Transcript Medically Unexplained Symptoms

Medically Unexplained Symptoms
Mark Feldman, MD
July 5, 2006
Case 1
• 36 year old woman presented with atypical facial pain admitted
to Teaching Service. Physical examination was normal.
• Past history: depression, anxiety and Mollaret’s meningitis.
• Meds: Trazodone, venlafaxine, chlorazepate; valacyclovir
• Started on gabapentin (Neurontin) with no pain relief.
• Switched to carbamazepine (Tegretol) with no pain relief.
• A few weeks later, she developed a severe generalized pruritic
maculopapular rash, “granulomatous” hepatitis, and
eosinophilia (35%), treated with prednisone and hydroxyzine.
She then developed CNS vasculitis with multiple strokes
(carbamazepine hypersensitivity syndrome [CHS] with CNS
vasculitis).
Case 2
• 53 year old woman referred for chronic upper and lower
abdominal pain and constipation.
• Past history of anxiety, depression, stress, perineal pain, fibromyalgia, nonulcer dyspepsia, and hysterectomy/oophorectomy.
• Recent flare of pain led to laparoscopic appendectomy, with no
pain relief (and no abnormality of the appendix on path exam).
• Common bile duct was slightly dilated (10 mm) on ultrasound
[history of cholecystectomy 20 years ago for upper abdominal
pain]. GI was consulted and an ERCP was attempted,
complicated by acute pancreatitis requiring hospitalization.
• Physical exam and lab studies at this time were normal.
• Abdominal pain and constipation improved with the 5-HT4
agonist tegaserod (Zelnorm). Her dyspepsia did not improve
and was treated with a PPI with minimal relief. She is being
seen by at least 3 gastroenterologists currently.
Case 3
• 22 year old woman (daughter of a physician) referred because
of flushing, abdominal cramps, and loose stools after eating.
She is unable to attend school or work due to her GI symptoms.
– Negative or normal: colonoscopy X2; stool fat; urine 5-HIAA, sprue
panel, EGD, CT, octreoscan, EUS, etc.
• Past medical history of obesity, “PCOS” [with normal ovarian
sonogram], asthma, multiple food sensitivities/allergies, chronic
headaches, myalgia and arthralgia compatible with FM, multiple
knee surgeries, possible Sjögren’s syndrome. Taking 23
medications from numerous specialists such as an
allergist/pulmonologist and endocrinologist, including
prednisone and octreotide.
• Exam (with parents present): morbidly obese and Cushingoid
with buffalo hump and hundreds of red and purple striae, but
otherwise well-appearing. Exam was otherwise normal and
laboratory studies were all normal.
Summary of Cases
Demographics
Symptoms
Complication
Case 1
36 year old
woman
Atypical facial
pain
CHS,
strokes
Case 2
53 year old
woman
Case 3
23 year old
woman
Upper/lower
ERCPabdominal
induced
pain
pancreatitis
Abdominal
Cushing’s
pain, flushing, syndrome
loose stools
Working definitions
• Symptom: a patient’s subjective experience of a
change in his/her body
• Disease: an objective, observable abnormality in
the body
When we can find no objective change to
explain the patient’s subjective experience, we
term the symptoms “medically unexplained” or
“functional”.
Synonyms for today’s topic
• Medically unexplained symptoms
• Somatization
• Somatoform disorder
• Functional Somatic Syndromes
Functional somatic syndromes,
classified by subspecialty *
Gastroenterology:
Gynecology:
Rheumatology:
Cardiology:
Infectious Disease:
Neurology:
Dentistry:
ENT:
Allergy:
IBS, nonulcer dyspepsia
PMS, chronic pelvic pain
Fibromyalgia
Atypical or non-cardiac CP
Chronic fatigue syndrome (CFS)
Tension headache
TMJ syndrome / atypical facial pain
Globus syndrome
Multiple chemical sensitivity
* Adapted from Wessely S, Nimnuan C, Sharpe M. Lancet 354: 936-9, 1999
Characteristics of the various
Functional Somatic Syndromes
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They are extremely common.
They are frequently persistent (i.e., chronic).
Conventional medical therapy is fairly ineffective.
They are associated with:
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Considerable distress (IBS > IBD in inpatients)
Considerable disability (CFS > CHF in outpatients)
Unnecessary expenditures of medical revenues
Unnecessary exposure to medical risks
• Case 1. Anticonvulsant drugs
• Case 2. ERCP
• Case 3. Glucocorticoids
Frequency of Functional
Somatic Syndromes
• Primary care consultations (UK):
20%
• New referral as medical outpatients (UK): 35%
• Medical outpatient visits (Denmark):
25%
Functional Somatic Syndromes:
One or Many ?
Potential Splitters:
Potential Lumpers:
Specialists
Specialty Societies
Support/Help Groups
Primary care providers
Epidemiologists
Researchers
Mental health
professionals
Enlightened specialists
local chapters
Internet sites
Researchers
A case for Lumping
Argument 1
There is a great deal of overlap in case definitions
of specific syndromes.
Of 12 “specific” syndromes analyzed by Wessely
et al, the definition of the syndrome included:
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Bloating/feeling of abdominal distention in 8
Headache in 8
Fatigue in 6
Abdominal pain features in 6
Fibromylagia (Arthritis Foundation)
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Pain (“tender points”)
Fatigue
Sleep disturbances
Depression
Anxiety
Brain fog (“fibro fog”)
Migraine headaches
• Abdominal pain,
bloating, alternating
diarrhea and
constipation (IBS)
• TMJ disorder
• Skin color changes
• Tingling limbs
• Restless legs
syndrome
Chronic fatigue syndrome (CDC)
Primary Symptoms (n=8):
– Cognitive dysfunction
– Post-exertion malaise
after physical or mental exertion
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Unrefreshing sleep
Joint pain
Persistent muscle pain
New headaches
Tender cervical/axillary
lymph nodes
– Sore throat
Other common symptoms:
Irritable bowel syndrome
Abdominal pain, diarrhea
Nausea, bloating
Chills and night sweats
Brain fog
Chest pain
Shortness of breath/chronic cough
Multiple food/chemical
allergies/sensitivities
Psychological problems
Depression, anxiety, mood swings,
irritability
Jaw (facial) pain
Weight loss or gain
Multiple Chemical Sensitivity
Syndrome. Common Symptoms
• Fatigue
• Difficulty
concentrating
• Depressed mood
• Memory loss
• Weakness
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•
•
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Headaches
Heat intolerance
Arthralgia
Numerous GI
symptoms
• Respiratory/mucosal
irritation
Magill and Suruda. American Family Physician, Sept. 1, 1996.
A case for Lumping
Argument 2
Patients with one functional syndrome
frequently meet diagnostic criteria for other
syndromes (if queried!). Wessely et al:
– CFS: linked to/overlaps with FM, tension headache,
multiple chemical sensitivity, food allergy, PMS, and
IBS.
– IBS: linked to NUD, CFS, hyperventilation, FM,
tension headache, atypical facial pain, non-cardiac
CP, chronic pelvic pain. and PMS.
A case for Lumping
Argument 3
Patients with “different” symptoms (functional syndromes) share
non-symptom features:
– Gender: female predominance of non-gynecologic FSSs, such as IBS,
CFS, TMJ dysfunction, atypical facial pain, globus syndrome, tension
headaches.
– Association of FFSs with emotional disorders: correlated with current and
past anxiety and depression. Examples: IBS, multiple chemical
sensitivity, CFS
– Pathophysiology: Little known, but FSSs may share a common
pathophysiology (altered functioning of the CNS) rather than be caused
by disorders in specific organ systems
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IBS: Colon  CNS
NUD/Bloating: Stomach  CNS
FM and CFS: Muscle  CNS
Facial pain: TMJ, etc.  CNS
}
? Role of 5-HT
neurons
A case for Lumping
Argument 3, cont’d
– History of childhood mistreatment and/or abuse, especially sexual abuse:
pelvic pain, PMS, IBS, tension headache, FM, CFS
– Difficulties in the doctor-patient relationship:
• Unsatisfactory for the doctor
• Unsatisfactory for the patient
– headache, non-cardiac chest pain, FM, CFS
A case for Lumping
Argument 4
All functional syndromes respond to similar therapies.
• General approaches:
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Take patients’ complaints seriously.
Explain the physiology of the symptoms.
Limit investigations.
Emphasize rehabilitation at the expense of cure.
• Antidepressant drugs (tricyclic, SSRI: off label):
• Accepted for PMS, atypical facial pain, non-cardiac chest pain
• Role in FM, CFS, and IBS less clear, but evolving
• Psychological therapies (e.g., cognitive behavioral therapy):
• Effective in CFS, PMS, IBS, and in nearly all pain syndromes
Rome III. Psychosocial aspects of
the functional GI disorders.
Levy et al. Gastroenterology 130: 1447-58, 2006.
The committee reached consensus in finding
considerable evidence supporting the association
between psychological distress, childhood trauma
and recent environmental stress, and several of the
FGIDs but noted that this association is not specific
to FGIDs.
… there is now increasing evidence that a number of
psychological treatments and antidepressants are
helpful in reducing symptoms and other
consequences of the FGIDs in children and adults.
Multiple Chemical Sensitivity
(MCS) Syndrome
Several theories have been advanced to explain the cause of MCS,
including allergy, toxic effects and neurobiologic sensitization. There
is insufficient scientific evidence to confirm a relationship between
any of these possible causes and symptoms.
Patients with MCS have high rates of depression, anxiety and
somatoform disorders, but it is unclear if a causal relationship or
merely an association exists between MCS and psychiatric
problems. Physicians should compassionately evaluate and care for
patients who have this distressing condition, while avoiding the use
of unproven, expensive or potentially harmful tests and treatments.
The first goal of management is to establish an effective physicianpatient relationship. The patient's efforts to return to work and to a
normal social life should be encouraged and supported.
Magill and Suruda. Amer Fam Physician, September, 1998
Functional Somatic Syndromes:
New or Old Concept ?
• Psychosomatic Syndromes
• Psychosomatic Affections
• Multiple Visceral Neuroses
• Syndrome Shift
Implications
• For sub-specialists:
– Elicit symptoms outside of your area of specialty (look at the big
picture)
– Ask about childhood/sexual abuse
– Minimize excessive testing if symptoms fit a functional disorder
– Consider more general and safer therapies
• For primary care physicians:
– Look at the company your patient’s symptoms keep
– Minimize referrals to sub-specialists if patient has evidence of
multiple functional somatic syndromes
– Seek co-existing anxiety and/or depression and treat accordingly
– Ask about childhood/sexual abuse
– Be willing to consider off-label antidepressants for symptoms
– Be prepared to refer difficult/refractory cases to a mental health
professional