MUS + NAD = DNA No engagement without communication

Transcription

1 MUS + NAD = DNA No engagement without communication Liaison Psychiatry Conference Royal College of Psychiatrists Friday, 12 th May 2017 Dr. Nikki Scheiner Consultant Psychologist Hertfordshire Rapid Assessment, Interface & Discharge Service

2 Aim of Presentation To highlight the importance of skilful and sensitive communication with patients with persistent physical symptoms who present to Liaison Psychiatry

3 Learning outcomes To enhance successful treatment outcomes in the PPS population and reduce the attrition rate

4 Content overview Confusing Terminology Why is communication a particular concern with the persistent physical symptoms population? Barriers to communication Engaging patients in Liaison Psychiatry

5 Linguistic Confusion

6 Nomenclature Somatic Symptom disorder It s all in your head Somatoform disorder Functional motor/movement disorder Functional neurological disorder Functional sensory disorder Functional symptoms Persistent physical symptoms Dissociative symptoms Psychogenic Psychosomatic Hysteria Medically unexplained symptoms Conversion disorder Chronic fatigue symptoms

7 The number needed to offend Terms need to be helpful to doctors AND acceptable to patients (Stone, 2002)

8 What does functional mean to patients? Altered functioning of the nervous system (Trimble, 1982; Stone, 2002)

9 Why focus on this population? ICD and DSM definitions highlight difficulties in patient-doctor communication; Therapeutic GP-patient relationship depends upon effective doctor-patient communication; Many doctors over-estimate their ability to communicate (Fong & Longnecker, 2010); Expectation (from doctor and patient) that GP/ OPA consultations will focus on physical health; 15-30% of GP consultations are for conditions that lack a [sufficient] organic explanation (Guthrie, 2008); 50% of Hospital OPAs

10 Why focus on this population? cont d Pressure of time/ lack of expertise/ desire to keep patient satisfied: Collusion Unnecessary tests/investigations (Ring et al, 2004) Delay in starting effective treatment; Increase in symptoms; Negative impact on patient s quality of life; Stress/burn-out in GP; High health-care utilization;

11 Why focus on this population? - cont d Or. Confront, alienate and don t be surprised when they DNA!

12 Barriers to Communication

13 1) A different language? Disease Illness Sickness

14 Speaking a different language Disease (objective: pathology, biology) Illness (subjective): deserters from the army of the upright ) (Woolf, 1926) Sickness (socially/culturally prescribed/negotiated) (Parsons, 1951) Patient Yes Yes Yes Consultant No Yes Ambivalent

15 Language, Narratives, and Outcomes Medical narratives are canonical and confer validity on the patient. If the consultant does not endorse the patient s narrative, his/her suffering is de-legitimised or reduced to an lesser category of illness Outcome: discredited/stigmatised identity (Goffman, 1963); frustration and anger

16 2) Emotion Old wisdom: persistent physical symptoms triggered by emotional trauma (e.g. CSA) New wisdom: impaired emotional repertoire perpetuates persistent physical symptoms

17 Alexithymia TAS-20 TAS <51 TAS TAS <61 Definite Alexithymia 44% Probable Alexithymia 41% No Alexithymia 15%

18 Vignette 1: Alexithymia Patient, 36 years Bullied at school; Emotional script in family of origin: We don t talk about emotions ; pt was emotionally passive; Acrimonious divorce; Stress at work; collapsed at work; Admitted to Stroke Unit; MRI, CT: NAD. Off work, incurred debt. Developed dissociative episodes characterised by dysarthria and spasmodic dysphonia rubbish words; functional gait disorder Very assertive/aggressive partner; angry re. lack of treatment; complained to MP.

19 Vignette : Internalising grief

20 3) Belief systems Extreme Cartesian bias in chronic PPS patients

21 Liaison Psychiatry: an integrated understanding of PPS

22 What our patients believe

23 Refuting beliefs Motivated scepticism: information consistent with our attitudes becomes entrenched (Taber & Lodge, 2006) Pick your battles carefully! (Cook & Lewandosky, 2011)

24 Correcting misperceptions If you start with the myth, you will end with the myth!

25 Correcting misperceptions cont d If you start with the fact, you will end with the fact

26 4) Lack of empathy/understanding We ve got another one for you! Liaison psychiatry s experience of stigma towards patients with mental illness and mental health professionals (Bolton, 2012) Clear clinical communication helps overcome prejudicial attitudes and pre-empt discriminatory behaviour towards patients

27 5) Discomfited by psychological issues Neurologists on Conversion Disorder: Not real neurology ; Psychological explanations not their concern; Some struggle to distinguish between CD and malingering Uncertain about how to explain or communicate (Kanaan, Armstrong, Barnes & Wessely, 2009) Consultants adapt their disclosure to their patients; Facilitates communication, but limits truthfulness. (May even change their diagnosis.) (Kanaan, Armstrong & Wessely, 2009)

28 Discomfited by psychological issues cont d Go to the PPS Clinic: they ll help you with your pain (Locum Rheumatologist to patient with Fibromyalgia)

29 6) Hypoactivity in Temporoparietal Junction Region where actual and predicted sensory feedback are compared (Edwards, 2012)

30 TPJ is also associated both with processing and observation, and Autistic Spectrum Conditions (impaired social cognition) Most PPS patients similarly demonstrate deficits in social interaction and concrete cognitive patterns, e.g. catastrophising, dichotomous thinking, over-generalising

31 CONSEQUENCES OF POOR COMMUNICATION

32 Patient s quality of life deteriorates [Patients with severe somatoform disorder] have significant disabilities, comparable to those seen in severe mental illnesses such as schizophrenia and chronic depression. (Bass, 2016)

33 Feeling out of control Doctors think you are lying Frustrated Nowhere else to go if people don t listen Making assumptions Being patronised Feeling dismissed It s all in your head Don t trust the doctors Focus on only one symptom at a time Not being taken seriously No empathy Being talked down to a number in a bed Poor eye contact Too many medical terms Inept Made to feel like a child Not knowing who you are No information for diagnosis Not being listened to Being lied to by health professionals Lack of information and answers Feeling rushed; long waiting times but only seen for 10 minutes Not being believed (severity of symptoms) Symptoms are not perceived as real Nothing we can do (attitude from health professionals) Farmed through like cattle If you don t tick the box, you re out Lack of communication

34 Quality of Life and Functioning QUALITY OF LIFE MENTALISATION EMOTIONAL REGULATION CHRONICITY COMPLEXITY DISTRESS

35 Communication in the PPS Clinic

36 A model of chronic functional symptoms THE FEELING/TALKING BODY Symptoms are the idiom of distress: Pain, Tremors, NEAD, Fatigue, Motor Weakness, Sensory disturbance Adapted BEHAVIOURS Give up; Avoid; Withdraw; Boom or bust ; Complain IMPAIRED MENTALIZATION & ALEXITHYMIA COGNITION Self: Loss; view of self as sick; Others: uncaring & unfair; People don t understand Future: hopeless: I ll never be better COGNITION

37 PATIENTS PHYSICIANS PPS CLINIC Biomedical discourse Psychosocial discourse Biopsychosocialspiritual Discourse of conviction Discourse of scepticism Discourse of curiosity Aetiology Pathology Experience Demanding Depriving Accepting Request interventions Decline interventions Offer Treatment Protocol Cartesian Non-dualistic Brain-Mind-Body Want time to explore No time to explore Plenty of time to explore Experience symptoms Measure symptoms Treat the person (not the symptoms) Dr. Google Organic medicine Liaison and Care Planning Scientistic Non-scientistic Experiential Suffering Non-suffering Compassionate

38 PATIENTS PHYSICIANS PPS CLINIC Certain that they are right Certain that they are right Accept patients narrative Frustrated Frustrated Acknowledge patients frustration Demand respect Demand respect Give respect/upr Fear of something being missed Fear of missing something Focus on functioning and Quality of Life

39 References Bass, C. and Pearce, S. (2016) Severe and enduring somatoform disorders: recognition and management. BJPsych Advances, 22 (2) Cook, J and Lewandowsky, (2011) The Debunking Handbook. St Lucia, Australia: University of Queensland Edwards, M and Bhatia, K. (2012) Functional (psychogenic) movement disorders: merging mind and brain. Lancet Neurology, 11: Fong Ha, J and Longnecker, N. (2010) Doctor-Patient Communication: A Review Ochsner Journal, Spring; 10 (1): Goffman, E. ( 1963) Stigma. Notes on the Management of Spoiled Identity. Guthrie, E. (2008) Medically unexplained symptoms in primary care Advances in Psychiatric Treatment, 4 (6) Kanaan, R, Armstrong, D., Barnes, P. & Wessely, S. (2009) In the psychiatrist s chair: how neurologists understand conversion disorder. Brain. A Journal of Neurology, 132; Kanaan, R, Armstrong, D, & Wessely, S. (2009) Limits to truth-telling: Neurologists communication in conversion disorder. Patient Education and Counselling, 77: Kaplan, M, Dwivedi, A, Privitera M, Isaacs, K. (2013) Comparisons of childhood trauma, alexithymia, and defensive styles in patients with psychogenic non-epileptic seizures vs epilepsy: Implications for the etiology of conversion disorder. Journal of Psychosomatic Research, 75: Ring A, Dowrick C, Humphris G and Salmon P. (2004) Do patients with unexplained physical symptoms pressurise general practitioners for somatic treatment? A qualitative review. BMJ 328:1057 Stone et al, (2002) BMJ, December. What should we say to patients with symptoms unexplained by disease? The number needed to offend. BMJ, 325 Taber, C. and Lodge, M. (2006) Motivated skepticism in the evaluation of political beliefs. American Journal of Political Science, 50, l Trimble, M (1982) Functional diseases. BMJ: 1982; 285: Woolf, V. (1926) On Being Ill in The Criterion.London.

40 THANK YOU @NikkiScheiner