Transcript 20090321_MUS_rural_MD_2003

Approach to Patients with
Medically Unexplained
Symptoms / Illnesses
Jeffrey P Schaefer MSc MD FRCPC
Rural Physician Video Conference Program
March 31, 2009
website
dr.schaeferville.com
Conflicts of Interest
• none
Objectives
Medically Unexplained Symptoms
• Session participants shall:
– be able to define MUS
– know that MUS are common
– have considered psychobiological framework
– become aware of management strategies
Case
• 42 yr old female administrator
total body pain and extreme fatigue x 5 years
previously assessed by GIM, Neurology, Gastroenterology
investigations  normal
What is the probability that you will find a
condition that risks loss of life or limb?
0%
50%
100%
What are your feelings at this point?
Negative
-10
Neutral
0
Positive
+10
Problem List
– daily occipitofrontal headache
• CT – negative  amitriptyline
– chest pain, episodic, at work
• EST / echo - negative
– abdominal pain
• GI assess / colonoscopy / endoscopy / CT – negative
– dysuria with ‘blood in the urine’
• U/A usually normal / low CFU but no blood
– fatigue
• CBC, lytes, renal, ESR, ANA, ferritin, TSH, ECG, CXR - normal
– poor concentration & dizziness
• neurology consult  no disease
– work issues
• disability questionnaire anticipated
• PMH
– cholecystectomy for abdo pain 7 years ago (pain returned)
• Meds
– citalopram 20 mg po od
– amitriptyline 25 mg po qhs
– gabapentin 400 mg tid
– fentanyl disk 50 ug/hr
– Tylenol #4 tablets, 2 po qid, prn
– lorazepam 2 mg po qhs
– pantoloc 40 mg po od
– multivitamin
• Family History
– two teenage children
• Psycho-social
– ‘perfectionist traits’, not much social contact anymore, supportive
husband, non-smoker, no alcohol or street drugs
• Examination
– normal except tender to palpation in all areas examined
• Investigations within last 2 years – all NORMAL
– CBC and SPE
– electrolytes, calcium, mg, phos, creatinine
– liver enzymes, albumin, INR
– glucose, TSH, and she has regular menstrual cycles
– ESR, ANA
– urinalysis
– ECG and echo
– CXR
– CT head
– Colonoscopy / Gastroscopy / CT Abdomen and Pelvis
What is the probability that you will find a
condition that risks loss of life or limb?
0%
50%
100%
What’s your diagnosis?
Diagnosis: ______________________
Diagnosis Menu
• What’s your diagnosis / diagnoses?
–
–
–
–
–
–
–
–
–
–
Chronic Fatigue Syndrome / Idiopathic Chronic Fatigue
Fibromyalgia
Tension Headache
Irritable Bowel Syndrome
Multiple Chemical Sensitivity Syndrome
Interstitial Cystitis
Hematuria Loin-pain Syndrome
Depression and Anxiety
Conversion Disorder
Somatization
Medically Unexplained Symptoms
• Physical symptoms that prompt the
sufferer to seek health care but remain
unexplained after an appropriate medical
evaluation.
Medically Unexplained Symptoms
Physical symptoms that prompt the sufferer to
seek health care but remain unexplained
after an appropriate medical evaluation.
Headache
Chest Pain
Irritable Bowel
Infertility
Fibromyalgia
Chronic Fatigue
Dizziness
Are Medically Unexplained
Symptoms Common?
MUS Prevalence
• 30% of primary care visits
• 13.6 visits in the previous year
Psychosomatic Med 2005;67:123-9
Most Frequent
Visitors 5th percentile
GI……………. 54%
Neuro…….. 50%
Rheum……. 33%
ENT………….27%
GIM………… 10%
If only… ‘an actual email’
• Dear Dr. Schaefer,
• This is great! I'm much relieved and grateful
for your care. Thank you THANK YOU!
• Michelle
This is a problem!
This is a big problem!
Unhappiness is…
• Patients Feel Unheard
– physician centered approach
• 69% of MD’s interrupt at 18 sec into the interview
• Ann Int Med 1984:101
– MD patient incongruence
• longer the patient talks  more likely to prescribe
• Psychosomatic Med 2007;69:571-7
– Why reassurance fails?
• PLOS Medicine 2006
P(Disease)
MUS
Depressed
Controls
15%
10%
5%
25
One condition or many?
Chronic Fatigue Syndrome
Fibromyalgia
Irritable Bowel Syndrome
Multiple Chem Sensitivity Syndrome
Sick Building Syndrome
Hypoglycemia
War Syndrome
BodilyGulf
Distress
Disorder
Undocumented Labels
Headache Syndromes
Asthma
Painful Conditions
Various
• Do functional symptoms cluster in a way
that support multiple conditions?
– Cross sectional survey of patients with
functional symptoms
– Screened 2,300 patients  978 were judged
functional
Median Number of Symptoms
Men  4
Women  6
Men & Women  5
“Bodily Distress Disorder”
Fink et al. Psychosom Med 2007
Chest Pain Group
GI Symptoms Group
Musculoskeletal Group
< 3% of patients had symptoms
confined to their predominant group
3 group model explained 36% of the variance
• associated with anxiety
• preoccupied with symptoms
• preoccupied with illness
• low threshold to request consultation
• difficult / impossible to reassure
Multiplicity of diagnostic
labels is an artifact of
medical specialization.
Psychobiology
‘the mind-body connection’
Psychobiological Framework
Mind Body Connection: neural and hormonal
Left: Areas of the brain that
‘light-up’ during strong emotion.
These correlate to Vagus Nerve
mediated Heart Rate Variability.
Below: HPA axis
Acute Stress and MI
• Mortality in Widowers
– 40% increase within 6 mo of spouses death
• Myocardial Infarction Onset Study
– incidence of AMI 14X among recent widows /
widowers
Self-report AMI Trigger
412 reports from 849 AMI
Chronic Stress & Immune Dysfunction
• Influenza Vaccination
• Difference between
stressed and nonstressed group.
– Lancet 1999
Stress and Wound Healing
Punch Biopsies
• 13 Care Givers vs 13 Controls
• Complete wound healing
–
–
Caregivers 48.7 vs 39.3 days (9 day diff)
Age and income did not effect outcome
So now what?
Several Approaches…
The Approach…
• Exclude bio-medical disease
–neoplasm
–infection
–auto-immune
–metabolic
The Approach…
• Exclude bio-medical disease
– Adrenal Insufficiency
– Hemochromatosis
– Hypercalcemia
– Amytrophic Lateral Sclerosis
– Multiple Sclerosis
– Alcoholism
– Temporal arteritis
– Subacute bacterial endocarditis
– Sleep Apnea
Assess the impact of known conditions
• Conditions Underestimated (e.g.)
– Chronic Cardiac Disease
– Chronic Respiratory Disease
– Chronic Sinusitis
– Recurrent genital herpes
– Diabetes mellitus
– Obesity
– Osteoarthritis
– Medication Effect
– Physical deconditioning
• RCT: n = 200
• OR  1.92 (95%CI 1.08 – 3.4)
• NNT to improve @ 12 months = 6.4
Smith’s Treatment Model
Cognitive – Behavioural Model
• Establish an information base & motivate
• Obtain patient commitment
– be clear about risk of somatic intervention
– stop addicting medications & alcohol
– start lifestyle interventions
• Negotiate a specific plan
– follow-up
– lifestyle
Key Components
50
Interpersonal Therapy
Scott Stuart
• Somatization
– distress owing to physical symptoms
– maladaptive illness behaviour
– the distress and behaviour impairs function
• Attachment Style
– insecure attachment & failure of reassurance
– seeking health care is a coping mechanism
• IPT
– communication analysis
– interpersonal incidents
– role playing
www.calgaryhealthregion.ca/cmbm/
CMBM Approach
• Principles
– symptoms are psychobiological
• real & explainable & diagnosable
– management
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•
•
•
cognitive reassurance is insufficient
uncovering a psychological trauma is insufficient
psychotropic medications are counterproductive
success lays in self-regulation
Self-regulation
• Somatic Awareness
– experiential
– link emotional state with body symptoms
– effortless breathing
• Medication Reduction / Elimination
• Group Therapy
– education
– Heartmath
– guided imagery Apple
Talk about Stress...
Acute Stress Response
Fight, Fright, Flight, Frolic Response
Hans Selye (1907-1982)
General Adaptation
Response
– Alarm
– Failure to adapt
– Exhaustion
Absolute Stress
Relative Stress
Interpretation of the world
Recipe for Stress
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•
•
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Novelty
Unpredictability
Threat to ego
Loss of control
Stress & Recovery
Allostatic Load
21 Program Completers
Unscheduled Visits
(ED / UCC)
Admissions Arising from Unscheduled
Visits
Period
Previous
During
After
8
2
1
Visits
Prev 365
During
Post 365
63
17
21
Unique Subjects
Frequency of Unscheduled Visits in the year prior and the year subsequent to
attendance at the Clinic for Mind Body Medicine for 39 patients.
39
38
37
36
35
34
33
32
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
-10
Prev365
Post365
-8
-6
-4
-2
0
2
Sum of visits prior to attendance (negative) and subequent to attendance (positive) at CMBM
4
• Questions
• Discussion
• Experiences to share