Approach to Medically Unexplained Symptoms

1. Approach toMedically Unexplained Symptoms Jeffrey P Schaefer MSc MD FRCPC Canadian Society of Internal Medicine Annual Meeting – Workshop #13 October 16, 2008 http://dr.schaeferville.com

2. Conflicts of Interest • none

3. ObjectivesMedically Unexplained Symptoms • Session participants shall: • be able to define MUS • know that MUS are common • have considered psychobiologicalframework • become aware of management strategies • know about the Clinic for Mind-Body Medicine

4. Medically Unexplained Symptoms • Physical symptoms that prompt the sufferer to seek health care but remain unexplained after an appropriate medical evaluation.

5. Case Presentations

6. What’s your diagnosis? Diagnosis: ______________________

7. Hopefully, uptodate.com has something…

8. Diagnosis Menu • What’s your diagnosis / diagnoses? • Chronic Fatigue Syndrome • Fibromyalgia • Tension Headache • Irritable Bowel Syndrome • Multiple Chemical Sensitivity Syndrome • Interstitial Cystitis • Hematuria Loin-pain Syndrome • Depression and Anxiety • Conversion Disorder • Somatization

9. Are Medically Unexplained Symptoms Common?

10. Prevalence of MUS Factoids • ~30% of visits to primary care are MUS • MUS averaged 13.6 MD visits in prev year Psychosomatic Med 2005;67:123-9

11. Most Frequent Visitors 5th percentile GI……………. 54% Neuro…….. 50% Rheum……. 33% ENT…………. 27% GIM………… 10%

12. This is a problem!

13. This is a big problem!

14. 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 • dissatisfaction relates to communication style • Soc Sci Med. 2001 Jun;52(12):1859-64 • Why reassurance fails? • PLOS Medicine 2006

16. One condition or many?

17. Chronic Fatigue Syndrome Fibromyalgia Irritable Bowel Syndrome Multiple Chem Sensitivity Syndrome Sick Building Syndrome Hypoglycemia Gulf War Syndrome Undocumented Labels Headache Syndromes Asthma Painful Conditions Various Bodily Distress Disorder

18. 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

19. Median Number of Symptoms Men  4 Women  6 Men & Women  5

20. 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 “Bodily Distress Disorder” Fink et al. Psychosom Med 2007

21. 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.

22. Psychobiology‘the mind-body connection’

23. Psychobiological Framework

26. 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

27. Self-report AMI Trigger412 reports from 849 AMI

31. Chronic Stress & Immune Dysfunction • Influenza Vaccination • Difference between stressed and non-stressed group. • Lancet 1999

32. Stress and Wound Healing

33. 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

34. So now what?

35. Several Approaches…

37. RCT: n = 200 • OR  1.92 (95%CI 1.08 – 3.4) • NNT to improve @ 12 months = 6.4

38. Smith’s Treatment ModelCognitive – 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

39. Key Components

40. Interpersonal TherapyScott 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

41. www.calgaryhealthregion.ca/cmbm/

42. Rockyview General Hospital, Calgary

44. CMBM Approach • Principles • symptoms are psychobiological • real & explainable & diagnosable • management is experiential • cognitive reassurance is insufficient • uncovering a psychological trauma is insufficient • psychotropic medications are counterproductive • success lays in self-regulation

45. Self-regulation • Somatic Awareness • link emotional state with body symptoms • effortless breathing • Medication Reduction / Elimination • Group Therapy • education • Heartmath • guided imagery

46. Role of Internist • Compassionate Listener • Expert • data gatherer and review • explicit address of patient fears • health promotion • co-morbidity manager • educator

47. Exclude bio-medical disease • Adrenal Insufficiency (hyper K / hypo Na) • Hemochromatosis (ferritin screen) • Hypercalcemia (calcium) • Amytrophic Lateral Sclerosis (twitches) • Multiple Sclerosis (neurological deficit) • Alcoholism (CAGE, MCV, GGT) • Temporal arteritis (ESR) • Subacute bacterial endocarditis • Sleep Apnea

48. Assess the impact of known conditions • Conditions Underestimated • Chronic Cardiac Disease • Chronic Respiratory Disease • Chronic Sinusitis • Recurrent genital herpes • Diabetes mellitus • Obesity • Osteoarthritis • Medication Effect • Physical decondition

49. Talk about Stress...

50. Acute Stress Response Fight, Fright, Flight, Frolic Response