Fog of War:

8 lessons
from the life of a liaison psychiatrist

(with apologies to Errol

Morris)

How
to
get
more of what
you want and
keep hold of
the little you
have

Lesson 1.
Get with the

National Service Framework for Mental Health

Standard 3:
any individual with a common mental health
problem should be able to make contact
around the clock with local services...

Lesson 2.
Find out who the real commissioners
are

wheres the money?

North West London

Strategic Health
Authority

Westminster PCT
Harrow PCT

St Marys NHS Trust

Liaison Psychiatry
at St Marys

Brent PCT

CNWL Mental Health

NHS Trust

Lesson 3.
It pays to

Lesson 4.
Get your patients on side...

Lesson 5.
Have all of those reports on
the tip of your tongue...

The Psychological Care of Medical Patients: Recognition of Need and

Service Provision (1995) Royal College of Physicians & Royal College of
Psychiatrists, London.

The Psychological Care of Medical Patients: a practical guide (2003) Royal

College of Physicians & Royal College of Psychiatrists, London.

Report of the Working Party on the Psychological Care of Surgical Patients

(1997) Royal College of Surgeons, London

The General Hospital Management of Adult Deliberate Self-harm: A

consensus statement on standards of service provision (1994). Royal
College of Psychiatrists, London

Self-harm: The short-term physical and psychological management

and secondary prevention of self-harm in primary and secondary
care. NICE guideline

Improving the management of patients with mental ill health in emergency

care settings (2004) DoH checklist

Health services research

Cost-effectiveness studies
...are they worthwhile?

Lesson 6.
a little bit of teaching
can do you a lot of good...

Lesson 7.
Go forth and multiply.

Lesson 8.
By any means necessary.

Serious
Untoward
Incident

SOMATISATION & PRIMARY CARE

Tom Sensky
Imperial College London
December 2004

OUTLINE

People who present with somatoform

disorders are often difficult to manage

People who present with somatoform

disorders may arose strong feelings in

clinicians

Most of the relevant research has been

done in primary care

Much of this research is also relevant to

work in A&E

?A&E attracts treatment failures

DIFFICULTIES IN DOCTORPATIENT RELATIONSHIP

Overall, 15% of patients were

rated as difficult by their doctor

67% of difficult patients had at

least one psychiatric diagnosis,
compared with 35% of nondifficult patients (p<0.001)

Rating as difficult strongly

associated with functional
disorders

Hahn (2001)

DIFFICULTIES IN DOCTOR-PATIENT
RELATIONSHIP: CORRELATIONS WITH
NUMBER OF SOMATOFORM
Extent
of frustration with patients
SYMPTOMS
0.31*
symptoms

Perception that patient is manipulative

0.19

Finding patient frustrating

0.14

Difficulty communicating with patient

0.14

Enthusiasm in caring for patient

0.11

* Controlling for number of physical illnesses

and number of psychiatric illnesses
All correlations p<0.01)

Hahn (2001)

CORRELATIONS WITH GP
CLINICAL GRADING OF
GP questionnaire item
SOMATISATION

Consultations in last 3 years

0.35

<0.001

Patient-rated somatisation
symptoms

0.09

ns

Chronic diseases

0.11

0.023

Functional syndromes

0.18

<0.001

Inadequate help-seeking behaviour

0.26

<0.001

Patient willing to discuss p/social

aspects

-0.28

<0.001

Patient asks for superfluous

examinations

0.56

<0.001

Helpless behaviour of patient

0.52

<0.001

Tiresome patient

0.54
Schilte <0.001
et al (2000)

ATTITUDES OF GPs TOWARD PATIENTS

WITH MEDICALLY UNEXPLAINED
SYMPTOMS
They are difficult
to manage
They have an
undiagnosed
physical illness
They have
personality
problems
They have a
psychiatric illness

20

40

60

80

100

% Respondents Agreeing
Reid et al (2001)

GPs VIEWS: IRRITABLE BOWEL AND

CHRONIC FATIGUE SYNDROMES
COMPARED
IBS
Anatomical/physiological
basis for syndrome

Yes

Low threshold for symptoms

No

Patients lack stoicism

No

Patients transgress the

obligations of the sick role

No

CFS

Raine et al (2004)

GPs VIEWS: IRRITABLE BOWEL AND

CHRONIC FATIGUE SYNDROMES
COMPARED
IBS

CFS

Anatomical/physiological
basis for syndrome

Yes

No

Low threshold for symptoms

No

Yes

Patients lack stoicism

No

Yes

Patients transgress the

obligations of the sick role

No

Yes
Raine et al (2004)

CHRONIC FATIGUE: DOCTORS

RESPONSES

Stereotyping the patient is

commonly defined by the diagnosis

Strained relationship with patient

Hopelessness regarding appropriate
interventions

Failure to adequately consider

psychological interventions

?Above probably widely prevalent in

patients presenting with somatoform

disorders
Raine et al (2004)

IATROGENIC FACTORS IN
SOMATISATION
DOCTORS
CONCERNS

CONSEQUENCES

Fear of missing a
physical disease

Excessive examination

Concern about
complaints

Defensive practice (excessive

investigations)

Lack of accessible
psychiatric
treatment

Persistence with purely medical

treatment

After Fink et al (2002)

IATROGENIC FACTORS IN
SOMATISATION

DOCTORS CONCERNS

CONSEQUENCES

Insufficient knowledge and

skills

Focus exclusively on
biomedical aspects

Narrow view of doctors role

Concern that there is
insufficient time
Fear of violating patient
boundaries
Fear of opening Pandoras
box

Avoidance of any
exploration of patients
psychological state

Fear of making the patient

dependent
After Fink et al (2002)

DO PATIENTS WITH
SOMATISATION PRESSURIZE THEIR
from 21
36 patients
DOCTORS?
practices
Effects of symptoms on
34 received somatic
interventions

27 drug
prescriptions

12 investigations
4 specialist referrals

Only 10 patients
requested somatic
interventions

Attributed to
Patient
Pressure

patients life
Graphic and emotive
language
Biomedical explanations
Emotional distress
caused by symptoms
External authority
Criticism and negation
Complexity of
presentation
Ring A et al (2004)

GPs VIEWS ON THEIR ROLE IN

MANAGING MEDICALLY UNEXPLAINED
SYMPTOMS
Reassurance
Act as gatekeeper (inappropriate referral)
Provide counselling
Refer for further physical investigation
Prescribe psychotropic drugs
Avoid getting too involved
No involvement at all
0

20

40

60

80

100

% Respondents Agreeing

Reid et al (2001)

GPs VIEWS ON THEIR ROLE IN

MANAGING MEDICALLY UNEXPLAINED
SYMPTOMS

Reid et al (2001)

REASSURANCE NO-DISEASE
PERSUASIVE STATEMENTS
Three types of statement

You do not have disease X

Your investigations have all been
negative/normal

Provision of a non-disease

explanation of the patients

symptoms

Coia & Morley (1998)

REASSURANCE PROBLEMS WITH

NO-DISEASE PERSUASIVE
STATEMENTS

Honest explanations are inevitably ambiguous

Medical tests are logically ambiguous
(possibility of false negatives)

Non-disease explanations are seldom

unequivocal

How these explanations are offered is crucial

to their effect on the patients distress

Being emphatic might work in the short term,

but could create further problems later on

PATIENTS PERCEPTIONS OF MEDICAL

EXPANATIONS IN SOMATISATION
METHOD

FEATURES

IMPLICATIONS

REJECTION Denies reality of

symptoms
Implies imaginary
disorder or stigmatising
psychological problem

Unresolved explanatory
conflict
Doctor distrusted with
future symptoms

COLLUSIO
N

Acquiescence by doctor
to explanation offered by
patient

Questioning of doctor's
openness and
competence

EMPOWER
-MENT

Tangible mechanism
Exculpation
Opportunity for self
management

Legitimises patient's
suffering
Patient understands and
owns the explanation
Removes blame from
patient
Allies doctor and patient

Salmon P et al (1999)

MAKING ATTRIBUTIONS

It is

commonly
assumed that
in making
attributions,
individuals
think like lay
scientists

INTERVENTIONS FOR
SOMATOFORM DISORDERS

INTERVENTIONS FOR
SOMATOFORM DISORDERS
SIMPLE
REASSURANCE
REATTRIBUTION
SPECIALIST
INTERVENTION
NB even simple
interventions
can have serious
adverse effects

INTERVENTIONS FOR
SOMATOFORM DISORDERS
SIMPLE
REASSURANCE
REATTRIBUTION
SPECIALIST
INTERVENTION
NB even simple
interventions
can have serious
adverse effects

ATTRIBUTIONS
Examples of attributions for I feel my
heart pounding in my chest
NORMALIZING

Ive exerted myself or

drunk a lot of coffee

PSYCHOLOGICA
L

I must be really
excited or afraid

SOMATIC

There must be
something wrong with
my heart

ATTRIBUTIONS IN HEALTH ANXIETY

CAUSAL
EXPLANATION
Attributed to
dispositional
factors

Attributed to situational
(environmental) factors

Explanation
insufficient

PSYCHOLOGICAL SOMATIC
ATTRIBUTION ATTRIBUTION
PATHOLOGICAL

NORMALIZING
ATTRIBUTION

NORMALIZING
ATTRIBUTION
BENIGN

ATTRIBUTION FREQUENCY BY
TYPE
Normalizing

Psychological
I nfrequent attenders
Frequent attenders

Somatic
0

Mean number of
explanations

3
Sensky,
MacLeod &
Rigby (1996)

ATTRIBUTIONS IN HEALTH ANXIETY

CAUSAL
EXPLANATION
Attributed to
dispositional
factors

Attributed to situational
(environmental) factors

Explanation
insufficient

PSYCHOLOGICAL SOMATIC
ATTRIBUTION ATTRIBUTION
PATHOLOGICAL

NORMALIZING
ATTRIBUTION

NORMALIZING
ATTRIBUTION
BENIGN

ATTRIBUTIONS IN HEALTH ANXIETY

CAUSAL
EXPLANATION
Attributed to
dispositional
factors

Attributed to situational
(environmental) factors

Explanation
insufficient

PSYCHOLOGICAL SOMATIC
ATTRIBUTION ATTRIBUTION
PATHOLOGICAL

NORMALIZING
ATTRIBUTION

NORMALIZING
ATTRIBUTION
BENIGN

POINTS TO CONSIDER WHEN

ASSESSING SOMEONE WITH
Starting point must be the patients own
SOMATISATION
model of his/her illness

Never offer generic reassurance

Remember that the patient is likely to
have several (possibly conflicting)
explanations for the illness already
this needs to be acknowledged!

Worth attempting to help the patient

reattribute the presenting symptoms

If possible, consider attributional style

more generally

THE NUMBER NEEDED TO

OFFEND

A doctor would be suggesting that I was putting it

on, mad or imagining symptoms if I had a
weak leg and they gave me this diagnosis

// 43

Stone et al (2002)

CONTACT DETAILS

Tom Sensky
t.sensky@imperial.ac.uk