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Primary care of the somatizing patient: A collaborative model
Abstract
Somatizing patients can be frustrating to treat, and their lengthy diagnostic workups represent a huge drain on health care resources. Cure of somatoform disorders is elusive; however, cost-effective, compassionate management is possible through collaboration between primary care physicians and psychiatrists or behavioral health care groups.
... From the very earliest days of efforts to classify mental disorders, how to characterize somatization clearly presented a very sticky problem (Lipsitt 1996 ). In spite of attempts to clarify different somatizing disorders described as distinct entities, the spectrum of somatoform disorders is large, diffuse, and often defying of defi nitive diagnosis (Wessely et al. 1999 ). ...
... The risks include delayed recognition, diagnosis and treatment, high and excessive utilization of medical resources, unreasonable and unnecessary costs, and prolonged suffering before the essential diagnosis and intervention are instituted. Such pitfalls can be avoided with the collaborative assistance of psychiatrists or other mental health professionals (Lipsitt 1996 ;Katon et al. 1999 ;Schaefert et al. 2013 ). ...
... Untutored efforts at psychiatric referral may result in aborted attempts to procure specialist advice or care. Some early experience with team or collaborative approaches would appear to show some promise (Lipsitt 1996 ;Katon et al. 1999 ;Schaefert et al. 2013 ). ...
On a busy day in a general physician’s office, perhaps 50% or more of the patients with physical complaints will have no definitive
explanation for their ailment (Kroenke and Mangelsdorff, 1989). The patients present with distress from fatigue, chest pain,
cough, back pain, shortness of breath, and a host of other painful or worrisome bodily concerns. For most, the physician’s
expressing interest, taking a thorough history, doing a physical examination, and offering reassurance, a modest intervention,
or a pharmacologic prescription suffices to assuage the patient’s pain, anxiety, and physical distress. But for some, these
simple measures fall short of their expected result, marking the beginning of what may become a chronic search for relief,
including frequent anxiety-filled visits to more than one physician, and in extreme cases even multiple hospitalizations and
possibly surgery.
... People seek medical care and enter the health care system generally due to the experience of physical symptoms, especially when they are persistent. For example, 8 common physical complaints (fatigue, backache, headache, dizziness, chest pain, dyspnea, abdominal pain, anxiety) account for more than 80 million physician visits annually in the United States (Lipsitt, 1996). However, researchers suggest that a demonstrable organic cause can be iden-We wish to express our gratitude to the reviewers of earlier versions of this manuscript as they provided important and insightful comments. ...
... This phenomenon often results in multiple hospitalizations, diagnostic tests, actual operations, and other medical procedures in the absence of ultimate answers. As a consequence, health care costs for such patients are nearly 10 times higher than the average patient (Lipsitt, 1996). As an example, Katon et al. (1990) found that 10% of primary care patients account for almost one third of outpatient primary care visits, one half of hospital days, one half of specialty visits, and one quarter of prescriptions. ...
Research has indicated that substantial numbers of physical or medical symptoms presented by patients remain unexplained medically. For example, studies have indicated that less than 25% of physical complaints presented to physicians have known or demonstrable organic or biological causes. Cognitive-behavior therapy (CBT) provides for a potentially effective means of impacting on this significant public health problem, both medically and psychologically. This paper reviews the extant literature regarding CBT for medically unexplained symptoms, as well as three related disorders—chronic fatigue syndrome, fibromyalgia, and noncardiac chest pain. Whereas this review provides support for the efficacy of CBT for such problems (e.g., effect sizes for CBT compared to control conditions centered around .40), it also identified a variety of methodological limitations regarding the studies themselves. Based on this analysis, recommendations for future research endeavors are provided and the implications of this area for prevention and treatment are offered.
... Individuals often seek medical treatment when they experience physiologically based symptomotology. Even when symptoms can be accounted for by anxious states, many patients report physical components such as changes in heart rate, respiratory functions and possibly chest pain (Lipsitt, 1996). However, research has demonstrated that organic causes of physical symptoms can only account for approximately one-quarter of the total variability in such cases. ...
Individuals coping with a diagnosis of chronic heart failure (CHRONIC HF) are confronted with many life-style changes, some of which include modifying eating habits, initiating an exercise program, taking numerous and different medications, and monitoring of weight for fluid retention on a daily basis. Although many patients succeed at adhering to a CHRONIC HF medical regimen, others find such adjustments difficult to make. Countless studies have investigated the nature of treatment adherence, however few studies yield consistent explanatory evidence and the medical community continues to be faced with this dilemma. The present study investigated the relationship between treatment adherence, health status, and problem orientation in a sample of patients diagnosed with chronic heart failure. Participants consisted of 61 individuals from the impatient and outpatient services and Hahnemann University Heart Failure-Transplant Center. Multiple regressions were performed in order to answer several hypotheses; health status will predict one’s level of adherence to medical treatment, problem orientation will predict one’s level of adherence to medical treatments, and problem orientation will moderate the relationship between treatment adherence and health status. Separate multiple regressions were performed for independent variable health status for each outcome variable, patient report general treatment adherence, patient report disease specific treatment adherence, nurse report general treatment adherence, and nurse report disease specific treatment adherence. Negative problem orientation was found to predict treatment adherence on several outcome measures including, patient report general treatment adherence, patient report disease specific treatment adherence, and nurse report general treatment adherence. However, the hypotheses health status will predict one’s level of adherence to medical treatment and problem orientation will moderate the relationship between treatment adherence and health status was not found to be significant. The results generated from this study may offer important information for health care professionals. Specifically, problem orientation may be used as a treatment indicator or “red flag” where those individuals who are experiencing orientation related difficulties may be offered additional support as a way to increase adherent behavior.
El máster en Danza Movimiento Terapia (DMT) de la Universidad Autónoma de
Barcelona (UAB) está de cumpleaños y, para celebrar este decimoquinto aniversario,
como no podía ser de otro modo, nos hemos puesto en movimiento. Nos movilizamos,
nos emocionamos y tratamos de entonar con un mundo que avanza a una
velocidad de vértigo. El dibujo de estos tiempos nos muestra oleadas inmensas de
refugiados, ataques terroristas inéditos, elecciones sorprendentes que chocan con
antiguas certezas y una enorme confusión entre quienes sí parecen tener un espacio
propio pero se sienten permanentemente amenazados.
En medio de esta vorágine, alumnos y docentes de medio mundo encuentran
razones suficientes para encontrarse cada mes en Barcelona alimentando una formación
empeñada en cambiar la forma de mirarse a uno mismo, de mirar al otro e
incluso de mirar el mundo. Y nuestra comunidad sigue creciendo, haciendo posible
celebrar este decimoquinto aniversario, en una ocasión increíble para reencontrarnos,
movernos juntos, conmovernos, reflexionar y compartir experiencias, de esas
que pueden aportar un granito de arena a esa balanza por momentos tan descompensada
hacia «el otro lado».
¿Y por qué no dejar una huella escrita de la esencia de eso que nos va a mover
en Barcelona durante tres días? Dicho y hecho: este libro impreso será la huella física
de una coreografía abierta que nos permitirá, a lo largo de tres días, disfrutar de
diferentes espacios de movimiento y reflexión.
Empezamos estableciendo el encuadre... conmuévete y mueve el mundo.
Christine Caldwell, quien ha dirigido durante mucho tiempo la formación de DMT
en Boulder (Colorado), nos desafía proponiendo una reflexión sobre la profesión
desde una perspectiva crítica y comprometida. Habla de las necesidades de un
mundo que precisa tanto de nuestra gracia como de nuestro coraje; este último, en
ocasiones, capaz de convertirse en arenilla molesta en los zapatos de aquellos que
tratan de mover el mundo en otra dirección. Busca en nuestras raíces como danza
movimiento terapeutas (dmt) y propone estrategias que deberían guiarnos en
nuestro trabajo, centradas siempre en intervenir dentro del actual panorama
geopolítico.
Continuamos con intervenciones en DMT y Helen Payne, pionera y visionaria
de la DMT en Gran Bretaña, introduce un trabajo en marcha en su país, en el que
los síntomas inexplicables desde el punto de vista médico encuentran alivio a través de la DMT. Sonia Malaquías, alumna de la cuarta promoción del máster en
DMT de la UAB y dmt en Portugal, profundiza en uno de los aspectos de la intervención
y presenta el contacto, más que como una herramienta para la DMT,
como algo intrínseco a la relación terapéutica y fuente de información muy valiosa
en nuestra labor. Dos alumnas de la sexta promoción, Isabel Álvarez y Patricia
de Tord, nos hablan del grounding (enraizamiento) y hacen un análisis detallado
del modo de utilizarlo y de los consecuentes beneficios con grupos de mujeres que
han sufrido cáncer de mama.
La siguiente parada en este camino es la DMT y la migración, donde Rebekka
Dietrich-Hartwell, dmt que actualmente realiza su doctorado en la universidad
Drexel de Filadelfia, y Sabine Koch, docente e investigadora, nos presentan la DMT
como un hogar temporal, capaz de servir de puente para los refugiados que llegan a
un país extranjero, y afirman que, si es posible construir un espacio de seguridad y
encontrar un significado, será posible forjar una identidad. Laia Jorba, docente en la
Universidad de Naropa (Colorado), nos habla con más detalle sobre la cuestión
identitaria, incluyendo su propia experiencia encarnada y reflexionando en torno a
un trabajo que cada vez supone mayor interacción en la diversidad. En esta sociedad
cambiante, nos invita a autoexplorar eso que se mueve en relación con el encuentro
con un otro diferente, que además se convierte en reflejo para la construcción
de nuestra propia identidad. Nos invita a movernos entre lo conocido y los
límites. Susana García, alumna de la sexta promoción del máster en DMT en la UAB,
ha evidenciado la idoneidad de ofrecer un espacio de DMT a emigrantes y nos presenta
aquí su experiencia como dmt en Glasgow. Expone los beneficios que un trabajo
psicoterapéutico, centrado en el cuerpo y grupal, aporta a un colectivo diverso,
capaz de encontrar en el movimiento un lenguaje común, poderoso e inclusivo.
Para finalizar, esta publicación cierra el círculo con la DMT y la prevención,
donde M. Elena García, docente de este máster, empieza reflexionando en torno al
movimiento auténtico como experiencia de conexión con el otro, que fomenta la
aceptación, pero también como acción que puede contribuir a la creación de un
mundo abierto a la diferencia y mucho más compasivo. Laura Martínez, formada
en DMT por la quinta promoción del máster, nos presenta una experiencia de cuidado
de cuidadores a través de la DMT, que se nos revela como una opción muy
válida en lo que al cuidado de equipos profesionales se refiere. Toda una oportunidad
para trabajar en la promoción de un desempeño profesional saludable y, como
consecuencia, una oportunidad para mejorar la calidad de la asistencia a los colectivos
en situación de vulnerabilidad con los que esos trabajadores interaccionan.
Manuel Carmona y Rosa María Rodríguez, docentes en la Universidad Europea de
Madrid, y esta última, además, alumna de la segunda promoción del máster y colaboradora
del mismo en la actualidad, centran sus esfuerzos en el colectivo docente dentro del ámbito universitario y proponen reconectar con un cuerpo a veces olvidado.
Todo ello en busca de una nueva educación donde las fronteras mente-cuerpo
puedan difuminarse. Y, finalmente, Aurora Leal, docente del máster en DMT en
la UAB y Heidrun Panhofer, directora de este máster, nos invitan a reflexionar sobre
la idea del no reconocimiento a través de una experiencia donde las distintas
formas de expresión, que encuentran en el cuerpo el nexo de unión, permiten abarcar
a la persona en toda su complejidad.
Y ahora sí, tras este breve resumen, os invitamos a sumergiros en todas y cada
una de las propuestas de los autores, dispuestos a conmoverse y a empezar a mover
el mundo.
https://ddd.uab.cat/pub/poncom/2018/222304/JornadesDMT15_a2018.pdf
The BodyMind Approach™ (TBMA) is discussed in the light of common features such as insecure attachment and alexithymia found in the large patient population with medically unexplained symptoms (MUS). This population appears world-wide. TBMA is unique in that it appeals to both psychologically-minded and those who prefer a physical explanation for their unexplained symptoms and can be delivered anywhere in the world.
Clinical outcomes derived from standardised instruments measuring benefits of the group treatment so far suggest that it may be of particular benefits to patients, for example self-managed care, improved wellbeing and functioning, reduced anxiety/depression and symptom distress. Furthermore, it is possible that TBMA can provide immediate cost savings, amassing year on year and increasing patient and GP treatment choice where there is currently none for the vast majority of symptoms apart from pain relief.
TBMA is affordable, effective and delivers much needed savings in both primary and secondary care in these times of austerity,
The blurred boundaries between illnesses presenting with somatic symptoms confronts both psychiatrists and primary care physicians with one of the most challenging issues in patient care. On a typical day in a general physician’s office, perhaps 50 % or more of the patients with physical complaints will have no definitive explanation for their ailment (Simon et al. 1996; Kroenke and Mangelsdorff 1989; Kroenke 2003; Baumeister and Harter 2007; Smith and Dwamena 2007). The patients present with distress from fatigue, chest pain, cough, back pain, shortness of breath, and a host of other painful or worrisome bodily concerns. For most, the physician’s expression of interest, taking a thorough history, doing a physical examination, and offering reassurance, a modest intervention, or a pharmacologic prescription suffices to assuage the patient’s pain, anxiety, and physical distress. But for some, these simple measures fall short of their expected result, marking the beginning of what may become a chronic search for relief, including frequent anxiety-filled visits to more than one physician, and in extreme cases even multiple hospitalizations and possibly surgery.
Patients with symptoms that elude medical explanation are a perennial challenge to practicing physicians of all disciplines. Articles appear virtually monthly advising physicians how to care for them. Efforts at postgraduate education have attempted to ameliorate the situation but have shown limited or disappointing results at best. Physicians continue either to avoid these patients or to resort to a "seat-of-the-pants" approach to management. Literature on patients with medically unexplained symptoms, along with extensive experience consulting with primary care physicians, suggests that it is not primarily lack of physician skills but rather a series of barriers to adequate care that may account for suboptimal management. Barriers to implementation of effective care reside in the nature of medical education, the doctor-patient relationship, heterogeneity of symptoms and labels, changes in the health care system, and other variables. These impediments are considered here, with suggested potential remedies, in the conviction that the proper care of patients with medically unexplained symptoms can, among other things, bring satisfaction to both the patient and the physician, and help to reduce ineffective health resource utilization.
A collaborative approach to behavioral health care breaks down when the patient does not make the 1st appointment to the mental health professional. This study explored individual motivations and reasons for appointment-keeping or appointment-missing behavior. Participants included 68 patients referred for behavioral health services. 19 of 41 Ss who kept their initial behavioral health appointment, and 17 of 27 Ss who did not keep their appointment were interviewed. Results show that Ss who did not keep their appointments were likely to cite financial, transportation, and administrative barriers. Additionally, increased stress, previous experience with behavioral health care, and motivation were identified as barriers. Those who kept their appointments identified that they had a problem for which they needed help, had the encouragement of another that also identified the problem, and linked getting or maintaining psychotropic medications with the referral. It is suggested that new areas for consideration include incorporating readiness-to-change staging in the referral process, management of distress by the provider at the time of referral, the role of negative affective experiences in seeking health care, and patients' willingness to help the provider in improving compliance. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
This study was designed to test the hypothesis that patients with a tendency to somatize psychological distress into physical symptoms could be differentiated from patients who do not somatize on the basis of specific predisposing factors defined by the High Risk Model of Threat Perception. Patients in a family practice were assessed for the tendency to somatize by the Diagnostic Interview Schedule (DIS) and by physician rating. Twenty-seven percent of the patients were positive for tendency to somatize by physician rating. These patients had relatively high negative affect, absorption, catastrophizing, self-reported pain and stress, and greater utilization of services. None of the patients assessed by the DIS met criteria for somatization disorder, but 28% were positive for somatoform pain disorder. These patients also scored higher on the negative affect questionnaire, tended to have higher absorption scores, reported greater pain and stress, and utilized more services. Results of this study are partially supportive of the High Risk Model of Threat Perception, because two of the predisposer factors were associated both with tendency to somatize by physician rating and with somatoform pain disorder by interview. The higher utilization of services in the somatizing patients has cost and service ramifications. Treatment of patients with tendencies to somatize within a family practice setting are discussed.
This study investigated the High Risk Model of Threat Perception (HRMTP) in middle-aged, urban chronic pain patients who had been referred to a secondary pain clinic after failing to respond to standard medical management. Relationships among absorption, social desirability (SD), and negative (e.g., depressive or anxious) affect were studied in 24 male and 73 female patients, (age range 22-88 years). Subjects completed the Tellegen Absorption Scale, the Marlowe-Crowne Social Desirability Scale, the Beck Depression Inventory--Second Edition, and the Beck Anxiety Inventory. The sample was significantly higher in SD and lower in absorption than normative groups. High SD patients endorsed significantly fewer items related to depression than those with low SD, but reported anxious ideation at about the same rate. These findings lend credence to the concept of chronic pain as a transduction of depressive, but not anxious, affect into somatic symptoms.
Mental health problems are underdiagnosed in general practice, primarily because they are often somatized and the patient reports only physical symptoms. These somatized symptoms are responsible for a large percentage of the frequent attenders in general practice. Palpitations are among those somatized symptoms. Here we present the theoretical background and the process of assessment and treatment of patients referred to a special counselling clinic for frequent attenders, through the report of a patient with palpitations. It illustrates the use of the narrative approach and the possible mode of action of this specific intervention.
A questionnaire was designed to document middle-aged patients' attitudes toward their family physicians' approach to their problems of daily living. Middle-aged patients were studied because they face numerous adaptational challenges and receive substantial medical care. Almost 90 percent of 116 patients interviewed indicated that they wanted to be asked about nonmedical problems as measured by life events, with this preference being more common among those under 55 years of age. Physicians expressed comfort in inquiring about life events; however, the patients reported that they were asked about such issues rarely or only occasionally. Although over two thirds of patients felt their physicians were sufficiently aware of their life events, those who recalled frequent questions by their physician were most likely to feel their physician was sufficiently aware. Implications of these findings on the physician-patient relationship are discussed.
The care of patients with diagnoses on the somatoform spectrum represents a challenge to all primary care physicians and is a matter of frustration to some. These patients tend to "doctor shop," and studies indicate that they generate health care costs that are at least six to 14 times higher than health care costs generated by control subjects. For all disorders on the somatoform spectrum, the most effective management is regular follow-up with the primary care physician. To accomplish this goal, a therapeutic delivery of the diagnosis to the patient is essential to firmly establish the therapeutic alliance. An approach is suggested for "administering" the diagnosis as the first step in treatment for patients with several types of somatoform and related disorders. These techniques allow the patient's emotional needs to be met, enable the patient to save face when necessary and solidify the doctor-patient relationship. A good relationship allows the physician to provide long-term management with empathetic, safe and cost-effective medical care. Physicians may at times dread somatic patients, and these useful techniques can help them begin a more satisfying relationship with their very challenging patients.