Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Somatisation or somatic fixation?
- Aya Biderman (16 July 2001)
-
Somatisation in primary care
- Antônio L Teixeira, Henrique Alvarenga-Silva (17 July 2001)
-
somatisation is a difficult problem for primary care
- Rhiannon England (17 July 2001)
-
Talking to a physician vs writing alone
- James W Pennebaker (18 July 2001)
-
Re: Somatisation or somatic fixation?
- A F Schilte (9 August 2001)
-
Re: Somatisation in primary care
- Bert Schilte (9 August 2001)
-
Re: somatisation is a difficult problem for primary care
- Bert Schilte (9 August 2001)
-
Re: Talking to a physician vs writing alone
- Bert Schilte (9 August 2001)
|
|
|||
|
Aya Biderman, Deputy chair Dept of Family Medicine, Ben-Gurion University, Ber-Sheva, Israel
Send response to journal:
|
The interesting work presented struck me with two thoughts: First, that the disclosure interevention was performed by other physicians, and not by the GP of the person. The other is that it is not clear whether there was a difference between recent important events and past events. The other point is related to "somatic fixation" vs "somatisation". This expression means that the physician, in his/her response to the patients' somatic complains, may add to the process of somatisation, causing more medicalization of patient problems. Therefore I would be interested to know if the authors looked at the physicians' responses to the patients' symptoms. Perhaps, the real issue is not the patient but the physician, and therefore the intervention should be aimed at them?! Thanks. Aya Biderman MD |
|||
|
|
|||
|
Antônio L Teixeira, clinical psychiatrists 1 Private clinic, Belo Horizonte/ 2 Dep. Engenharia Biomédica, Funrei, São João del Rey, Brazil, Henrique Alvarenga-Silva
Send response to journal:
|
Multiple or unexplained physical symptoms cause substantial patient disability, excess use of medical services, therapeutic disappointment and physician frustration.(1) At present somatisation is employed as descriptive term in somatoform disorders characterised by physical symptoms for which there are no demonstrable organic findings or known physiological mechanisms.(2) Somatisation is a much broader phenomenon than reflected by categories in the official diagnostic classifications. The operational definition of somatising patients in the paper of Schilte et al. (3), based on previous studies from Escobar's group (4), is interesting since most patients with unexplained symptoms do not meet high symptoms threshold requested for DSM-IV somatoform disorder diagnosis. On the other hand, the criteria for undifferentiated somatoform disorder are overly inclusive. Some reasons could be elicited for explaining the absence of effect of the disclosure intervention on the health of somatising patients, including the brief period of intervention, the high prevalence of anxiety and depressive disorders appointed by the authors. Another possible reason is that different treatment interventions must be designed to treat patients at different levels of distress.(5) Despite that, somatisation includes a very heterogeneous population and the descriptive use of the term somatisation should not be confused with its conceptualisation. While some authors support the concept of somatisation as the expression of personal distress in an idiom of bodily complaints with medical help seeking behaviour as adopted in the paper, others have emphasised the need to clearly define the concept, encompassing coping style, personality traits. The effectiveness of treatment strategies derived from such conceptualisations, such as promoting verbal expression of emotions or psychological conflicts in alexithymic patients has not been demonstrated.(6) The present study confirms this. References: 1. Kroenke K, Spitzer RL, deGruy FV, Hahn SR, Linzer M, Williams JBW, Brody D, Davies M. Multisomatoform disorder: an alternative to undifferentiated somatoform disorder for the somatizing patient in primary care. Arch Gen Psychiatry 1997; 54: 352-358. 2. Martin RL, Yutzy SH. Somatoform disorders. In: Hales RE, Yudofsky SC, Talbott JA, eds. The American Psychiatric Press Textbook of Psychiatry. Washington, DC: Amercian Psychiatric Press, 1999: 663-710. 3. Schilte AF, Portegijs PJM, Blankenstein AH, van der Horst HE, Latour MBF, van Eijk JTM, Knottnerus JA. Randomised controlled trial of disclosure of emotionally important events in somatisation in primary care. BMJ 2001; 323: 86-89. 4. Escobar JI, Gara M, Silver RC, Waitzkin H, Holman A, Compton W. Somatisation disorder in primary care. Br J Psychiatry 1998; 173: 262-266. 5. Guthrie E. Emotional disorder in chronic illness: psychotherapeutic interventions. Br J Psychiatry 1996; 168: 265-273. 6. Bach M, Bach D, de Zwan M. Independency of alexithymia and somatization. Psychosomatics 1996: 37: 451-458. |
|||
|
|
|||
|
Rhiannon England, GP Statham Grove Surgery London N16 9DP
Send response to journal:
|
Editor, We would like to make a few comments on Schilte et al's paper on somatisation in primary care.This was a carefully designed project looking at a very important topic, but we were concerned that by concentrating on rigorous methodology the authors may have missed the opportunity to examine some key issues. We were concerned that there were only two or three disclosure sessions used without any attempt made to connect emotional trauma and somatic symptoms. It was stated that some patients had disclosed sexual abuse. Was any further support offered to these patients, or others disclosing similar events? Kolk et al (1996,ref) discussed the links between severe trauma and dissociation, and we wondered if any of the patient were "disclosing" without giving the disclosures any emotional content,thereby dissociating previous trauma from present reality. Garland (1996) has pointed out that such disclosures in themselves can sometimes lead to further traumatisation when isolated from further therapeutic work. It was also surprising that GPs had not picked up anxiety and depression in these frequent attenders. However it is unclear whether the authors feel that detection and treatment of these disorders would have any effect on presentation of somatic symptoms or attendance in primary care. Another related question is to what extent the optional third session conducted with the GP affected the GPs' subsequent practice with these patients and indeed their perceptions of the patients' presenting symptomatology Rhiannon England (GP) Alice Cook (psychotherapist) Statham Grove Surgery, London N16 9DP |
|||
|
|
|||
|
James W Pennebaker, Department of Psychology University of Texas at Austin, USA
Send response to journal:
|
The Schilte et al (1) project is an impressive study in both its scope and findings. On the surface, it suggests that disclosure of emotional events has no effect on markers of physical health or health- related behaviors – a finding at odds with dozens of published studies over the last few years (2, 3). A critical difference between the Schilte et al study and most other disclosure studies is that Schilte et al required participants to talk about a traumatic experience to another person. Most successful disclosure studies, on the other hand, have had participants write anonymously about a trauma for several days either in a laboratory, a neutral setting, or at home. The Schilte study may help us to learn when disclosure can be helpful versus harmful. It may also speak to recent controversies surrounding critical incident stress debriefing (CISD) where recently traumatized individuals are pressed to talk about their emotions to people in a group context. An increasing number of controlled tests of techniques wherein people have been asked to talk about emotional upheavals to others have found this form of debriefing to be either unhealthy or to have no effect (4). Having to deal with deeply emotional topics in a social setting forces the listener to help regulate what is and isn’t said. The social pressure of talking to an “expert” may invite embarrassment or humiliation on the part of the patient. When people are writing (or talking into a tape recorder) by themselves, they are able to determine how much they are willing to disclose. In short, solitary disclosure allows people to determine their own dose. More than anything, the Schilte project suggests that it is not in the physician’s or patient’s best interest to encourage the deep disclosure of highly traumatic experiences. Separate, equally-controlled projects should address whether disclosure in alternative ways (e.g., disclosive writing) may bring about the beneficial effects that the authors were originally predicting. 1. Schilte AF, Portegijs PJM, Blankenstein AH, van der Horst HE, Latour BF, van Eijk JTM, Knottnerus JA Randomised controlled trial of disclosure of emotionally important events in somatisation in primary care. BMJ 2001; 323: 86. 2. Smyth JM. Written emotional expression: effect sizes, outcome types, and moderating variables. J Cons Clin Psychol 1998; 66: 174-184 3. Pennebaker JW, Graybeal A. Patterns of natural language use: Disclosure, personality, and social integration. Cur Dir in Psychol Sci 2001; 10: 90-93. 4. Small R, Lumley J, Donohue L, Potter A, Waldenstrom U. Randomised controlled trial of midwife led debriefing to reduce maternal depression after childbirth. BMJ 2000; 321: 1043-1047. |
|||
|
|
|||
|
A F Schilte, general practitioner Maastricht, The Netherlands
Send response to journal:
|
Dear colleague Biderman, Thank you for your response on our article on disclosure in somatisation. Due to my vacation I am answering your response a couple of weeks later. The disclosure intervention in our study was applied by a trained disclosure GP, not the patient’s own GP. Had we used a different design in which we had trained the participating GPs to apply the intervention themselves, we would have had to randomise on practice level instead of patient level. This would have required a large number of practices (40- 100), with per practice at least ten patients. The size of the trial (and the costs) would have been multifold. While preparing the study there was no evidence that disclosure was effective in somatisation, and we therefore made a choice beforehand for a more rigorous methodology to investigate whether there was any effect at all of a short disclosure intervention on somatisation. Since we did not see any effect of disclosure we do not encourage a larger design in which GPs are trained to apply disclosure in their own patients. We also found that being interested in life stories of patients may positively influence the communication with the patient. When patients disclose their life story GPs may understand better why certain patients visit the clinic so often and GPs may have more patience with and less irritation about these patients. However, our findings show clearly that the somatisation pattern is not essentially influenced by disclosure. Many practising GPs have observed feelings of frustration in case of somatising patients, and this is possibly further enhanced because as a method asking about life events (frequently applied by GPs) does not really influence the somatisation tendency. In the disclosure meetings any important life event (according to the
patient’s opinion) could have been subject of disclosure. In the
questionnaires and the analysis between we included:
We looked at the physicians’ judgement on somatisation and wrote a
separate article about it (Schilte AF Somatisation in primary care:
clinical judgement and standardised measurement compared. Social
Psychiatry and Psychiatric Epidemiology 2000; 35:276-282).
The concept of somatic fixation was studied extensively in the Netherlands
in the early 1980s. The concept ‘somatic fixation’describes three circles
influencing the somatisation process:
The somatic fixation model was so complex with its range of variables, that no international publication came out of a ten year programme here in the Netherlands. However, in medical vocational education the model still serves as an excellent “map” of somatisation. In our study we limited our outcome measures to the first circle, the circle of the patient. It would be interesting to study doctors rather than patients. An interesting design would be an explorative study on different factors influencing somatisation in different countries (qualitative design with interviews or focus-groups). However, it will not be easy to apply the findings of such a study in an intervention, e.g. are GPs ready to and able to change their financial reward system, or can one change the legal tradition and the resulting defensive style of doctors? However, the results would be helpful in the vocational training of GPs. |
|||
|
|
|||
|
Bert Schilte, general practitioner Maastricht, the Netherlands
Send response to journal:
|
Dear Mr. Teixeira, Thank you for your response on our article from a psychiatric point of view. Due to my vacation I am answering your response a couple of weeks later. Somatisation as operationalised by us according to the criteria of Escobar should certainly not be classified as a psychiatric disorder. Most of us have episodes with physical complaints which are not explained by organic disease. The tendency to frequently visit the health care system with such somatisation symptoms, however, can lead to problems. Especially in primary care, ‘low grade’ somatisation is seen often (1 in 20 patients have a long term tendency to visit GPs frequently with somatisation problems) and creates at least 20% of the workload of the GPs in our study (other studies with different inclusion criteria mention even larger percentages). There is a need for effective strategies for somatisation which are not too complex to apply for general practitioners. Of course one can design an ideal long-term disclosure intervention encompassing many contacts with the patient. However, patients willing to participate in such long-term psychological interventions are open to help from psychiatrists, psychologists and social workers, who are better trained to do so. Most somatisation patients, on the other hand, are not open for psychotherapy, and are managed by primary care physicians in the Netherlands. And overbooked GPs will usually not find the time for psychological interventions requiring a larger number of contacts. We wanted to test a promising, relatively brief intervention which would be acceptable to somatising patients and could be applied by GPs. bert schilte |
|||
|
|
|||
|
Bert Schilte, general practitioner Maastricht, the Netherlands
Send response to journal:
|
Dear colleagues England and Cook, Thank you for your comments on our paper. Due to my vacation I am answering your response a couple of weeks later. The intervention consisted of two meetings between the patient and a disclosure GP. When important information was disclosed an additional meeting was planned with the patient’s own GP. This could in certain cases result in further treatment by the GP (prescription of antidepressants or further meetings) or referral to psychological health care. In case patients suddenly disclosed a dramatic life story which was too complex for the disclosure GP, the advice of a psychiatrist (connected to the project) was sought. The psychiatrist was consulted in several occasions. We ask patients on several moments how they felt and how they evaluated the project, and we could only identify one patient who was clearly negative and did not want to be confronted with her childhood story again. We had no psychiatrists interview our patients, to investigate the level of dissociation of previous trauma, and can therefore not comment on this point. Connecting present symptoms to traumatic memories was not our aim; in our opinion it is often not possible to draw a direct link between symptoms at present and traumatic events long ago. The aims of our disclosure intervention were to release stress and to ‘broaden’ the topics with which the patient felt invited to visit their GP (from purely physical complaints to their life-stories). Emotional expression through talking and writing, as applied in other studies on disclosure, typically released stress, improved the function of the immune and autonomic nervous systems, improved subjective health and reduced the use of health care services in healthy individuals (Smyth JM. Written emotional expression: effect sizes, outcome types, and moderating variables. J Cons Clin Psychol 1998;66:174-184). The 81 intervention patients were screened for the presence of depressive, anxiety and somatoform disorders with the DSM-IV interview schedule. When any active disorders were discovered the patient and GP were informed on this. In some situations patients were already on treatment for these disorders, in other cases treatment was started by the patient’s GP or the patient was referred. Some patients did not want to be treated for the psychiatric disorders. Control patients were not screened with the DSM-IV interview schedule. In the final evaluation intervention patients (with and without psychiatric disorders) were not better off than control patients at the three moments of follow-up (6, 12, 24 months). Patients with detected depressions or anxiety disorders visited as often as beforehand their GPs with somatising complaints, felt as unhealthy as before and were equally often on sick leave. From the feedback of the participating GPs, the third session with the GP did influence the contact between patient and GP. Commonly, GPs noticed that they now better understood their patient’s life-story and felt that the communication with the patient had improved. In spite of the improved communication this did not result in improved patient outcome on subjective health, use of health care services and sick leave. bert schilte |
|||
|
|
|||
|
Bert Schilte, general practitioner Maastricht, the Netherlands
Send response to journal:
|
Dear Mr. Pennebaker, Thank you for your interesting comment on our article with your extensive experience on the effects of disclosure therapies. Due to my vacation I am answering your response a couple of weeks later. As you have stated we have not studied the effect of written, anonymous emotional expression in our group of patients. Your theory that written expression is superior to the talking methods as applied by us, may explain the difference between our negative findings and other positive studies on disclosure. However, some other articles on the effect of disclosure through talking did show an effect, although, as you point out, not as impressive as in written and anonymous disclosure. In somatisation the problem is very much of an interactive nature: the patient and the health care professional (with very often the GP in a central position). For that reason we chose talking rather than anonymous writing, with the aim to extend the outcome of the talks to the patient-GP relationship. This may very well have influenced the contents of what patients disclosed. The disclosure intervention was offered by us in an open inviting way, reflecting sincere interest in the patient’s story and following the patient’s frame of reference. Most patients filled in afterwards that they felt they disclosed important information and felt good about the meetings. Instead of explaining our negative findings by inadequacy of disclosure methodology, we explained our contrasting findings by the difference in the groups of patients under study: somatising patients in primary care in our design versus relatively young, healthy and intelligent college students in most other studies on the effect of disclosure. We selected patients with a long-term tendency towards somatisation, often with a problematic childhood- and life-story and mostly of lower socio-economic and education background. In this group there are often fixed patterns of ‘health care behaviour’, such as frequent attendance in primary care, tendency to explain symptoms with a disease model (with external locus of control), wish to undergo further diagnostic procedures and referrals, frequent use of symptomatic medications (painkillers, tranquilizers) and physiotherapy, and high sick leave. The high rate of prescriptions and referrals is often also increased by inadequate methods and frustration of the physicians managing these patients. Somatisation, as a pattern of health care behaviours and interactions between patients and health care professionals, may be influenced in an effective way with the help of cognitive-behaviouristic models adapted to primary health care, such as the re-attribution method (Morriss RK et al, see original article for specifications). Disclosure, as a more solitary method, may be effective in lowering stress levels of subjects adapting to changes in their lives (first year college students, unemployed managers, persons in detention). bert schilte |
|||