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MEDICALLY UNEXPLAINED SYMPTOMS. ST3. AIM To increase confidence in managing patients with symptoms which are difficult to explain on the basis of any known pathology OBJECTIVES By the end of this session we will have
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AIM • To increase confidence in managing patients with symptoms which are difficult to explain on the basis of any known pathology • OBJECTIVES • By the end of this session we will have • Considered how to assess and manage patients with medically unexplained symptoms. • Been challenged about managing our own anxieties when confronted with such symptoms. • Shared our own experiences of patients with medically unexplained symptoms. • Heard from each other about the presentation, investigation and management of commonly presenting illness.
REFERENCES • “Explaining the unexplainable” Des Spence BMJ 19.2.11 Vol. 342 p446 • “Prescriptions for misery” Helen Burnett BMA News 2.4.11 p 10 • Clinical Review: Assessment and management of medically unexplained symptoms BMJ 15.5.08 Vol.336 pp1124-1136 Simon Hatcher and Bruce Arroll • “Regular Attenders in Primary Care Study”-funded by NIHR and on-going at the University of Nottingham- presented to local GPs May 2013 at a “Time Out” • Excellent guidelines for GPs for MUS were developed in 2011 by the Forum for Mental Health in Primary Care, hosted by the RCGP and RCPsych. http://www.nmhdu.org.uk/silo/files/guidance-for-health-professionals-on-medically-unexplained-symptoms-mus.pdf
Brainstorm • Think of symptoms which might possibly turn out to be medically unexplained
Next week • Chronic fatigue syndrome • Fibromyalgia • Unexplained chronic chest pain • Unexplained chronic back pain • Non-epileptic seizures • Chronic daily headache • Irritable bowel syndrome • Chronic regional pain syndrome • Overactive bladder • Halitosis • Lump in throat • Etc. Prepare a short lecture on the likely presenting symptoms, any evidence based investigations and management of the above- could be in pairs or triplets splitting each lecture into the 3 parts. Max time 5-10 minutes per disease.
Mary Jones Mary is 68y old and presents with burning legs and nocturia. The burning is terrible and wakes her at night- she gets up to pass urine and then finds her legs are better but only for a short while. During the day she has no frequency of micturition. She is very distressed and has made an emergency appointment because she can’t bear it any longer. ICE is just concentrated on getting relief. Examination of her legs is normal apart from mild varicose veins. Urine dipstick shows blood + What do you do?
Investigations • Concentrated first on urine- MSU was negative- VE mild atrophic vaginitis- still blood + so referred. • Cystoscopy and USS normal so discharged- vaginal oestrogens made her worse. • Burning legs as bad as ever daughter-in-law says something must be done. • What next?
Neurologist • Arranges nerve conduction studies and an MRI scan- all normal- take ages. • Recommendation is pregabalin and if this doesn’t work then duloxetine. • Pregabalin makes her worse. • Duloxetine makes her feel funny. • Any cream makes the burning worse. • Daughter-in-law tells you she’s threatening suicide and something must be done. • What to do?
You decide by now that this is MUS • Rather cross with yourself it’s taken you too long to come to this conclusion • Still no help from ICE- “I just want it to stop” • What to do?
How many primary care patients in England have unexplained chronic pain, irritable bowel syndrome or chronic fatigue? 25% These disorders are important because they are common, cause similar levels of disability as symptoms caused by disease and if not treated properly they can result in large amounts of resources being wasted
Stress for all! • Doctors may get frustrated: “heart sink patients”, “frequent fliers”. • Doctors feel incompetent. • Anxiety about missing serious pathology. • Patients feel disbelieved. • Highly controversial. • Psychological disorders seen as not real and patients partly responsible for their actions.
Who gets MUS? • Less educated • Those who experienced lack of care or parental illness in childhood • Rates of psychiatric morbidity in regular attenders twice that of normal attenders (normal attendance 4-5 times per year- regular attenders average 20 attendances) • Regular attenders have a poorer self-reported quality of life • Attendance rates tend to increase over the years. • Have higher rates of health anxiety
ASSESSMENT : ICE/ PSO/EFFECTS! Why now and what’s the agenda? • What are the symptoms? Take a full history of the onset of all symptoms, exacerbating factors, and relieving factors • ICE • How much impairment do the symptoms cause? Do they cause disability? What is a typical day like? • Does the patient have a history of lack of care or illness in childhood? • Are there any signs of disease on physical examination? • Encourage discussion of psychosocial difficulties • Is there associated pathology?
Assessment • Gather old notes and investigations. Review these first before ordering more investigations • Balance the iatrogenic risks of further investigation or treatment against the probability of finding associated pathology • Does the patient have an anxiety or depressive disorder? • Does the patient have any mood symptoms or anxiety symptoms? • Consider using a screening questionnaire: PHQ-9 for depression or PHQ-15 for somatisation disorder • Is this some other emotional distress presenting as physical distress?
PHQ -15 A 15 item Somatic Symptom Severity Scale Score: Not bothered at all = 0 Bothered a little = 1 Bothered a lot = 2 0 – 4 = no somatisation disorder 5 – 9 = mild somatisation disorder 10 – 14 = moderate somatisation disorder 15 + = severe somatisation disorder The PHQ-15 is intended to supplement clinical judgement
Could there be any associated pathology? • A systematic review found that about 4% of people diagnosed with a conversion disorder develop an illness that could explain their presenting symptoms. The most likely missed diagnoses are psychiatric. • In a follow-up study of 73 patients with unexplained motor symptoms, 33 had an undetected psychiatric disorder (usually a mood or anxiety disorder) at presentation.
Explanation and Reassurance • Appropriate investigation, explanation and reassurance versus over investigation with the risk of iatrogenic harm. • Explanation and reassurance should not involve telling the patient that there is nothing wrong, as clearly this is not the case.
Explanation and Reassurance • A qualitative study of GP’s explanations found that patients were most satisfied if their doctors gave an explanation for symptoms that made sense, removed any blame from them, and generated ideas about how they could manage their symptoms. • The same group found that GPs who encouraged patients presenting with medically unexplained symptoms to talk about their psychosocial problems were less likely to offer a new drug treatment, investigation, or referral to a specialist.
Reassurance • Deal with the patient’s fears (fear of cancer, for example). • Encourage the patient to express thoughts and feelings about the symptoms as well as the history of symptoms. • Don’t imply that nothing is wrong because clearly something is wrong or the patient would not have consulted a doctor!
Explanation Integrate physical and psychological explanations that avoid blame and provide an opportunity for self management— for example, “stress can make our muscles tense, when your muscles are tense for any length of time they get painful: tense chest muscles can cause chest pain”
USE OF INVESTIGATIONS • The effect of diagnostic testing depends on what patients think a normal result means. • One randomised controlled trial investigated the effect of providing information about the meaning of a normal exercise stress test in patients with chest pain. Patients who received pre-test information were significantly less likely than those who received no information to have chest pain one month later.
THE RISKS OF IATROGENIC DAMAGE Over investigation and overtreatment can cause iatrogenic damage. • Giving a disease a label may lead to relief because the symptoms are seen as “legitimate,” but it may lead to increased “illness behaviour.” In a longitudinal survey of primary care patients with chronic fatigue, those who were diagnosed with ME had a worse prognosis than those diagnosed with chronic fatigue syndrome. • Over investigation and treatment—“abnormal treatment behaviour”—risks harming the patient through complications of the investigation, with false positive findings promoting more uncertainty and further tests; overtreatment; and surgical removal of normal organs. • Sometimes patients don’t want referral as they then feel abandoned by their GP • Over investigation can increase anxiety
DOES THE PERSON HAVE AN ANXIETY OR DEPRESSIVE DISORDER? • This is a particularly useful question in primary care, where most people with depression or anxiety present with somatic rather than emotional symptoms. • It is especially relevant in developing countries, where around two thirds of women and a quarter of men who have anxiety or depressive disorders present with predominantly physical symptoms
IS THIS SOME OTHER EMOTIONAL DISTRESS PRESENTING AS PHYSICAL DISTRESS? • Where there is little evidence of associated pathology or the presence of a depressive or anxiety disorder, it is useful to consider three other factors—the patient’s model of the illness, the role ofpredicaments, and the role of allies. The model of illness is the way that patients explain their disorder. Asking patients to explain their disorder can provide examples of unhelpful thinking, such as, “if I exercise I get tired, therefore I must be doing my body some harm, therefore I should rest.” Cognitive behaviour therapy can generate interventions that identify and modify these unhelpful thoughts.
Patients whose physical distress is caused by emotional distress are often in a predicament, particularly that of being in a dilemma where any choice they make has negative consequences- they are “damned if they do and damned if they don’t.” Identifying the dilemma may help generate treatment strategies based around problem solving or more formal psycho-dynamically informed interventions. • The role of allies is to encourage the patient to get help for their distress from the medical profession. Allies can be family members with health qualifications or other doctors who encourage the patient to seek further investigations or treatment. Identification and communication with these allies is essential to ensure that the patient gets a consistent treatment plan. Allies are particularly important for people who refuse treatment or who are unable to engage in treatment
Management in Primary Care • Regularly scheduled appointments; performing a brief physical examination at each visit, to look for signs of disease rather than relying on symptoms • Avoiding investigations and hospital admission unless clearly indicated • Likely to decrease health service use and increase physical functioning.
Antidepressants • Antidepressants can help —asystematic review of 94 randomised controlled trials (6595 people) of antidepressants prescribed for medically unexplained symptoms found that they significantly improved symptoms (number needed to treat four). • No one type of antidepressant was better than the others. • Because their effectiveness was independent of their anti-depressive action, low doses may be helpful.
Activity is good for you! • Randomised controlled trials show that advising activity rather than restfor back pain, fatigue, and fibromyalgia is helpful. The activity should be agreed with the patient, be relevant to their situation, and be structured so that it gradually increases. Pacing is important—patients should not do more activity than they have agreed, even if they feel like it. You should tell patients that feeling worse after activity is not a sign of “damage” or pathology—point out that even top athletes feel sore and stiff when resuming training
Psychiatric management CBT works! • A systematic review of 29 randomised controlled trials of cognitive behaviour therapy compared with various control treatments, mainly in secondary care, 20 found that cognitive behaviour therapy was an effective treatment for “somatisation or symptom syndromes” and that physical symptoms were more responsive to treatment than psychological symptoms.
How to discuss making a referral to a psychologist • One way to persuade patients to see a psychologist is to say: “We cannot find a cure for your symptoms but we need to help you to find a way to live with them.”
Reattribution model for Somatoform Disorder Stage 1 – feeling understood o Take full history of the symptoms o Explore emotional cues o Explore social and family factors o Explore the patient’s health beliefs o Brief focused physical examination if indicated Stage 2 – broadening the agenda o Feedback the results of the examination o Acknowledge the reality of the symptom o Reframe the complaints: link physical psychological and life events Stage 3 – Making the link o Simple explanation o How anxiety causes physical symptoms o How depression lowers the pain threshold Demonstrate o Practical example how pain results from tensed muscles o Link to life events (how pain is worse on days with stress) o Here and now (how the pain is at the moment and enquiry about feelings) Project or identify (ask if anyone else in the family or amongst friends have suffered from similar symptoms)
Doughnut The ring represents resources: • Family, friends, doctor, medication, personal attributes The hole represents hopes • Goals/ Aims • May not exist yet- activate the resources to fill the hole If you emphasise and are interested in the good things in a patient’s life then the patient may start talking about other good things e.g. the fact that they coach a local football team
Role play • Explain IBS • Explain Chronic Daily Headache • Explain Chronic Fatigue
What is the prognosis? • Few prognostic studies have looked at people who present with medically unexplained symptoms. • In primary care, one study found that at least a quarter of unexplained symptoms persist after 12 months. • Frequent attendance tends to increase year on year. All this makes a good case to tackle the problem for the good of our patients, the NHS and ourselves!
