Transcript Adrian`s Powerpoint presentation here

Medically Unexplained
Symptoms
Adrian Flynn
Consultant Liaison Psychiatrist
January 2013
Aims
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Be contentious
Explore current practice
Consider costs and prevalence
Empathy
Psychological Explanation
New classifications / way of thinking
General tips
Format
 45 mins presentation and discussion
 15mins trainee’s experience
BREAK
 30 mins Group discussion and feedback
 20mins Consultation / suggestions
 10mins Discussion / re-cap
MUS
 Medically Unexplained Symptoms
(MUS) are persistent bodily
complaints for which adequate
examination does not reveal sufficient
explanatory structural or specified
pathology.
Never Have Your Dog Stuffed
3 Recent Referrals
 Miss P
 Ms F
 Mrs T
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?
Classification
 Somatisation Disorder
 Somatoform pain disorder
 Hypochondriasis
 Functional Somatic Syndromes
 Dissociative Disorder
 Conversion disorder
 Are you comfortable with any of these?
 Are your patients?
But does it really matter?
 22% of all people attending primary care have subthreshold 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
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
But does it really matter?
 Clinic Prevalence (95% CI)
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Chest
Cardiology
Gastroenterology
Rheumatology
Neurology
Dental
Gynaecology
 Total
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59%
56%
60%
58%
55%
49%
57%
(46-72)
(46-67)
(45-73)
(47-69)
(45-65)
(37-61)
(50-68)
56% (52-60)
Nimnuan et al 2001 J Psychosom Res
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?
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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
Scottish Neurological Symptoms
Study
 N = 3782 - ‘To what extent can the
patients symptoms be explained by
organic disease?’
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Not at all Somewhat Largely
Completely -
12%
19%
- 24%
45%
12 Month Outcome of the 31% with
MUS
60%
50%
40%
30%
3 months
12months
20%
10%
0%
Much
better
Just the
same
Much
Worse
Do Medically Unexplained Symptoms Matter?
Carson et al. J Neurol Neurosurg Psychiatry 2000;68:207–210
 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%
Change of Diagnosis
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Completely
Largely
Somewhat
Not at all
-
0.3%
2%
0.5%
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.
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
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?
Never Have Your Dog Stuffed
The Development of Symptoms
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
What is really going on?
Mother
Caring
Valuing
Child
Cared for
Valued
Child/Self
Caring
Valuing
Child/Self
Cared for
Valued
What is really going on?
 Abuse and Neglect
Withholding
(limited)
Contemptuous
(disgusted)
Deprived
(unsatisfied)
Contemptible
(disgusting)
Demanding
Unreasonable
Overwhelmed
Inadequate
Critical
Rejecting
anger
Crushed
Rejected
Hopeless
Powerful
Imposing
Bullying
Disempowered
Silenced
Bullied
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:
1. Convey the feelings associated with the role
to others, in whom corresponding empathic
feelings may be elicited (identifying) or
2. Seek to elicit the reciprocating response in
the other’ (reciprocating)
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?
‘A ghost in the machine?’
 Descartes –
‘substance’ ‘lead the
mind away form the
senses’
 Demertzi et al 2009
Disorders of
Consciousness.
N=2100,
 53% mind and brain
are separate
 37% mind is
fundamentally physical
‘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-incompetent 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.
New Classifications
 Higher order constructs
 Less context dependant
 Less vulnerable to change
 Current FSS etc…
 Absence of biological correlates /
points of rarity
MUS
Hypochondriasis
Medical Illness
Depression and
Anxiety
Somatoform
Disorders
Functional
Somatic
Syndromes
text
New Classifications
 Complex Somatic Symptom Disorder
- health related anxiety
- disproportionate concerns
- excessive time and energy
 Bodily Distress Syndrome
- cardiopulmonary
- musculoskeletal
- gastrointestinal
- general
What to do?
 Metabolic syndrome – knowing what
to expect and what to do about it?
 Can we make it that straightforward?
Expect and Enquire
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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
Numbers needed to offend
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Medically unexplained
Depression related
All in the mind
Stress related
Hysterical
Functional
Psychosomatic
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
Don’ts
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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Do’s
 Indicate that you believe the patient
 Explain how symptoms occur
 Explain what they don’t 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
Also
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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
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
Resources
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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
London Pilot
 227 patients from 3 practices (0.84%)
 >£1M 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)
Training GPs
 Knowledge
 Practice
 Treatment
 Services / commissioning
Aims







Be contentious
Explore current practice
Consider costs and prevalence
Empathy
Psychological Explanation
New classifications / way of thinking
General tips
A Service
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


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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
Identify
 >/= 10 attendances in 2 years
 >/= 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
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
The End - Culture Change?
 Is this how we will
be practicing
medicine with these
patients in 10 years
time?