Does excessive physician utilisation prolong the sick role?
Written by listed counsellor/psychotherapist: West Suffolk CBT Service
16th September, 2008
Individuals presenting with somatisation or multiple somatic complaints not related to any demonstrable pathology, are frequent attenders at both primary, and secondary care levels, (Weich, Lewis, Donmall & Mann, 1995). Early recognition and effective clinical management are thought to be crucial with this group of individuals, as it is thought that, excessive physician-utilisation can prolong the sick role, multiple investigations can promote poorer outcome, and ‘iatrogenic’ factors can lead to medically unexplainable symptoms becoming intractable. In order to investigate the efficacy of management, and attitudes towards management of this group of individuals by primary care physicians, a protocol was used to search a series of databases. Relevant studies were then examined. Results indicated that individuals with somatisation could be managed effectively at a primary care level, with a reduction in associated healthcare costs. However, negative reactions of physicians were associated with the management of this client group, leading to difficulty implementing these management strategies in practice. It is suggested that further research is required to investigate the range of emotions evoked in physicians by individuals with somatisation and to understand how these emotions can impact on management decisions. Clinical Psychologists are likely to have an increased level of involvement in primary care in the near future, (HMSO, 2000). As such it is proposed that there is scope for clinical psychologists to become much more heavily involved in the collaborative management of this client group
Individuals presenting with multiple somatic complaints not related to any demonstrable pathology, are frequent attenders at both primary, and secondary care levels, (Weich, Lewis, Donmall & Mann, 1995; Bass, Bond, Gill & Sharpe, 1999). For the majority of these individuals, symptoms are more likely to be related to underlying psychological distress and/or psychosocial difficulties, than to any demonstrable pathology, (Salmon, 2000). Although presenting frequently at heath care services, many individuals with multiple unexplained symptoms (MUS) in addition tend to respond unfavourably to a predominantly medical approach or to multiple medical investigations. In this respect, medicalisation of this problem can result in considerable utilisation of National Health Service resources, with many individuals receiving at best no benefit, and at worse intractable, ‘iatrogenic’ damage, (Lin, Katon, von Korff, Bush, Lipscomb, Russo, J. & Wagner, 1991; Katon, 1990; Nimnuan, Hotopf & Wessely, 2001; Reid, Wessely, Crayford, & Hotopf, 2002).
Maintenance Factors Associated with Chronic Somatisation
For many, this process of somatisation may be transient, but for others, personal interactions may instigate a deleterious spiral of ‘somatic fixation,’ (Biderman, Yeheskel & Herman, 2002). Somatic fixation or preoccupation with symptoms (leading to increased distress and more frequent visits to physicians) may be maintained and exacerbated by several factors. One prominent suggestion is that, due to the development of insecure attachment as a result of childhood experiences, individuals who somatise display inflexible care-seeking behaviours under stress, ultimately leading to rejection by others, including health care professionals, (Stuart & Noyes, 1999). In this respect, an evoked or perceived negative reaction by a physician in individual with somatisation may lead to further exacerbation of care-seeking behaviour, while conversely somatic treatment can exacerbate dependency, (Biderman et al, 2002; Stuart & Noyes, 1999).
Faced with negative test results and continued somatic symptoms, some individuals may believe that their symptoms are a result of an undiagnosed physical illness. Attempts to seek legitimisation of their symptoms and of their sick role may mean that they present arguments for further medical investigation. In this respect, negative medical investigations may often be followed by repeated cycles of tests, (Salmon, 2000; Bridges, Goldberg, Evans & Sharpe, 1991; Sheehan, 2002). As a result individuals with somatisation may be exposed to unnecessary and at times dangerous medical testing, (Salmon, 2000) and even experience unnecessary surgery, (Salmon, 2000; Fink, 1992). This can lead to additional high social costs as chronic illness behaviour can lead to absence from work as well as family dysfunction, (Katon, 1990).
Screening and Identification in Primary Care
Early recognition of somatisation is thought to be crucial, as it is thought that excessive physician utilisation can prolong the sick role, that multiple investigations can promote poorer outcome, and that ‘iatrogenic’ factors can contribute to medically unexplainable symptoms becoming intractable, (Craig et al, 1993; Lin et al, 199; Reid et al, 2002). However, despite the high prevalence of somatisation and the clear need for early intervention, somatisation is often not recognised until individuals have been presenting for some time or have become chronic attenders of medical services, (Fink, Erwald, Jensen, Sorensen, Engberg, Holm & Munk-Jorgensen, 1999; Angenendt & Harter 2001). Several reasons have been postulated as to why this may occur. Formal recognition of somatisation presents difficulties, and while many individuals may obtain a diagnosis of a somatoform disorder, others presenting with fewer symptoms (although presenting equal management difficulties) may not, (Peveler, Kilkenny & Kinmouth, 1997). In this respect, constructs such as “abridged somatization disorder” have been proposed, but have yet to be validated, (Escobar, Gara, Waitzkin, Silver, Holman, & Compton, (1998); Peveler et al, 1997).
General practitioner recognition has also been heavily criticised. In a recent UK study looking into General Practitioner (GP) recognition of unexplained symptoms, Peveler et al (1997), found that when psychological symptoms were not recorded in the case notes, GPs were likely to recognise mood disorder manifested by unexplained symptoms at only chance levels of probability. However GPs were much more likely to recognise unexplained symptoms in patients with coexisting high levels of health anxiety. Less is known about the physicians ability to detect unexplained symptoms when combined with apparently low levels of emotional disorder.
Many problems are associated with the identification of somatisation and this adds difficulty for physicians working in general practice. For example, some individuals may have additional physical illnesses, making if difficult to differentiate between somatisation and symptoms of organic disease. Overt description of somatic symptoms and/or an alexythymic presentation can also hinder the recognition of psychosocial or psychological difficulties, (Peveler, Kilkenny & Kinmouth, 1997; Stuart & Noyes, 1999).
Treatment for Medically Unexplained Symptoms
In recent years, a growing number of random controlled trials have begun to demonstrate that cognitive behaviour therapy can be effective in treating individuals with medically unexplained symptoms, (Speckens, Van Ham, Spinhoven, Hawton, Bolk & Rooijmans, 1995; 1996; Sumathipala, Hewege, Hanwella & Mann, 2000). Adjunctive group treatments utilising a variety of platforms have also proved useful, as have multidisciplinary referral clinics, (Lidbeck, 1997; McCleod, Budd & McClelland, 1997; Peters, Stanley, Rose, Kaney & Salmon, 2002) However, large numbers of individuals continue to attend primary care services with multiple unexplained symptoms (between 19% and 30% of all attenders), (Peveler, Kilkenny & Kinmouth, 1997; Fink, Sorenson, Engberg, Holm & Munk-Jorgensen). Most continue to be managed by their GP, with only those individuals showing the most severe difficulties tending to be referred to specialist mental health services.
Management of Unexplained Symptoms in Primary Care
When the high volume of individuals presenting with multiple unexplained symptoms (MUS) in primary care and the considerable costs both to the individuals concerned and to society are taken into account, research connected to the effective management of this group of individuals has received surprisingly little attention, (Sheehan, 2002). Research in this area could be considered crucial, as it is thought that physician’s attributions towards somatic symptoms can play a pivotal role in MUS escalating or being contained. When faced with continual lack of evidence of organic pathology, for example, some physicians may attempt to adopt a psychological/psychosocial approach and reduce further investigation, while others may choose to take a more medical approach and pursue further investigations, (Fink, Rosendal & Toft, 2002). Further investigations may occur for a variety of reasons such as fear of litigation, fear of overlooking organic disease, pressure from the patient or even medical uncertainty, despite the fact that genuine physical disease is thought to be overlooked in fewer than 3%-4% of cases, (Crimlisk, Bhatia, & Cope, 1998; Fink, Rosendal & Toft, 2002).
Lack of recognition of somatisation, (and investigations looking to identify organic pathology despite continual lack of evidence), may lead to loss of valuable opportunities to exercise early reattribution techniques, (Goldberg, Gask & O’Dowd, 1989). Three stages are suggested in reattribution, a) to help the patient feel understood by exploring their problem, b) to explore somatic complaints but then broaden the agenda to include psychosocial issues and c) to help the patient make a link between physical complaints and psychological distress. According to Blankanstein et al (2002) reattribution needs to be applied early (preferably within six months) as it is likely that the longer that individuals somatise, the more likely it is that they will become ‘true somatisers’ (i.e. they will be less likely to accept an psychosocial/psychological explanation for their symptoms). With respect to remedying this difficulty, Mayou & Sharpe (1995) suggest that individuals with suspected somatisation should be identified early, that management aims be reviewed and improved access to social care instigated.
According to Angenendt & Harter, (2001) correct recognition and early diagnosis presents the first of many difficulties for physicians, as attributions about the somatic complaint held by the primary care physician and individual may begin to diverge and impact on the relationship. Patients may refuse referral to mental health experts or a referral option may not be available. This may leave physicians attempting to apply psychological principles for which they are often not adequately trained, or which they have no time to carry out without diminishing the efficiency of their practice.
The remaining part of this review (please see West Suffolk CBT website) concentrates on the efficacy of psychological management by general practitioners of individuals with MUS or somatisation presenting in primary care settings.
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