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:
(a) recent life events: less than one year ago, we considered the impact
of recent life events to be the largest
(b) chronic difficulties: ongoing long-term difficulties in 20 different
fields of life, such as work, family, relatives, neighborhood, etc
(c) problems in childhood, including parental lack of care, bearing too
high responsibility, abuse (sexual, physical and mental), and other
childhood life events or chronic difficulties.
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:
1. the patients personal circle (his own body producing complaints and his
mind concluding about
it and the decision to present it to the doctor).
2. the social circle, experience and suggestions of family members and
friends, problems at work, sick leave advantage
3. the medical circle: defensive work styles of doctors scared of
lawsuits, financial rewards increasing somatisation (when doctors are paid
extra for certain diagnostic and therapeutic actions), personal styles of
GPs (the 5 or less minutes per patient system leads to frequent
prescriptions and diagnostic procedures), do GPs count psychological
problems of patients to be part of their task and how do they approach
patients with psychological problems.
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.
Rapid Response:
Re: Somatisation or somatic fixation?
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:
(a) recent life events: less than one year ago, we considered the impact
of recent life events to be the largest
(b) chronic difficulties: ongoing long-term difficulties in 20 different
fields of life, such as work, family, relatives, neighborhood, etc
(c) problems in childhood, including parental lack of care, bearing too
high responsibility, abuse (sexual, physical and mental), and other
childhood life events or chronic difficulties.
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:
1. the patients personal circle (his own body producing complaints and his
mind concluding about
it and the decision to present it to the doctor).
2. the social circle, experience and suggestions of family members and
friends, problems at work, sick leave advantage
3. the medical circle: defensive work styles of doctors scared of
lawsuits, financial rewards increasing somatisation (when doctors are paid
extra for certain diagnostic and therapeutic actions), personal styles of
GPs (the 5 or less minutes per patient system leads to frequent
prescriptions and diagnostic procedures), do GPs count psychological
problems of patients to be part of their task and how do they approach
patients with psychological problems.
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.
Competing interests: No competing interests