Transcript Pilot study evaluating methods of identifying MUS among

Medically Unexplained Symptoms
Dr Rebecca Jacob
Consultant Psychiatrist
Fulbourn Hospital
Cambridge
Background
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MUS are defined as physical symptoms which are not
or insufficiently explained by somatic disease.1
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Clinically, conceptually and emotionally difficult area.
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Patients referred to in pejorative terms: ‘Frequent
fliers’,‘heard sink’ patients, ‘thick folder patients’
or ‘somatisers’.
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Clinical presentations vary: frequent attender
to GP with minor complaints versus bed
bound chronic fatigue patient
Common symptoms include chest, abdominal,
or back pain, tiredness, dizziness, headache
ankle swelling, shortness of breath, insomnia
and numbness2
Studies show that MUS are presenting
problem of 35-53% specialist medical clinics
and 10-33% in primary care clinics.3,4
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In those with MUS rates of mental and physical
dysfunction are high, disability and poor work records
common and relationships poor.6
MUS is also associated with excessive health costs
and utilisation- investigations, doctor appointments,
admissions and indirect costs such as lost working
days, carer input etc.7
One study suggests the cost to NHS is 3 billion/year.8
Classification of MUS
Divided into different but overlapping groups including:
 Functional somatic syndromes, which classically
describes Irritable bowel syndromes, Fibromyalgia
and Chronic fatigue (post viral fatigue).
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Somatoform disorders-main features is repeated
presentation of physical symptoms together with
persistent request for medical investigations, in spite
of repeated negative finding and reassurance that
the symptoms have no physical basis.
Functional somatic
syndromes
Somatoform
disorders
Medically Unexplained
symptoms
Creed et al 2011
Functional Somatic Syndromes
according to medical specialty
Medical specialty
Functional somatic
syndromes
Gastroenterology
IBS
Rheumatology
Fibromyalgia, chronic back pain
Cardiology
Non cardiac chest pain
Neurology
Non-epileptic Seizures, tension
headache
ENT
Globus syndrome
Infectious Disease
Chronic Fatigue Syndrome
Psychiatry
Somatoform disorders, conversion
Can you define:
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Somatisation Disorder
Conversion Disorder
Hypochondriasis
Factitious Disorder
Malingering
Risk Factors for MUS
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Fewer years of formal education
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Parental illness
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Lack of care in childhood
Assessment
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Why now and what is the agenda?
Assess presentation
Is there associated pathology?
Does the patient have an anxiety or
depressive disorder?
Is this some other emotional distress
presenting as physical distress
Could there be associated
pathology?
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Systematic review : 4% patients diagnosed with a
conversion disorder develop illness that could explain
presenting symptom
Follow up study of 73 patient with unexplained motor
symptoms suggest psych disorders most commonly
missed: 33 had undetected psych disorder (mainly
anxiety and depression.
Reassurance, explanation and
use of investigations
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Reassurance- deal with fears, encourage patient to
express feelings as well as history of symptoms
Explanation: encourage talk about psychosocial
problems, integrate physical and pschological i.e.
stress can make your muscles tense lead to pain,
tense chest muscles can cause chest pain etc.
Use of investigations: before ordering, explain
what a normal result means, other possible reasons
for symptoms, and what happens if test is normal
and symptoms persist.
Signs/Tests: Unexplained weakness and
Non epileptic seizures
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Hoovers sign
Videotelemetry- beware true and
‘pseudoseizures’.
Raised serum prolactin (at least double
of baseline
Risks of Iatrogenic Damage
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Over investigation and over treatment can be
damaging
Being given a dx may cause abnormal illness
behaviour
Longitudinal study those with Chronic Fatigue
termed as ‘myalgic encephalomyelitis’ had a
worse prognosis than those whose doctors
termed illness CFS.
Emotional Distress presenting
as Physical Distress?
Where there is no evidence of mental illness,
consider:
Patients model of illness
Role of predicaments – are there are dilemmas
that patient is facing where all choices have
negative consequenses?
Role of allies- people who encourage patient to
get help from medical profession, they may
need to be involved in solutions.
Management
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Non psychiatric settings, in primary care,
regular scheduled visits brief physical exam,
avoiding repeated Ix, improve outcome
Anti-depressant help- systematic reviewed of
94 RCT’s showed significant improvement
RCT’s show activity rather than rest helpful
for CF/Fibromyalgia
Psychiatric Management
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Systematic review 29 RCT’s CBT vs other Rx
(secondary care):
(1)CBT more effective for somatisation (2)physical
symptoms more responsive to treatment than
psychological.
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Psychodynamic therapy effective for chronic pain
and IBS.
Referral to Psychiatrist?
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Reasonable in patients not improving with
structured explanation, graded activity and a
trail of antidepressants.
Beware interpretation by patient ‘the doctor
thinks I’m making this up’
Be honest- not able to find a cure but we
need to find a way for your to learn to live
with these symptoms.
Prognosis
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Few robust studies, but literature suggests
one quarter of patients in primary care
continue to have symptoms after 12 months
Secondary care a study of people presenting
to neurologists-58% continued to have
unexplained symptoms 12 years later.
References
1. Fink P, Toft T et al .Symptoms and syndromes of bodily distress:
An exploratory study of 978 internal medical, neurological, and
primary care patients. Psychosomatic medicine 2007; 69:30-9
2. Nimnuan C, Hotopf M et al. Medically unexplained symptoms:
how often and why are they missed? QJM Monthly Journal of
the Associations of Physicians 2000;93
3. Mangwana S, Burlinsons S et al. medically unexplained
symptoms presenting at secondary care. International Journal
of psychiatry in Medicine 2009;39:33-40
4. Peveler R, Kilkenny L et al. Medically unexplained physical
symptoms in primary care. Journal of Psychosomatic Research
1997; 42: 245-52
5. Wessely S, Nimnuan C et al. Function somatic syndromes: one
or many? Lancet 1999; 354:93609
6. Dirkzwager A & Verhaak P (2007) Patients with persistent medically
unexplained symptoms in general practice: characteristics and quality
of care. BMC Family Practice, 8:33
7. Dwamena F, Lyles J, Frankel R & Smith R (2009) In their own words:
qualitative study of high-utilising primary care patients with medically
unexplained symptoms. BMC Family Practice, 10
8.Bermingham S, Cohen A, Hague J & Parsonage M (2010) The cost of
somatisation among the working-age population in England for the
year 2008-2009. Mental Health in Family Medicine, 7, 71-84
9. Hatcher S, Arrol B (2008) Assessment and management of MUS. BMJ
336;335-1124.
10.Carson AJ et al (2003). Outcome of neurology outpatient with MUS. J
Neurol Neurosourg Psychiatry;74; 884
11. Henningzen S eta l (2007). Management of functional somatic
syndromes. Lancet ;369: 946-55