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The Elephant in the Room – Somatisation in the ED

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Author: Andy Ashton / Codes: CAP30 / Published: 05/05/2015

One of the CEM General regular attenders was in the other day, a young woman with lower abdominal symptoms. She was needing more analgesia, and was not happy with the protocol we have for her.

Of course, its all in her head, one of our nurses said, and this reminded me of the fantastic information leaflet put out by the Oxford centre for re-enablement about somatisation disorders. If you read nothing more of this blog, then read this.

Somatisation in Emergency Medicine is the elephant in the room. We know that many of our patients who attend have functional illness, and the evidence states the same. Studies on patient.co.uk state, Epidemiological studies generally quote a prevalence of 0.1-0.2% for the general population and a figure of 5% has been quoted for general practice. From these figures we could conservatively estimate a 1% prevalence in the ED attending population, meaning that one or two patients a day pass though our doors whose presentation is somatisation or have at least Medically Unexplained Physical Symptoms (MUPS).

Yet we always seem to tip toe around it, despite talking about it. Why? Maybe we are afraid that we will miss some rare diagnosis, which has not been made during many specialist consultations and investigations (all normal of course). Maybe we are afraid we will spark a furious reaction from the patient, that we are accusing them of malingering, or that you’re saying this is all in my head.

Lets get a few things straight. Patients with somatisation are not making it up. That would be malingering, or Munchausen’s. These patients are experiencing the symptoms of which they complain, and an essential element of dealing with the patient is to acknowledge this. But it is important to address the issue that the symptoms might not arise from an organic cause.

Eloquently defined in a paper on the British Journal of Psychiatry ’Somatisation’ is a process in which there is inappropriate focus on physical symptoms and psychosocial problems are denied. This presents as a dilemma in the Emergency Department as we do not want to miss the patient who cried wolf. However, the paper by Benjamin & Bass, albeit not new, gives a number of pointers on how to manage these patients including: setting a limit for investigations, providing unambiguous information and avoiding spurious diagnoses.

I do not think the ED is the correct area to make this diagnosis outright. However, when this is backed up by several normal findings, papers show that reinforcing the idea that a somatic problem exists, make the matter worse. I, for one, have written it as part of my differential and I have told the patient that I have done so. Key phrases I have used:

These are obviously very distressing symptoms and my heart goes out to you

The cause of this is either something weird and wonderful we have not diagnosed yet, although you have had a lot of tests which were all negative. The other thing to think of is that these symptoms are arising from stresses within yourself. We know we can get physical symptoms from how we feel, such as butterflies in the tummy when we are nervous, and other symptoms can come about as well. That doesn’t mean that it’s all in your head, you are definitely feeling them.

In the ED I think we can help by making the suggestion, in a sensitive way, and letting the patient investigate the proposition for themselves. I have given them, sometimes, the Oxford Functional Illness leaflet mentioned above. And I have communicated this to the GP, to allow them to continue, step by step, to address the issue. Do not underestimate the power of an opinion from someone in scrubs in the hospital.

This is a delicate area but I think it is an important one in which we can contribute: at least by writing it as one of the differentials.

References:

  1. Bass C, Benjamin S. (1993) The management of Chronic Somatisation. Br J Psychiatry. 1993 Apr;162:472-80.
  2. http://www.patient.co.uk/doctor/somatic-symptom-disorder
  3. http://funktionellelidelser.dk/en/
  4. http://www.harbourviewhealthcare.com/website/H82023/files/Functionaldisorderleaflet.pdf

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