Approach to Patients with Medically Unexplained Symptoms / Illnesses

1. Approach to Patients withMedically Unexplained Symptoms / Illnesses Jeffrey P Schaefer MSc MD FRCPC Rural Physician Video Conference Program March 31, 2009

2. websitedr.schaeferville.com

3. Conflicts of Interest • none

4. ObjectivesMedically Unexplained Symptoms • Session participants shall: • be able to define MUS • know that MUS are common • have considered psychobiologicalframework • become aware of management strategies

5. Case • 42 yr old female administrator total body pain and extreme fatigue x 5 years previously assessed by GIM, Neurology, Gastroenterology investigations  normal

6. What is the probability that you will find a condition that risks loss of life or limb? 0% 50% 100%

7. What are your feelings at this point? Negative Neutral Positive -10 0 +10

8. Problem List • daily occipitofrontal headache • CT – negative  amitriptyline • chest pain, episodic, at work • EST / echo - negative • abdominal pain • GI assess / colonoscopy / endoscopy / CT – negative • dysuria with ‘blood in the urine’ • U/A usually normal / low CFU but no blood • fatigue • CBC, lytes, renal, ESR, ANA, ferritin, TSH, ECG, CXR - normal • poor concentration & dizziness • neurology consult  no disease • work issues • disability questionnaire anticipated

9. PMH • cholecystectomy for abdo pain 7 years ago (pain returned) • Meds • citalopram 20 mg po od • amitriptyline 25 mg po qhs • gabapentin 400 mg tid • fentanyl disk 50 ug/hr • Tylenol #4 tablets, 2 po qid, prn • lorazepam 2 mg po qhs • pantoloc 40 mg po od • multivitamin • Family History • two teenage children • Psycho-social • ‘perfectionist traits’, not much social contact anymore, supportive husband, non-smoker, no alcohol or street drugs

10. Examination • normal except tender to palpation in all areas examined • Investigations within last 2 years – all NORMAL • CBC and SPE • electrolytes, calcium, mg, phos, creatinine • liver enzymes, albumin, INR • glucose, TSH, and she has regular menstrual cycles • ESR, ANA • urinalysis • ECG and echo • CXR • CT head • Colonoscopy / Gastroscopy / CT Abdomen and Pelvis

11. What is the probability that you will find a condition that risks loss of life or limb? 0% 50% 100%

12. What’s your diagnosis? Diagnosis: ______________________

13. Hopefully, uptodate.com has something…

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

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

16. Medically Unexplained Symptoms Physical symptoms that prompt the sufferer to seek health care but remain unexplained after an appropriate medical evaluation. Headache Chest Pain Fibromyalgia Irritable Bowel Chronic Fatigue Dizziness Infertility

17. Are Medically Unexplained Symptoms Common?

18. MUS Prevalence • 30% of primary care visits • 13.6 visits in the previous year Psychosomatic Med 2005;67:123-9

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

20. If only… ‘an actual email’ • Dear Dr. Schaefer, • This is great! I'm much relieved and grateful for your care. Thank you THANK YOU! • Michelle

21. This is a problem!

22. This is a big problem!

23. 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 • Why reassurance fails? • PLOS Medicine 2006

24. 25

26. One condition or many?

27. 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

28. 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

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

30. 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

31. 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.

32. Psychobiology‘the mind-body connection’

33. Psychobiological Framework

36. Left: Areas of the brain that ‘light-up’ during strong emotion. These correlate to Vagus Nerve mediated Heart Rate Variability. Below: HPA axis Mind Body Connection: neural and hormonal

37. 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

38. Self-report AMI Trigger412 reports from 849 AMI

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

43. Stress and Wound Healing

44. 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

45. So now what?

46. Several Approaches…

47. The Approach… • Exclude bio-medical disease • neoplasm • infection • auto-immune • metabolic

48. The Approach… • Exclude bio-medical disease • Adrenal Insufficiency • Hemochromatosis • Hypercalcemia • Amytrophic Lateral Sclerosis • Multiple Sclerosis • Alcoholism • Temporal arteritis • Subacute bacterial endocarditis • Sleep Apnea

49. Assess the impact of known conditions • Conditions Underestimated (e.g.) • Chronic Cardiac Disease • Chronic Respiratory Disease • Chronic Sinusitis • Recurrent genital herpes • Diabetes mellitus • Obesity • Osteoarthritis • Medication Effect • Physical deconditioning