Thinking differently in rheumatological psychosomatic conditions (changing the doctor's style of thinking)

The concept of a 'health care realm' is introduced. The healthcare realms considered were those patients who have only Physical Health Problems (PH), patients with neither physical nor mental health issues and who are seeking advice to remain healthy (HP), patients only with Mental Health Problems (MH), patients with both Physical Health and Mental Health Problems (PH&MH) and patients with Psychosomatic Health conditions (PS). Described is how patients' minds and bodies interact and its relevance to rheumatology practice. Presented is the culmination of 34 years of the author's experience of rheumatological disorders based in Family Medicine in a United Kingdom General Practice. Also presented are 2 small studies supplementing the main conclusions. The first small study counted the main consultation content of 246 patients, as considered by the principals in the practice. Of these 73.5% were for physical health conditions, 13.3% for health promotion, 11.5% for mental health conditions and 1.8% for psychosomatic conditions. The second small study was a survey of experienced GPs, Physicians and Psychiatrists, asking about their opinions on how well the patients in different health care realms were being managed across the healthcare system. Of the 5 realms, the collective view was that it was the patients in the PH realm who was clearly received the best care. The least good care was being given to patients in the PS realm and only marginally better were patients in the MH Realm. This paper argues that clinicians need a different thinking approach when meeting patients from different healthcare realms. It is known that when doctors treat PH patients, they consider the patient's symptoms against templates of knowledge for the conditions in the differential diagnosis. Furthermore, HP patients are assessed by comparing the patient's bio-measurements against known markers of good health When being consulted by patients in the MH or PS realms, it is advocated, not to follow the approach of PH patients. For patients in the MH realm it is best to address the patient's life as a whole and to consider, how did the person arrive to the situation he is in and what needs to be done to restore the patient's life back on track. For patients in the PS realm, ideally the aim is to help the patient make the link between the physical symptom and its psychological aetiology. A step towards this is to describe how the body physically mediates the symptom.

1. Bishop SR, Lau M, Shapiro SL, et al. Mindfulness: A proposed operational definition. Clinical Psychology: Science and Practice. 2004;(11):230–41.

2. Karelaia N, Reb J. Improving decision making through mindfulness. In Mindfulness in organizations: Foundations, research, and applications. Singapore: Research Collection Lee Kong Chian School Of Business; 2015. P. 163-89.

3. Bu CN, Cotzias E, Panagioti M. Mindfulness intervention for foundation year doctors: a feasibility study. Pilot Feasibility Stud. 2019 Apr 27;5:61. doi: 10.1186/s40814-019-0449-y. eCollection 2019.

4. Toft T, Fink P, Oernboel E, et al. Mental disorders in primary care: prevalence and comorbidity among disorders. Results from the Functional Illness in Primary care (FIP) study. Psychol Med. 2005 Aug;35(8):1175-84. doi: 10.1017/s0033291705004459.

5. Haller H, Cramer H, Lauche R, Dobos G. Somatoform disorders and medically unexplained symptoms in primary care: a systematic review and meta-analysis of prevalence. Dtsch Arztebl Int. 2015 Apr 17;112(16): 279-87. doi: 10.3238/arztebl.2015.0279.

6. Nimnuan C, Hotopf M, Wessely S. Medically unexplained symptoms. An epidemiological study in seven specialities. J Psychosom Res. 2001 Jul;51(1):361-7. doi: 10.1016/s0022-3999(01)00223-9.

7. Reid S, Wessely S, Crayford T, Hotopf M. Medically unexplained symptoms in frequent attenders of secondary health care: retrospective cohort study. BMJ. 2001 Mar 31;322(7289): 767. doi: 10.1136/bmj.322.7289.767.

8. Creed F, Barsky A, Leiknes KA. Epidemiology: Prevalence, causes and consequences. In Creed F. Henningsen P. Fink P. Editors. Medically Unexplained Symptoms, Somatisation and Bodily Distress: developing better clinical services. Cambridge: Cambridge University Press; 2011. P. 1-42.

9. Yon K, Nettleton S, Walters K, et al. Junior doctors’ experiences of managing patients with medically unexplained symptoms: a qualitative study. BMJ Open. 2015 Dec 1;5(12):e009593. doi: 10.1136/bmjopen2015-009593.

10. Warner A, Buszewicz M, Walters K. Training doctors in the management of medically unexplained symptoms: a qualitative study of the views of hospital specialists. Oral presentation 17th WONCA European Conference. Warsaw; 2011.

11. Dowie J, Elstein A. Professional Judgement: a reader in clinical decision making. Cambridge: Cambridge University Press; 1988.

12. Matcham M, Rayner L, Steer S, Hotopf M. The prevalence of depression in rheumatoid arthritis: a systematic review and meta-analysis. Rheumatology (Oxford). 2013 Dec;52(12): 2136-48. doi: 10.1093/rheumatology/ket169. Epub 2013 Sep 3.

13. Lisitsina TA, Vel'tishchev DYu. Mental disorders in patients with rheumatic diseases: Diagnosis and treatment. Nauchno-prakticheskaya revmatologiya. 2015;53(5):512-21. (In Russ.).

14. Abramkin AA, Lisitsina TA, Vel'tishchev DYu, et al. Effects of synthetic disease-modifying antirheumatic drugs, biological agents, and psychopharmacotherapy on the mental disorders in patients with rheumatoid arthritis. Nauchno-prakticheskaya revmatologiya. 2017; 55(4):393-402. (In Russ.).

15. Bernardy K, Klose P, Busch AJ, et al. Cognitive behavioural therapies for fibromyalgia. Cochrane Database Syst Rev. 2013 Sep 10;2013(9):CD009796. doi: 10.1002/14651858.CD009796.pub2.

16. Okifuji A, Gao J, Bokat C, Hare BD. Management of fibromyalgia syndrome in 2016. Pain Manag. 2016 May;6(4):383-400. doi: 10.2217/pmt-2016-0006. Epub 2016 Jun 16.

17. Casale R, Cazzola M, Arioli G, et al. Non pharmacological treatments in fibromyalgia. Reumatismo. Jul-Sep 2008;60 Suppl 1:59-69. doi: 10.4081/reumatismo.2008.1s.59.

18. Arnold LM, Clauw DJ, Dunegan LJ, Turk DC. A Framework for Fibromyalgia Management for Primary Care Providers. Mayo Clin Proc. 2012 May;87(5):488-96. doi: 10.1016/j.mayocp.2012.02.010.

19. Henningsen P, Fink P, Haustner-Wiehle C, Reif W. Terminology, classification and concepts. In Creed F. Henningsen P. Fink P. Editors. Medically Unexplained Symptoms, Somatisation and Bodily Distress: developing better clinical services. Cambridge: Cambridge University Press; 2011. P. 43-68.

20. Chew-Graham CA, Heyland S, Kingstone T, et al. Medically unexplained symptoms: continuing challenges for primary care. Br J Gen Pract. 2017 Mar;67(656):106-7. doi: 10.3399/bjgp17X689473.

21. Capek ME. Medically Unexplained Symptoms. In L., Owens, J. & Williamson, A. Brann. Editors. The Handbook of Contemporary Clinical Hypnosis. Chichester: Wiley; 2012. P. 229-45.