Transcript The Patient with Medically Unexplained Symptomsx

THE PATIENT WITH
MEDICALLY UNEXPLAINED
SYMPTOMS
Prof. Trudie Chalder
Dr. Rina Dutta
Different terms for medically unexplained symptoms
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Medically unexplained symptoms (MUS) / Medically unexplained physical symptoms
(MUPS) (symptoms not explained by the medical model)
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Functional (e.g. “functional dyspepsia”; affecting physiological or psychological
functions but not due to structural / physical / chemical disorder)
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Idiopathic (e.g. idiopathic chest pain – means ‘unknown cause’)
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Somatisation (usually implies physical symptoms are expression of emotional distress)
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DSM-IV somatoform disorders (criticised for containing mixture of relatively specific
categories such as somatisation disorder and hypochondriasis, and vague non-specific
categories such as undifferentiated somatoform disorder)
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Miscellaneous specific terms (e.g. irritable bowel syndrome (IBS), chronic fatigue
syndrome (CFS)
Which clinics see patients with MUS?
Gastroenterology:
Rheumatology:
Infectious diseases:
Neurology:
Hand surgery:
Dental:
Cardiology:
Gynaecology:
Urology:
Irritable bowel syndrome
Fibromyalgia
Chronic fatigue syndrome
Headache/Non-epileptic seizures
Repetitive strain injury
Atypical facial pain
Non-cardiac chest pain
Chronic pelvic pain
Irritable bladder syndrome
What is the prevalence of MUS in medical
clinics (Nimnuan et al., 2001)
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)
What is Chronic Fatigue Syndrome:
Oxford Criteria (Sharpe et al., 1991)
• Fatigue is the principal symptom. Fatigue is severe, disabling, and affects
physical & mental functioning
• Definite onset that is not lifelong
• Fatigue has been present for a minimum of 6 months, during which time it
has been present for more than 50% of the time
• Other symptoms may be present, particularly myalgia, mood, and sleep
disturbance
• Exclusion criteria include presence of medical conditions that produce chronic
fatigue & certain psychiatric disorders (substance abuse, eating disorders,
organic brain disease)
Chronic Fatigue Syndrome (“ME”)
• More common in women than men
• Prevalence estimates vary widely.
o Can be difficult to differentiate CFS from depressive
& anxiety disorders. Estimates that do not exclude
those diagnoses are much higher than those that
do.
o Depends on criteria used.
o Prevalence in adults perhaps 0.3-1.0%.
• 50%+ have psychiatric disorders, especially depression
Diagnosis
• IBS is a clinical diagnosis
• A symptom complex for which no organic
cause has been found
• No physical test by which to identify the
syndrome
• Identified by symptoms
• Usually ESR and full blood count exclude
other diagnoses
Irritable bowel syndrome:
Rome II criteria
•
At least 12 weeks (not necessarily consecutive), in the preceding 12 months
of abdominal discomfort or pain that has 2 out of 3 features:
1) Relieved with defecation; and/or
2) Onset associated with a change in frequency of
stool; and/or
3) Onset associated with a change in form
(appearance) of stool.
Other symptoms that are not essential but support the diagnosis of IBS:
• Abnormal stool frequency (greater than 3 bowel movements/day or less
than 3 bowel movements/week);
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Abnormal stool form (lumpy/hard or loose/watery stool);
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Abnormal stool passage (straining, urgency, or feeling of incomplete
evacuation);
Passage of mucus;
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Bloating or feeling of abdominal distension.
Irritable Bowel Syndrome (IBS)
• Symptoms that might indicate another disorder and
hence further investigation necessary include; rectal
bleeding, unintended weight loss, frequent awakening
by symptoms, fever, anaemia.
• Very common, 9-12% of population (up to 30% have
some features), small minority get disability
• More common in women than men
• In gastroenterology clinics about 40-60% have
psychiatric disorders, mainly anxiety & depression
Evidence from RCTs: CFS
• CBT generally found to be significantly better than standard medical care /
group psychoeducation / pacing
(e.g. Sharpe et al., 1996; Deale et al., 1997; Prins et al., 2001; White et al 2011)
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Graded exercise therapy (e.g. Fulcher & White, 1997; Powell et al., 2001;
White et al 2011)
Treatments with little or no supportive evidence include:
- Antidepressants; Nutritional supplements
- Extended rest; Complementary / alternative therapies
Evidence from RCTs: IBS
•
CBT:
- More effective than control conditions
(Greene & Blanchard, 1994; Dulmen et al. 1996)
[although Boyce et al. (2003) found no diffs between
CBT & relaxation training & routine medical care]
- Group CBT is superior to psycho-education or usual
medical care (Toner et al., 1998)
- CBT in combination with antispasmodic drugs is
superior to drugs alone (Kennedy et al., 2005).
More evidence from RCTs: IBS
•Hypnotherapy (e.g. Whorwell et al., 1984) and
psychodynamic interpersonal therapy (Guthrie et al.,
1993; Creed et al. 2003) effective in reducing symptoms /
↑ quality of life in secondary care.
• Antidepressants – most effective drugs for treating IBS;
modify gut motility and alter visceral nerve responses,
reduce pain.
•Antispasmodics (e.g. mebeverine hydochloride) are
associated with improvement in symptoms for some
people.
Engagement
• Be empathic
• Explicitly convey belief in reality of physical
symptoms; doesn’t mean ‘all in the mind’
• Shift focus from “cause” to “symptom
management”
• Avoid physical versus psychological discussions
• Use physical illness analogies to illustrate
approach
• Reinforce any helpful responses patient is
already using
• Elicit concerns and expectations
Presenting CBT approach
Assumes multiple contributory factors
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Predisposing factors
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Precipitating events or triggers
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Maintaining factors
(Physiological, behavioural, cognitive, emotional, social)
Use information from assessment to develop individualised model of the
different contributory factors
Modifying predisposing & maintaining factors can help to:
- reduce symptoms and impairment
- decrease risk of future relapse
CBT for unexplained symptoms: Basic components
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Guided by individual conceptualisation
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Rationale for every aspect of treatment
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Expanding understanding of contributory factors
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Physiological explanations where possible
• Begin with behaviour change
• Cognitive work on unhelpful thinking patterns &
underlying beliefs
• Normalising and acceptance of symptoms
• Pain does not necessarily mean damage / harm
• Work on other psychological issues if necessary
(e.g. low self-esteem, lack of assertiveness).
• Be aware how underlying beliefs may affect
therapy
• Recovery defined in terms of concrete behaviour,
not necessarily symptom free or returning to
previous lifestyle
• Relapse prevention
Other aspects of treatment
• Close liaison with all practitioners (party line)
• Deal with reassurance seeking (provide rationale
/ liaise with those providing reassurance)
• Suspend further investigations or agreeing a
compromise
• Rationalise medication
• Reduce drugs with adverse side effects
Components specific to fatigue
• Establishment of consistent baseline
activity level
- Use activity diaries at beginning of
treatment
• Balance between activity and rest
• Identify activity targets (exercise, social,
work-related, leisure)
•Break down targets into specific manageable
steps
•Increase activity level if managed at least
75% of time over past fortnight
•Don’t increase exercise time more than
about 10% at a time
•Address high action proneness
Sleep Management Programme
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Sleep diaries for assessment
Set getting-up time
No sleeping in the day-time
Stay in bed only for amount of time sleep for
(e.g. if patient usually sleeps 8 hours in total,
don’t go to bed at 10pm & get up at 8am)
• If sleeping excessively, gradually reduce
• Sleep hygiene
- Check caffeine, use bedroom for sleep only,
wind down before bedtime, make sleep
environment comfortable etc.
• Address unhelpful beliefs about sleep
Example of initial activity programme for underactive person with CFS
Someone who is resting for 6 hours a day:
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Get up at 8 a.m.
• Housework for 15 mins twice a day
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Paperwork or other chores for 15 mins twice a day
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Read for ten minutes a day
• Email for ten minutes a day
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Two 10-minute walks each day
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Rest for six 1-hour periods, spaced through day
• Talk to friends on phone for 10 mins, every other day
Presenting the model with a Case Study
• Sally: 30-year old woman with a 3-year history of severe
fatigue, concentration / memory difficulties, muscle and
joint pain.
• Believes that a virus was the cause of her problems as
has never been well since she had a bout of
gastroenteritis three years ago. At that time there were
also stresses at work and her relationship with her
partner was breaking down.
• Unable to walk for more than about ten minutes
without becoming extremely fatigued and experiencing
more muscle pain.
• Reduced from full-time to part-time work because of
her symptoms.
• Goes to bed at 9pm and gets up at 7.30am. Often has trouble getting to
sleep or staying asleep. Quite often sleeps in the daytime.
• Limited social life - it is fatiguing to be with people or staying out late.
• Lives with her mother who does most of the housework and shopping.
• Believes that her mood has become low because her quality of life has
decreased. Is sure that depression is not the cause of her problems and
is fed up with doctors assuming that she is simply depressed.
• Reluctant to see a psychologist but is offered no alternatives.
DISCUSSION
Components specific to IBS
• Familiarise self with anatomy & functioning of the
digestive system
• Education about bowel functioning to challenge
misconceptions such as:
• “I should have a bowel movement every day”
• Everyone’s bowel habits are different; normal bowel
movements may occur as often as three times a day to
as few as three a week.
• IBS is a problem with how the digestive system
functions but is not a disease
Brain-gut connection
• Bowel is a segmented tube
• Food is propelled down by the sequential squeezing of each
segment.
• Nerves from the brain control this motion.
• If the nervous control is disrupted, problems with this movement
can result.
• Stress and other psychological factors cause bowel symptoms by
affecting this nervous control.
Stress and intestinal functioning
• Effects that stress can have (general population):
- Spasms in muscles in gut wall, resulting in pockets of high
pressure, gas or painful contractions
- Decreased gastric emptying and accelerated colonic transit.
• Results in symptoms such as cramps, diarrhoea etc.
• These gut responses to stress are enhanced in IBS patients.
• IBS patients report greater pain response to distension of the
bowel (e.g. in experiments with inflatable balloon)
• Any intervention that helps the person to manage stress more
effectively is likely to help
Components specific to IBS (con)
• Avoiding foods can:
- result in increased sensitivity &
- make it more difficult to get nutritionally balanced diet
• Re-introduce avoided foods
• Address other safety-seeking behaviours around bowel
functioning (e.g. not eating for long periods of time
before an important event)
assess carefully, there may be many!
PATIENTS LOG BOOK
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Establish healthy bowel routine
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Healthy, varied diet (not too much of one food)
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Eat regularly; chew food slowly and thoroughly
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Drink 6-8 cups of water daily
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Maintain a regular program of physical exercise and activity
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Avoid delaying the urge to have a bowel movement
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Avoid straining / forcing
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Dealing with pain (e.g. accepting, not trying to suppress or
focussing on pain excessively)
Behavioural experiments – examples of beliefs to target
• Beliefs about needing to avoid
particular foods, places to eat
• Beliefs about needing to avoid
particular activities that use up energy
or result in increase in symptoms
• Perfectionism
Stepped Care
• Self help materials
• IAPT
• Primary care
• Specialist care – CBT
Key Assessment Tools
Questionnaires for use in CFS: examples
• Chalder Fatigue Scale (Chalder et al., 1993)
• Work and Social Adjustment Scale (Mundt et al.,
2002)
• Beliefs about emotions scale (Rimes & Chalder
2009)
• SF-36; Physical functioning subscale (Ware &
Sherbourne, 1992).
• Measures of anxiety & depression e.g. Hospital
Anxiety & Depression Scale (Zigmond & Snaith,
1983)
Questionnaires for use in IBS: examples
• IBS Symptom Severity Scale (Francis et
al., 1997)
• Behavioural Scale for IBS (Reme et al
2010)
• Work and Social Adjustment Scale
(Mundt et al., 2002)
• Measures of anxiety and depression
(HAD)
The CBT model of MUS
Deary V, Chalder T & Sharpe M. (2007)
One of the Resources for Self-Study on Moodle
Key Points
• Assessment
• Treatment
• Evidence
• Where to refer
It’s good to talk
CBT style of course!