Managing medically unexplained symptoms in primary care

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Managing medically unexplained symptoms in
primary care

• Dr Jim Bolton
• Department of Liaison Psychiatry, St Helier
  Hospital

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Introduction

• What are medically unexplained symptoms (MUS)?
• How common are they?
• Why do they happen?
• Management in primary care

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Mind-body divide

• In our thinking language
• In our health services
• Where does it come from?

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Mind-body divide

• Light microscopy - observable pathology
• Symptoms due to something we can see
• With positive findings on examination
• or investigation
• Problems when physical symptoms
• remain medically unexplained

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What patients hear ( what some health
professionals think!)

• Your investigations are normal
• Your problem isnt real
• Youre putting it on
• Youre mad
• Its all in the mind
• Which leaves a disgruntled patient, who still has
  their symptoms

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Making a diagnosis
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Making a diagnosis

• By aetiology
• Examples
• Dissociative disorder (hysteria)
• Somatisation disorder
• Hypochondriasis

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Making a diagnosis

• By aetiology
• Examples
• Dissociative disorder (hysteria)
• Somatisation disorder
• Hypochondriasis

• By syndrome
• Examples
• Irritable bowel syndrome
• Chronic fatigue syndrome
• Atypical chest pain
• Fibromyalgia
• Tension headache

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Making a diagnosis

• By aetiology
• Examples
• Dissociative disorder (hysteria)
• Somatisation disorder
• Hypochondriasis

• By syndrome
• Examples
• Irritable bowel syndrome
• Chronic fatigue syndrome
• Atypical chest pain
• Fibromyalgia
• Tension headache

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So what should we call them?

• Symptoms not adequately explained by physical
  pathology
• Umbrella terms
• Functional disorders
• Medically unexplained (physical) symptoms

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How common are MUS?

• Primary care 20
• Outpatient clinics 25-50

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Symptoms which commonly remain medically
unexplained

• Muscle and joint pain
• Low back pain
• Headaches
• Fatigue
• Chest pain
• Palpitations
• Irritable bowel symptoms

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What causes MUS?
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How do symptoms arise?

• Perception
• Interpretation
• Symptom

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How do symptoms arise?

• Perception
• Interpretation
• Symptom

• Many symptoms are due to the perception of
  organic disease
• But others remain medically unexplained
• What factors are associated with MUS?

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What factors are associated with
MUS?Vulnerability factors

• Genetics
• CFS, IBS
• Experiences of illness
• Childhood illness
• Parental illness
• Childhood abuse
• Illness beliefs

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What factors are associated with
MUS?Precipitating factors

• Infection injury
• Life events
• Stress

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What factors are associated with
MUS?Maintaining factors

• Anxiety depression
• Reaction of others
• Iatrogenic

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A model of MUS

• Perception
• Experience of illness
  Stress
• Interpretation
• Reactions of others
• Symptom

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Management in primary care

• History
• Examination investigation
• Explanation
• When to refer

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History

• What are the patients concerns and beliefs?
• What do you think is wrong?
• Are there any background problems?
• Screen for drug alcohol misuse
• (dont forget caffeine)
• Screen for anxiety and depression

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Examination investigation

• How much should I investigate?
• As much as is appropriate
• Over-investigation can reinforce the patients
  conviction that there must be something physical
  wrong

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Examination investigation

• Prepare patients for results
• If they are negative, what might this mean?

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Reassurance

• Most patients are reassured
• Bland reassurance is unhelpful
• Address the patients fears and beliefs
• Correct any misconceptions

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Explanation

• Give a positive explanation
• Put the mind and body back together
• Explain how physical, psychological and social
  factors interact
• Reattribution

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Explanation

• Bodily symptoms of emotions
• blushing
• butterflies in the stomach
• Vicious circle of pain depression
• Hardware vs. software
• Fight or flight response

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Explanation
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Further management

• Lifestyle advice
• Reduce caffeine, alcohol, drugs
• Graded activity exercise
• Treat anxiety depression
• Diary of symptoms and events
• Referral?

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Referring on

• Services
• IAPT in primary care
• Liaison Psychiatry in secondary care
• Who to refer
• Patient finds explanations difficult to accept
• Underlying reasons unclear
• Complex recurrent problems
• Co-morbid psychiatric disorder

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The future

• Recent recognition by policy makers
• Common expensive
• Development of services
• Explicit clinical problem
• Comprehensive care pathways
• Specialist treatment
• Reinforce basic skills

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Conclusions

• Medically unexplained symptoms
• Common
• Costly
• Treatable
• Cost savings

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Medically unexplained symptoms - are they all in
the mind?

• Not unexplained
• Explaining them depends on consideration of
  physical, psychological social factors
• And recognising that we are not separate minds
  bodies

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Misdiagnosis?

• 1950s/1960s mis-diagnosis of hysteria 30
• Slater et al (1965)
• 1970s onwards misdiagnosis medically unexplained
  neurological syndromes 5 (equivalent to other
  medical and psychiatric disorders)
• Crimlisk et al (1998)
• Stone et al (2005)

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Simulated disorders

• Malingering
• Feigned illness
• Conscious motivation
• External incentives

• Factitious
• Self-induced signs symptoms
• Unconscious motivation
• Internal incentives?

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How much do MUS cost?

• Population of 400 000
• 1,200 chronic MUS
• Average 22 hospital admissions in lifetime
• Estimated 600 000 per year
• 18,000 less severe illness
• But greater cost as a whole in appointments,
  admissions, investigations
• Shaw Creed (1991)

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Cost savings

• Single psychiatric consultation
• 40 reduction in cost of investigations
• Barsky et al (1986)

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The future aetiology

• Functional neuroimaging in dissociative disorder
• Looking at areas involved in planning and
  execution of movement
• Differences between subjects with dissociative
  disorder and controls
• Not putting it on

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Chronic fatigue syndrome

• Definition
• Chronic physical mental fatigue
• Associated symptoms
• No identifiable organic cause
• Disability
• Anxiety and depression common

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Chronic fatigue syndrome

• Trigger
• Symptoms
• Physiology Cognition
• Behaviour

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The future diagnosis

• ICD 11 DSM V under review
• Suggestions include
• Abolish current diagnostic categories
• Redistribute diagnoses where possible?
• Or collect into single group?
• Still looking for a name...
• Somatic symptom disorders
• Functional disorders

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Making a diagnosis

• By aetiology
• Examples
• Dissociative disorders
• Somatisation disorder
• Variety of somatoform disorders
• Hypochondriacal disorder
• Body dysmorphic disorder

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Making a diagnosis

• Different aspects of the same phenomenon
• Physical symptoms not adequately explained by
  underlying physical pathology
• Umbrella terms
• Functional disorders
• Medically unexplained symptoms (MUS)
• Use this as a starting point

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Back to basicswhat is a symptom?

• A phenomenon... arising from and accompanying a
  disease.
• Oxford English Dictionary
• Disease
• Symptom

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What is a symptom?

• Perception
• Interpretation
• Symptom
• (Behaviour)

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Step 2Specialist management

• Chronic problems
• often several volumes of notes
• Referral to number of specialities
• Reasons for the problem are unclear
• Patient finds alternative explanations difficult
  to accept

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Step 2Assessment

• Aims
• Build a relationship
• Broaden the agenda
• Education
• Treatment plan
• May be a long meeting!

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Step 2Antidepressants

• Anxiety and depression have physical symptoms
• Patients often have both physical illness and
  depression
• Analgesic effect
• Helpful even in the absence of depressive
  illness
• Evidence IBS, chronic fatigue syndrome, chronic
  pain

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Step 2Psychotherapy

• Most evidence for CBT
• e.g. somatisation, CFS, IBS, non-cardiac chest
  pain, chronic pain
• What about psychodynamic therapy?
• Often more helpful in understanding than
  treatment

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Step 2Psychodynamic perspective

• Useful aetiological models
• Childhood emotional deprivation
• Lack appropriate emotional responses
• Symptoms a way of expressing emotions a
  defence against difficult feelings
• Metaphorical symptoms
• Carer / invalid relationship
• What would life be like without symptoms?

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Step 3What about more severe problems?

• Damage limitation
• Psychological understanding may not lead to an
  improvement in symptoms
• Recognise poor prognosis
• Reduce expectations of cure

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Step 3What about more severe problems?

• Facilitate communication
• Limit unnecessary investigations and appointments
• Contain consulting behaviour with regular
  appointments

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Mrs B

• 31 year old lady
• Gastroenterology outpatient
• 15 years vomiting
• Episodes of hospitalisation
• Negative investigations
• Persistent daily vomiting

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Mrs B

• Assessment
• Childhood vomiting
• Relationship problems
• Link with severity
• Current relationship difficulties
• Initial explanation

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Mrs B

• Management
• Symptom diary - meal times
• Physical / psychological link
• Dealing with difficult feelings
• Mrs Bs solution
• Cost savings?