Dr Adrian Hemmings

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Working with Medically Unexplained Physical Symptoms (MUPS)

During this presentation we will examine:

The outline of a psychoeducuative group Different classifications of MUPS An overview of theories of aetiology What do Neuro-imaging studies have to offer? An overall theory of MUPs So what ? How might this be relevant to 10 minute

consultation?

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Initial letter to patient from GP

I am writing to let you know about a new course that we are about to start that will be held here at the surgery. It is called ‘Coping with Health Problems’. I know that you have had a series of health problems and I thought that this programme might be helpful to you

It will be run by … who has a special interest in working with people with health problems in order to help them cope with their illness.

The course consists of an initial assessment when a comprehensive history will be taken along with few simple and harmless tests. You will be told more about the course and, if you both agree that it might be useful, you will be invited to eight one-and-a-half-hour weekly group meetings.

If you would like to attend simply contact….

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Assessment

Client’s attitude to the referral and the problem Details of the illness Present symptoms: Type of pain, Occurrence What makes it worse and what makes it better Thoughts accompanying pain

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Assessment

Coping Strategies Consequences on life Others response History including previous treatments General beliefs about the nature and meaning

of the symptoms

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Assessment

Biofeedback:EMG,GSR,Peripheral Temp Medication Other treatments Goals of treatment What would you like to

change? Rationale for psychological treatment

(contribution of stress as a cause or effect. Test out hypothesis of psychological element)

Description of course:

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Follow-up letter from group leader to patient

Following our meeting on ….. concerning the effects of your (symptom description), enclosed is the course outline that I promised. The course will start on (date) at the … (directions) . It will start at ... in … room. Each meeting will last for one and a half hours.

As I explained when we met the course is a mixture of education and self help. This means that in between each meeting an exercise will be set which will help you to monitor your progress.

Before we meet I'd be grateful if you would have a think about what you would like to gain from the course - try imagining yourself in eight weeks time and think of what you would like to have changed by then. You'll be able to discuss this in more detail at our first meeting.

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Programme Outline

Week 1: General introduction , goal setting and models of health

Introduction to the notion of coping Hot cross bun Goals on a flip chart Introduction to self monitoring

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Programme Outline

Week 2: What happens when we are stressed by health problems

Self monitoring review Stress what is it? Individual stress reactions to symptoms Early experiences of illness

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Programme Outline

Week 3: Physical reactions to stress Self monitoring review Cave person exercise Active progressive relaxation

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Programme Outline

Week 4: How do individual views of illness effect health?

Review of self monitoring How thinking and beliefs effect feelings NATS and BATS

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Programme Outline

Week 5 : How does behaviour affect health: in introduction to TA

Self monitoring review How behaviour can maintain behaviour How we interact with other people TA overview – Ego states, transactions and

games

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Programme Outline

Week 6: Pain and Pain management Review of self monitoring exercises The relative nature of pain – the gateway

theory Autogenic training

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Programme Outline

Week 7: Putting together the pieces Open ended group for participants to bring own

agenda So what?

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Programme outline

Week 8: Evaluation of goals and the future

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Exercise

Thinking of your childhood how was illness managed in your family?

How did your parents respond to you/your siblings when you were ill?

How did you respond to your parents/siblings? How has this effected your current relationship

with illness?

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The Organic Genesis of Patient Presentations (Kroenke and Manglesdorf 1993)

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Types of MUPS

Functional

Symptoms

Somatic presentation among patients with depression or anxiety and somatisation

Hypochondriacal Worry/ Health Anxiety

Functional somatic syndromes

Gastroenterology Irritable Bowel Syndrome,

Functional dyspepsia

Cardiology Atypical chest pain

Neurology Common Headache, CFS

Rheumatology FibromyalgiaComplex regional pain syndromes

Gynaecology Chronic pelvic pain

Allergology Multiple chemical sensitivity

Orthopaedics Chronic back pain

Dentistry Temporomandibular joint dysfunction

Somatisation

A transient or persistent tendency to experience and communicate psychological distress in the form of somatic symptoms and to seek medical help for them. It occupies a continuum from a simple misinterpretation of a subjective bodily sensation to an unwavering belief that a physical disease is present

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Health Anxiety

Health anxiety OCD spectrum of ‘disorders’. Obsessional preoccupation with the idea or the

thought of currently (or will be) experiencing a physical illness.

Common health anxieties tend to centre on conditions such as cancer, HIV, AIDs etc,

May fixate on any type of illness. Also called illness phobia/ illness anxiety or

hypochondriasis.hemfipsych.com

The Spectrum of MUPS

Duration: transient persistent

No. of Sx: one multiple

Insight: good none

Disability: none severe

Theories of Aetiology

Psychobiological High levels of physiological arousal Alexithymia

Cognitive/Behavioural Somatisation is rewarded Secondary gains reinforce symptoms

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Theories of Aetiology

Psychoanalytical Real conflicts denied, suppressed or repressed Anxiety displaced into physical symptoms Sociocultural Emotions expressed through physical

symptoms Specific “culture bound” syndromes (Koro,

taijin kyofusho)hemfipsych.com

• EP posits a theoretical framework to understand false illness signaling

• An EP approach to somatisation asks whether false illness signaling represents an innate psychological mechanism triggered by situational exigencies

• Somatisation may represent a behavioural strategy that bestows survival value

Theories of AetiologyEvolutionary psychology (EP)

Theories of AetiologyEarly Trauma

High correlation with early trauma and MUPs(Roelofs and Spinhoven 2006) (Salmon et al 2003)

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Theories of AetiologyAttachment styles

Secure – reliable care giving as children, positive view of self and comfortable depending on others

Dismissing – unresponsive caregiving, self reliant others not to be relied on

Preoccupied – inconsistent caregiving, negative view of self seen as unlovable and expecting others to view negatively preoccupied vigilant

Fearful – needs not met when young negative view of self and others approach and avoidant

High correlation with MUPS and preoccupied and fearful AS hemfipsych.com

Continuum of Attachment

B

Secure

A

Avoidant

C

Resistant/Ambivalent

Up regulateDown regulate Flexible

Theories of AetiologyDissociation

Higher levels of dissociative amnesia in somatising patients (Brown et al 2005)

Linked to pseudo-seizures (Prueter et al 2002)

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Theories of AetiologyImmune system

Activation of the immune system seems to induce behaviour patterns that are similar to the illness behaviour seen in depression and somatisation (Rief and Barsky 2005).

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Neuro-imaging studies: Irritable Bowel Syndrome

Anterior Cingulate Cortex (ACC) as having a role in the regulation of pain in IBS (Ringel et al 1999)

Uprated in chronic and downrated in acute (Peyron et al 2000)

Association with CSA and dissociation (Salmon et al 2003)

Neuro-imaging studies: Chronic Fatigue Syndrome

Significant positive relationships were found for cerebellar, temporal, cingulate and frontal regions and a significant negative relationship was found for the left posterior parietal cortex in CFS patients v controls (Cook et al. 2007).

Increased activation in the occipito-parietal cortex, posterior cingulate gyrus and parahippocampal gyrus, and decreased activation in dorsolateral and dorsomedial prefrontal cortices (Caseras et al. 2008).

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Neuro-imaging studies: Fybromyalgia

Low stimulus pressure associated with 13 regions of brain activated compared with only one in controls. (Gracely et al. 2002).

Greater activation in contralateral insular cortex in both non painful warm and pain stimulus (Cook et al. 2004).

Neuro-imaging studies: Expectation (Nocebo effect) (Rief & Broadbent 2007)

Expectation of symptoms leads to the activation of brain areas corresponding to symptom perception

Distraction from symptoms reduces brain activity in perception areas

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The perception-filter model of somatisation (modified from Rief and Barsky 2005 in Rief and Broadbent 2007)

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The Triune Brain

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The role of emotion

Emotion associated with profound physiological changes

Often unconscious as bypasses frontal cortex Often clients have limited language for emotions Affect avoidance (having feelings, expressing

feelings and confusion about feelings)

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Common Safety Behaviours

Checking pulse Hypervigilence of ‘symptoms’ Reducing activity Symptom browsing on internet Seeking reassurance from GP Palpating parts of the body Reducing food intake Slowing down/speeding up

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Potential interventions: Behavioural

Reducing “boom and bust” mode Reducing symptom-focusing behaviours Anxiety management skills Re-education re somatising precipitators and

perpetuators and treatment programme Graded exposure (using exposure hierachy) Identifying and reducing safety behaviours

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Potential interventions: physiological

Relaxation exercises (diaphragmatic breathing, APR autogenics)

Graded exercise Moving specific symptom focused parts of

body Diet Substance use

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Potential interventions: Emotional

Identifying feelings Developing language for feeling Reducing feeling avoidance Having conversation with symptom

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Development of ‘illness behaviour’

Often related to attachment styles When GP and patient are together – two

attachment styles and illness behaviours are interacting

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Attunement enables affect-regulation

Like the securely attached mother, the empathic psychobiologically attuned clinician’s regulation of the patient’s affective-arousal states is critical to transforming the patient’s insecure nonconscious internal working model that encodes strategies of affect regulation

Schore 2007 12

• B.. Background -What is happening in your life at the moment?

• A.. Affect- How do you feel about that?

• T.. Trouble -What is the most troubling part of..

• H..Handling - How are you managing to deal with that?

• E..Empathy - That must be difficult for you.

The BATHE technique(Stuart and Leiberman 2002)

Dos and Don’ts: DO

Talk about coping Use one designated GP Schedule frequent, brief, regular visits not

contingent on new complaints. Allow "sick role;" focus on function rather than

symptoms. Explore psychosocial issues. Prescribe benign treatments and enjoyment

time.

.

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Dos and Don’ts:DON’T

Suggest "It's all in your head.“ Pursue invasive diagnostic tests, medications

or surgical interventions without good indications.

Refer excessively to specialists. Focus on the symptoms themselves

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MUPS Further Reading

Bass, C Ed (1990). Somatisation: physical symptoms and psychological illness. Blackwell Oxford.Donohugue, P. & Seigel ,M. (1997). Sick and Tired of Feeling Sick and Tired, Living with invisible chronic illness and SageMayou, R., Bass,C. & Sharpe, M. (1995). Treatment of functional somatic symptoms. Oxford University Press. Oxford. Gill, D. (2007). Hughes’ Outline of Modern Psychiatry. Wiley & Sons (see Chapter 9 on Physical Symptoms and Psychiatric Disorders)Sanders, D., (1996) ofor Psychosomatic Problems. London: Sage PublicationstWoolfolk, R. & Allen, L. (2007).Treating Somatization. A Cognitive Behavioral Approach Guildford PressJohnson,S. (2008). Medically Unexplained Illness. Gender and Biopsychosocial Implications. APAJournals: Journal of Psychosomatic Research, Psychosomatics 

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