The treatment of somatisation – reattribution skills
The model that we propose for the consultation has threedistinct stages. These are outlined below:
1. Feeling understood
Take a full history of the pain:
It is essential to start from where the patient is at, but a thesame time ask questions that may reveal key cues relating tomood. Useful techniques here are to a) go through a “typicalday” and b) ask about associated symptoms.
Respond to mood cues:
Cues can then be responded to by clarification, the use ofempathic comments and questions that probe mood state. it isimportant to remember to ask about biological symptoms. Alsoimportant at this stage are questions that:
Explore social and family factors:
Explore health beliefs:
what does the patient think may be causing the symptoms?
Finally in this first stage of the interview it is essential tocarry out a brief focused physical examination. Unless this iscarried out it may be very difficult to move on to the nextstage.
2. Broadening the agenda
When all the information has been gathered, the stage is setfor changing the agenda from one where the problem is seenessentially as physical to one where both physical andpsychological problems can be acknowledged. The key elements inthis stage are as follows:
Summarise the physical findings:
If any abnormality has been found but it does not (as is commonlythe case) fully explain the patient’s symptoms it should bementioned and discussed honestly with the patient.
Acknowledge the reality of the patient’s pain or othersymptoms:
This is essential and must be sensitively done. many doctors findthis difficult if they have not found anything abnormal onphysical examination
Reframe the patient’s complaint:
Remind them of other symptoms (especially the affective) and linkthem to life events if this is possible.
3. Making the link
There are a range of techniques that may be then used formaking the link between the patient’s physical and psychologicalsymptoms. Only one or two will be appropriate for each patientand different techniques may be useful at different times.
a) Simple explanation
It not is sufficient to say that “anxiety causesheadaches”. A three stage explanation in which anxiety islinked to muscle tension which then causes pain is required. Asimilar approach can be used to explain how depression causeslowering of the pain threshold which results in pain being feltmore severely than it would in a euthymic state.
- link to life events
- here and now
Practical demonstration could involve for example asking apatient to hold out a heavy book on an outstretched hand to showhow tension causes pain, however, simply reminding the patient ofwhen something similar has happened eg: carrying heavy luggage,is usually sufficient. Information from the “typicalday” can be used to link pain with stressful life events.Information about how the patient is feeling, both in terms ofmood and pain/physical symptoms in the “here and now”during the interview can be used to link mood state withsymptomatology. Two final techniques involve exploration ofillness in other family members.
- family member
Other members of a patient’s family may have experiencedsimilar symptoms at the time of life threatening illness and thesignificance of the present symptoms can be explored in terms oftheir “special meaning” to the patient.
- family member
It is often easier to understand psychological mechanismswhich occur in others and if other members of the patient’sfamily have experienced physical symptoms when clearly understress, the significance of this link may be used to draw helpfulparallels with their own situation.
Clearly this is not a totally comprehensive model as furthertechniques are now required to help in the management of thesymptoms themselves eg: cognitive techniques to cope with pain,anxiety management etc.
4. Negotiating treatment
- Explore patients views – “how do you feel so far about what we have discussed? what would you like to do from here?”
- Acknowledge worries or concerns
- Problem solving or coping strategies
– 3 sorts of problem
– creating a problem list
– concerns about symptoms now
- Appropriate treatment for depression
- Specific plans for follow up
Patients come with problems, not diagnoses.
Beginning the interview.
- Verbal cues.
- Nonverbal cues.
- Open questions
- Asking for an example.
- Supportive statements.
- Health beliefs and concerns “is this a realistic fear?”
- Eye contact.
- The columbo scam “you tell me…but…”
Sources of information
- Ventilation of feelings.
- Making links.
- Problem solving.
- Special types of interviewing.
Summary: the structure of problembased interviewing
- Take a full history
- elicit other associated symptoms
- ask about a typical pain day
- Respond to mood cues
- empathic comments
- probe mood state/thought content
- Explore social and family factors
- Check for biological symptoms
- Explore patients health beliefs
- Specific example
- Carry out focussed physical examination
Changing the agenda
- Feed back results of physical examination
- Acknowledge reality of pain
- Reframe the patient’s complaint
- summarise psychological symptoms
- remind them of mood symptoms and link to life events
- negotiate: “I wonder if…”
Making the link
- Between anxiety and physical symptoms
- “uptight” and muscle tension
- Between depression and physical symptoms
- how depression can lower pain threshold
- How symptoms can make you feel more depressed – the vicious cycle
- By practical demonstration – how tension can cause physical pain
- holding a book
- carrying heavy luggage
- To life events – how symptoms related to life events
- link with mood or stressful events
- “typical day”
- Linking in the “here and now”
- “how are things today/now/at this moment?”
- With illness in other family members or significant others
- by explaining shared symptoms (identification) – symptoms may be learned from significant others
- by explaining shared illness behaviours (projection) – special significance of symptoms in relation to the history of significant others
- How symptoms might have occurred before during stress
Keeping a record
- What were you doing?
- Who were you with?
- When was it?
- Where were you?
- What symptoms?
Teaching problem based interviewing
Assessment and management of medically unexplained symptoms