Deemica Patel

Chronic pain and persistent physical symptoms

Blog Post by Deemica Patel (Trailblazer GP 2019/20)

Write up of Trailblazer GP Education Session. This session was delivered by Suzanne Heywood-Everett, Consultant Clinical Psychologist, who has an interest in eating disorders, Autism and Chronic pain.

The session focussed on how we as GP’s can manage chronic pain and persistent physical symptoms. Frequently health professionals can feel that they are out of their depth with these issues and see patients with these problems as ‘heart sinks.’ This can create a culture where health professionals may avoid such patients, medicalise their issues, medicate the problem, and refer inappropriately for investigations and to different specialities. This in turn can make the problem worse as patients may experience further psychological issues, feel they aren’t being listened to and they may seek quick solutions.

Chronic pain

Chronic pain is pain experienced for more than 3 months duration and is due to changes in the state of the individual’s tissues and influenced by other external factors.

Some key points around chronic pain management:

  • It is important to elicit cultural norms and health beliefs as these can lead to somatisation.
  • It is normal for health professionals to medicalise problems and they have a tendency with patients experiencing chronic pain to over investigate in case they feel that something is missed
  • Take ownership – patients can see lots of different professionals and sometimes this may be due to unavailability of appointments with a particular health professional, certain health professionals may not feel comfortable/ experienced seeing patients with chronic pain so do not actively encourage follow up with them.
  • It is important for continuity to be established.
  • Referrals to other services may make the problem worse.
  • Quick fixes can reinforce health beliefs
  • Admit that you don’t always have the answer
  • Patients should take responsibility for their pain- empower them
  • Role for GP to challenge a patient’s narrative around chronic pain

Points during the consultation

  • Try to explore the impact of the pain and pain medication on their life and the impact of medicalisation. Often pentinoids/ opiates can cause multiple side effects and patients may be prescribed medications to counteract these
  • Explore their experience of investigations and referrals
  • Patients commonly feel worse as the referral and investigation culture can make them feel that something is being missed
  • Ask about psychological trauma- this can help you understand when and why the pain began
  • Be mindful of your reaction to the issue – e.g. using negative words (ouch, oh no), negative body language can reinforce a patient’s perception of the problem
  • Think of way you explain terms e.g. degeneration and trapped nerve are unhelpful words
  • Patients with chronic pain can be reluctant to change a certain behaviour
  • Exercise: think of a behaviour that you have found hard to give up. How would you feel if we were asked to give it up and what would the best way would be for somebody to ask you to give it up.
  • Most people minimise the negative aspect of the behaviour e.g. I know I shouldn’t drink more alcohol but it helps me to relax and I have had a stressful week at work, therefore I deserve a drink to help me relax
  • Understanding this highlighted that it would be difficult to make changes if you are not in the correct mind-set
  • Patients need to be self-motivated and either pre contemplating or contemplating making changes before embarking on this journey
  • Offer a follow up appointment when they are ready to make changes

Going forward

  • Acknowledge pain is real and about protection e.g. twisted ankleà swollen and painful, cannot walkà restà symptoms improve 
  • Advise management is not a quick fix and will take time
  • Need to learn about pain and why it occurs and why the body responds to this- a useful tool are videos on chronic pain. 1. Tame the beast, Lorimer Moseley: 2. Understanding pain in less than 5 minutes and what you can do about it:

For chronic pain need to retrain an individual’s pain system

  • Learn about pain
  • Learn about body
  • Retrain pain system: emphasis on scientific approach and why medications not working  
  • The way you think about pain changes it  

Patients will admit to still being in pain despite medications and getting side effects. Encourage them to gradually reduce to see if pain gets worse and if side effects improve

This cannot be achieved in one appointment- advise patients it will take time!    

Persistent physical symptoms

There is no organic medical reason for this, despite investigations and there may be a psychological component

Can be more than pain e.g. any physical symptom

Delayed symptom onset –usually occurs post stressful period

Should be viewed as part of the recovery process of chronic stress and trauma  

The management is very similar to chronic pain – see above