 Okay, good evening everybody. Welcome along to the next of our MHPN series of webinars 2018, Unraveling the Myth of Thematic Tint and Disorder. My name is Dr Conrad Gungroomer, Rural General Practitioner and Prosper Bind in North Queensland and it's my great pleasure to welcome the 540 participants we've already got joining us for tonight's webinar and those who have also taken the opportunity to access the recording, the podcast, the play of the day. Thank you very much to all of you for your participation and for being part of it. Before I begin, MHPN would like to acknowledge the traditional custodians of the land, the seas and the waterways across Australia on good which our webinar presenters and participants have located. We wish to pay our respects to elders past, present and future for the memories, the traditions, the culture and hope of Aboriginal and Torres Strait Islander Australia. As I mentioned, I'll be the facilitator for this evening's session so it's a pleasure to be sharing this with you. I'm not a mental health expert, I'm a rural general practitioner as I mentioned and I always love the opportunity to learn not only from the panelists but also from yourself as the participants who are making sure that you're getting the most out of these sessions as well. Now we always acknowledge that however that we acknowledge that many people have had difficult experiences in their interactions with the health care system and may not have received the kind of best practice care that we might be talking about in this webinar. The purpose of this webinar is to give a broader group of health professionals the skills they need so that they can help people more effectively in the future. Personal stories of illnesses are very important and MHPN often includes consuming care as on our panels. The chat box however is not a form of a personal story it is designed to complement the panel discussion by allowing professionals to share their resources and their experiences with practice. So I'm just going to thank you all in anticipation for respecting this forum. So we'll just introduce the other panelists. First we're going to introduce Liz Muldoon. Liz is a, I'm sorry, I'll start off with introducing the station provider Louise Stone. Louise is a general practitioner and an academic general practitioner working at the ANU Medical School. She's got vast experience not only in general practices but obviously in mental health which is a major part of our work including leading a number of mental health training programs. Louise is the clinical lead in the masters of the psychiatry medical program at New South Wales Health and when she was doing her PhD she actually undertook that further study in ways that GPs assess and manage medically unexplained symptoms. So Louise welcome along to tonight's discussion. I was wondering if you might be able to share with the audience. Now we're talking tonight about somatic symptom disorder but the definition can be a bit confusing. Can you tell us how you make a diagnosis? Yes, sure Conrad. I mean one of the problems with the diagnosis of somatic symptom disorder is it's quite new. It's just come into DSM 5 and really it's part of a series of disorders that we deal with looking at medically unexplained symptoms where patients present with physical and mental issues together but don't have a physical health diagnosis. Wonderful. Thanks Louise. We're now moving on to Professor Alex Holmes. Alex is a psychiatrist who's in private practice in sorry at the University of Melbourne and he also participates in consultationally asian psychiatry at Royal Melbourne Hospital. He's the interest particularly for research been on those the psychiatric clear of physical illnesses including serious brain injury, pain, multiple sclerosis and brain tumours. Alex what are the main disorders listed under the category of somatic symptoms and related disorders in DSM 5 that were previously known as somatophore disorder? Okay well the DSM 5 under this sort of forward category of somatic symptom and relating disorders clearly has somatic symptom disorders as one of its major diagnoses but then there's also the conversion disorder which is similar to past DSM illness anxiety disorder which is the old hypochondriasis, fictitious disorder which is similar and psychological factors affecting other conditions. Wonderful. Thanks Alan. And finally a pleasure to introduce you this evening Liz Muldoon. Liz is a psychologist working in the ACT and her area she's been actually been in in psychological practice in 2019 although completed her master's in 2013. As a generalist Liz has interests in general clinical psychology across the full age spectrum and as most of you will be participating in the cells there's a wide range of psychological disorders including anxiety, PTSD, sport and performance issues, personality disorders and somatic disorders. Liz also has prior practice working in community mental health in the New South Wales Health Service as well as participating in teaching activities with Charleston University. Liz welcome along to the MHVM group. What are some of the risk factors you see sometimes with traumatic symptoms? Often we see early childhood traumatic experiences so childhood abuse when it lacks emotional avoidance, sometimes the childhood history of chronic illness and also social norms that stigmatize psychological symptoms compared to physical symptoms. Wonderful. Thanks for that Liz and I hope you'll all enjoy being part of as much as we do. As I mentioned earlier just a few background rules that we have to go through for this evening please just make sure that everybody wants to get the most from this live event so be respectful of other participants in the panel. Even though we're far away we don't want to leave people at worries remember to treat others as you would be in a face-to-face activity. The best way to do that is to interact with each other via the chat box. I'll try the best we can to get through as many of your questions and topics that you raise but just try to make your comments on topic keep them brief that'll be the best chance. However you don't use the chat box for your technical issues you'll find the technical support FAQ tab at the top of your screen and if that's not helping for you you can call the Red Health Help Desk on 1-800-2-9-1-8-6-3 and if there is a problem that technical issue affecting all the participants will be letting you know about that. So for this evening we're covering as I mentioned somatic symptom disorder and we really want to make sure that everybody gets a good opportunity to cover these important learning outcomes. This evening we're hoping that you'll all come away with it with the opportunity to identify practical strategies to deal with a person standing with medically unexplained symptoms. Recognize the importance of working with families who are terrorists for someone with somatic disabilities and be able to identify approaches to collaborate with other health professionals to avoid unnecessary investigations and hydrogenic harm. So you've hopefully all had the opportunity to to read Anna's story and as a kind of challenging 35 year old female we're not going to have time just to go back through the whole case study now but as so often happens in all of our practices she'll be part of the setting foot for many of us. Louise we might come to you first as a general practitioner who might be looking after Anna how would you go about being part of this important condition and patient life there? So Anna is not an unusual presentation for us in general practice. A person who has a combination of physical and emotional issues all tied up together leads to some sort of symptoms that are difficult for us to characterize and diagnose. So at the core of her type of symptoms is three things a type of somatization which is somatization is a process and it's a tendency to experience, conceptualize and communicate mental disorders as physical symptoms. So I think it's important to look at all three that from Anna's point of view Anna experiences those physical symptoms they're very real for her. She sees them as coming from a physical course so she attributes something and she turns up to us as health professionals to try and get relief for those symptoms. From a GP perspective patients like that fall into a number of groups and somatic symptom disorder is one of them or in Anna's case perhaps conversion disorder and I know Alex will talk about this in a minute but really patients can turn up with a variety of things they can turn up with the physical symptoms of depression or anxiety so it's not unusual for instance for patients to come with anxiety disorder to present their telepathy to us for instance or come in short of breath or chest pain and actually have depression but there are other things that they can also have like Munchausen's disease that idea of presenting in a way causing their own symptoms or something like Anna where we feel that the symptoms come from a past history of the emotional trauma and they've converted into a physical symptoms or conversion disorder. It's important that we don't think that Anna in this case is lingering it's not that she's putting it on in order to gain some sort of evidence some sort of outcome from that from us but certainly there are some patients that turn up that way. The other three types of presentations are really common for us in general practice and they are quite difficult it's not unusual for us to see someone with illnesses that haven't yet declared themselves where we know that in the future this patient might present with an autoimmune disease something like lupus and we haven't yet been able to work that out so it's not unusual for us to not be sure yet whether the patient has a physical illness. It's also unfortunately not unusual for patients to present with what we call contested illnesses so they've gone onto the internet and they've joined a group and they've decided that they've got chronic Lyme disease or some sort of unusual multiple chemical sensitivity or something along those lines and come to the GP to try and prove that that's the case and it's certainly not unusual for us to see patients who have what we call chaotic illnesses so patients with long-distance trauma with layer on layer on layer of difficulties in their lives and now presenting with physical symptoms seem to be in response to chronic and severe stress. I think with patients like Anna it's really important to try and work out what's what so from a TT point of view it's incredibly important that we try and make a medical diagnosis sometimes it's not easy for us to do that and sometimes we have to wait and see a long period of time particularly for unusual things like autoimmune diseases that can take a while to present. It's also important for us to make a psychiatric diagnosis so that we make sure that we exclude things like eating disorders or psychosis those sorts of things and it's important for us to have a sort of broad understanding what might be going on so someone like Anna to think that perhaps in her past she hasn't been able to express emotions very clearly and so in this circumstance those emotions like expressing themselves through her body rather than expressing themselves psychologically for her and coming out as a series of symptoms in her body rather than coming out in her mind. I think from GT's point of view that you know there are always four parts to any mental health presentations no matter what patients come in they usually come in with some sort of physical sensation like pain or like palpitations some sort of feelings like anxiety or depression usually some sort of disorder thoughts or concentration and some sort of unusual behaviors so in Anna's case we're looking at you know she's coming in seeking medical help and trying to define herself in a very medical way which is unusual. As GT's our responsibility is very much to try and look at all four sides of the equation and make sure that we keep that open because unfortunately patients like Anna they do develop physical illnesses at the same time as their dermatization illness so in this case her conversion disorder she may also develop something else so we have to keep an open mind and make sure that that we keep looking after Anna as a whole person not simply as her mental illness. One of the hard things in general practice of course is that patients get terribly worried about their illnesses and we're very worried about missing something too so it can be quite difficult for us to not succumb to the desire to do he says MRI scans and CAT scans and get terribly worried about the fact that we might be missing something. The core business for us is to try and validate Anna that Anna is absolutely experiencing symptoms and Anna is quite distressed try and give her an explanation that she can understand and to keep that consultation nice and open to coordinate care and advocacy so that she can get the care that she needs and to manage symptoms as they emerge and to keep that agenda broad so that Anna can talk about her emotional symptoms as well as the physical symptoms we don't get stuck into arguments about whether it's really real or not. It's important we protect her from people in the community that can exploit people like Anna so there's plenty of people who will sell various products that aren't evidence-based and certainly cases like Anna sometimes go overseas to clinic spend a fortune and we it's in it's very important as GPs that we're trying to protect Anna from those things and also maintain that very ecstatic approach. Anna is suffering and just because our understanding of why she's suffering is different to Anna doesn't make that suffering any less real so I think as a GP they're the main things that would come up for us. That's fantastic Louise and a great open summary of where things are at. Of course it is a challenging diagnosis and a challenging condition to be able to to manage and to take on. Alex I'm wondering yeah as that's the treating psychiatrist who might be asked to give them advice on where we go next with Anna how would you take on her care? Well following on from what Louise has said and perhaps sort of emphasizing some of its details the key in managing patients like Anna is confidence in the diagnosis which to a certain degree will always be challenged by her alternative perspective around her symptoms. In Anna's case despite the title of the seminar rather than having the symptomatic symptom disorder she clearly has a conversion disorder so she has a neurological style symptom which is incompatible with what we know about neurology and medical conditions and it's not better explained by any other condition but faced with her preoccupation that this is a physical disorder and our nagging concerns about not getting things wrong how can we be confident? Well I think this tests our very cut the very nature of medical practice we understand the things in physiological and pathological terms such that there are there's a point where a constellation of symptoms cannot viably result from a single lesion and then our knowledge of multi-lesion pathology indicates that once those disorders such as multiple sclerosis or multiple strokes have been excluded the diagnosis one can confidently make as a conversion disorder. There's always this concern about getting it wrong and the reassuring aspect of the modern diagnosis is the current literature really suggests this is very rare so once one has made a reasonably confident diagnosis of conversion disorder only a very small percent in criminalistic is a kind of reasonably recent study perhaps less than five percent of patients will actually go on to develop an organic condition which fully or partly explain their previous symptoms so one can be in other words 95 percent certain of the diagnosis at least so once the diagnosis is made before one communicates this with a patient it's worthwhile building a formulation now formulation is a hypothesis it's not a gold standard fact but it's a an idea or a set of ideas that can change over time but start you start with which answers the question why is Anna presenting with this problem now there may be a recent psychological persistence such as a loss or a bereavement or abandonment that recent literature really indicates this is probably only present in about half of the patients it may be the risk factors that we've already alluded to and it's common you'll find sort of developmental challenges or early exposure to physical illnesses or cultures within families that promote somatic rather than physical expression the final piece the puzzle is often the people around the person whether they're solicitous supporting of the symptom take a very somatic perspective or in some cases take that one step further and have a sort of some sort of something to gain from the person having a physical illness some some cohesion occurs when a family is sort of directed towards helping a symptom whether it be actually caused by a physical illness or not so once we have this confidence the next step is to communicate to the patient now that the truth is that this will often occur in primary care patients often won't embrace this sort of notion of a psychological cause in the first instance and they won't see a psychologist or psychiatrist even to confirm that diagnosis so one's left to the best of one's ability trying to communicate the diagnosis and although there's no sort of text script a sort of general approaches to as we've already discussed clearly state that something is wrong the good news is that we've excluded major progressive neurological illness that the the symptom is a manifestation of some sort of stress that's impacting the nervous system sometimes the term functional somatic symptom is used and that's the term that's available on the web and people will search we don't exactly know what causes this so there's allowing a degree of uncertainty in which both you and the patient can kind of exist rather than absolute certainty about what the cause may or may not be that's indicating that the focus of treatment is providing support simple goals and if there is a stress component involved identifying the source of that and helping if if possible it may be that over time the patient embraces this and is willing to kind of consider engagement with other practitioners such as the physiotherapist or exercise physiologist or even a psychologist and a psychiatrist the management is a way in a way is about avoiding the kind of relapsing to an argument about whether this is in my head or this is physical and allowing some way the patient to kind of make a transition from their conviction this is physical to the possibility that this may be due to sort of a broader holistic problem and that requires a pathway where they can make that adaption which is without undue pressure and aware that they may feel some degree of shame or embarrassment or fear about the possibility of being a psychological condition it's always important to identify and hence the mature aspects of the patient the patients the aspects of the patient that aren't happy with the symptom that want to improve that want to embrace life challenges despite the symptoms and when that sort of a success occurs it's the I think it's impositive to highlight that in the same way that moving away from current discussions about diagnosis is important my final comments are that these patients are difficult to treat they're difficult for in primary care they're difficult in specialist care the very symptom itself challenges the nature of medical practice we often feel frustrated and the patient often feels frustrated the frustration expressed at us may be about not doing more investigations not believing them or Anna may be upset that we're not fixing her our frustration towards Anna may be the fact that she's expressing hostility to us or that she may in fact question our competence or commitment is that longer-term challenge of lack of change or an entrenchment in the symptoms the refusal to sort of even embrace the possibility of a psychological dimension but that part and parcel of sitting with the patient involves accepting these frustrations fantastic thanks thanks so much for that great depth into what is it really challenging area Liz there's no question that Anna is really going to need a good therapeutic relationship with a skilled therapist in this area as the treating psychologist who might be looking after her what would you bring to the care of patients like Anna? Yeah I guess much the same as Louise and Alex talked about I guess as a psychologist what is important as it is with all clients that we work with is to develop that comprehensive case formulation as Alex said it's important in the case of Anna to try and understand why she's presenting with these symptoms and whether they're physical or psychological at this time and under these circumstances we need to consider those possible predisposing and precipitating factors but I think most importantly what we need to look at is what's currently maintaining her symptoms so as Alex mentioned secretary gain care eliciting emotional avoidance accommodation by family members this formulation will then not only help you better understand the client symptoms but I think it can also then be used to share with the client to help them develop some insight into possible causes and maintenance factors for their symptoms. I find that if you work collaboratively with the client to develop her hypotheses around what might be going on for them that can be the best way to develop a shared understanding of the problem. I think one of the biggest challenge again as Alex mentioned was that in working with clients such as Anna engaging them in treatment can be quite difficult because they do not recognize their symptoms as being in any way psychologically related. Anna for example denied any mental health concerns and she reported not being overly concerned by her physical symptoms as well so the question then becomes how do we engage her? I think first and foremost is that we make the client feel heard and listen to and it's often means avoiding jumping straight into challenging their beliefs around their symptoms and trying to diagnose necessarily straight away rather I think trying to understand again the impact their symptoms is having on them specifically focusing on the psychological impact of the somatic symptoms rather than merely the cause of the symptoms and the possible medical etiology. In the case of Anna for example you might try exploring other reasons she might benefit from seeing a psychologist such as the noted impact on her occupational functioning. You can also try to build Anna's insight by discussing the link between our minds and our body and overall I guess again we just want to develop a shared understanding and often the best way to do that is by validating the client's and their experience to them these symptoms are real and they're real for them and distressing for them so providing validation and empathy I think is key. So the treatment I guess is my symptom disorders I guess requires a multifaceted approach that is tailored specifically to the needs of the individual client. The research I guess is still limited but of that that does exist CBT and mindfulness based therapy have shown some promise in the treatment of somatic disorders. I think regardless of the modality use the main goal of treatment is to improve the client's functioning. I'm going to build the client's emotional awareness and understanding so that I guess we find that as the client becomes more attuned to their emotional experiences there's a greater likelihood they might consider a link between their physical symptoms and a possible psychological explanation underlying them. We also want to explore with the client their coping style in the case of Anna apparent that she's quite emotionally avoidant and I guess exploring that and discussing with her that can help possibly make links between that coping style and her presentation and then we want to introduce more effective ways to cope with her symptoms. I think it's also very beneficial obviously to provide psychological education on the etiology of somatic symptoms and how these can manifest both physically and psychologically. I guess finally working with cases such as Anna it's important we collaborate with other health professionals and family. I think we really want to focus on removing any false beliefs that might arise from both health professionals and the family particularly the suggestion that the client is faking or seeking attention. Working with clients such as Anna can be slow and quite a challenging process and for psychologists the main focus really needs to be on building the therapeutic alliance and creating a safe place for the client to discuss their concerns. I think it's also beneficial if we try to upskill the family as much as possible on ways in which they can validate and support the clients while also not reinforcing or accommodating their symptom briny dysfunctional behaviour. I think overall patients and a shared understanding from all that's involved is key in treating someone like Anna. Wonderful thanks thanks for that. Yeah it's difficult but it can be done you know it's just taking that first step and being confident to take on the care of Anna and patients like her and we'll do the best that you can. So move on to the question and answer part of the presentation now and there's got a few fantastic questions which are coming up in the chat box to move on to but I'm going to cover some of those which we had at the initial registration questions. Louise I'm just going to put the first question to you. Managing patients with medically unexplained symptoms in primary care certainly can be very difficult and challenging. How would you suggest health professionals guard against transference in these instances? I think Louise has raised a really important point there about the shared frustration. You know we share a lot with these clients we worry that we'll miss something it's like they worry that we'll miss something we worry that we'll get sucked into their perspective on the world and these patients present to us often with symptoms and they often their symptoms change over time and a 166% of our patients have rare diseases so it's quite often that we're looking at things wondering if there's something we might have missed that we might have not covered off so our anxiety can be raised. I think the main thing is something that Alex said which is we need to be confident that we've covered the major medical illnesses that are most likely even when we do keep an open mind because these patients they do get hypertension, they do get cardiac disease, they do get other things. So GPs in particular one of the things that we need to do is to be confident of our diagnosis and to keep a good relationship going with the patient and that often means remembering to ourselves as how much this patient is suffering and just how much they value our care and making sure that the patient remains front and center of our concerns rather than spending our time worrying ourselves sick about whether or not a disease is likely to emerge that we're unable to diagnose and that's very difficult particularly when you're a young GP in practice it can be particularly difficult because you do worry that one of those rare diseases may emerge at any given point and that's always a bit of a concern for you. So speaking help from peers is always really helpful I think for these patients to make sure that you keep yourself on track. Alex we've had a few questions asking about the role of medications in treating patients like Anna. What would your advice be to those individuals? Well in short there's no role for medication in Anna's case however what we're hoping for is some evolution we don't want her to be stuck and it may be in the course of a good psychotherapy where she's being able to explore some underlying issues that someone who is avoidant or has elixotymic features starts to develop some symptoms so if like any other patients she was developed significant anxiety generalized anxiety or even panic or depressive symptoms one must always be prepared to say look we have a new psychological or psychiatric condition that requires treatment but in the first instance medications have no role in the treatment of conversion disorder. No that's great I'd like also one of the comments from one of our audience that this actually you know does affect nervous system it does lead to nervous system dysregulation and it might be that actually we don't want to per the clouds that picture with putting medications which we don't think are gonna make that much of benefit. Liz it's a great question here there was to put in about does the diagnosis of the metaphor and symptom disorder require the patient in highly anxious or absolutely preoccupied with their symptoms? Yes according to DSM-5 I guess somatic symptom disorder does require that the client be either highly anxious or preoccupied with their physical symptoms as you know the DSM-5 categorises that is somatic symptoms disorder and related disorders and conversion disorder which is what Anna is presenting with doesn't necessarily have to come with that level of psychological distress or acknowledgement of that often there's a lack of concern about the nature or interpretation of symptoms associated with conversion disorder and often the psychological stress is often at the unconscious level so that's sometimes where the family and collaboration with them might be important to determine if there is conflict or an impact on functioning that the client may not be acknowledging but is evident those around them. Louise Riem has put a really interesting question here about when do you differentiate the diagnosis of somatic disorder and chronic persistent pain following injury is there a great one that a lot of participants have been asking about? Yeah pain's interesting isn't it and I think over time there's been so much discussion about this area about what diagnoses apply and every time a new DSM comes out a new set of words and diagnoses come up I think what's really important is to understand that actually pain is the the research around pain is helping us a lot in this category because we're understanding more and more about central sensitisation pain and the way that over time chronic stress and various emotional states can upregulate our pain management system so I think over time we're going to find that a lot of these diagnosis overlap I have no doubt that when do we get to DSM 6 there'll be another set of classifications and another set of diagnostic names because I'm not really sure that we've got it right but I do think that idea that comes from the pain literature that that we can have neurological changes that can vary to chronic stress and certainly to early trauma helps us a lot in understanding why patients like Anna can present with physical symptoms that run along neurological path. Fantastic. Well I had the important question about what happens when we've got patients who are continuing to present in emergency departments or going through different different practices. Alex I guess there's been plenty of occasions where you've been called by a frustrated medical team to come in and see the patients. How do you manage when patients are you know representing time after time and not willing to engage with the diagnosis? Well I think this is common and the key concept is communication. Communication of the core opinion so I think in those patients it's very important that if possible someone with a certain amount of expertise can sort of authoritatively make the diagnosis and then communicate that to as many people as possible that may be attached to some treatment recommendations which would very much be along the lines of the things we've already discussed and it's about sort of staying the core. I think there'll always be situations where individual practitioners will feel that they want to you know that that demonstration that we're there for them for the long the long haul with this that we're not expecting this to be just a five-minute episode of care that this is going to take some time to properly work through and Archer I think we'd also all agree with you that nobody wants to make this type of diagnosis early that it's something which we need to take seriously. Now there's also some questions coming through about the link with fibromyalgia and chronic pain syndrome as well that Paul's mentioned about that that concept called nervous distance dysregulation. Is there any overlap with what we know with fibromyalgia and and traumatic symptom disorder or conversion disorder at all? I'm happy to make a comment but I'm sure other people have a comment. Look these are diagnostic systems they're not sort of veneco pathological entities where we have ever understand everything so of course what is described under the rubric of chronic fatigue may well sit under the same rubric of conics of a somatic symptom disorder and often what's being implied though in choosing one diagnosis or the other is the hope of the persistence of or the persistence of the idea that there is an underlying medical cause which can be found and treated. Again the management is one would recommend to try and stay away from that kind of discourse because it certainly is anywhere productive. So you know if a patient wants to feel that chronic fatigue is a good descriptor for them and you feel that this somatic symptom disorder is also a descriptor I don't think it matters too much as long as you can agree that the patient is suffering and has difficulties and that you are willing to stay with them and as much as possible help them to progress to a sort of better functional state. Can I just add to that I agree with you I agree with that it Alex in primary care I often try and get past what is true and start to look at what is helpful because what happens with these patients is that you start with them very entrenched and you try and be sideways just gradually over time until they begin to accept more emphasis on their psychological state and the way that that's emerging. I don't think there needs to be a very distinct moment when you are definite about whether it's one thing or another that idea of thoughtfulness is actually very important and I do think over time we've learned a lot more about for instance the neurological consequences of early childhood trauma we know that it causes changes in the neurological system so I think over time some of these diagnoses like chronic fatigue and fibromyalgia will begin to understand a lot more in psychological terms and neurological terms and the way those two intersect. For sure for sure of course there's a whole lot of extra stuff about trauma which we probably just aren't going to be able to get into with this session and I know that it's something that a lot of a lot of participants are asking about Alex we've mentioned about those types of techniques Liz have you found any particular techniques that are most suitable when you can't find when you can't elicit an underlying trauma when there's no clear trigger to address? I guess yeah the main focus is still on the impact that it's having on the client in currently I guess like looking at whether it's an occupational it's impacting on them occupationally or socially usually by the time they've come to us there's some kind of acknowledgement that it's affecting them in some way and perhaps at the start it's just exploring that with them as to how is their life affected by these symptoms rather than trying to I guess as a psychologist steering away from whether there's a medical explanation or not but looking just more at what does it mean to them to have these symptoms what does their life look like what would they like their life to look like in terms of managing these symptoms so I think it's more working with them to develop that kind of understanding around the impact more than anything else and Liz I might just ask you to expand on that a little bit because Malia has asked about you know how do you actually what might be some of those simple steps in establishing that that therapeutic rapport before you actually engage into the psychoeducation I guess that these are often having patients who are very cynical or skeptical about their importance of proper psychological therapy and how they engage into it so Malia I think is just asking for some pragmatic tips about that a lot of the steps you might be just going through yeah I guess that's important I think for myself when I'm working with clients such as this paying attention to referral first and foremost before I even see the client make kind of note that they perhaps won't be so open or willing to engage and so the first step I guess is really to just spend some time in that initial kind of assessment phase just building a relationship explaining the different ways in which psychology might be able to help them perhaps looking past just the fact that we only see people who have a mental health diagnosis that we also help I guess other people who just in terms of emotional regulation strategies and coping skills and you know I guess talking to them about patients that we have worked with who do have medical issues chronic pain and how they can benefit from psychological services as well but I would spend those first few sessions just really working on building a relationship with the client and I guess engaging them and I guess that it's always dependent on the clients that is sitting in front of you as to how best to do that but letting them feel heard I think is the most important part and part of that will probably be just their frustration with the process and the number of perhaps medical practitioners they've seen or procedures that they've had and the lack of answers that they've got and just being able to validate their struggle with that is often sometimes the best way to initially engage them. Fantastic, I hope that helps a bit there. Alex we're also getting quite a few questions about just some of the I guess maybe iatrogenic effects of our therapies so a lot of the participants are asking about the autonomic impact of the metaphor symptom disorder and that's perhaps some of the some of the traditional tools we might use mindfulness relaxation therapy and the like might not really be that the most appropriate in that setting. I'm sorry to those therapists to much more converse in those therapies than I am but Alex is there any harm that we're likely to inflict with with any of our usual therapeutic measures for these patients? I don't think so I mean I don't think the literature is very strong on this. Liz has always already mentioned that the sort of perhaps the sort of cognitive challenging is not something that one necessarily wants to embark on early that's been a constant theme but the those kind of strategies which if they provide some sort of whole body relief or mind body relief can be an interesting starting point in in change in as much as maybe Anna can do some relaxation therapy and then she can sort of acknowledge that maybe afterwards she felt a bit more relaxed or she she felt a bit stronger or you know who she moved a bit better and that that can and then one can take the conversation not to aha I told you it was all in the mind but to isn't it interesting how these things kind of interact when you feel sort of better in yourself you feel stronger in yourself when you feel stronger in yourself you're better in yourself that these kind of very general kind of accepting the complexity of the human condition which again allows a space into which the patient can somewhat change the way they think about their symptoms. Great great perspective there. Louise Melinda's raised a really interesting question that I hadn't actually thought about myself is that we know that you know as we've already mentioned that a lot of the pharmaceutical therapies don't have any great role and we know that properly engaging in psychological therapy is beneficial. We've also talked a bit about occupational therapy and and physical therapies as well in this area but we haven't really thought about what happens if we do nothing. Melinda's asking why don't you put diagnosis for somebody like Anna if there's no treatment or no psychological intervention and we basically just most on lifestyle intervention good you know support these things we do in general practice you know nutrition activity good sleep patterns all those types of areas. I think one of the things that's terribly important is protecting her from harm there are a lot of practitioners out there that will recommend all sorts of not evidence-based things for someone like Anna. She will go online and she'll be recommended everything from therapies particularly overseas type therapies and those sorts of things. One of the things I think is really important in general practice is to try and keep the relationship going with someone like her so that she doesn't spend her time lurching from doctor to doctor to doctor to doctor. I think the harm is very much in entrenching her idea that there's something wrong because every time she goes to a new practitioner they start from the beginning and they do another rough test and that just is a socially atrogenous effect embeds in her mind that there must be something wrong and if she finds the right practitioner then they will discover it and so she she invests more and more in her life in trying to find the answer and unfortunately you will find one on the internet it just won't necessarily be correct. So I think it's very important that we we keep those conversations open in the hope that as Alex says that gradually she begins to make the link that that her stress level impact on her symptoms so just comment on physical therapy there's good evidence of physical therapy things like massage for hydro therapy for those sorts of things in trying to relieve these sorts of symptoms and also to assist her in her management of her physical symptoms so I do encourage anything that helps the patient become more aware of what their body is doing often I find with these patients they're not terribly aware of the way that their emotions work and the way that their bodies work and so trying to make that link with massage or hydrotherapy or or movement and I sometimes even with young people sometimes use things like martial arts where there's a bit of a connection between the mind and body and they can explore that connection a little bit in the hope that she will gain that insight over time so yes I think the main thing for a primary care perspective is to try and and actively do nothing which is actually a lot harder than itself. And Liz I guess that brings us back to the the burden of if we aren't active we aren't being seen to actively do more investigations more more medications and we're really you know engaging in this area of therapy instead then we do worry about the loading or the or the the burn out load for the carers and the family or around the patient how would you suggest best protecting that the family or the carers to insulate them from that type of load? I think as much as you possibly can engaging family and carers in the therapy process would be important obviously with the consent of the client but really providing a lot of psycho education I think for the family in regards to why these physical symptoms are presenting and their link I guess the same way you would with Anna explaining to her the links between the psychological and the physical and that I guess removing kind of or answering their questions around what's going on because I think they can sometimes over time just get a bit fed up and kind of feel like you know they say unhelpful things like it's all in your head and you know you just you know you're making it up and things like that and I think to be able to help them frame their frustration perhaps to to the client in a way that's more well understood and I guess with a more validating and empathic approach. So I would spend a lot of time educating the family and then also talking to them about more effective ways they can communicate to the to the person. Annabelle and Karen have raised a really really frightening prospect that patients with medically unexplained symptoms being subjected to unnecessary operations and actually undergoing surgery and that that is indeed terrifying. We know that there are plenty of areas of surgery where we recognize there's potential underlying psychological issues and make sure that we get a thorough assessment done beforehand but for anybody to under unnecessary or go operation would be horrifying in this area. Well there's a lot of fantastic questions that are coming in from the participants and a lot of extra resources. Now a lot of you have made references to overseas authors and guidelines. I'd also encourage you all to use the resources folder which has been supplied you'll find that on the bottom right of the screen down here and there might be some of that which you're able to get some benefit from into your own practice with this very challenging area. We might actually just take a couple of moments now just for each of the panelists to reflect on the case and discussion tonight and just to sum up for Louise might just go to you first. I think the main thing with Anna is to be prepared to hold the uncertainty. You will never absolutely be convinced that Anna has no physical underlying disease. None of us can be convinced that we have no underlying disease. What's important with Anna is to continue to care for her the best way that we can and that's not about arguing the money she or whether there's a diagnosis whether there's not a diagnosis in terms of physical health. That's about promoting the most helpful way for Anna to live in the world in a way that is much healthy and helpful for her. So I think trying not to get caught up in that anxiety that we might be missing one of those six percent of very rare diseases for us as GC is hugely important and focusing more on what is it that Anna needs and what she needs is empathy and support and validation to help her understand why she is the way to use in the world. Is there help to improve that over time? Alex, if you're opportunity just to come right tonight as well. Okay, well look at clearly from what we said this is very difficult work and in a way allowing the possibility that it's not going to work that if you're going to engage in trying to help some of these patients some of these patients are going to sack you on the spot and you're going to feel useless and they're going to disappear and not let that colour your approach to your next patient. They are difficult but with some patients we can have significant successes over time and when that does occur I think it's very rewarding. Liz, I will just a lot of participants are really asking about how do we manage the trauma. I'm not sure that we're able to get through the trauma therapies in this area. We've got plenty of other webinars which have dealt more effectively with post-traumatic issues and recovery but I don't know if that's something which you'd be able to cover in the summary at all. Briefly, I guess the client has to be at a position where they're prepared to discuss and acknowledge the trauma as with any case any lesson with trauma you need to have the client be at a stage where that's something that you can do with them. In the case of Anna you wouldn't go there for quite some time until you kind of helped her understand the impact of her symptoms and her emotional avoidance and the situations that she's been through and the possible impact that they've had on her. She's quite convinced she's fine and nothing's a problem and they've all been okay and I guess maybe reflecting that those things aren't necessarily those things are challenges I guess that people would find distressing and traumatic and then explore that very gently with someone like Anna and then you'd go into all the trauma work if that was something that the client was actually willing to do. It's from the client that you need to do that trauma work and you won't get that unless they've actually got an awareness that it's an issue. Really now I've all come back to that in five times. That's absolutely right. Thank you so much everybody for what's been a really really engaging session and we knew from the start that sadly we're going to open up a lot more questions and we're going to be able to get answers to but I think for all of us as we've discussed earlier being able to accept unexplained symptoms and illnesses where sometimes we just don't always have the answer but being able to move past that and to move on really is a professional step that all of us probably would be delighted to know that we've are that we've what got in our armamentarium. So the upcoming sessions for MHPN we've got the final BPD webinar on management and mental health services for primary and private sectors coming up next week on Monday the 26th of November and then we've also got a webinar on psychological treatments for trichotillomania a very interesting area that's coming up on that the 6th of December so I'd encourage anybody who's interested to to register for either of those. Of course MHPN supports the engagement and ongoing maintenance of practitioner networks where clinicians from different disciplines meet regularly with other mental health practitioners share tips or resources builds local referral networks and pathways and engage in their CPD activities so to learn more about joining or even starting a local practitioner network please don't hesitate to contact MHPN or go into the new section of the website and that's also where you can find your interest on the the exit survey that you'll be seeing. So please do make sure that you do complete the the exit survey before you log out we really do take your your comments on board and they've made a tremendous impact being able to help us develop the program that you that you need. We also that's also we make sure that you get the correct details for your attendance certificate which will be emailed out to you in the next the next month or so and you'll also be emailed to that stage a link to the resources which we've mentioned as being online. So it's going to take this final opportunity to thank the panelists for a lot of being a fantastic session and to all of you who you're illuminating and really really thoughtful comments that you've been sharing with us tonight. Thank you so much everybody and I hope you enjoy the presentation.