✅ L9 - Medically-unexplained symptoms

Question 1

What are Medically Unexplained Symptoms/Syndrome (MUS)?

Answer 1

• Medically Unexplained Symptoms (MUS): symptoms with no medical diagnosis or explanation.
• Syndrome: when symptoms regularly occur together to form a recognisable illness
• Some examples of “Medically Unexplained Syndromes”: irritable bowel syndrome, chronic fatigue syndrome, non-specific chest pain etc.

Question 2

How prevalence are MUS? How bad are they?

Answer 2

1. In general population: 80-90% per week (e.g. fatigue is normally distributed in community)
2. In primary care: 19-25% per week
3. ## Secondary care outpatient (hospitalisation): 30-70%, avg 53%
   • For many, MUS are fleeting and self-limiting
   • But MUS can persist for a long time for some
   • Dutch primary care study (n=254) of patients with unexplained fatigue, abdominal or musculoskeletal complaints => 43% still had unexplained symptoms 1 year later

Question 3

What is the problem of MUS with the biomedical model and somatisation, and the alternative response for these symptoms?

Answer 3

• MUS violate the biomedical model which conflates disease and illness (unsatisfactory)
  => Biomedical model: disease > symptoms > diagnosis > intervention > cure
• MUS is the somatisation of distress, with 4 elements:
  1. Assumes psychological distress as cause
  2. Defined by absence of pathology
  3. Patients attribute symptoms to disease
  4. Patients seek medical help for that disease
  => Patients hate it, thinking it delegitimizes their symptoms (unsatisfactory)
• Evidence of psychological factor: MUS is often accompanied by psychological symptoms or distress -> More MUS, greater likelihood of anxiety/depression symptoms.
• Alternative approach: explain the experience of symptoms in terms of interacting biological, psychological and social factors, and help people to manage/cope with them.

Question 4

What are the perceptual and cognitive factors of bodily sensations/symptoms?

Answer 4

1. Perception of bodily sensations
   - Noticing sensations
   - Attending sensations
   - Competition of cues
2. Interpreting sensations as symptoms
   - Context important
   - Beliefs and personal models of illness
   - Use heuristics (e.g. stress & age heuristics)
   - Interpretations affected by emotional factors

Question 5

What are the 3 types of (causal) attributional style?

Answer 5

1. Normalisation: associate something as normal/usual
2. Psychologising: associate something to feelings and moods
3. Somatising: associate something to internal/biological cause

Question 6

How does mood affect our symptoms?

Answer 6

1. Fear of being ill -> more vigilant to bodily sensations
2. Physical sensations of anxiety (e.g. sweating, shaking, dry throat, nausea, stomach cramps)
3. Physical sensations of depression (e.g. weight change, sleeplessness, aches and pains)
4. Many patients with unexplained symptoms are depressed or anxious (~85%)

=> In the community, emotion is positively correlated with physical symptoms.

Question 7

How do GPS and doctors deal with patients with MUS?

Answer 7

1. Many GPs try:
   - ‘Reassurance’ (effective for ~24 hours)
   - Secondary care referrals (30-70% no physical pathology)
   - Physical investigation (e.g. blood tests, scans)
   - Symptomatic treatment (e.g. antibiotics)
2. Surgery: 15-40% of appendectomies have normal histology

———
Qualitative study for patients with persistent MUS, about explanations they had received from GPs and other health professionals.

1. Rejecting explanation:
   - Denies reality of symptom
   - Implies imaginary disorder
2. Colluding:
   - GP sanctions patients’ own explanation =
   - Implications: questioning GP’s openness and competence
3. Empowering explanations:
   - Tangible mechanism
   - Exculpation
   - Opportunity for self-management
   => Implications:
   - Legitimises patient’s suffering and removes blame from patient
   - Allies between GP and patient
   - Discussion of psychological features
   - Empowering

Question 8

What are the consequences of current medical approach?

Answer 8

• Excessive investigation and treatment
• Iatrogenesis (harm caused by healthcare) -> e.g. unnecessary treatment
• Heightened awareness of symptoms
• Lack of explanation causes distress -> patient feels disbelieved
• Breakdown of therapeutic relationship

Question 9

CBT approaches to managing MUS?

Answer 9

1. Identifies patients’ interpretations of sensations and beliefs about symptoms
2. Helps patients to develop alternative models
   - e.g. This pain is not indicative of disease
   - It is normal so I can live a normal life
3. ## Promotes behavioural changes -> improve symptoms -> feeds back into beliefsIs it effective? Systematic review of 31 controlled trials of CBT for MUS.
   => Result - 12 month improvement compared with treatment as usual in:
   - Physical symptoms
   - Functional status
   - Emotional distress

Question 10

What are issues in engaging patients with psychological therapy?

Answer 10

• Disenchanted with medical care
• Suspicious of mental health services
• Beliefs that symptoms are caused by disease
• Feel symptoms are not believed
• Sheer volume of individuals with MUS and limited capacity of CBT-trained therapists

=> It is important to be able to explain the rationale for treatment convincingly

Question 11

What is the adaptation of CBT to primary care?

Answer 11

1. Feeling understood: Explore illness belief, respond to emotional cues
2. Broadening the agenda: Exploration of emotional factors
3. Making the link (e.g. Stress response, muscle tensions)
4. Collaborating on a treatment or management approach
   => Benefits found in studies of MUS in Dutch and UK Primary care.
   —-
   Limitations:
   - No studies have yet compared the full cost effectiveness compared with CBT.
   - Unlikely to be as effective as full CBT for some patients with complex presentations.

Question 12

Do trained GPs make a difference in assuring/supporting patients with MUS?

Answer 12

1. Comparison of two cohorts of patients:
   - Before GPs trained vs. After training (N=150)
   - Results: improvements in patient satisfaction & decrease in patient somatising beliefs
   - BUT! No reduction in healthcare use

=> Patients with trained GPs less likely to still believe that the cause of their symptoms was purely physical (after 3 months)

2. RCT with 141 MUS patients:
   - Trained vs Control GPs
   - Significant (p<.001) improvement in GP’s communication behaviours:
   + Feeling understood
   + Broadening the agenda
   + Making the link
   + Negotiating treatment

=> Increased patient satisfaction (p<.05)
=> No increase in consultation length