ask these questions, because they feel that it will take up too much time. However, our present knowledge strongly indicates that such questioning is a necessary precondition for good clinical practice. It does save time to make direct inquires during the consultation, because you may avoid the so-called door knob questions.48
It is important to ask about psychosocial circumstances and relationships early on in the assessment. The patient may otherwise feel that the physician is trying to dismiss the symptoms as being "all in the mind," because he or she cannot find anything else wrong.
Explore the Patient's Functional Level and How He or She Copes with the Illness
The physician should ask the patients how the symptoms have affected their work, family life, and social interactions, for example: "how has this affected your ability to do this or that," "how do you cope with this," or "how did you usually cope with this?"
Explore the Patient's Health Beliefs (and Do Not Reveal Yours Right Away)
Recent years have seen general recognition of the importance of the patient's own illness perception and illness models to his or her morbidity and functional level and to the patient's reactions and coping when faced with symptoms (please refer to the section about symptom perception and illness understanding, p. 110). It is therefore important to uncover the patient's health beliefs. The physician could, for instance, ask "what thoughts do you have about your condition," "...and about the cause," "have you thought of a particular disease," or "you must have had some thought of what...."
If necessary, use a few guiding questions, because the patient may, out of fear, be reluctant to bring up the subject or he or she may not want to sound ignorant. It is vital to avoid the temptation to correct the patient and to interrupt with an explanation, even though this may seem the obvious thing to do to the physician. Instead, listen to the patient and ask questions out of genuine interest while keeping the focus. What is interesting at this point is not the factual state of affairs but the patient's subjective perception of the situation, knowledge of which is the key to later efforts to help the patient change his or her way of thinking.
Explore the Patient's Expectations of Treatment and Examination
Ask the patient about his or her expectations of the consultation. This may be instrumental in uncovering veiled motives, including emotional ones, for seeking consultation, and it may facilitate the working relationship between the physician and the patient. Knowledge of the real wishes and expectations of the patient will also help the physician meet and consider these expectations, and it will be easier to agree on treatment plans and goals.
Patients with functional disorders often have unrealistic ideas about (nonpsychiatric) treatment options and about the diagnostic possibilities in medicine. In other words, they do not have a realistic understanding of the limits of medicine (as is also the case for some physicians!). Patients may think that something must be organically wrong, that is, "if only I am examined thoroughly, they will find out what is wrong with me and I will be treated and become well again."
This may be one of the reasons why patients with functional disorders often consult a physician and may continue to consult different physicians ("doctor shopping"). Patients who have not accepted the limits of medicine may even conclude that it is the physician who will not examine or treat them properly. Ask the patient, "what are your thoughts about what is going to happen now/what treatment should be initiated," or "what are your expectations of this visit?"
Brief Focused Physical Examination and Indicated Nonclinical Examinations
For many years, it has been a widely held misunderstanding that a physical examination of the somatizing patients should be shunned in order not to afford the patient any chance of secondary gains. However, patients with functional disorders have the same right to careful examination as other patients. Even though the patient's symptom description does not raise suspicion of organic pathology, it may serve a valid psychological purpose to physically examine the relevant organ, for example, performing a heart stethoscopy if the patient complains of "heart trouble." This reassures the patient that he or she is being taken seriously and that the physician is careful and meticulous: "Nothing in your description makes me think that there may be something wrong with your heart. However, I would like to listen to it anyway." If the patient demands repeat examination, the physician may suggest a psychological explanation, "I can see it worries you, so I would like to listen to your heart."
Especially when dealing with chronically somatizing patients, it is important to focus on objective symptoms and signs and certain findings and not on subjective symptoms and provoked findings. In chronic cases, further diagnostic procedures and laboratory tests should be avoided unless they are based on certain findings or an illness history that points to a well-defined physical disease.
TERM Model Step 2: The Physician's Expertise and Acknowledgment of the Reality of the Symptoms
Provide Feedback on the Results of the Examination
When the medical history has been taken and the patient has been examined clinically, the result should be summed up for the patient. It is important to mention both positive and negative findings to the patient. Never say that there is nothing wrong with the patient. You may, instead, use phrases such as, "I have now examined your stomach (or the organ system in focus) and I have found no signs of changes (causing your pains). The tenderness you feel in the left side is often seen in muscular tension, and it is completely harmless."
It is important to speak as an authority and to communicate expert knowledge that rests on facts obtained by—so to speak—"looking inside" the patient during the clinical examinations and nonclinical examinations, etc. The patient cannot justly claim or assess such knowledge, and, by implication, therefore cannot dispute the information received.38
Acknowledge the Reality of the Symptoms
It is important on one hand to inform the patient about the absence of any signs of organ-pathological or pathophysiological changes in a manner that bars the patient from challenging the physician's expert judgement. On the other hand, it is also crucial to acknowledge that the patient's symptoms are real, because the physician in fact cannot dispute the patient's feeling of being ill. The patient is the authority on illness—that is, the subjective experience of not being well—whereas the physician is the authority on medical terms, disease, and disorder. The patient may take a remark that nothing is wrong to indicate that the physician believes he or she is a malingerer. The physician should therefore always, almost automatically, acknowledge that the symptoms are real and troublesome whenever it is mentioned that the symptoms are organically unfounded. A possible wording is "I can see you are very troubled by your pains (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."
Stress the Absence of Indications for Further Tests or Physical Treatment
It must be made absolutely clear to the patient that neither the physician's expertise nor the examinations (clinical as well as nonclinical, etc.) provide any basis for further diagnostic tests or procedures and that no relevant medical or surgical treatment can help relieve the symptoms. This will serve to stop the patient immediately after the consultation from entertaining the idea that some test could have been forgotten. Likewise, it emphasizes that the decision is made because the limits of medicine have been reached and not because of the physician's reluctance or negligence.
"I can find no indication for making further tests and there is no medical or surgical treatment that will help you." It is important to base the wording on the illness(es) the patient fears or the treatment he or she believes could help him or her.
Feedback cushioned in authoritative or metaphorical language will often prove highly effective. Greater effect and better comprehension is achieved through metaphorical expressions that convey the impression that the physician has "seen into the patient," for example, by scopes or diagnostic imaging techniques, and found everything to be normal than through statements such as "we have found nothing abnormal." It also has carries greater weight if you have "seen or tested the kidney or the liver" through blood tests and the organs were functioning normally than simple statements like, "the blood tests did not show anything abnormal."
TERM Model Step 3: Negotiating a New Model of Understanding (Reframing)
Physical symptoms are commonly assumed to be caused by physical diseases, that is, caused by organic changes or pathophysiological dysfunction. This assumption defies the fact that this seems to be the exception rather than the rule.29 The either-or-thinking is widespread and comes to life in expressions such as "if the symptoms do not have an organic cause then the cause must be found in something psychological." This is often viewed as sheer imagination, and it communicates the attitude that the patient should pull him- or herself together or just stop it. The implication carried in this attitude is that the patient produces the symptoms on purpose and thus is to be blamed.
If these patients sense that other people and, notably, the physician, believe it is their own fault, treatment will more or less be impossible. Rightly, the patients cannot understand this, and they will feel rejected and powerless.65 Helping these patients to get a deeper understanding of their illness, which is more in line with the actual facts, is therefore a most pertinent issue. The objective is to make the patients feel that they understand what is wrong with them, that it is not their fault, that they can do something themselves, and that they have a certain amount of control over their illness/symptoms (empowerment).
The principal purpose at this stage is hence to reframe the complaints, that is, localize the complaints in new contexts and give the patients a new frame of understanding. As was mentioned before, it is very important that they do not feel corrected, and it would be very effective if the patients themselves could reach some of the conclusions. Particularly crucial is that the patients are offered explanations that do not clash with their own understanding, and that the physician does not force the pace of the reframing process. However, it is important not to simply accept the patient's suggestions but also to try to facilitate or even suggest other possible alternative explanations, even if the patient is reluctant. Before going into steps 3 and 4 of the model (see items 3 and 4 in Table 7), we will present some general rules of communication below (see also Table 6).
Avoid Resistance
In some cases, it is not possible to change the patient's perception about an organ-pathological basis of the complaints, and it is important not to enter a locked and confrontational discussion. "Rope-a-dope" (a professional boxing expression) or "go along" with the patient's resistance. "I can hear (or see) you are convinced you have heart trouble (or another organ). However, I can find no signs of changes of 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 measures?" Depending on the problem, one should discuss relevant possibilities. The physician may, for example, say "it is a fact that exercise is important for your health condition; this also applies to people suffering from a heart disease. How does this sound to you?" "Many people are afraid that the heart may be harmed when exercising or that it may even kill you. Did you worry about this? I can reassure you that this is not the case. However, you will certainly feel worse if you do not exercise—try to keep busy, even though I do understand you may find it difficult."
Support Self-Efficacy and Empowerment
It is vital to support the patient's feeling of being able to do something him- or herself and of controlling the illness and its symptoms. This can be accomplished by showing the patient in practice what to do (see below) and by helping the patient to a new understanding of his or her illness and a general understanding of what is taking place.
This is also called "empowerment" or "self-efficacy." Contrary to what we as physicians are often induced to believe, the patient sees him- or herself and not the physician as the highest authority. The physician is more likely to be seen as a consultant and often in competition with alternative therapists, magazines, friends, family, etc.66 The patient may use the physician to test hypotheses and thoughts about illness relations or to be confirmed of the validity of his or her own ideas. If the physician wishes to change the patient's perception, it is necessary to fit new ideas into the patient's own world of ideas and not to conflict with these that have been tested and evaluated by the patient,—who is "the final authority." This goal is best achieved by facilitating the patient in finding possible solutions, for example by deploying the summarizing technique whereby the physician may discreetly guide the patient via the emphasis and focus of the summary. It is important that the patient does not feel that the physician rejects his or her opinion but that he or she is taken seriously. The ideal is a dialogue in the form of a conversation between physician and patient. The patient's thoughts can be recognized by statements like, "I understand what you are saying. However, you could also see it this way..." or "I can follow your thoughts. However, I do not understand ...." Studies have shown that the time used in supporting patient self-efficacy and empowerment is time saved in the long run and that successful empowerment is reflected in greater patient satisfaction and less somatization.65
Simple Explanations
Try to explain that tension or mental stress is commonly accompanied by physical symptoms and/or that it may worsen existing physical symptoms. Physical symptoms are quite rarely caused by organic or pathophysiological dysfunction, for example, "all people might react with physical symptoms and trouble when having problems or feeling tense or stressed," "it is harmless, but I do understand it worries you and it is unpleasant," or "I often see such symptoms in stressed or tense persons; could this also be the problem in your case?" In some cases, it is hard for the patient to believe this. This approach often induces a radical change in the patient's perception of the symptoms' cause, and the patient may therefore need time to adjust to the idea. The most successful way of doing this is by giving the patient a chance to express his or her own thoughts and ideas and by helping the patient to weigh the pros and cons.
Examples of simple explanations could be:
- You may experience palpitations, breathlessness, and other physical symptoms when frightened or nervous over something. Most patients have experienced this themselves and therefore understand this explanation (Table 3).
- When depressed, you are more sensitive to physical symptoms.
- When you are frightened or stressed, you tighten your muscles. This can result in pains that may increase the tension and give more pain. Thus you are trapped in a vicious circle.
Demonstrations
Practical exercises and demonstrations may effectively illustrate the link between physical symptoms and behavior. It is crucial that these exercises and demonstrations allow the patients to experience that they can influence the symptoms themselves and that the symptoms are not beyond their control.
- Muscle pains can be demonstrated by asking the patient to tighten the muscles, for example, in an arm (lift a book with the arm outstretched), which will almost always be painful after a while: even minor muscular tension can quickly cause muscle pain. Logically, even minor muscular tension will cause muscle pains if it persists almost day and night. In some cases, tension headache can be demonstrated by pressing the patient's tight occipital muscles.
- It is often possible to connect emotional reactions and life events with physical reactions. The patient is gradually guided into speaking about their physical trouble when experiencing straining and stressing events. The physician presumably has relevant information from the patient's medical history. The best effect is obtained by using the patient's own examples, "You told me before that you were especially troubled last Monday; that was also the day your spouse came home very late. I wonder whether this is linked somehow: what do you think?"
- Finally, spontaneous situations may be used to good effect, "I can see you feel bad when we talk about this; it must be hard on you." The patient has often been nervous about the visit, and the physician may enquire whether the visit has caused a worsening of the physical symptoms.
Severe Cases
In more severe cases of somatizing, it is necessary to help the patient to a meaningful understanding of his or her illness.
- The patients often believe that they are the only ones in the world who have a particular type of illness and are therefore afraid that the physician has overlooked something. The patients must be told that this is a known phenomenon called somatization. It could be phrased, "Many people feel like you do. It is in no way a rare condition." "We have a name for it, somatization or functional symptoms/disorders." (The patient will in most cases ask what it is.)
- The physician may continue by explaining that the fundamental cause is unknown, as is also the case for many other illnesses (e.g., essential hypertension). You could say, "we do not know the actual cause or the mechanisms behind it, but it is subject to a lot of research" or "we do know with great certainty that it is not caused by any hidden physical disease and neither traditional medical nor surgical treatment will help, but may actually worsen, the condition."
- To take away the patient's sense of guilt, it is advisable to state the likelihood of a biological basis for the disorder, which is supported by scientific evidence (just as today it is quite certain that depressions do have a biological substratum). The physician could, for instance, say "Several studies indicate that the reason is changes in the brain and the nervous system and some people are more bodily sensitive than others. In other words, they do not filter physical sensations and symptoms as well as others and are therefore more troubled by the different symptoms." The physician may assist the patient's understanding by using well-known examples such as when you think about fleas and lice, you start itching. The senses and your attention are sharpened. In somatizing, the increase in attention is just much stronger. Furthermore, it could also be mentioned, "we know that for some it runs in the family."
- The physician should explain to the patient that how he or she acts and reacts to symptoms is important for his or her 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 (i.e., accepting the limits of medicine), because this may harm the patient even more.
TERM Model Step 4: Negotiating Further Treatment
At the end of the visit, the result is summed up, for example, by asking the patient, "what is your outcome from this visit," "is there something you can use," "would it be reasonable to do (such and such)," or "could we agree...?"
In some cases—especially chronic cases—it is not possible to change the patient's belief that the illness is caused by a physical disease. It is important in this situation not to engage in deadlocked, confrontational discussion (see Table 11 in Chapter 7 about advice on chronic cases).
The further course of the treatment is negotiated with the patient. The physician may mention the existence of other possibilities of treatment than orthodox medical or surgical ones. Suggest looking into this together with the patient and to find out what he or she can do to feel better, no matter what the cause of the problem is.
The following four courses should be considered:
- Acute cases: no further appointments
- Subacute cases: agree to have therapy sessions in the form of regular, scheduled appointments.
- Chronic cases: consider a status consultation. Agree to have regular, scheduled appointments (see practical advice)
- Consider referral to psychiatrist, psychologist, or special service.
Please note the paramount importance of regular, scheduled appointments!
Acute Somatization
This group of patients includes those who present with medically unexplained symptoms and who are not subacute or chronically somatizing patients, according to their medical history. After having used the general model during the consultation, the patients are normally discharged. However, it may in some cases be suitable to agree that the patient return, if necessary.
Subacute Somatization
This group includes acutely somatizing patients, who are consulting the physician again or who have already consulted the physician because of illness worrying or functional symptoms that they have been feeling for a period of less than 6 months. Agree on a short series of regular, scheduled appointments. If the physician already has learned and mastered a method or the technique for brief psychotherapy, this can be used in combination with TERM model elements. Another possibility the use of the technique of problem solving described below. In many cases, it could be beneficial to use the advice aimed at chronically somatizing patients also on patients with a shorter duration of illness.
Chronic Somatization
Please refer to Chapter 7 regarding treatment and management of chronic somatization conditions.
Referral
The possibilities of referral depend on the services available in the local area. The reason for a referral could be formulated as follows, as not to offend the patient: Referral to psychiatrist.
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Chapter 6: Follow-Up Appointments
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General Advice About Follow-Up Consultations
Do not avoid asking about the patient's physical symptoms (Table 8). However, this should not take up too much time and should not become the focal point of the consultation. The patient's need to discuss his or her symptoms will often diminish as treatment progresses. The physician should seek to focus the conversation on the factors that cause the problems and that maintain the patient's symptoms and behavior.
Concentrate on current tangible and specific problems, not childhood and past problems. It may be relevant to work with childhood during long-term psychotherapy, but it is seldom a good idea in other situations—rather, the opposite is true. A patient with many skeletons in the closet can become totally absorbed and paralyzed. For them, it would be a great help to be kept in the present and focused on practical specific problems. Other patients may use speaking about childhood as an escape from dealing with present-day problems.
The consultation should take the form of a dialogue. As was mentioned above, it is crucial for the physician and the patient to reach a common understanding, an end that may be reached by use of the Socratic questioning technique. The aim is, through negotiation, to help the patient solve the problem him- or herself. It is ultimately the patient's choice where to step in. The physician may help the patient in making this choice by engaging in a joint brainstorming that produces a number of different possible solutions to the problem.
Termination of therapy should be planned well in advance, preferably 2–3 appointments before the actual conclusion. As soon as the final appointment is set, the dialogues will automatically change character and become more forward-looking ("How do I manage new problems from now on—from whom can I expect to get help?").
Further Assessment
Although the patient has acquired insight into the relation between mental and physical factors, it is far from certain that he or she can immediately see which factors influence the symptoms. During the scheduled follow-up visits it may therefore be necessary to continue the exploration of the symptoms.
Provoking and relieving factors can be explored via a diary or weekly chart (see Appendix A1). The result of this exploration is used directly in the cooperation between the patient and the physician for finding strategies the patient may use in coping with his or her symptoms and problems.
- Which factors would normally worsen the condition?
- Which factors would normally relieve the symptoms?
- How did the onset of the symptoms affect the patient's functional level?
- How does the patient function (i.e., cope) when having symptoms?
Training
Impairment due to functional symptoms should be relieved by gradually resuming activities. It is important to be empathic with the patient's fear of the exercises and to explain that it will do with one small step at a time and that the next step will always be manageable. The patient is often seized with overweening confidence when things start falling into place again. They may therefore risk defeat and lose confidence in possible treatment. Gradual introduction and gentle progression of the challenges is hence of utmost importance. The patient should proceed from easy to gradually more and more difficult problem-solving exercises.
Problem-Solving Therapy
Problem-solving therapy has been effective and easy to use when treating somatizing patients in general practice.67 It is a suitable method that allows the therapist, in a structured way and in a few sessions, to help the patient explore and solve problems that used to be difficult to manage. The patient learns to use his or her own abilities and use this experience to handle both present and future problems. The physician will function more as a consultant and trainer than as an expert. A problem-solving session normally lasts more than the 10–12 minutes usually allotted for a consultation,9 and it is therefore recommended to use a regular therapy session.
The patient may find it a boundless undertaking to face the entire problem complex at once, so individual sessions should address a single problem at a time. Always start by making an agenda and revising the result of the homework and exercises since the last session.
The seven steps of the problem-solving model are examined for each problem addressed:
- Identification and clarification of a present problem, for example, the patient isolates him- or herself and does not get out of his home.
- Clarification of alternative targets and choice of one concrete goal, for example, being able to go shopping.
- Formulate together possible solutions (brainstorming). It is important at this point not to exclude any solutions beforehand.
- Each solution's pros and cons are evaluated. Choose the solution model that seems most feasible after evaluation. It is important that the patient feels that he or she is the one who chooses the solution.
- The solution model is broken down into steps, each of which can realistically be managed. Each step is elucidated in terms of method, time frame, and initiation; for example, start the first week by taking small walks with the dog.
- The patient summarizes the plan for the solution of the problem, and this agenda may be perceived as a sort of a contract. The physician's providence may greatly help the patient, as may advance, joint consideration of possible hindrances.
- At the next appointment, evaluate progress and adjust target and measures if necessary.
In the beginning, the patient will often find the method difficult and may come to the appointments without having tried to use the agreed problem-solving method. Try to be relaxed about this and avoid at any cost becoming admonitory toward the patient. Discuss, instead, what was difficult and find out what hinders the patient from progressing.
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Chapter 7: Treatment and Management of Chronic Somatization
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The more severe cases of chronic somatoform disorder present a lifelong illness that may seriously disable the patient. In many cases, it is therefore more realistic to use the term "management" rather than treatment, which is to say that the instituted therapy will not have a curative intent but will aim at giving the patient the best possible life, as when dealing with other chronic physical or mental disorders. Some take the view that the most severe cases of chronically somatizing patients can only be managed through long continual ambulatory contact with a psychiatric specialist. A physician who deals with a chronically somatizing patient often faces a rather bewildering scenario of illness images and may find it impossible to get a clear picture of the condition of a patient who has gone through a plethora of tests and futile attempts at treatment. The scenario often presents a difficult mixture of different probable pathological findings and signs and obviously medically unexplained symptoms. The patient will not be less confused. The physician may think, "Is it her again? What shall I do? Could there be anything I have overlooked in the extensive case history?" The physician can feel insecure about seeing the patient and must brace him- or herself when spotting the patient in the waiting room. Agreement with the patient to have status consultations is a method the physician may resort to in order to obtain a general overview of a complex case and to get on top of the chronic somatizing condition.
Status Consultation
Before the Consultation
Allot the necessary time to go through the patient's case. This may seem boundless and demands great effort, but later it will definitely be worth the effort, both because it saves time and because it improves the relationship with the patient (Table 9).
Go through the patient's medical history on the basis of case notes, commentaries, etc. Sum up in a few main groups or subjects the symptom groups the patient has presented with and has been examined for. Sum up the examinations and treatment trials the patient has gone through, including any positive and negative findings.
A one- to two-page outline based on these summaries will clarify the illness picture and make the physician feel on safer grounds. Both positive and negative results must be covered so that the patient will not feel that one half has been overlooked. Also, be aware of any patterns over time in the intensity of the illness and complaints in relation to external stress and life events.
Look for psychiatric disorders. Physical and emotional symptoms often both occur and worsen simultaneously. The patient may, for example, focus only on bodily symptoms of a depression, even in cases where symptoms have disappeared with the treatment of the depression. This correlation can be rendered probable to the patient, which may in turn mediate a dialogue about the subject.
During the Status Consultation (Table 10)
The reason for the status consultation is explained to the patient. An explanation could be that the patient has gone through many examinations and treatments but has not become better, that the patient has come often, is very tormented, and the physician can tell that the patient is not feeling very well. It is therefore obvious that orthodox medical treatment, indeed, has not helped. The physician and the patient could therefore try jointly to approach the matter from a different angle, as it is unsatisfactory with all the examinations and treatment attempts that do not help. The physician could give the patient the following offer, "Could we together try to find new ways to make you feel better?" "Unfortunately, there are many illnesses that we cannot treat such that they disappear completely. However, certain things could be done to mitigate the inconveniences." "There are no miracle cures." "An objective could be to stop all these unnecessary examinations, because they are not helping you anyway." "I will, of course, be observant in case you show signs of a physical disease."
Present the summary of the medical history as neutral facts: It is important that both positive and negative findings are emphasized and discussed with the patient. A careful and systematic summary should make it clear to the patient that he can safely leave it to the physician to oversee that a future physical disease is not overlooked.
The limits of medicine: We physicians must acknowledge that the biomedical model allows us to explain only a small part of the illnesses and disabilities caused by physical symptoms and to cure an even smaller part. This recognition has only been reached by few people, which may explain why somatizing patients will continue to seek treatment. It should be borne in mind that this recognition applies not only to somatoform disorders but also to many physical diseases. Essential hypertension could be an analogous example, as the aim of the treatment of this disorder also is to avoid secondary damage.
General Advice—Management of Chronic Somatization (Table 11)
- Make a brief physical examination that focuses on the organ system to which the patient's new complaints are referring. This contributes to making the patient feel that he or she is taken seriously and not superficially, as may otherwise be the case. In the examination and in the whole assessment of the patient, it is important to emphasize objective findings instead of subjective complaints. Perceive the complaints as primarily emotional communication and not as a sign of a physical disease. Avoid investigations and tests if there are no indications based on objective findings or a well-defined (new) clinical illness picture. If the patient is a chronically somatizing patient, the possibility of finding a disease explaining the illness is very small (less than 1%–2%).31,41 However, somatizing patients have the same risk as everybody else of getting a (independent) genuine physical disease.
- Rationalize medication. Avoid habit-forming medication. The typical chronically somatizing patient uses several different types of medication. Consider whether medication, both the psychoactive and other types, is doing more harm than good. Many somatizing patients have a high potential for misuse. Medication can cause physical damage, it is expensive for the patient, and he or she will often become emotionally dependent and may use the medication as proof of the illness both toward other people and him- or herself. The patients will often resist withdrawal of their medication. It is important to explain the reason for the change: "You have been taking this medication for a long time, and I can see that it has not helped you very much, because you still complain of... I therefore think we should try phasing it out." Warn the patient that inconveniences may occur during a transition period. It can be harder to reduce the patient's consumption of psychoactive medication and painkillers than to reduce other kinds of medication. An explanation could be, "I can imagine you are afraid to give up the medication and you feel that it is helping you somewhat. I am sure when you have adjusted to not taking the medication you will feel better, because it also sedates you and you can become dependent on it, which will cause you more trouble than now (i.e., medication is only helpful during the short term)." Be firm but not hard or punishing when rationalizing medication. Prevention is better than treatment, which emphasizes that it is better to avoid medication that may be habit-forming.
- Make the diagnosis and inform the patient that the disorder is known and has a name. It is important to realize the diagnosis, because keeping this in mind makes one think twice before initiating new tests or treatments (see paragraph 1). Thus, it is also easier to resist the pressure the patient may put on the physician. Furthermore, unfamiliar things often involve anxiety and insecurity for both physician and patient. When "the enemy is known" and has a name, it is easier for the patient to relate and fight against it. This reduces anxiety.50
- Acknowledge the reality of the patient's symptoms. This is crucial, because it is a precondition for the patient's acceptance and cooperation.
- Be direct and honest about the areas you agree in and those you do not, but be careful as not to make the patients feel ignorant or disrespected. "I can see you find it difficult to believe what I am saying."
- Be stoical; do not expect rapid changes or cure. Hesitate a while before you evaluate whether treatment has helped or not.
- Reduce expectations about cure and accept the patient as being chronically ill. Try instead to aim at containment (iatrogenic) and damage limitation. The therapeutic focus is, in other words, more on management than on treatment, in the same way as in other chronic physical or mental disorders.
- Understand worsening and new symptoms as emotional communication rather than as a manifestation of a new disease. The physician who knows the patient could, for example, say, "nothing of what you are telling me makes me think you have contracted a new disease ..." or "we have talked about your inclination to react with strong physical symptoms when something upsets you and I was wondering whether something has come up or anything specific is worrying you at the moment?
- Consider specific therapy (TERM model steps 1–3 and follow-up appointments) and consider referral to specialized treatment if such is available.
- Consider psychopharmacological treatment. There are no randomized studies of the effect of various psychoactive drugs for somatizing conditions. It is the clinical impression that many somatizing patients benefit from antidepressants or Buspirone, and this should be considered, even though the patient denies symptoms of depression or anxiety. Be cautious to discontinue the medication if it has no effect when used in sufficient dosage and for a sufficient period (Table 11).
- Treat any coexisting psychiatric disorders according to usual guidelines. In chronic cases, more than 50% of the somatizing patients also have another mental disorder. Start with smaller dosage than usual and increase slowly, because the somatizing patient often has a low threshold and low tolerance for side effects. Be stoical and try to hold on to the initiated treatment until the patient has gone through a sufficient treatment regime. Preferably choose medication that can be serum monitored, because these patients can be very unstable in their medication habits and in their compliance. Furthermore, by choosing this medication, the physician does not depend only on the patient's subjective information about adverse effects.
- Be proactive instead of reactive. Agree on a course with fixed, scheduled appointments with 2- to 6-week intervals and avoid visits on patient demand (if needed, accept on demand one phone call per week). This is an absolute must for any treatment or management of patients with functional symptoms with a certain severity. If you cannot accomplish this, you may as well give up the treatment.
- If the patient has a job, avoid giving him or her sick leaves if at all possible. Somatizing patients are predisposed toward being trapped in the sick role and get caught in self-perpetuating vicious circles that confirm them in their ill health and how little they can accomplish. It is important to formulate the reason for not letting the patient go on sick leave, so that the patient does not feel rejected or misunderstood. There is presumably no risk involved in a short-term sick leave for a well-defined genuine physical disease such as fractures in a somatizing patient. This could be explained by the clinical observation that the patient surprisingly seems able to distinguish, even though they are not conscious of this distinction.31
- Try to become the patient's only physician and minimize the patient's contact with other health care professionals, physicians on call, and alternative therapists as much as possible. The health care system (and the gray market) has a significant responsibility for the somatizing patients becoming chronic and disabled, because in this market the patients are often treated and examined in the same way as patients with genuine physical disorders. Many examinations and treatments involve considerable risk of physical damage as well as personal and financial costs for the patient.
- Inform your colleagues of your management plan and develop contingency plans for when you are off duty, on leave, etc. A physician who does not know the patient will often be driven into a corner by a severely somatizing patient, because his or her medical history is often boundless and the physician only hears the patient's own perception. Providing colleagues with necessary information and, preferably, instructions to make them able to manage the patient and to withstand the pressure they may be exposed to is therefore of utmost importance.
- Inform the patient's nearest relatives and try to co-opt relatives as therapeutic allies. Especially chronically somatizing patients often have a very close symbiotic familial interplay. In many cases, the whole family life revolves around the patient and his or her illness, and changes can be directly opposed by the family because of misunderstandings or a fragile balance of power within the family. Changes will thus interfere deeply with the whole family life, and it can be very complicated to change such patterns. It is necessary that the family accepts or, better yet, supports the patient in going through treatment and making the necessary behavioral changes. Actual family therapy demands specialist knowledge, but it is always possible to have a talk with the patient and his or her family. If possible, consider co-opting a health counselor and to get help from the local psychiatric system.
- The physician may also wish to arrange support/supervision for him- or herself. Chronically somatizing patients often belong to the group of patients that it is most difficult to treat and manage. The physician is often exposed to almost constant pressure to make examinations and attempts at physical treatment. Because the patients are often very active in their search for treatment, many other health care professionals may try to interfere in the management and suggest inappropriate treatment or unnecessary examinations because they lack knowledge of the patient. It is advisable to find a close colleague with whom you can discuss the problems.
- If relevant, motivate the patient for psychiatric treatment. It may be a question of assessment and exclusion of another coexisting mental disorder, reduction of unnecessary drugs, mobilization and activation, behavioral therapy and family therapy, etc. This is usually best done in a psychiatric setting. Moreover, many hold the opinion that continual, ambulatory psychiatric treatment is superior to other types of treatment when dealing with the most severe cases. Unfortunately, many psychiatrists are disinclined to care for these patients.
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Introduction
Aim
