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Mental Health Nursing · Chapter 11

The Reassurance Loop and the New Symptom

Ms Farrell is 47, has somatic symptom disorder, and has had 41 normal investigations in six years. The dials below start on ordinary care, which is why she is getting worse. Change one decision at a time and watch twelve weeks respond — reassurance will make the line drop for about twenty minutes and then rebound higher. Then do the part that keeps her alive: decide which new symptoms get escalated.

Design the care model

Five decisions. Every one of them has evidence behind it, and every one of them is made dozens of times a week without anybody noticing they are decisions.
When is she seen?
Symptom-triggered visits teach the system’s lesson: symptoms are the way to obtain contact and care.
She asks whether it could be cancer, and for another scan
Reassurance-seeking is a compulsion, and it behaves like one.
What goes on the care plan as the goal?
Goals are set at the first visit and quietly govern everything after it.
What is prescribed?
She also meets criteria for a depressive disorder and generalised anxiety.
What happens with her body at each visit?
There is a documented history of childhood sexual trauma, as there frequently is.
Why the goal dial matters more than it looks A goal that cannot be reached while symptoms persist is a goal that guarantees failure and teaches her that recovery has not started.
“Be pain-free”“Walk to the corner shop twice this week”
“Get an answer”“Return to two shifts”
“Stop the dizziness”“Sleep in my own bed”
Recovery here is measured in function, not in feeling. The person who walks to the shop while still in pain is recovering; waiting for the symptom to go first is waiting forever.

Twelve weeks

Twelve weeks of unscheduled contacts, investigations and function
Unscheduled contactsInvestigationsFunction
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Contacts in week 12
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Tests ordered
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Function score

The new symptom

Six things Ms Farrell and others like her report over the following year. Every one of them gets a genuine assessment — that is not the question. The question is which ones you escalate tonight.
Diagnostic overshadowing — attributing new physical symptoms to a known psychiatric diagnosis — is one of the leading causes of preventable death in people with serious mental illness. A prior psychiatric diagnosis is not a shield against physical illness; it is a risk factor for having physical illness missed. And “nothing is wrong” is never a true statement: something is wrong, because she is symptomatic and disabled. What you mean is that one specific dangerous cause has been excluded. Say that instead, then say what the positive diagnosis is, and stay in the room.