Medically Unexplained Symptoms how to tell whether symptoms are organic or not

1. Medically Unexplained Symptomshow to tell whether symptoms are organic or not Dr. Ramesh Mehay Programme Director (Bradford VTS), 2011

2. ‘I am worried about missing something’ • ‘I don’t want to do unnecessary tests’ • ‘Getting them onto your way of thinking is a nightmare’ • ‘And I don’t want to wind them up’ • ‘I feel helpless. How do I help them. There’s no focus in the consultation’ • ‘And yet I still feel I have a sense of responsibility or moral obligation to make things better’ To tackle 1 & 2  you need to create a bit more certainty out of uncertainty  make better decisions To tackle 3-6  The art of Reattribution. Why do these patients irritate us?

3. Getting certainty out of uncertainty • ‘I am worried about missing something’ • ‘I don’t want to do unnecessary tests’ • These two worries come from being: uncertain/unsure/insecure/unconfident in your diagnosis • The diagnosis is simply whether there is something organic or not. • But it’s not surprising as MUS patients come with vague symptoms.

4. Getting certainty out of uncertainty There is always an element of uncertainty when patients present with MUS. Therefore: • The aim is not to get rid of uncertainty • The aim is not to simply tolerate the current level of uncertainty • The aim is to reduce it to a point where what is left is acceptable and manageable. initial level of uncertainty final level of uncertainty

5. ‘In my heart and in my mind, I really don’t get the feeling that there is anything physically wrong with this patient’. To get to the point where you can say:

6. The real question: ‘How can we tell if this is something organic or not?’ • We don’t need a fancy diagnostic name. • We simply need to answer this question of whether it is organic or not. • You can’t never be 100% definitive about this but you need to reduce the level of uncertainty to tolerable levels. • And here’s how to do it…

7. The real question: ‘How can we tell if this is something organic or not?’ Doing loads of investigations is not the answer…. there’s a lot more you can do before doing that. Inappropriate use is wasteful (in terms of costs), creates a load of unnecessary work for others in the NHS (and thus waiting lists) and creates anxiety in the patient. Here are some simple things you can do. • Take a goodenough history • Good examination • Look at the notes • ICE • PSO It’s not rocket science! It doesn’t need to be. Two other things throughout the process… • Don’t be too swayed by others. • Be prepared to change your view at any point.

8. Good History • Detailed enough history – don’t be swayed too early by what others have written before • Red flags – fever, weight loss, anorexia and night sweats • Especially the ‘review of systems’ – make sure nothing is there • Effect of symptoms on daily living - explore to right depth • PMH - especially depression, anxiety, drugs or alcohol. I would be less worried about headaches which: Didn’t have any alarm features, which had been going on for years, didn’t fall into a particular pattern (i.e. a bit weird), in a patient who repeatedly attended surgery for minor things, always seemed anxious, used over-expressive terminology which did not marry with her physical presentation(e.g. ‘it’s absolutely killing doctor all the time and has been for the last 2 years’), yet didn’t take anything over the counter because she just ‘coped with it’.

9. Good examination • You should be prepared to be FLEXIBLE with your working diagnosis (the working diagnosis here being whether something is organic or not). • For instance, if you’ve taken a history and are thinking ‘non-organic’, you must be prepared to ‘switch tracks’ if anything abnormal is found on examination. • Abnormal examination should make you exclude the organic. • Remember, in most cases, history gives you 90% of the working diagnosis and the examination just adds another 10%.

10. Look at the notes • What have other GP colleagues said? • What prev. Ix have been done? Great if someone has done FBC U&E LFTs TFTS RBS and ESR within symptom duration. • Consultation behaviour / freq of attendance • Look at the letters section. I would be less worried about headaches which: Previous GPs had looked at in quite some detail and didn’t think there was anything organic. And even more so if they’d made links to things in the patient’s psycho-social-occupational history (e.g. loneliness, bullying, abuse, domestic violence etc). And even more so if I could see from the notes that a) the patient comes into surgery every other week for various vague ailments and b) has been referred to loads of different specialties in the past with nothing much fruitful in the end (or there is collusion of anonymity).

11. Look at the notes How often do they come to surgery and how many symptoms?

12. Exploring ICE • What do they think is going on? - Is there evidence of crooked thinking that needs rectifying? Is this a way into discussions? - Do they make links to life problems? • What are their concerns? • What they are hoping for from the consultation or from me? Sometimes, these patient’s do not come up with crazy beliefs. Sometimes, what they say is quite reasonable. And therefore, sometimes, you may need to hop onto their track of thinking rather than them hoping onto yours! I would be less worried about organic stuff in the patient who did have crazy ideas, crooked thinking or unrealistic expectations. But remember, I don’t just rely on this – I look at the bigger picture and see how their ICE fits in with other markers which point to a MUS diagnosis (covered in other slides).

13. PSO • What are relationships like? • Think work and home. • Domestic violence, sexual/physical/emotional abuse, bullying, isolation/lonliness, poverty. I would be less worried about headaches: In a patient who is the victim of domestic violence (unless they’re being bashed in the head). May be their physical symptom is an expression of emotional distress. May be I need to start working on the emotion rather than the physical? Surely the hidden agenda is the domestic violence, and I need to do something about that.

14. Remember, MUS often accompanies… (Co-morbid conditions) • Depression, anxiety, OCD, Anorexia/Bulimia Nervosa, Dysthymia, Personality Disorders • Fibromyalgia/Chronic Fatigue Syndrome/Irritable Bowel Syndrome • Severe psycho-social-occupational upset? (domestic violence, sexual/physical/emotional abuse, bullying, isolation, poverty) • Obstructive Sleep Apnoea syndrome • Drugs & Alcohol (be sensitive, decide on the right moment to ask, don’t ignore in elderly) ARE ANY OF THESE PLAYING A PART?

15. But equally, the following can be mistaken for MUS (Differential Diagnosis for MUS / Somatisation) LEVEL 1 • Anaemia (whatever the cause); Folic acid or Iron deficiency (FBC, folate, ferritin ) • Addison’s Disease (U&E – low Na, high K, low serum cortisol at 0800h) • Diabetes (RBS) • Hypercalcaemia(LFTs will give a Ca) • Hypo or hyperthyroidism (TFTs) LEVEL 2 • Vitamin D deficiency/Secondary hyperparathyroidism - esp. asian women/ladies in hijab with total body pain and vague symptoms (Vit D levels) • AIDS (HIV test) • Coeliac Disease (coeliac antibodies) • SLE (autoantibodies, lupus anticoagulant) • Hyperprolactinaemia(prolactin levels) • Multiple Sclerosis (CSF) • Cancer of Ovary/Pancreas (don’t often cause clear cut symptoms). LEVEL 3 • Rare  Myasthenia Gravis, Wilson’s, MS, Porphyria (just keep in back of your mind) Minimum tests in moderate-severe MUS: FBC, folate, ferritin, U&E, LFTs, TFTs, RBS (and perhaps one or more of vit D, HIV test, cortisol, coeliac Abs, auto-antibodies, prolactin if suspicious).

17. Severity of MUS

18. The Normal-Mild Bruce Thomas, a general practitioner in Hampshire, UK, pointed out in the 1970s that in up to 40% of patients in general practice no diagnostic label could be attached. These patients did not require, and generally were not given, specific treatment, and most recovered spontaneously.

19. The others – according to DSM-IV

20. Don’t forget to build a picture of things. • Think of it like a jigsaw puzzle. • Where all the things I’ve mentioned in blue are the individual pieces. • Do not rely on any one jigsaw piece. In other words, do not make judgements just on ONE or TWO bits of information. • You have to build up a picture. • You will probably never build a complete picture. • The aim is to build up a good enough and fairly reliable picture (even if one or two pieces are missing). Final word…

21. “When pattern recognition and iterative diagnosis do not give an answer, when symptoms are vague, or when a clear diagnosis does not “crystallise” from investigations or tests of time or of treatment, patients will need to be managed without having a diagnostic label.” R Jones. When no diagnostic label is applied; BMJ (2010)

22. In these set of slides We mainly talked about getting to that point of deciding whether we think something is organic or not. To reduce uncertainty to a tolerable level so that we don’t feel the following: • ‘I am worried about missing something’ • ‘I don’t want to do unnecessary tests’ Now that we are more sure that things are not organic, the next step is to get the patient on board with that. The problem with this is that… • ‘Getting them onto your way of thinking is a nightmare’ • ‘And I don’t want to wind them up’ • ‘I feel helpless. How do I help them. There’s no focus in the consultation’ • ‘And yet I still feel I have a sense of responsibility or moral obligation to make things better’ Tackling 36 involves the art of Reattribution. Please move onto those set of slides.

23. Other articles worth reading • When no diagnostic label is applied. R Jones. BMJ2010;340;(Published 25 May 2010) • The treatment of somatization: teaching techniques of reattribution. Goldberg D, Gask LL, O'Dowd T. (1989). J Psychosom Res, 33( 6), 689-95. • Nottingham has a fab site on MUS: http://iapt.nmhdu.org.uk/special-interest/special-interest/medically-unexplained-symptoms/the-nottingham-tool/ • Loads more on www.bradfordvts.co.ukclick ‘online resources’ and then ‘02 The GP Consultation’ then ‘somatisation and medically unexplained symptoms’ folder.