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Door-handle conversation: ‘By the way, I’m getting a divorce’

Advice on handling those last-minute disclosures in your consultations

Case study

A 38-year-old man attends your minor illness clinic complaining of vague intermittent abdominal pain, associated with headaches, over the past seven months or so. You discuss the options available and give him written information to support your advice. Just before leaving he mentions that he is getting a divorce

This is an important disclosure and must be noted down in the patient’s history as it may have an impact on his future presentations. It’s unlikely you will need to extend the consultation but it may need to run over by a short period to briefly discuss the disclosure.

The symptoms that this patient is describing could be attributed to stress, anxiety or depression relating to his ongoing marital breakdown, especially as this was most likely precipitated by some stress prior to the end of the relationship.

It is important to find out whether the physical symptoms or low mood were present before the marital breakdown to see if you can exclude any underlying mental health problems.

Most people with depression who are seen in primary care are not recognised as depressed, in large part because most of them book an appointment for a somatic symptom and do not consider themselves to be depressed.1

An anxiety disorder may also be suspected in people who have experienced a recent traumatic event or with possible somatic symptoms, as well as those with a past history of an anxiety disorder or an avoidance of social situations. The person’s responses to initial questions about their symptoms can be useful for spotting signs of anxiety or depression.2

It is important to take a thorough patient history as depression and anxiety disorders often first appear in early adolescence, even though they may not have been diagnosed or recognised at the time.1,2

It would be useful to spend a few moments discussing how stress and anxiety can manifest themselves into physical symptomology close to what the patient is describing, as well as other physical symptoms such as shortness of breath, shaking, trembling, insomnia and sweating.

By providing the patient with some information about stress and anxiety, as well as ways to manage both, you may prevent further physical symptoms developing from the possible underlying stress.

It may also be appropriate to investigate the patient’s mood by asking about how they are feeling, sleeping and eating to get a better picture of how they are coping with the divorce. 

It is also useful to check if the patient is connected with family, friends, people at work or through social activities as this can alleviate loneliness. 

Depending on the outcome of the discussion, ask the patient to return in a week or so to see you to find out if there has been an improvement, as well as gather further family history.

NICE recommends that if the presentation and history suggest a mild and self-limiting (ie if the symptoms are improving) common mental health disorder of recent onset, consider psychoeducation and active monitoring before offering or referring for further assessment or treatment.3

When discussing treatment options, you should consider:3

  • Past experience of the disorder, as well as experience of and response to previous treatment. 
  • The trajectory of symptoms.
  • The diagnosis or problem specification, and severity and duration of the problem.

It is also important to signpost the patient to services in the third sector, such as Mind (see resources), who offer national support services for people experiencing mental health problems.

AUTHOR
Fiona Brand is a psychiatric liaison nurse at Oxford Health NHS Foundation Trust

References

  1. NICE. CG123: Common mental health disorders. London;NICE:2011
  2. NICE. QS53: Anxiety disorders. London;NICE:2014
  3. NICE. Pathways: Principles for treatment and referral in common mental health disorders. London;NICE:2011

Resources