Transcript Medically unexplained symptoms

David Protheroe, Liaison Psychiatry, LGI
October 2014
[email protected]
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What do you want to learn – in
45mins?
Social model of managing acute
illness
 Patient notices symptom
 Doctor examines and elicits signs of illness
 Doctor orders tests
 Doctor makes diagnosis
 Doctor prescribes treatment
 Patient undertakes to take the treatment
 Cure!
Symptoms in US primary care
Kroenke and Mangelsdorff, 1989
90
80
N
u
m
b
e
r
o
f
P
r
e
s
e
n
t
a
t
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n
s
70
60
50
Unexplained
Organic
40
30
20
10
0
Chest Pain
Fatigue
Dizziness
Headache
Back Pain
Dyspnoea
Abdo Pain Numbness
Prevalence of unexplained symptoms in consecutive new
attendees to medical clinics at Kings College Hospital
Clinic
Prevalence
Chest
59%
Cardiology
56%
Gastroenterology
60%
Rheumatology
58%
Neurology
49%
Dental
49%
Gynaecology
57%
Total
56%
What groups of patients are we
talking about here
 Frequent attenders with many transient symptoms
with little or no organic illness
 Single symptom:
 limb paralysis or memory loss or non epileptic attack
disorder
 Long term or short term
 Multiple syndromes:
 Headaches, migraine, IBS, fibromyalgia, chronic fatigue,
temporo-mandibular joint dysfunction, vulvodynia, etc
 Patients with mixture of organic illness and functional
symptoms
MUS: does it really matter?
 22% of all people attending primary care have sub-
threshold levels of somatisation disorders
 50+% of new attendees in medical clinics attracted a
diagnosis of unexplained symptoms
 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
 Cost to English NHS = £3bn or £14Bn to society
Do we miss organic pathology?
 Slater 1965
 Many “hysteria” patients were later diagnosed with organic
illness
 Repeated
 Roth, Trimble/Mace, Crimlisk – 2-4%
 Kooiman et al - 5 out of 284
 Stone et al – 4 out of 1030
 When should we stop investigating?
 Iatrogenic harm
ICD-10
 Somatisation Disorder
 Undifferentiated somatoform disorder
 Hypochondriasis
 Somatoform autonomic dysfunction
 Somatoform pain disorder
 Dissociative Disorder
 Conversion disorder
Other terms in use
 Somatisation
 Functional illness
 Functional Somatic Syndromes
 Medically unexplained symptoms
 Somatoform illness
 Bodily distress syndrome
 Psychogenic illnesses
 Psychosomatic illness
 Stress related illness
 Its depression
Psychosomatic Medicine, Alexander 1950
 Upper GI problems
 Comparative clinical studies conducted in the Chicago
Institute for psychoanalysis have shown that in all patients
suffering from psychogenic gastric disturbances a
predominant role is played by the repressed help seeking
dependent tendencies. A strong fixation to the early
dependent situation of infancy comes in conflict with the
adult ego resulting in hurt pride; and since this dependent
attitude is contrary to the wish for independence and selfassertion it must be pressed.
Psychosomatic Medicine, Alexander 1950
 Constipation
 The psychogenic findings in chronic constipation are typical
and constant; a pessimistic, defeatist attitude, a distrust or lack
of confidence in others, the feeling of being rejected and not
loved, are often observed in these patients. Chronically
constipated patients have a trace of both attitudes: the distrust
of paranoia and the pessimism and defeatism of melancholia.
 … in such cases psychotherapy must be directed toward a
reorientation of the total personality.
 Diarrhoea
 Financial obligations which are beyond the patient’s means is a
common factor in some forms of diarrhoea. Abraham
described the emotional correlation between bowel movement
and spending of money.
What are the difficulties in caring
for this group?
 People don’t seem to like them
 Demanding, time consuming
 Expensive
 Fear of missing an important diagnosis
 Fear of litigation
Aetiology of M.U.S
 Secondary gain or social benefits of illness
 Early trauma
 Neglect
 Sexual, physical, psychological abuse
 Modelling in childhood
 Precipitated by stressful events
 Dilemmas
 Organic illness?
 Autoimmune illnesses
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Low grade anxiety/depression
FH anxiety/depression/functional illness
Cultural component
Illness beliefs
 Family
Precipitating life
event (or
infection/trauma)
Adversity
Maintaining
factors:
Illness beliefs
Social benefits of illness
Systemic issues
Symptoms &
disability
Modelling?
20 things that clinicians say (or do)
to patients which is unhelpful
Unhelpful things that we say or do - 1
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Talk down to the patient
Monologue freezing out patient’s view
Feel defensive or uncomfortable –so patient picks it up
Dismissive attitude
Stigmatise the patient
Imply that the patient is not experiencing the pain
Appear to blame the patient because there is no
pathology
 Pass the patient to a junior doctor
 Imply it is the patient’s responsibility or they can get
themselves out of it
Unhelpful things that we say or do - 2
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Answer definitively when unsure
“There is nothing wrong with you”
“It’s just depression”
“It’s psychological”
 What do doctors mean by that?
 What do patients understand by that?
 “You have genuine pain”
 Over investigation may promote sick role and abnormal
illness behaviour
 Quickly switch the agenda from seeking pathology to
psychological explanation
Number needed to offend (Stone, 2002)
DIAGNOSIS
NNO
 All in the mind
 2
 Hysterical
 2
 Psychosomatic
 3
 Medically unexplained
 3
 Depression related
 4
 Stress related
 6
 Functional
 9
Aims of treatment
 Move from a an acute model of illness to a chronic
model of illness
 Move towards acceptance and coping
 Gain a shared understanding of the problem
 Improved self management
 Encourage patient to rebuild life with symptoms
 Contain costs
 Reduce iatrogenic harm
10 things that are true about
functional syndromes
True/useful facts about functional
syndromes - 1
 Common, well recognised
 We doctors do not always deal with these problems very well
 Humility
 Can be very unpleasant and disabling
 Will not shorten your life
 Not well understood
 “I don’t know but I don’t think any one else does either”
 It isn’t your fault
 You did not do anything to bring it on
 It may be a brain/mind problem rather than a knee problem
 May have started with an injury to your knee but although you
knee has healed your pain continues
 There is something wrong but we just cannot see it…
 May be a physiological explanation at some level
 Will not show up on scans
True/useful facts about functional
syndromes - 2
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Share physiological explanation of chronic pain,
Brain unable to filter out benign messages
If you get one or two symptoms likely to get more at some point
Can be precipitated by stress
Early life experiences may make things worse
Some syndromes may be precipitated by infections and physical
trauma
Not consciously manufactured
Some unconscious factors
Explain links to physical illness
Autoimmune, atopic illness
Can never completely eliminate all risk of pathology in anyone
even if they have no symptoms
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
What else can we do?
 Introduce the concept of functional illness early on
 Agree a shared vocabulary
 A named syndrome such as IBS or fibromyalgia helps
 Open “adult to adult” communication
 Two way inclusive dialogue
 What do you think?
 Consistent approach
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www.neurosymptoms.org
Avoid over-psychologising
Broaden rather than switch the agenda to psychological issues
Involve a family member
Use analogies
 Computer: software vs hardware
 Satellite looking down at a school
 Agree to limit unnecessary investigation or medication
 If you disagree with a patient in a letter
 Put both sides views with equal prominence
In a nutshell…
Good communication…
And finally