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PAGE 35 for medically unexplained
symptoms ( somatoform disorder , hypochondriasis , somatic symptom disorder ) in DSM and ICD classifications have always been contested , and many believe they do not belong in
29 , 30 a psychiatric classification at all . Patients will often comment , “ You think it ’ s all in my head ; don ’ t you , Doctor ?” This implies we do not see them as having real symptoms of a real disorder . 31 , 32 The idea that a disease originates in the mind or the body is overly simplistic . Recent research into the role of the gut , immunological and inflammatory agents and the neurological system has challenged our understanding of how the mind and the body interact , particularly in response to psychological trauma . 33-37
There are , however , some circumstances — particularly in children — where physical symptoms do arise from a psychological cause . Somatisation is the tendency to experience , interpret and communicate emotional symptoms as physical ones , and we see this every time a child presents with a tummy ache secondary to stress ( see figure 2 ). 38 , 39 Clinicians must make delicate decisions when discussing how the mind can influence the body because patients and their families may find such an approach dismissive and invalidating . 40
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Box 1 . Coping with patients who have persistent medically unexplained symptoms : managing heartsink feelings |
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• Accept that the patients are experiencing these symptoms : — Patients with medically unexplained symptoms need respect , empathy and compassion .
— They experience significant shame and stigma and need to be revalued as people deserving of care .
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MAINTAINING A POSITIVE THERAPEUTIC RELATIONSHIP
BECAUSE there is a high association
with early childhood trauma , many patients with medically unexplained illness already have interpersonal difficulties and can find it challenging to develop and maintain trusting therapeutic relationships . 41 These patients need to manage difficult feelings . In the absence of a diagnosis , they feel they have to fight for the right to access care and also lack a narrative or vocabulary to make sense of their experiences . 42
Having unexplained symptoms heightens the vulnerability that is part of the morbidity of any chronic disease . 43 Many patients describe feeling like ‘ medical orphans ’ without a legitimate place in their social or medical worlds . 44 , 45 Many doctors find these patients frustrating and difficult to help . 46-48
The use of terms such as ‘ difficult ’ or ‘ heart-sink ’ when referring to patients reflects the way negative emotions can be triggered in the doctor . Heart-sink patients offer a moral dilemma . 49 , 50 We recognise “ their suffering but , at the same time , struggle with the feelings they engender in us . These patients can trigger aversion , fear and even hostility ”, creating “ turmoil in the emotional world of the
51 , 52 medical healthcare team ”.
Most doctors are not proud of these feelings . Most of us are motivated to practise medicine because we achieve satisfaction from solving medical problems and helping patients and their families . 53 Feelings of helplessness and guilt are not part of our vision of a good doctor . Even the term ‘ heart-sink ’ ( see box 1 ) captures an uneasy ambiguity : the doctor ’ s heart sinks , but the patient gets the label . 54 , 55 It is therefore understandable that it can be difficult to maintain a healthy therapeutic relationship .
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Figure 1 . The 19th century diagnosis of hysteria began a tendency to characterise medically unexplained symptoms as affecting women and to attribute the cause to psychological issues . Freud ’ s work on neurosis continued this trend and strengthened the idea that medically unexplained symptoms were caused by psychological processes . Both led to the invalidation of women and their medical needs .
Figure 2 . Somatisation may occur in children .
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• Remain patient centred :
— GPs may need peer support in challenging relationships to provide appropriate ongoing care .
— In some cases , it may be necessary to share care with another GP and , where possible , with a multidisciplinary team .
• Accept responsibility :
— These patients often experience Balint ’ s ‘ collusion of anonymity ’, being passed around an endless cycle of multidisciplinary carers . 57
— This can lead to a career of medical attendance that cements the sick role and exhausts carers and families .
— It often does not help manage their needs effectively .
• Decide how to incorporate psychological concepts and treatments early in the therapeutic relationship : — Introducing terms such as
‘ stress ’ early means it is easier for patients to link their physical and psychological health when necessary .
— It would be unusual not to have psychological consequences of medically unexplained symptoms , so even if the condition does not originate in psychological ill health , techniques to improve wellbeing are helpful .
• Practise harm minimisation : — There are no easy guidelines to decide when , or if , to investigate or treat .
— There are always risks in missing disease , but these are balanced by the risks of overdiagnosis and iatrogenic harm .
— The potential for harm is always present , so it helps to recognise that this is the price of uncertainty .
• Shift the focus from curing to healing : — Doing so often means widening the scope from biomedical care to include psychosocial elements and concepts like meaning and purpose .
— While it may be necessary to refocus on potential diagnoses regularly , focusing on coping with illness rather than curing disease can be more helpful .
Source : Stone L 2013 56
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THE DILEMMA OF UNCERTAINTY
UNCERTAINTY is a fact of life , but it
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