Abstract
The new MRCGP curriculum devotes a whole section to the care of people with mental health problems—and rightly so, for up to 30% of us will have some kind of significant episode of psychological disturbance in our lifetimes. Far more of us suffer transient but problematic psychological distress, especially when we or others for whom we care are unwell. So the GP registrar doing a routine clinic in UK general practice will find that as many as one in four of their patients are experiencing psychological symptoms, with higher rates in the elderly. Previous articles have covered the specific tasks of performing mental health assessments and diagnosing depression: this article aims to review the broader context of psychological distress in the consultation. It pays additional attention to factors associated with psychological distress to which GPs and other primary care staff should be alert and to ways of addressing these in a sophisticated and humane manner. Finally, I address the queston of self-management—that is minimizing the ‘human sponge’ effect often incurred by empathic GPs at the start of training.
The GP Curriculum and psychological distress in the consultation
Statement 13 of the GP curriculum (Care of people with mental health problems) has many outcomes that relate to this article. The curriculum addresses not only the specific issues of mental illness but also the spectrum between well-being and ill health and the factors that may exacerbate psychological problems. The sections on a person-centred approach and a holistic approach to diagnosis and management are central. Appendices 2, 5 and 7 also relate to this article. For example:
Working in partnership to provide care and treatment that enables service users
and carers to tackle mental health problems with hope and optimism, and to work
towards a valued lifestyle within and beyond the limits of any mental health
problem. Working in partnership to gather information to agree health and social care
needs in the context of the preferred lifestyle and aspirations of service
users, their families, carers and friends
Incongruity between the patient's distress and the comparatively minor nature
of the symptoms Failure to recover in the expected time from an illness, injury or
operation Failure of reassurance to satisfy the patient for more than a short period
Why do people become distressed?
Most people can relate to the frustration and anxiety caused by the disruption of illness—the guilt and hassle of cancelling the day's duties, the prolonged effort to get an appointment to be seen, the struggle to get a febrile or vomiting individual into the surgery without significant material contamination and the bigger questions of what, why and how long. When the episode is associated with negative memories of previous illness (such as a late diagnosis), if the patient feels fearful that this may herald a serious problem or if they are in pain, then the distress is likely to be heightened. Prolonged uncertainty, other concurrent stressors in personal life and the overall loss of control involved in ill health are additional causative factors. Small wonder then, that most of our surgery patients when answering screening questionnaires show rates of psychological distress significantly above that of the general population and that people from time to time seem unreasonably tearful or cross when they consult. Ultimately, illness can be construed as a threat to identity and as a reminder of our bodily frailty. So, distress is explicable and may serve as an evolutionary protection, driving us to seek help and to reduce demands on our selves before major damage is done.
Allaying distress
Part of the purpose of effective consultation is to move with the patient to a point where the diagnosis of their presenting problems reduces some of the distressing uncertainty and the management plan may alleviate some of their symptoms. In addition, the good practice of empathic listening, clarifying ideas and concerns and addressing the patient's agenda is known to have a positive impact on people's satisfaction, adherence and distress. A thorough focused examination and a clear explanation of what the doctor is thinking and proposing allows the patient insight into the basis for the advice given. For most people in the grip of illness, this will be enough for them to feel sufficiently in control of the situation to undertake self-care with confidence and to comply with suggested treatment.
Components of an effective doctor-patient relationship which lead to improved outcomes of consultation
Patient actively listened to and the views acknowledged and respected Patient encouraged to ask questions Patient obtains desired information Physician provides clear information and emotional support Physician willing to share decision making with the patient Both physician and patient agree about approach to patient's problems and
the necessary next steps
Patient utilizes advice and management plan Reduced anxiety, reduced role limitation and reduced physical limitation Improved functional and physiological status Improvement in pain control, function, mood and reduced anxiety Reduced psychological distress and improved symptom resolution Reduced patient anxiety Acceleration of problem and symptom resolution
When to go further
GP registrars will quickly learn to recognize the presenting signs of people whose distress appears more overwhelming—apart from the classic presentations of anxiety, the patient who repeatedly recounts their symptoms and worries, the ‘but what if and ‘yes but’ and the returnee ‘just to check’ are all potential cues that the patient has not yet reached a position of equipoise with their situation. Such behavioural cues in the consultation require some additional diagnostic effort and reflection as there may be background factors relating both to the patient and the doctor. For example, the literature shows that the following patient factors are more likely to be associated with significant psychological distress:
Adverse socio-economic circumstances, acting as a chronic stressor Recent stressful life events—for example bereavement and house moves Concurrent demands—carers, high levels of work stress and relational
instability Personal vulnerability, including the threat of violence—victims of domestic
abuse, partners of addicts and people with ongoing mental health problems Social isolation—lack of positive personal relationships and confidantes Poor coping mechanisms, low self-esteem, external locus of control and lack of
psychological resilience are all personality factors which usually relate to
disruptions in emotional security during childhood experiences, and these can
remain relatively hardwired in our adult lives.
Protective factors against psychological distress
Most patients warrant some basic enquiry into how their personal circumstances are affecting their health. Simple questions about work and home circumstances, who they can turn to for support and how they are feeling ‘in themselves’ will usually reveal non-verbal or verbal cues as to additional factors. Self-blame and guilt at being ill may denote a negative self-image, and an impression of wanting to be dependent on the doctor may reveal a lack of internalized coping mechanisms. If the patient's health beliefs are very much at odds with the epidemiological likelihood (e.g. a young female non-smoker who is convinced that her chesty cough may mean cancer), this may also indicate a tendency to think negatively and ‘catastrophize’—which in itself needs follow-up and active management.
There are also doctor factors which can contribute to patient's distress. A doctor who is rushing, not acknowledging the patient's worries and who does not address their full agenda is not likely to have a therapeutic effect on their state of mind. Sometimes, there is a mismatch between the doctor and patient expectations—an older male doctor may be the father figure needed for comfort or may be the ‘authority figure’ in whom an anxious adolescent is least likely to confide. Well meaning efforts to relate across cultural barriers by asking questions about personal background can be construed as racist if a patient is already on edge, especially if they have had previous ‘run-ins’ around their rights to care. Sometimes, GP registrars will be on the receiving end of the aftermath of breakdowns in trust—‘last time I had this pain it turned out to be chlamydia but the GP didn't treat me for ages’. Again, good consulting practice usually prevents these barriers from being destructive, and at least an honest discussion of the basis for patients' concerns and expectations allows some mutual understanding.
Systems factors
GP registrars who will one day run their own practice can be useful observers and constructive critics of the ways in which practice systems can contribute to or reduce levels of psychological stress. Patient complaints about the service they receive are worth learning from, as every negative experience makes the next encounter more likely to be one where the patient expects hassle, and may therefore increase psychological tension. The ease and speed with which patients can access appointments, the physical environment of the reception desk and waiting room, the level of noise and lighting and the behaviour of staff can all impact positively or negatively on a patient who is anxious, angry or fearful. Practices known to reduce conflict have clear and consistent routines, maximize comfort, minimize waiting times, keep noisy kids away from people who are ill and distressed and can spot trouble coming—giving additional ‘attention’ to the patient who appears to be on the edge of self-control. They also allow patients some choice with whom they can consult—the male patient who (consciously or subconsciously) feels he cannot share his ‘unmanly’ terror with a male partner will be better seeing a female doctor, while the elderly female patient who has finally plucked up courage to see someone about her breast lump may be deterred by a didactic ‘next available appointment is with Dr Manperson’ approach.
Concealed distress
Not all patients reveal their feelings even when directly invited to express these in a sympathetic way. The expression of emotions tends to be socially and culturally conditioned—so men may be less expressive than women, older people may be less expressive than younger, some people regard anxiety and fear as character weaknesses to be concealed if at all possible and some people experience distress predominantly through physical symptoms. Denial is a common psychological reaction to situations that cause anxiety, of which becoming ill is one, and many patients will not want to admit even to themselves how worried they are. In addition, the stigma of mental illness, the fear of repercussions on the abused or addicted and some health beliefs about illness can all lead patients to a ‘rational’ decision to conceal the background to their presentation. Prior knowledge of the patient's personality, their pattern of consultation, a sensitive index of suspicion and some well-practised screening questions are valuable here. Frequent attendance, especially across different agencies, is a common clue to psychological distress and undisclosed problems.
There are no ‘golden rules’ for dealing with concealed distress, but there are some evidence-based guidelines. The regular and genuine use of the safety netting question ‘Is there anything else you would like to talk about before I examine you/before we part company?’ allows patients a real chance to open up, even if they have been hesitant to do so in the earlier part of the consultation and gives the message that they could come back to you later if they wish to. Judicious explanations which allow emotional as well as biological factors into the mechanisms of ill health may be permissive to more introvert characters and people who somatize: It sounds to me as if your work must be quite demanding since you are so worried about taking time off with your bad back. I wonder if some of the problem is muscle tension—that tends to get worse when people are worried and in pain, it can be a vicious circle…. ‘An openness to the patient's point of view ‘how are you dealing this? What do you think might help?’ may allow the patient who has particular therapeutic preferences to explain these. In abusive situations, there is some evidence that patients are more likely to disclose if asked directly—‘You seem really frightened. I wondered if you were afraid of someone hurting you? Has any one hurt you?’—these parallel the direct questions recommended in suicide risk about intentional self-harm.
Making a full diagnosis
Previous articles have already addressed suitable questionnaires to screen for depression: a high index of suspicion should trigger their use in patients with relevant presenting symptoms and cues, in people with multiple unexplained symptoms, chronic pain, serious illnesses and major life events. Early results of ongoing research (Dowrick, et al., submitted for publication) suggest that patients find such questionnaires acceptable, and sometimes a high score enables them to admit to themselves that they are depressed.
Psychologists and psychotherapists use a concept akin to the ‘biopsychosocial’ model of diagnosis, called a ‘formulation’, which is an attempt to explain problems in terms of the dynamics of the patient's social context and world view. Although GP registrars (or indeed GPs) do not need to be specialists, the idea of arriving at a shared version of the interface between personality, life chances and current challenges is a useful goal, which both respects the patient's narrative and can offer doctor and patient useful insights to how to solve the problems together. For example:
Case vignette 1
‘Jim J’, white male 25, presents in distress following a near fatal injury to his nephew in an road traffic accident: the child is on intensive care. He initially describes himself as ‘gutted’ by the accident and is needing time off both because he wants to support his brother and the family and to cope with his own distress. He then asks for several further weeks off, and admits to hating his job, losing touch with his friends and becoming obsessed with anxiety about further traumas to those he loves. His Patient Health Questionnaire (PHQ) score is 12.
After taking a full personal history over several appointments, the causes of Jim's problems are agreed between him and the GP as: recent distressing trauma to close family member causing ongoing problems, resulting in mixed anxiety and depression.
Jim is vulnerable because he has low educational achievement and low self-esteem, is not very good at making social relationships and tends to cut himself off when upset or angry. He sees this as being related to the fact that his mother left him and his brother with their dad when he was 2 and his dad worked full time to care for them, leaving them in care of his grandma. His father was a very tough man who had little sympathy for Jim's shyness, but the love of his grandmother taught him that family could be the mainstay of emotional support. He still misses his grandma who died 2 years ago. He experiences separation anxiety when anyone he cares about is under threat, copes with this by withdrawing into himself and has a tendency to protect himself from intimacy to avoid further desertion—thus losing support from those who would otherwise give it to him.
The value of this extended picture is not only the therapeutic experience of being understood by another and the value of these insights to enable Jim to make different choices about his life but also to suggest options like social skill development, vocational training and computerized cognitive behavioural therapy to overcome negative thinking about himself and others. The doctor's acceptance of the terror of loss (which is ‘normal’ for most people) and her positive feedback to him for his caring and loving response to his family also helps him to confront some of the ‘stuck’ nature of his responses and to consider ways to deal with them for the future without putting himself (or his employability) at risk.
Why go there at all?
Many doctors have times when they really do not want to ask the extra questions or make the extra effort to check something out. The evidence, however, is strongly in favour of doing so: it improves patient's trust and accurate diagnosis, improves psychological state and self-management, leads to accurate risk assessment and opens up the consultation to discussions of how to improve coping mechanisms and address psychosocial factors. Not all of this work needs to be done at once—a follow-up may reveal the patient where everything has settled down—but give time for a more reflective consultation on the patient's background and perspective. A full review may require a long appointment, but the understanding gained can act as a reference point for the future and enable more effective management, which is timesaving in the longer term and is likely to improve both the doctor-patient relationship and therapeutic outcomes.
Managing yourself
The more complex the task, the more demanding it is and the more valuable an appropriate training in the relevant skills. Rehearsal of consultation approaches (role play and simulations) are an effective way to explore one's own possible emotions and attitudes as well as developing techniques to approach difficult situations. Case-based discussions of patients with complex emotional reactions are very valuable, both for learning by reflection and also for debriefing. In particular, they are valuable to develop insight into one's own reactions to patients, which can be a very important clue as to what is driving their agenda and sometimes why they are becoming dysfunctional. General practice has one of the strongest traditions of using interpersonal dynamics to make psychological diagnoses and the skill of ‘thinking up a level’ from one's baseline emotions is an important professional competence.
Case vignette 2
A very distressed middle-aged lady consulted the new GP registrar about an ongoing gynaecological problem which the consultant and one of the partners had agreed did not warrant surgical intervention. She talked continuously and insistently about how she could not live with the problem and about how it was making her life unbearable. She wept, grabbed the doctor's hands and seemed completely out of control. The GP registrar felt overwhelmed and also increasingly irritated by the difficulty of being able to play any role, ending the consultation by offering a follow-up appointment—but without having examined the patient and with no management plan at all.
On discussing this with her trainer, they acknowledged how exhausting this was, both for the doctor and also the patient. They experimented with ways of feeding back to the patient how difficult it was to help her if she did not allow some two-way conversation, also exploring what questions the registrar should ask to explore the possibility of a psychotic illness and looking at suggestions she might make to the patient to reduce what might be a cycle of self-induced anxiety.
The next consultation started in the same way, but the GP registrar interrupted quite early, saying that she could see how distressed the patient was and that she really wanted to help, but needed to be able to ask some questions herself to understand what had gone wrong. The patient expressed herself as being very happy to do this, acknowledged that she was over-talkative, attributing it to her anxiety. The registrar then tried to establish a more normal consultation, taking control where possible and also making some basic suggestions about how to relax and avoid increased physical and psychological tension making matters worse.
Over the next 2 consultations, the patient was able to normalize her behaviour to an extent which was much less demanding for the doctor and herself and to proceed with a management plan for both her anxiety and her gynaecological problem. She also revealed a history of an alcoholic father, which she felt had made her chronically overanxious and caused her to overreact to many problems in her life. For the first time, she accepted a referral to an anxiety management group, saying that ‘I thought they all thought I was mad’. The registrar reported to her trainer that she had been tempted to say ‘well you do seem a bit crazy sometimes’ but had felt this would not be therapeutically valuable! The trainer discussed how to avoid undue patient dependence on the registrar, given that the good relationship now established and the complexities of making effective and confidential records which would enable other staff to pursue an effective management plan using these insights into the patient and her character.
This vignette shows both the need to use one's reactions and the value of sharing these appropriately with patients: it also shows the ways in which working with patients can potentially reduce undue demand on ourselves as well as reducing patient's distress. The concept of ‘transference’ is a crucial one which is underused in generalist medicine, but which explains some of the problems of resistance and burnout in general practice. Transference is ‘an unconscious displacement of thoughts, feelings, and behaviours from a previous significant relationship onto a current relationship. sometimes resulting in a dramatic intensification of those relationships. Transference can pertain importantly to understanding and managing the complex, dynamic, intersubjective system that constitutes the… helping relationship’ (Robertson, 1999).
In order to manage oneself around this, notes or reflective writing, self-awareness and group discussion can all be helpful. Other mechanisms to avoid overload include managing caseload and case mix; giving rest breaks and catch-up time in appointment sessions; having some restful and attractive ‘distractors’ to look at after consulting (flowers, pictures and short texts); letting off steam to colleagues and a quick walk round the park at lunchtime. Leisure activities, a clear cut-off from work and having hobbies outside medicine also help in different ways!
Sometimes doctors themselves start to become psychologically distressed. Symptoms include avoidance of, or excessive, engagement with patients; irritability and a sense of demands being unreasonable or untenable; guilt and sense of failure plus poor sleep, mood swings, loss of healthy lifestyle and so on. We need to be alert to persistent symptoms of psychological distress in ourselves as well as our patients and to intervene early by discussing with others and ‘easing back’. Hopefully, some of the mechanisms suggested earlier for turning patient's distress to something more constructive will help! There are also help lines and counselling services (e.g. those on the British Medical Association website), and a confidential discussion with colleagues or trainers will often lead to an unburdening of feelings and constructive help.
Conclusion
Registrars who use the basic rules of patient-centred consulting and who exercise empathy and insight will find that they can accurately identify, discuss and manage the majority of psychological distress caused by life events including illness. They can also learn to make broad biopsychosocial diagnoses based on the patient's life story. A shared understanding of the triggers to their responses can assist patients with greater levels of distress to prevent further deterioration and to manage the factors which predispose to them becoming distressed in times of adversity. The use of these skills alongside standardized assessment tools and structured screening and diagnostic questions enables the registrar to be competent in the differential diagnosis of psychiatric illness and abusive relationships or addictive problems. Finally, a detailed assessment can form both a robust basis for future management and a real insight for both doctors and patients into the deeper reasons for our behaviours. This can be healing and engenders a truly therapeutic relationship. It can also be really satisfying.
Key points
Psychological distress is very common in patients consulting in primary
care, particularly in elderly people and those with concurrent or previous
adverse life events Good consultation skills and empathy will reduce the impacts of this
distress and improve the outcomes of the doctor-patient relationship both in
the short and longer term It is useful to understand the risk factors for psychological distress
because it can lead to a fuller assessment of possible hidden causation and
an understanding of the reasons why some patients are much more distressed
than others by the same trigger factors Understanding the basic principles of psychodynamics in the doctor-patient
relationship enables doctors to be more effective in using the relationship
to help the patient Doing good interpersonal work with patients requires some effort and
self-protection: the use of supervisors and peers to review such cases is
important.