L1 Early Professional Experience Diagnosing and managing somatisation

Overview

This lecture covers diagnosing and managing somatisation in general practice: the definition and mind-body basis of somatisation, patterns that suggest a functional illness, how to set the scene for taking a history, four standard screening questions used to make a positive diagnosis, and an approach to investigation and management.

Definition and the Mind-Body Basis

• Somatisation: the expression in physical symptoms of psychological distress.
• Somatising illness is not confined to symptoms without an organic cause: it spans a spectrum from illness without organic pathology through to illness with organic pathology, both ends included.
• Underlying rationale: the brain is wired to every other part of the body (mind-body connection, illustrated by clasped hands labelled MIND and BODY).
• Body systems commonly affected by somatisation, with examples: Skin (dermatitis, acne, psoriasis, angioedema), CVS (angina, palpitations, hypertension), RS (asthma, hayfever), GI (heartburn, gastritis, peptic ulcer, IBD), GU (irritable bladder, PMS, dysmenorrhoea, dysfunctional uterine bleeding, infertility), Neuro (migraine, MS, Parkinson disease, tremor), MSK (inflammatory arthritis, back pain).
• Specific organ-emotion links given as examples: stomach/gut (“butterflies in the stomach” with anxiety, diarrhoea, loss of appetite), skin (going red with embarrassment, going pale with fright), breathing (sobbing when crying, gasping with fright, breathing quickly when anxious).

Two illustrative metaphors appear with no explanatory text: a dam wall with water breaking through (used straight after the mind-body slides), and a mostly-submerged iceberg (on the closing slide). Their intended meaning is not stated on the slides.

Standard Clinical Reasoning

Steps: history (physical and psychological factors), examination, differential diagnosis, exclude urgent diagnoses, investigation (physical and psychological), start management based on the most likely cause whether or not this includes somatisation, review if not getting better and consider further investigation.

Core principle: make a positive diagnosis of somatisation based on what is there, not a negative diagnosis based on what is not there (i.e. do not treat it purely as a diagnosis of exclusion).

The transcript notes that on the corresponding handout thumbnail the phrase "Diagnosis of Exclusion" may be struck through, which would reverse its meaning to "not a diagnosis of exclusion" - consistent with the instruction that follows it. This could not be confirmed at full resolution.

Patterns of Functional Illness

Five patterns:

1. Worse with stress (busyness, pressure, responsibility, relationship challenges).
2. Usually absent at night and first thing on waking; better when more relaxed, e.g. weekends, holidays, during or straight after exercise.
3. Poor fit to biomedical patterns; symptoms may be atypical, unique, or hard to describe.
4. Sensitisation: a stressful event precipitates the symptoms and then resolves, but the symptoms persist afterward, maintained by other, lesser day-to-day pressures, responsibilities or stresses.
5. Multiple symptoms in different organ systems; when one symptom is prominent, the others usually recede.

Setting the Scene for History-Taking

Four-step approach before enquiring about psychosocial factors:

1. Empathise.
2. Introductory comment plus non-blaming comment: “These sorts of symptoms are often connected to what’s going on in a person’s life”, and “if there is a connection this doesn’t mean you are not coping.”
3. Normalise and self-disclose: “We all get physical symptoms with stress. I get … and some get what you have.”
4. Explain: give the patient a patient-centred explanation of somatisation (the mind-body connection and organ-specific examples above).

The Four Standard Questions

Used to make a positive diagnosis of somatisation:

1. “What was going on in your life around the time your (symptoms) started?” If the patient says “Not much,” follow up with: “There may not have been much going on but can you tell me what was happening?”
2. “Are your (symptoms) ever related to stress?”
3. “Are there any times you don’t have (symptoms) or when (symptoms) is better?”, e.g. immediately on waking, weekends, holidays (note the time of the patient’s last holiday), during exercise.
4. “Are there any times when you are very likely to have your (symptoms) or when your (symptoms) is worse?”

Investigation

• Somatising patients do not want more investigation than other patients, but they do want an explanation.
• Enlist the patient as a co-investigator, via a handout [slide does not elaborate further on this handout’s content].

Management

Approach, in the order given across the two management slides:

1. Empathy.
2. Explanation.
3. Address specific fear.
4. Ask the patient: “What do you think the most helpful next step might be?” (highlighted on the slide as a key question).
5. Discuss lifestyle: diet, sleep, exercise, holidays.
6. Treat anxiety, depression, hyperventilation.
7. Refer to counsellor, clinical psychologist, psychotherapist, or pain clinic.
8. Relaxation exercises / meditation (slide notes a suggested duration of 20-30 min).
9. Medication: benzodiazepine, SNRIs, TCAs.

Self-test

1. Define somatisation.
2. Describe how somatising illness relates to the categories “with organic pathology” and “without organic pathology”.
3. List the body systems commonly affected by somatisation, with one example condition from each.
4. Describe the standard clinical reasoning steps used in assessing a patient with possible somatisation.
5. Explain what “diagnosis of exclusion” means in this context and how the lecture’s recommended approach differs from it.
6. List the five patterns of functional illness.
7. Describe what is meant by “sensitisation” as a pattern of functional illness.
8. Describe the four-step approach to setting the scene before enquiring about psychosocial factors.
9. List the four standard questions used to make a positive diagnosis of somatisation.
10. A patient says “not much” was going on in their life when asked about the onset of their symptoms. What should the clinician say next?
11. What do somatising patients want, if not more investigation?
12. Describe the approach to managing a patient with somatisation, in order.
13. Which classes of medication may be used in managing somatisation?
14. A patient’s symptoms are worse during the working week, improve at weekends and during exercise, and are hard to describe in typical biomedical terms. Which patterns of functional illness does this suggest?
15. Explain how the four standard questions put the patterns of functional illness into practice during a consultation.

Answers

Reveal answers

1. The expression in physical symptoms of psychological distress.
2. Somatising illness is not restricted to symptoms without an organic cause; it spans a spectrum from illness without organic pathology through to illness with organic pathology, with both ends included.
3. Skin (dermatitis, acne, psoriasis, angioedema), CVS (angina, palpitations, hypertension), RS (asthma, hayfever), GI (heartburn, gastritis, peptic ulcer, IBD), GU (irritable bladder, PMS, dysmenorrhoea, dysfunctional uterine bleeding, infertility), Neuro (migraine, MS, Parkinson disease, tremor), MSK (inflammatory arthritis, back pain).
4. History (physical and psychological factors), examination, differential diagnosis, exclude urgent diagnoses, investigation (physical and psychological), start management based on the most likely cause whether or not this includes somatisation, review if not improving and consider further investigation.
5. A diagnosis of exclusion means diagnosing somatisation only once other causes have been ruled out, a negative diagnosis based on what is not there. The lecture instructs making a positive diagnosis based on what is present instead (transcript flags that the slide title “Diagnosis of Exclusion” may itself be struck through on the handout, unconfirmed).
6. (1) worse with stress; (2) usually absent at night/on waking, better when relaxed, e.g. weekends, holidays, exercise; (3) poor fit to biomedical patterns, atypical/hard to describe; (4) sensitisation; (5) multiple symptoms across organ systems, with one prominent symptom while others recede.
7. A stressful event precipitates the symptoms and then resolves, but the symptoms persist afterward, maintained by other, lesser day-to-day pressures, responsibilities or stresses.
8. (1) empathise; (2) give an introductory, non-blaming comment that a connection to life events would not mean the patient is not coping; (3) normalise and self-disclose that everyone gets physical symptoms with stress; (4) explain, giving a patient-centred explanation of somatisation.
9. (1) “What was going on in your life around the time your symptoms started?”; (2) “Are your symptoms ever related to stress?”; (3) “Are there any times you don’t have your symptoms or when they are better?”; (4) “Are there any times when you are very likely to have your symptoms or when they are worse?”
10. “There may not have been much going on but can you tell me what was happening?”
11. An explanation.
12. Empathy, explanation, address the specific fear, ask “what do you think the most helpful next step might be?”, discuss lifestyle (diet, sleep, exercise, holidays), treat anxiety/depression/hyperventilation, refer to counsellor/clinical psychologist/psychotherapist/pain clinic, relaxation exercises/meditation, medication.
13. Benzodiazepines, SNRIs, TCAs.
14. Pattern 1 (worse with stress), pattern 2 (better when relaxed, e.g. weekends, during exercise), and pattern 3 (poor fit to biomedical patterns, hard to describe).
15. Question 1 probes for a stressful trigger event, relevant to patterns 1 and 4 (sensitisation); question 2 probes the stress link directly, relevant to pattern 1; questions 3 and 4 probe for times of relief or worsening, relevant to pattern 2. Together they build the evidence for a positive diagnosis rather than one of exclusion.