working with physical symptoms in camhs
TRANSCRIPT
Psychological Intervention for
Physical Symptoms in CAMHS
Dr Rachel BrackenridgeClinical Psychologist
Fleur-Michelle CoiffaitTrainee Clinical Psychologist
NHS Lothian Paediatric Psychology and Liaison Service
Monday, 14 May 2012
Overview Introduction to somatisation How this presents in children and
young people Psychological factors Intervention
Step 1: Communication and formulation Step 2: Self-help info and self-
management Step 3: Referral to psychology Step 4: Psychological intervention
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Definition of somatisation “The manifestation of psychological difficulty or
distress through somatic symptoms, a tendency to experience and communicate somatic distress and symptoms unaccounted for by pathological findings, to attribute them to physical illness and to seek medical help” Lipowski (1988)
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Psychosomatic symptoms Abdominal pain Headache Diarrhoea Muscle pain/weakness Nausea Fatigue Dizziness Other physical sensations (tingling,
etc.)
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Headaches
dry throat
cold sweats
wide eyes
short breaths
chattering teeth
pounding heart
feel sick
goose bumps
tight stomach
‘butterflies’ in tummy
cold hands
shaky knees
cold feet
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Prevalence rates Psychosomatic symptoms
2 -10% (Goodman & McGrath, 1991) 11% girls, 4% boys: 12-16y (Offord et al., 1987)
RAP 10% of British school children (Apley, 1958) 13% of 10-14 year old Americans (Hyams, 1996) 17% of 15-17 year old Americans (Hyams, 1996) 8% of the 10-17 year olds had consulted a
physician for these problems in the previous year (Hyams, 1996)
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Prevalence rates Headache and migraine Overall prevalence all types of headache 66% Up to 50% 5 year olds Up to 80% of 12-15 year olds
(Abu-Arefeh & Russell, 1994)
Roughly equal prevalence in boys/girls pre-puberty 3:1 ratio of girls:boys after adolescence Migraine most common, then tension headache
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Psychological correlates Child personality features Family factors Biological factors Stressful life events
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Child personality features Conscientious Obsessional Insecure Anxious Social difficulties
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Family Factors Health problems Preoccupation with illness High expectations
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Biological Factors Biological vulnerability Increased sensations in specific areas
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Stressful psychosocial stimuli
Recent change in home or school environment School problems, altered peer relationships Separation difficulties - significant family member Recent loss (family members, pets etc) Parental separation Chronic illness in parents or sibling Family work / financial problems
Discuss in absence of parents Discuss in absence of child
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Environmental reinforcement
Reinforcement by parents, school, GP Child / YP refuses to go to school School sends child home Specific attention at time of pain e.g.
rest Medication given at time of pain (PRN
drugs) Daily responsibilities not demanded Any feared situations avoided
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Intervention at Step 1: GP/RHSC
Good communication including
Formulation of difficulties
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Formulation Acknowledge ‘realness’ of pain Give it a name – recognised entity Gut as a ‘nervous’ organ Intensity of nerve impulse and
perception at brain level varies Other factors affect this ‘nerve path’ Emotional centre/ feelings ‘Butterflies in the stomach’
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Formulation Familiar symptoms with different
feelings:Sweaty palmsRacing heartInfluenced by certain situations
The gut is a ‘feeling’ organ ‘Finding out more about these feelings
will help’
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Biopsychosocial model of RAP
Physical symptoms (‘disease’) due to complex interaction of organic, social and psychological factors
Introduction of “stress” issues in a non-threatening context
Emphasis on stress vs biological factors will vary depending on acceptability to family
Psychologicalstress
Alteredmotility
Visceralhypersensitivity
inflammation
nausea/spasm pain
geneticfamily/
environment
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The brain gut axisand the biopsychosocial model
Psychological factors‘feelings’
Visceral hyperalgesia‘pain’
Altered Physiology
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Communication
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Communication
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Principles to aid communication
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Principles to aid communication
Being CalmCommunicates that the situation is manageable
Empathic non-judgemental approach Communicates acceptance
Monday, 14 May 2012
Principles to aid communication
Being CalmCommunicates that the situation is manageable
Empathic non-judgemental approach Communicates acceptance
Monday, 14 May 2012
Principles to aid communication
Being CalmCommunicates that the situation is manageable
Empathic non-judgemental approach Communicates acceptance
Reflective listeningBeing quiet & listening carefullyMinimal encouragers – nodding, affirmingReflecting back a short summary “it sounds
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Principles to aid Awareness of non-verbal cues
Open posture Eye contact / level Facial expression Tone Aim to convey warmth, openness and interest
Normalise Everybody’s bowels get irritable sometimes Everybody poos Everybody’s body reacts to stress, worries,
excitement….
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Practical aids to communication
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Practical aids to communication
Open questions What's important about coming here for
you today? What are your concerns at the moment? What do you know already about this?
Monday, 14 May 2012
Practical aids to communication
Open questions What's important about coming here for
you today? What are your concerns at the moment? What do you know already about this?
Giving information Chunk-check-chunk
What have you understood by what I’ve just said?
How do you feel about this information? Monday, 14 May 2012
Standard treatment Through:
effective communication that no organic cause found
reassurance that child will probably grow out of it informal support via clinic review
= 40% of RAP patients will experience spontaneous remission of symptoms
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Step 2: Self-help information (pilot)
Booklet 1: Explaining Irritable
Bowel Syndrome What and why How it’s treated Symptom diary
Booklet 2: Stress, Worries and
Excitement What and why How the body
responds Managing stress
Booklet 3: Strategies to Manage
Deep breathing Relaxation Visualisation Distraction Thought challenging
Review
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Step 3: Referral to When difficulties persist…. Importance of good communication between
referrer and psychologist phonecalls, emails, fortnightly psychosocial
meetings Formulation already presented to family in
sensitive way Emphasis on pain/symptoms as REAL
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Step 4: Psychological intervention
Cognitive Education re: link between cognitions and
physical symptoms Self - monitoring via diary keeping Challenging attributions re: bodily
symptoms (somatisers more likely to perceive organic cause)
Development of coping strategies
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Combined with…Behavioural Complaints of pain used as triggers to
prompt use of coping strategies Removal of secondary gain (e.g. increased
time with parents, time off from chores etc.) Graded approach to increased activity (aim:
resumption of normal functioning) Token reinforcement for behaviours
unrelated to pain e.g. school attendance
NOT ‘time out’ or ‘aversion therapy’ (!)
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Drawing on the Evidence
“Cognitive behavioural techniques, combining progressive muscular relaxation, self-monitoring, distraction and positive self-statements by children, and distraction and contingency management of pain and non-pain behaviours by parents, have been shown to be effective in the management of recurrent abdominal pain.” Wolpert et al 2002
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BUT…..Facilitate in minimising stressful stimuli Acknowledging role of these factors Where possible reduce impact:
E.g. through family work (family culture), liaison with school, problem solving, generalised thought challenging work, referral to other agencies….etc.
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Case 1 – KM 9 year old RAP aged 4 Central, lasts 1 – 2 hours Responds to mum rubbing her tummy Incidental Gilberts aged 2 (following
Pneumonia) Mum (gall stones); Grandmother
(stomach cancer)
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Returns home from school twice a week
Abdominal pain made worse by Mebeverine
Headaches Trial of Pizotifen - unsuccessful
Age 10: Scores ‘7 – 10’ Admits to clashes with supply teacherMum admits to problems with
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Patient KM Stomach aches reduced by initial
psychology appt 2 types Other concerns
School work Social relationships Sleep difficulties
Diaries Triggers relate to above concerns
Liaison with school Teacher and parent meeting to agree
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KM contd… 6 Sessions
Review formulation Mind and body connection Relaxation Distraction Select successful strategies
Walking, deep breathing Stomach aches infrequent, manageable and no
functional impairment Mum prompting / modelling → K initiating
Discharged, pending CAMHS ADHD assessment
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Case 2 - LN 13 year Recurrent abdominal pain 18 months
Central and right-sidedAssociated with pallor/ ‘distressing’
Bloods - FBC, coeliac serology, thyroid FT, & Stool Calprotectin
6 months later – USS abdomen (shows up bulky spleen)
4 months later – barium swallow (normal)
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Age 14 – stops going to school, home tuition!
Referred to clinical psychology Presents to OOH GP with acute pain –
repeat USS – normal Recurrent crops of mouth ulcers,
fluctuating weight:Upper and lower GI endoscopy (normal)
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Patient LN Initial joint assessment – PPALS &
CAMHS Symptoms and pain main focus No significant hx of anx or MH problems Sister and nephew moved in at time stomach pains began
Pain management work initially Engaged but still focused on on-going investigations (IBD
been mentioned)
Liaison with school Hx of anxiety / peer difficulties Referral to reporter unsuccessful
Endoscopy completed – line drawn
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LN contd…Focus on psychological aspects MD Clinic Review Confront emotional aspects L acknowledges anxiety / peer problems Begin cognitive work along with graded reintroduction to
schoolBUT Cancelled appts – step forward, step back….CURRENTLY (13 months on….) Home tuition stopped S’Grades dropped to 2 School leaver age – but chooses to continue and to engage
in psychology more openly….. Varying symptoms continue MD Reviews continue but less frequent
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Closing considerations Good communication key to promoting
understanding, change and patient well-being
Addressing own attitudes re. validity of illness/symptoms
Clear formulation of difficulties Collaboration rather than confrontation Resist frustration at apparent lack of progress
fluctuating course, small steps
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Any questions?
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