Medically Unexplained Symptoms

1
Medically Unexplained Symptoms

• Adrian Flynn
• Consultant Liaison Psychiatrist
• January 2013

2
Aims

• Be contentious
• Explore current practice
• Consider costs and prevalence
• Empathy
• Psychological Explanation
• New classifications / way of thinking
• General tips

3
Format

• 45 mins presentation and discussion
• 15mins trainees experience
• BREAK
• 30 mins Group discussion and feedback
• 20mins Consultation / suggestions
• 10mins Discussion / re-cap

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MUS

• Medically Unexplained Symptoms (MUS) are
  persistent bodily complaints for which adequate
  examination does not reveal sufficient
  explanatory structural or specified pathology.

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Bertrand Russell

• When one admits that nothing is certain one
  must, I think, also add that some things are more
  nearly certain than others

6
Never Have Your Dog Stuffed
7
3 Recent Referrals

• Miss P
• Ms F
• Mrs T

8
Is this familiar?

• What do you want to say to these patients?
• What would you have said to them 20years ago?
• Do you use diagnostic terms with these patients?
• How were you taught or where did you learn about
  the management of these patients?
• What guidelines do you follow?
• Do doctors manage this consistently?
• How do you feel about these patients?

9
Classification

• Somatisation Disorder
• Somatoform pain disorder
• Hypochondriasis
• Functional Somatic Syndromes
• Dissociative Disorder
• Conversion disorder
• Are you comfortable with any of these?
• Are your patients?

10
But does it really matter?

• 22 of all people attending primary care have
  sub-threshold levels of somatisation disorders
• A further 5 of individuals have clinical
  somatisation disorders
• They account for
• 8 of all prescriptions
• 25 outpatient care
• 8 inpatient bed days and
• 5 accident and attendances
• 50 more likely to attend primary care
• 33 more likely to attend acute secondary care
• 20 of MUS patients account for 62 of spend

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Signs, symptom ill-defined conditions ICD

• 6.3 in US healthcare
• 25 of new symptoms in primary care but one
  visit only
• But 10 (2.5 of total) are persistent
• More common in secondary care 40 persist

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But does it really matter?

• Clinic Prevalence (95 CI)
• Chest 59 (46-72)
• Cardiology 56 (46-67)
• Gastroenterology 60 (45-73)
• Rheumatology 58 (47-69)
• Neurology 55 (45-65)
• Dental 49 (37-61)
• Gynaecology 57 (50-68)
• Total 56 (52-60)
• Nimnuan et al 2001 J Psychosom Res

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But does it really matter?

• The NHS cost in England amounts to 3.1Bn
  (2008/9) with a further 5.2Bn attributable to
  lost productivity and 9.3Bn reduced quality of
  life Total 14Bn
• Sainsbury Centre for Mental Health - 2.8Bn
• Equates to 25M 130M per year in Cornwall
• Diabetes?
• Bermingham S, Cohen A, Hague J, Parsonage M. The
  cost of somatisation among the working-age
  population in England for the year 2008/09 Mental
  Health in Family Medicine
• No health without mental health A cross
  Government mental health outcomes strategy for
  people of all ages Supporting document The
  economic case for improving efficiency and
  quality in mental health.2010 Department of
  Health

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Scottish Neurological Symptoms Study

• N 3782 - To what extent can the patients
  symptoms be explained by organic disease?
• Not at all - 12
• Somewhat - 19
• Largely - 24
• Completely - 45

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12 Month Outcome of the 31 with MUS
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Do Medically Unexplained Symptoms Matter? Carson
et al. J Neurol Neurosurg Psychiatry
200068207210

• N 300
• Similarly categorised
• Similar levels of physical disability
• Higher total symptom count and pain in those with
  lower organicity
• Higher levels of anxiety and depression in the
  lower organicity group 70 vs 32

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Change of Diagnosis

• Completely - 0.3
• Largely - 2
• Somewhat - 0.5
• Not at all - 2
• At follow-up only 4 out of 1030 patients (0.4)
  had acquired an organic disease diagnosis that
  was unexpected at initial assessment and
  plausibly the cause of the patients original
  symptoms.

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Underlying Pathology

• Slater 1965
• Repeats Roth, Trimble/Mace, Crimlisk 2-4
• Kooiman et al - 5 out of 284
• Stone et al 4 out of 1030
• ?Negligent to continue to investigate

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Medical Generalism RCGP 2012

• Real conversations are required
• Real conversations require real empathy
• Empathy requires understanding
• Understanding needs to be conveyed
• Understanding combines
• - biomedical knowledge
• - biographical knowledge
• Conveying requires communication skills

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• Is there a way of doing things differently?

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Never Have Your Dog Stuffed
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The Development of Symptoms
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Is this familiar?

• What do we do now?
• What has changed to make this happen?
• Does that mean that outcomes have improved?
• Medical Generalism RCGP 2012

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Familiarity Breeds Contempt?

• Do we care about these patients?
• Do we like them?
• Do you collect these patients?
• Are we secretly happy when they move to a
  colleague?

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What is really going on?

• We tend to respond to people in the way we
  anticipate they will treat us
• and
• From how others relate to us, we learn how to
  relate to ourselves.
• Personal biographical history
• Reciprocal roles
• Abuse and Neglect

26
What is really going on?
Mother Caring Valuing Child Cared for Valued
Child/Self Caring Valuing Child/Self Cared
for Valued
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What is really going on?
Self Self
Other Self (Me)
Self Other

• It is our nature is to be nurtured we are born
  to relate
• We need the responsive understanding from others
  to provide meaning and to regulate our emotional
  states

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What is really going on?

• Abuse and Neglect

Critical Rejecting anger Crushed Rejected
Hopeless
Contemptuous (disgusted) Contemptible
(disgusting)
Withholding (limited) Deprived (unsatisfied)
Demanding Unreasonable Overwhelmed Inadequate
Powerful Imposing Disempowered Silenced
Bullying Bullied
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What is really going on?

• We tend to respond to people in the way we
  anticipate they will treat us
• A person enacting one pole of a RR procedure may
  either
• Convey the feelings associated with the role to
  others, in whom corresponding empathic feelings
  may be elicited (identifying) or
• Seek to elicit the reciprocating response in the
  other (reciprocating)

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(No Transcript)
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But does it really matter?

• Could we make the argument that modern medicine
  is spending 30-50 of its time, poorly managing
  the consequences of abuse and neglect?

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A ghost in the machine?

• Descartes substance lead the mind away form
  the senses
• Demertzi et al 2009 Disorders of Consciousness.
  N2100,
• 53 mind and brain are separate
• 37 mind is fundamentally physical

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A ghost in the machine?

• There is a doctrine about the nature and place of
  the mind which is prevalent among theorists, to
  which most philosophers, psychologists and
  religious teachers subscribe with minor
  reservations. Although they admit certain
  theoretical difficulties in it, they tend to
  assume that these can be overcome without serious
  modifications being made to the architecture of
  the theory.... the doctrine states that with
  the doubtful exceptions of the mentally-incompeten
  t and infants-in-arms, every human being has both
  a body and a mind. ... The body and the mind are
  ordinarily harnessed together, but after the
  death of the body the mind may continue to exist
  and function.

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New Classifications

• Higher order constructs
• Less context dependant
• Less vulnerable to change
• Current FSS etc
• Absence of biological correlates / points of
  rarity

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MUS
Hypochondriasis
Medical Illness
Depression and Anxiety
Somatoform Disorders
Functional Somatic Syndromes
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New Classifications

• Complex Somatic Symptom Disorder
• - health related anxiety
• - disproportionate concerns
• - excessive time and energy
• Bodily Distress Syndrome
• - cardiopulmonary
• - musculoskeletal
• - gastrointestinal
• - general

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What to do?

• Metabolic syndrome knowing what to expect and
  what to do about it?
• Can we make it that straightforward?

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Expect and Enquire

• CFS IBS FMA
• NEAD / dissociation
• Functional neurology
• Pelvic / Abdominal / Vertebral Pain
• Dysuria / retention symptoms
• Dysmenorrhoea
• Anxiety / depression
• Start explaining and making the links
• Avoid cure discussions / treatments

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Numbers needed to offend

• Medically unexplained
• Depression related
• All in the mind
• Stress related
• Hysterical
• Functional
• Psychosomatic

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Numbers needed to offend

• DIAGNOSIS
• All in the mind
• Hysterical
• Psychosomatic
• Medically unexplained
• Depression related
• Stress related
• Functional

• NNO
• 2
• 2
• 3
• 3
• 4
• 6
• 9

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Donts

• Tell them that there is nothing wrong.
• Normalise. They are not normal for the patient.
• Say it is all in your mind
• Only reassure repeatedly
• Tell them there is nothing you can do to help.
• Give results of normal tests and reassure and
  think that this alone will help.
• Remove gall bladder, appendix, uterus, bowel,
  teeth
• Prescribe dependence forming drugs
• Retire them on grounds of ill-health

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Dos

• Indicate that you believe the patient
• Explain how symptoms occur
• Explain what they dont have
• Explain what they do have
• Emphasise that it is common
• Emphasise that it is reversible
• Emphasise that self-help is a key part of making
  a recovery
• Involve a carer and repeat the explanations
• Be honest and use praise

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Also

• Metaphors may be useful
• Brain playing tricks
• Use written information
• Get the family on side
• Consider Anxiety / Depression
• Use anti-depressant medication
• CBT often re-framed
• Communicate and deal with the system

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Care Plan

• Improving well-being
• - relaxation / mindfullness
• - 5 a day
• - routine / pacing / structure / diary
• Managing a crisis
• - self-management / local support
• - clear plans for primary and secondary care
• Avoiding harm
• - in-built review
• - being clear that medicine can be harmful
• - dealing with the system
• - sharing information
• - dependence forming drugs

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Resources

• Diaries
• Self-management toolkit
• Boom and bust graph
• Mental Health 5 a day
• Relaxation CD
• www.mentalhealth.org.uk
• www.neurosymptoms.org
• www.nonepilepticattacks.info
• www.NEADtrust.co.uk
• www.paintoolkit.org

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London Pilot

• 227 patients from 3 practices (0.84)
• gt1M expenditure in 2 years
• 307k in GP time alone
• 1/5 had in-patient treatment - 250k
• Intervention (over one month)
• Reduced GP contacts by 1/3 (258 vs 375)
• Reduced investigations by 1/4 (54 vs 74)

47
Training GPs

• Knowledge
• Practice
• Treatment
• Services / commissioning

48
Aims

• Be contentious
• Explore current practice
• Consider costs and prevalence
• Empathy
• Psychological Explanation
• New classifications / way of thinking
• General tips

49
A Service

• Clear point of entry
• One-stop-shop Out-patients
• Liaison Psychiatry formulation
• CBT / GET
• Hypnotherapy (IBS)
• Mindfulness
• Physiotherapy / OT
• Pain / self management groups
• Managing the system

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Identify

• gt/ 10 attendances in 2 years
• gt/ 2 negative investigations in 2 years
• the symptom does not fit with known disease
  models or physiological mechanisms
• the patient is unable to give a clear and precise
  description of the symptoms
• symptoms seem excessive in comparison to the
  pathology

51
Identify

• symptoms occur in the context of a stressful
  lifestyle or stressful life events
• patient attends frequently for many different
  symptoms
• the patient seems overly anxious about the
  meaning of the symptoms and has strongly held
  beliefs about a disease process causing the
  symptoms
• patient complains of pain in multiple different
  sites

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Kroenke et al 2001
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3 Recent Referrals

• Mrs T
• Ms F
• Miss P

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The End - Culture Change?

• Is this how we will be practicing medicine with
  these patients in 10 years time?