Whether a patient has a diagnosed long-term condition or undiagnosed persistent physical symptoms, being able to make straightforward links between the mind and the body doesn’t always come easily, especially when services can be set up in ways that separate the two. Some of the patients described below will not be ready for psychological therapy. They are often the patients who fall between gaps in mental health services and the GP practice might be the only place they get support. It’s important to ensure your practice is equipped with as many resources as possible to support this patient group and the clinicians caring for them. This includes reception and administrative staff, who can often have the most contact with these patients.
“No, it’s not all in your head”: Persistent physical symptoms and mental health, with Dr Warner
Dr Warner explains how to make straightforward links between the mind and the body, either as a precursor to a discussion about mental health services, or as part of an ongoing search for a shared understanding with the patient about their confusing and distressing bodily experiences.
00:06 Our minds and body are intimately linked…
So, you may know this intuitively as a clinician, but your patient may not. There are a range of ways of talking about it…
00:19 Fear: the body gets ready to fight or flee…
· If you or I were to hear a door slam right now, we’d jump. Our pulse would increase, our blood would flow to different parts of our body, some muscles would tense, our hairs might even stand on end
00:33 Flushing and sweating…
· We flush red when we’re hot, when we’re embarrassed, when we’re ill
· We sweat when we’re anxious, when we’re hot, when we have too much or too little blood sugar
· We are breathless after exercise, when we feel worried, when our chest is restricted
· We feel differently about what breathlessness means based on what we’ve been through
· We feel pain when we hurt ourselves, when we are tense and stiff, and when parts of our body swell due to a stress response
· We eat differently when we lack energy, when we feel stressed and when we don’t have time to look after ourselves
01:22 Real changes in the body: emotion or illness?
· Sometimes the body doesn’t know when to distinguish between when a bacteria or virus is threatening it or when a loss, shock, stress, or change in the environment is threatening it
· In both cases the immune system can kick in, leading to swelling, pain, tenderness
What’s most worrying is when there are changes in our body and we’re not sure why – sometimes the default is to think the feeling of threat, vigilance and attack, means an illness is present. This might be the case, but it might also mean the body is stressed in different ways – what’s key here is the fact the dizziness, swelling, ringing, pain, chest ache, tightness, is real. The body is moving and changing in response to a threat, but this threat might not be what you think
Our emotions also happen in the body, where else would they occur? And, if we’ve also got arthritis or diabetes symptoms happening there, or if we’ve recently had frightening surgery, then we’re told by one person do more, one person do less. Before we know it, we’re more overwhelmed and anxious and then everything gets on top and feels too much and it’s hard to tell what sensation is coming from where. None of us can figure this out entirely alone
02:46 Cortisol and stress
The hormone cortisol is also a simple way of explaining the mind-body link. During times of stress, adrenalin and cortisol are released. In the short term, cortisol has anti-inflammatory properties, but in the long-term it can lead to stress responses. To fatigue, weakness, weight change, pain, loss of concentration, swelling, low libido, changes in the skin, impaired memory, insomnia, irritability, menstrual abnormalities, or blood sugar dysregulation, high blood sugar or high blood pressure
Throw in the fact that cortisol and adrenalin are usually signals for us that there is a threat, it is not surprising that any physical symptoms are felt to be very, very worrying – we are already in a state of high alert
Maybe the idea that stress could contribute is unsettling, but this is helpful to know, because we can target stress with a range of different approaches. So, psychological, social, dietary and physical
If you’re talking about cortisol and the stress response with patients, try to avoid doing so in a way that makes it sound like a potential disorder or condition. Instead it’s a natural response to stress that can be thought about further
Complex consultations and persistent physical symptoms: a whole practice approach
Complex consultations impact the whole practice. The following animations describe approaches that you may already follow, but which can be dropped when service pressure increases. The content draws on well-established research and clinical evidence, as well as work done by the Plymouth IAPT team, who have developed a whole systems approach to Medically Unexplained Symptoms.
This animation explains why it’s important to acknowledge the distress caused by complex consultations within the team. This distress is a necessary part of the work, and for a team to work in a healthy way, a designated time and space is needed to share it. This is a core clinical finding that contributes significantly to what makes a healthy team. If you do not have either mental health or complex case meetings in your practice it’s important to ask why that is.
Some consultations leave us feeling things that we don’t want to. Dread in the built up, frustration, ineffectiveness or guilt afterwards… they may challenge the hopes that drove us towards the profession in the first place. Where we may ordinarily by able to treat, cure or find a pathogen, here there’s often no satisfactory explanation, and the patient’s distress persists
This may be telling you what you already know: that these consultations are hard, and they can take their toll. But, such feelings are also signs that we are appropriately “tuned in” to our patients. They are a form of clinical information that can be looked at and thought about further
01:42 For example, “I never feel like I’m doing enough for this patient”
“Whenever I go on leave my patient ends up calling the practice daily”
“This patient says they don’t trust anyone in the practice except me”
“I always feel really unskilled with this patient, like I’m getting it wrong”
And, no matter how many tools or how much experience we have, these feelings are as central to certain consultations as prescriptions, examinations and the pleasure of helping others
This might be disappointing to hear, but accepting that distress, frustration and uncertainty are central to the work with persistent physical symptoms can be understood as a healthy starting place for patients and colleagues rather than a hopeless end-point
02:32 Unfortunately, when this distress cannot be discussed, unhealthy things can happen within teams
As you’ll know, clinicians can end up feeling weighed down if they’re not supported. This might be experienced tangibly in sickness, turnover and staff burnout. Or via tensions within the team, adding pressure to our existing struggle to meet more targets with fewer resources
By accepting the unavoidable emotional impact of the clinical work as a starting point, a number of robust practices can be put in place before a patient even gets into the room
03:23 Things such as, longer consultations, a planned break in your clinic after these consultations, and regular complex case meetings, for example
03:39 Whole practice patient plans (including admin and reception staff), utilising psychology resources for liaison and joint work, and thinking about releasing staff for training
These approaches obviously don’t make the complexity go away but research demonstrates that they can determine the health of your team
They can often be the first things to be dropped when the practice gets stressful or busy. But it’s only with a whole practice approach in place can we begin to think about individual encounters with patients
Complex consultations and persistent physical symptoms: consultations with patients
The second animation explains how to approach individual consultations with patients experiencing medically unexplained or persistent physical symptoms. It can be helpful to acknowledge, validate and emphasise the patient’s worry or concern, rather than being accidently pulled into a debate on whether the bodily experiences are “real”. Whether the distress is due to an as yet undiagnosed medical condition, local sensitisation in chronic pain, bodily memories of significant trauma, or stress responses in developmentally neglected patients, it is definitely real. The challenge comes in finding a shared way to understand and talk about it with patients.
Patients with persistent physical symptoms don’t come to see us because of their symptoms. They come because they’re disturbed by changes in their body… a small but important difference
00:26 Try first meeting the patient where they are with their distress or concern
For example, “you seem to be worried about this , this might feel a bit too much to take…” or, “you think we’re missing something. That must be hard”.
Clinical research shows that offering reassurance before acknowledging distress does not work… It is perceived as dismissive
00:53 Try ascertaining whether there are any underlying fears
For example, “what do you worry this pain might indicate?”
Patients also come because nobody else they know has alleviated their distress
01:15 Try acknowledging a potential lack of support
For example, “Who is around for you? Are you getting much support at the moment?”
Any potential offers of psychological support have now been framed as somewhere to share the distress of living with the symptoms… rather than because you think, its “all in their head”
The patient will likely place a lot of hope in further investigations
01:59 Try preparing for negative results from the outset
For example, “we can try this investigation, but I think it might come out negative”
This might avoid a more upsetting consultation later
02:23 Try to be honest when discussing the potential harm caused by excessive examination
A patient might say, “well, you can’t be certain”.
02:37 Try acknowledging that there is uncertainty, which is difficult
Something like, “you’re right, and uncertainty is hard, but my team and I are monitoring this”.
02:53 Try backing up your statement of care with the offer of intermittent appointments
Once these appointments are in place, you have a robust care plan. And, you can be firmer in asking the patient to either wait for their next planned appointment or use crisis services in the interim (though this can make us all feel guilty as clinicians)
00:24 Try ensuring any treatment plan is shared among all of your colleagues to avoid team divisions
And, finally, with all of this in place, you are still left with a patient who is suffering. If you notice yourself struggling to acknowledge this, it might be helpful to bring the case for discussion with your colleagues.
Team Around the Practice: thinking about complex cases in primary care
Tim Kent, Consultant Psychotherapist and Social Worker, explains who might be suitable for the Team Around the Practice (TAP), a Camden-based service. He describes a common case example where the GP is drawn into a difficult dynamic with their patient. TAP is a collaboration between MIND in Camden and the Tavistock & Portman NHS FT. The service currently offers psychodynamically informed treatment of up to 16 sessions, Social Prescribing, and consultations to practice staff for complex cases. Please contact TAPAdmin@Tavi-Port.nhs.uk for further information about the service.