Review
Managing physical symptoms:: The clinical assessment as treatment

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Abstract

Physical symptoms are a common cause of attendance at general hospital out-patient clinics. There is good evidence that cognitive therapy is effective in the management of such physical symptoms. This narrative review suggests that the assessment itself, without formal psychological therapy, may be used as a treatment, regardless of whether relevant pathology is absent or present. Changing patients' beliefs about their symptoms may improve a broad range of outcomes, including symptoms, disability, distress, and health-care resource use. The evidence for investigations as treatment is reviewed, along with potential for further development and possible pitfalls. A rationale is presented for a brief psychoeducational intervention that can be delivered in the clinic. This would be a logical extension of the kind of simple explanation and reassurance that occurs routinely today, but which is not explicitly used as, or regarded as, treatment. The dearth of relevant evidence is emphasized, and recommendations are made for future research.

Introduction

A major function of general hospital out-patient clinics is the management of physical symptoms, such as chest pain or breathlessness. Traditionally, management is divided into two stages, assessment and treatment. During assessment, the doctor aims to understand the cause of the problem and make a diagnosis. He does this by taking a history, performing a physical examination, and perhaps arranging investigations. The cause is usually described in terms of known or suspected physical pathology, such as ischemic heart disease or asthma. Explanation of the suspected cause forms the first stage of treatment, following which decisions are made about the administration of medical or surgical treatments. The traditional function of assessment is, therefore, to facilitate decision-making about treatments that may then improve outcomes, rather than to directly improve outcomes.

In patients in whom physical pathology is indeed responsible for their symptoms, this traditional approach may be appropriate. However, there are two important problems associated with this approach. First, when relevant pathology is found, the success of medical management is often modest. Symptoms often persist despite treatment [1], and patients are often dissatisfied with aspects of their management. This may be because clinicians do not effectively deal with patient needs other than the management of pathology. Research in UK primary and secondary care has shown that patients' main expectations are for explanation and understanding, above expectations for support and for tests and diagnosis 3, 4. Second, relevant physical pathology is often not found. For example, in a USA general medical clinic, 84% of presentations of common physical symptoms had no identified organic cause [1], and over half of new referrals to a Dutch medical out-patient clinic had symptoms that remained medically unexplained [2]. In the absence of easily identified physical pathology, a protracted search for such pathology may ensue. Further investigations may be ordered. The patient may be referred to another specialty, with the supposition that the pathology lies undetected in a different system. Alternatively, “empirical” treatment for presumed physical pathology may be commenced. This has major implications for the consumption of health-care resources.

Any physical symptom has two essential components: a “physical” component, which is a bodily sensation due to physiology or pathology; and a “psychological” component, which is the thoughts and beliefs relating to that sensation. Traditional management focuses on the physical component and, specifically, on the detection and treatment of pathology. Yet this approach ignores the clear links between the physical and psychological components and, therefore, neglects a potentially useful additional intervention. An alternative model of clinical practice views the assessment as being a vital and powerful part of treatment, rather than merely its subordinate and prelude. It is proposed that this additional treatment effect is mediated by changes in beliefs held by the patient about the presenting symptom.

The results of the clinical assessment can therefore be seen to have two effects. First, results change the beliefs that the doctor has about the symptom—beliefs about its cause, seriousness, likely response to treatment, and prognosis. This is the traditional management approach, in which the assessment exists in order to guide treatment and assess prognosis. Second, results change the beliefs that the patient has about the symptom. This is the alternative view, in which the assessment not only guides, but is a part of, treatment. This is seen most explicitly in cognitive therapy for medically unexplained physical symptoms, such as chronic fatigue syndrome or noncardiac chest pain. Cognitive therapy is a psychological treatment that, in the treatment of persistent and troubling physical symptoms such as these, aims to change symptom attributions, and thereby improve outcomes. Patients are actively involved in testing out and modifying their dysfunctional beliefs about their physical symptoms. Cognitive therapy is time-consuming and expensive. However, the assessment as treatment is seen most frequently in primary care, where the majority of physical symptoms are managed by simple and brief assessment and reassurance. Between these extremes lie most patients with medically unexplained symptoms seen in general hospital out-patients, who may benefit from a more intensive and explicit approach to the modification of beliefs than is seen in current clinical practice.

Although the potential treatment effect of the assessment will exist principally where tests are normal, it may also exist when relevant physical pathology is present. The relevant factor here is the direction of change in the patient's beliefs about the symptom. An investigation does not need to be normal to be good news. Many women with pelvic pain, for example, fear that their pain is due to cancer. The discovery of endometriosis rather than cancer at laparoscopy may therefore be reassuring, and thereby reduce symptom severity and disability. Equally, a normal test in the presence of continuing symptoms may be considered bad news, rather than good, as the cause remains unexplained, and untreatable. This dimensional approach to test results and health anxiety implies that the assessment may function as treatment for physical symptoms whether findings are normal or not.

This review is primarily intended to stimulate interest and debate in an area that has been neglected by clinicians and researchers. Although its ideas and conclusions are derived from a wide variety of sources, including unpublished evidence, it is not intended to provide a systematic assessment of the state of our knowledge. The search for relevant evidence was not systematic, trials were not subjected to rigorous quality appraisal, and not all trials of potential relevance have been mentioned. A systematic review of investigations as treatment for pain is currently in progress, and will be submitted shortly for publication.

Section snippets

Physical symptoms: the product of both sensation and attribution

A physical symptom has two essential components: first, the awareness of a bodily sensation; and, second, the attribution of abnormality to that sensation. Attributions influence the sufferer's response to the sensation. If the sensation is thought to be abnormal, the sufferer is more likely to monitor its nature and severity, to consider self-treatment options, and, if it persists, to seek advice from someone else. Cognitions, such as symptom attributions, therefore clearly have a role in the

Cognitive therapy for physical symptoms

This unified understanding of the etiology of physical symptoms allows us to consider new ways of treating symptoms. It suggests that attempting to change cognitions about the cause and prognosis of symptoms may be a form of treatment that is as legitimate and powerful as medicines or surgery. Cognitive therapy is the “gold standard” treatment for changing cognitions. It is a psychological treatment that seeks to systematically identify and modify dysfunctional thoughts and beliefs, in order to

The clinical assessment as cognitive therapy

One way forward for health services to improve care for patients presenting with physical symptoms would be to increase the availability of cognitive therapy. This would, however, be problematic. First, the availability of cognitive therapy is restricted. It is a specialized treatment that requires significant input from skilled therapists. It is therefore expensive, and there may be a shortage of suitably trained therapists. Second, some patients would not accept cognitive therapy, as it is a

Evidence

Clinical evidence about the cause of symptoms may be derived from history, physical examination, or investigation. Each aspect of the clinical assessment may, therefore, contribute to cognitive change and influence outcomes. However, investigation is the part of the assessment, which, in most secondary care out-patient clinics, is most frequently and confidently used by the clinician to confirm either the presence or absence of disease.

There is considerable evidence from nonexperimental

Different investigations

Evidence therefore supports the possible treatment effect of investigations. Just like medical or surgical treatments, “investigations as treatment” may differ in effectiveness. It seems plausible that some investigations are more therapeutic than others. Medicines have a placebo effect, in which the effect is influenced by size, color, and place of manufacture [41]. Similarly, an investigative technology that is new, or which appears highly technological, may have a greater placebo effect.

Cognitive-educational interventions

Our aim must be to gain the benefits of investigations as treatment without the potential financial and health costs. In the trial of “ultrasonographic counselling” [43], the clinician plays the central role, and the investigation is a tool to assist him. This raises the question of whether the therapeutic effects can be precipitated by the clinical assessment without investigation. Some clinical problems do not require investigations to confidently exclude serious illness. There is evidence to

Slow progress

The issue of investigations as treatment has been raised in successive editorials in the 1990s 54, 55, 56. However, limited progress has been made in advancing our understanding of this potentially exciting area. An editorial in The Lancet in 1992 [54], recommended further research, including randomized, controlled trials, to assess the effectiveness of investigations as treatment, and their comparison with a cognitive-educational intervention. We are little further forward 7 years later. Few

Conclusions

The traditional medical approach to the management of symptoms is to diagnose relevant pathology and then to treat that pathology. This presents problems when no relevant pathology is found and when symptoms do not respond to treatment. An approach to the management of symptoms that acknowledges their basis in both pathophysiology and cognition opens up an additional therapeutic avenue. With this approach, the assessment—diagnosis and explanation—is potentially a powerful new form of treatment.

Acknowledgements

I am grateful to colleagues, including Richard Mayou, Christopher Bass, Tony Hope, and Stephen Kennedy, for helpful ideas and discussion. I am supported by a Medical Research Council/Anglia and Oxford R&D Directorate Special Training Fellowship in Health Services Research.

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