Medically Unexplained Symptoms in Primary Care

David Protheroe, Liaison Psychiatry, LGIOctober 2014

david.protheroe@nhs.netOr via LinkedIn

What do you want to learn – in 45mins?

Social model of managing acute illness

Patient notices symptomDoctor examines and elicits signs of illnessDoctor orders testsDoctor makes diagnosisDoctor prescribes treatmentPatient undertakes to take the treatmentCure!

Symptoms in US primary careKroenke and Mangelsdorff, 1989

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Number of

Presentations

Chest Pain Fatigue Dizziness Headache Back Pain Dyspnoea Abdo Pain Numbness

Unexplained

Organic

Prevalence of unexplained symptoms in consecutive new attendees to medical clinics at Kings College Hospital

Clinic Prevalence

Chest 59%

Cardiology 56%

Gastroenterology 60%

Rheumatology 58%

Neurology 49%

Dental 49%

Gynaecology 57%

Total 56%

What groups of patients are we talking about hereFrequent attenders with many transient symptoms

with little or no organic illnessSingle symptom:

limb paralysis or memory loss or non epileptic attack disorder

Long term or short termMultiple syndromes:

Headaches, migraine, IBS, fibromyalgia, chronic fatigue, temporo-mandibular joint dysfunction, vulvodynia, etc

Patients with mixture of organic illness and functional symptoms

MUS: does it really matter?22% of all people attending primary care have sub-

threshold levels of somatisation disorders50+% of new attendees in medical clinics attracted a

diagnosis of unexplained symptomsThey account for

8% of all prescriptions 25% outpatient care 8% inpatient bed days and 5% accident and attendances 50% more likely to attend primary care 33% more likely to attend acute secondary care20% of MUS patients account for 62% of spend

Cost to English NHS = £3bn or £14Bn to society

Do we miss organic pathology?Slater 1965

Many “hysteria” patients were later diagnosed with organic illness

RepeatedRoth, Trimble/Mace, Crimlisk – 2-4%Kooiman et al - 5 out of 284Stone et al – 4 out of 1030

When should we stop investigating?Iatrogenic harm

ICD-10Somatisation DisorderUndifferentiated somatoform disorderHypochondriasisSomatoform autonomic dysfunctionSomatoform pain disorderDissociative DisorderConversion disorder

Other terms in useSomatisationFunctional illnessFunctional Somatic SyndromesMedically unexplained symptomsSomatoform illnessBodily distress syndromePsychogenic illnessesPsychosomatic illnessStress related illnessIts depression

Psychosomatic Medicine, Alexander 1950Upper GI problemsComparative clinical studies conducted in the

Chicago Institute for psychoanalysis have shown that in all patients suffering from psychogenic gastric disturbances a predominant role is played by the repressed help seeking dependent tendencies. A strong fixation to the early dependent situation of infancy comes in conflict with the adult ego resulting in hurt pride; and since this dependent attitude is contrary to the wish for independence and self-assertion it must be pressed.

Psychosomatic Medicine, Alexander 1950ConstipationThe psychogenic findings in chronic constipation are typical

and constant; a pessimistic, defeatist attitude, a distrust or lack of confidence in others, the feeling of being rejected and not loved, are often observed in these patients. Chronically constipated patients have a trace of both attitudes: the distrust of paranoia and the pessimism and defeatism of melancholia.

… in such cases psychotherapy must be directed toward a reorientation of the total personality.

DiarrhoeaFinancial obligations which are beyond the patient’s means is a

common factor in some forms of diarrhoea. Abraham described the emotional correlation between bowel movement and spending of money.

What are the difficulties in caring for this group?People don’t seem to like themDemanding, time consumingExpensiveFear of missing an important diagnosis Fear of litigation

Aetiology of M.U.SSecondary gain or social benefits of illnessEarly trauma

Neglect Sexual, physical, psychological abuse

Modelling in childhoodPrecipitated by stressful events

Dilemmas

Organic illness? Autoimmune illnesses

Low grade anxiety/depressionFH anxiety/depression/functional illnessCultural componentIllness beliefs

Family

Adversity

Precipitating life event (or infection/trauma)

Symptoms & disability

Maintaining factors:Illness beliefsSocial benefits of illnessSystemic issues

Modelling?

20 things that clinicians say (or do) to patients which is unhelpful

Unhelpful things that we say or do - 1Talk down to the patientMonologue freezing out patient’s viewFeel defensive or uncomfortable –so patient picks

it upDismissive attitudeStigmatise the patientImply that the patient is not experiencing the painAppear to blame the patient because there is no

pathologyPass the patient to a junior doctorImply it is the patient’s responsibility or they can

get themselves out of it

Unhelpful things that we say or do - 2Answer definitively when unsure“There is nothing wrong with you”“It’s just depression”“It’s psychological”

What do doctors mean by that?What do patients understand by that?

“You have genuine pain”Over investigation may promote sick role and

abnormal illness behaviourQuickly switch the agenda from seeking

pathology to psychological explanation

Number needed to offend (Stone, 2002)DIAGNOSIS NNO

All in the mindHystericalPsychosomaticMedically unexplained

Depression relatedStress relatedFunctional

2233

469

Aims of treatmentMove from a an acute model of illness to a

chronic model of illnessMove towards acceptance and coping

Gain a shared understanding of the problemImproved self managementEncourage patient to rebuild life with

symptoms

Contain costsReduce iatrogenic harm

10 things that are true about functional syndromes

True/useful facts about functional syndromes - 1

Common, well recognisedWe doctors do not always deal with these problems very well

HumilityCan be very unpleasant and disabling

Will not shorten your lifeNot well understood

“I don’t know but I don’t think any one else does either”It isn’t your fault

You did not do anything to bring it onIt may be a brain/mind problem rather than a knee problemMay have started with an injury to your knee but although

you knee has healed your pain continuesThere is something wrong but we just cannot see it…

May be a physiological explanation at some levelWill not show up on scans

True/useful facts about functional syndromes - 2Share physiological explanation of chronic pain, Brain unable to filter out benign messagesIf you get one or two symptoms likely to get more at some pointCan be precipitated by stressEarly life experiences may make things worseSome syndromes may be precipitated by infections and physical

traumaNot consciously manufacturedSome unconscious factorsExplain links to physical illnessAutoimmune, atopic illnessCan never completely eliminate all risk of pathology in anyone

even if they have no symptoms

Medical Generalism RCGP 2012Real conversations are requiredReal conversations require real empathyEmpathy requires understandingUnderstanding needs to be conveyedUnderstanding combines

Biomedical knowledgeBiographical knowledge

Conveying requires communication skills

What else can we do? Introduce the concept of functional illness early on Agree a shared vocabulary

A named syndrome such as IBS or fibromyalgia helps Open “adult to adult” communication

Two way inclusive dialogue What do you think?

Consistent approach www.neurosymptoms.org Avoid over-psychologising Broaden rather than switch the agenda to psychological issues Involve a family member Use analogies

Computer: software vs hardware Satellite looking down at a school

Agree to limit unnecessary investigation or medication If you disagree with a patient in a letter

Put both sides views with equal prominence

In a nutshell…

Good communication…

And finally