Medically Unexplained Symptoms in Primary Care

1. Medically Unexplained Symptoms in Primary Care David Protheroe, Liaison Psychiatry, LGI October 2014 david.protheroe@nhs.net Or via LinkedIn

2. What do you want to learn – in 45mins?

3. Social model of managing acute illness • Patient notices symptom • Doctor examines and elicits signs of illness • Doctor orders tests • Doctor makes diagnosis • Doctor prescribes treatment • Patient undertakes to take the treatment • Cure!

4. Symptoms in US primary careKroenke and Mangelsdorff, 1989

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

6. What groups of patients are we talking about here • Frequent attenders with many transient symptoms with little or no organic illness • Single symptom: • limb paralysis or memory loss or non epileptic attack disorder • Long term or short term • Multiple syndromes: • Headaches, migraine, IBS, fibromyalgia, chronic fatigue, temporo-mandibular joint dysfunction, vulvodynia, etc • Patients with mixture of organic illness and functional symptoms

7. MUS: does it really matter? • 22% of all people attending primary care have sub-threshold levels of somatisation disorders • 50+% of new attendees in medical clinics attracted a diagnosis of unexplained symptoms • They 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 care • 20% of MUS patients account for 62% of spend • Cost to English NHS = £3bn or £14Bn to society

8. Do we miss organic pathology? • Slater 1965 • Many “hysteria” patients were later diagnosed with organic illness • Repeated • Roth, Trimble/Mace, Crimlisk – 2-4% • Kooiman et al - 5 out of 284 • Stone et al – 4 out of 1030 • When should we stop investigating? • Iatrogenic harm

9. ICD-10 • Somatisation Disorder • Undifferentiated somatoform disorder • Hypochondriasis • Somatoform autonomic dysfunction • Somatoform pain disorder • Dissociative Disorder • Conversion disorder

10. Other terms in use • Somatisation • Functional illness • Functional Somatic Syndromes • Medically unexplained symptoms • Somatoform illness • Bodily distress syndrome • Psychogenic illnesses • Psychosomatic illness • Stress related illness • Its depression

11. Psychosomatic Medicine, Alexander 1950 • Upper GI problems • Comparative 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.

12. Psychosomatic Medicine, Alexander 1950 • Constipation • The 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. • Diarrhoea • Financial 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.

13. What are the difficulties in caring for this group? • People don’t seem to like them • Demanding, time consuming • Expensive • Fear of missing an important diagnosis • Fear of litigation

14. Aetiology of M.U.S • Secondary gain or social benefits of illness • Early trauma • Neglect • Sexual, physical, psychological abuse • Modelling in childhood • Precipitated by stressful events • Dilemmas • Organic illness? • Autoimmune illnesses • Low grade anxiety/depression • FH anxiety/depression/functional illness • Cultural component • Illness beliefs • Family

15. Maintaining factors: Illness beliefs Social benefits of illness Systemic issues Precipitating life event (or infection/trauma) Adversity Symptoms & disability Modelling?

17. 20 things that clinicians say (or do) to patients which is unhelpful

18. Unhelpful things that we say or do - 1 • Talk down to the patient • Monologue freezing out patient’s view • Feel defensive or uncomfortable –so patient picks it up • Dismissive attitude • Stigmatise the patient • Imply that the patient is not experiencing the pain • Appear to blame the patient because there is no pathology • Pass the patient to a junior doctor • Imply it is the patient’s responsibility or they can get themselves out of it

19. Unhelpful things that we say or do - 2 • Answer 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 behaviour • Quickly switch the agenda from seeking pathology to psychological explanation

20. Number needed to offend (Stone, 2002) DIAGNOSIS NNO • All in the mind • Hysterical • Psychosomatic • Medically unexplained • Depression related • Stress related • Functional • 2 • 2 • 3 • 3 • 4 • 6 • 9

21. Aims of treatment • Move from a an acute model of illness to a chronic model of illness • Move towards acceptance and coping • Gain a shared understanding of the problem • Improved self management • Encourage patient to rebuild life with symptoms • Contain costs • Reduce iatrogenic harm

22. 10 things that are true about functional syndromes

23. True/useful facts about functional syndromes - 1 • Common, well recognised • We doctors do not always deal with these problems very well • Humility • Can be very unpleasant and disabling • Will not shorten your life • Not 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 on • It may be a brain/mind problem rather than a knee problem • May have started with an injury to your knee but although you knee has healed your pain continues • There is something wrong but we just cannot see it… • May be a physiological explanation at some level • Will not show up on scans

24. True/useful facts about functional syndromes - 2 • Share physiological explanation of chronic pain, • Brain unable to filter out benign messages • If you get one or two symptoms likely to get more at some point • Can be precipitated by stress • Early life experiences may make things worse • Some syndromes may be precipitated by infections and physical trauma • Not consciously manufactured • Some unconscious factors • Explain links to physical illness • Autoimmune, atopic illness • Can never completely eliminate all risk of pathology in anyone even if they have no symptoms

25. Medical Generalism RCGP 2012 • Real conversations are required • Real conversations require real empathy • Empathy requires understanding • Understanding needs to be conveyed • Understanding combines • Biomedical knowledge • Biographical knowledge • Conveying requires communication skills

26. 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

27. In a nutshell… • Good communication…

28. And finally