Lecture 7 - Medically Unexplained Symptoms

Question 1

What did Pawlikowska et al. (1994) find about mood and fatigue?

Answer 1

There is a strong positive correlation between mood and fatigue
People who scored more highly on a measure of distress also rated themselves with higher levels of fatigue

Question 2

What percentage of people received no medical diagnosis in a sample of 13.5k people with lifetime prevalence of common symptoms?

Answer 2

31% - no explanation for symptoms

Question 3

What is the meaning of medically unexplained syndromes?

Answer 3

When symptoms occur together regularly in clusters to form illness defined as a syndrome. E.G - IBS, chronic fatigue

Question 4

What are examples of medically unexplained symptoms?

Answer 4

Heavy periods, abdominal pain, seizures, dizziness, chronic fatigue, low back pain

Question 5

How many people receive no diagnosis once referred to secondary care?

Answer 5

1/3 to 1/2 of PPTs

Question 6

What did Koch et al. (2009) find? - Dutch primary care study about MUS

Answer 6

254 patients with unexplained fatigue, abdominal or musculoskeletal complaints. Attended doctors multiple times and 43% still had unexplained symptoms one year later

Question 7

What is the problem of MUS?

Answer 7

• Problems for patients and medical professions
• Violates the biomedical model for disease and illness:
  Disease -> symptoms -> diagnosis -> intervention -> cure

Question 8

What is Somatisation? - Lipowsky 1988

Answer 8

The manifestation of psychological difficulty or distress through somatic symptoms, tendency to experience and communicate somatic distress and symptoms unaccounted for by pathological findings and attribute them to physical illness and seek medical help.
PSYCHOLOGICAL DISTRESS IS EXPRESSED AS PHYSICAL SYMPTOMS

Question 9

Why do patients dislike the construct of somatisation?

Answer 9

• Delegitimises their symptoms
• Symptoms are often debilitating - feel like they are not being taken seriously
• Makes patients feel stupid / as if they are imagining / feel dismissed

Question 10

What are perceptual and cognitive factors to symptoms?

Answer 10

• Noticing bodily sensations and attending to them
• Sensations
• Context
• Heuristics - stress in exam period = headache
• Age - attribute sensations to a sign of ageing

Question 11

How does mood affect symptoms?

Answer 11

• Fear of being ill, people are more alert to bodily sensations (vigilant)
• Hypochondria - transient symptom my become worse / phobia of illness
• Physical sensations of anxiety - sweating, shaking, fainting
• Depression - affects appetite and sleep

Question 12

How does emotion correlate with physical symptoms?

Answer 12

When sad, may stay in bed = more tired, don’t exercise or socialise = more tired

Question 13

What can doctors do with MUS patients?

Answer 13

• Reassure
• Refer to secondary care department (30-70% no diagnosis)
• Physical interventions such as blood tests

Question 14

How do doctors explain MUS to patients?

Answer 14

• Rejecting = some deny reality of symptoms, claim it’s imaginary. Implication = unresolved conflict, GP appears untrustworthy
• Colluding = GP sanctions patients own explanation and agrees with patient. This can make a patient question the GPs competence
• Empowering = Tangible mechanism, opportunity for self management - give physical or muscular explanation, TENSION CAUSING NECK PAIN - find a solution together - regaining control of body

Question 15

What is iatrogenesis?

Answer 15

Harm caused by healthcare - unnecessary treatment

Question 16

How can psychological factors maintain MUS?

Answer 16

Bodily sensation -> interpreted as symptom -> worry -> preoccupied and hyper-vigilant -> increased bodily sensations

Question 17

How can CBT help MUS?

Answer 17

• Identifies the patients interpretation of their sensation
• Develop an alternative belief - the pain is not a disease
• Remain active but not over vigilant - reduce worry
• Reduces preoccupation & less debilitating

Question 18

What did Kroenke & Swindle (2000) find about CBT for MUS?

Answer 18

12 month improvement compared with normal treatment in physical, functional and emotional symptoms
When patient is engaged, CBT is effective

Question 19

What are the issues with engaging patients to CBT?

Answer 19

• Likely to be fed up and frustrated with the lack of answers
• Believe they are ill - hard belief to change
• Feel like they aren’t being taken seriously

Question 20

What is Reattribution Therapy

Answer 20

• Hierarchical model of stages:
• Feeling understood (explore the illness and listen)
• Broadening the agenda - exploration of emotional factors and how the physical symptoms may be linked to this
• Making the link - STRESS, TENSION
• Collaborating on a treatment
• Important to feel heard

Question 21

What’s the evidence of Reattribution Therapy working?

Answer 21

• Improvement in patient satisfaction and decreased somatisation
• Less likely to believe cause of symptom was purely physical - change of beliefs
• However, no benefit in reduction in healthcare use - still just as likely to take meds and see GP

Question 22

How many MUS occurs in dental sector?

Answer 22

50% males, 33% females

Question 23

How many MUS occurs in chest sector?

Answer 23

26% males, 53% females

Question 24

How many MUS occurs in cardiology?

Answer 24

42% males, 63% females