Lecture 9 - Medically Unexplained Symptoms Flashcards
What are medically unexplained symptoms?
No medical diagnosis/explanation can be found for these symptoms (MUS)
What are medically unexplained syndromes?
Symptoms occur together regularly in clusters to form recognisable illness
What are some examples of medically unexplained syndromes?
Irritable bowel syndrome, chronic fatigue syndrome, tension, tinnitus, premenstrual syndrome
How much of the population experiences medically unexplained symptoms?
80-90% per week (general)
19-25% (in primary care)
30-70/avg 53% (secondary care)
How is fatigue distributed in the community?
Normally distributed
What are some groups of symptoms?
Gynaecological symptoms, neurological symptoms, regional pain presentations, musculoskeletal symptoms, etc.
What did a Dutch primary care study find about persistence of symptoms?
43% still had symptoms 1 year later
What is the “problem” of MUS?
MUS violates biomedical model which conflates disease and illness
Disease>symptoms>diagnosis>intervention>care
But there isn’t disease so what’s happening?
What is somatisation?
Manifestation of psychological difficulty/distress through somatic symptoms
Unaccounted for by pathology, attribute them to physical illness + seek help
Point: MUS caused by distress
What is somatisation unsatisfactory?
Patients hate it bc feels like delegitimizes their symptoms, what does it mean for “psychological distress” to “come out”
Scant evidence having lots of bodily symptoms related to denying emotional problems, opposite is true
MUS often accompanied by psychological symptoms or distress
Why is medically unexplained unsatisfactory?
Diagnosis by exclusion, continued concern “have we missed something?”
Indicates failure of medical system, patients feel dismissed
Symptoms are real, not imaginary
What are other approaches?
Explain experience in therms of interacting biological/psychological/social factors + help people manage them
What is a symptom?
Bodily sensations/signs attributed to illness
How do we perceive bodily sensations?
Notice + attend to sensations, competition of cues
Pennebaker/Lightner: make people cycle + listen to music or own breathing, listen to own breathing group reported more fatigue/pain/effort
How to we interpret sensations as symptoms?
Context important, beliefs/personal models of illness (illness prototypes), may use heuristics, interpretations affected by emotional factors
What is normalising (causal attribution)?
The room is too hot (open window), out late last night (early night)
What is psychologising (causal attribution)?
I’m stressed and wound up (emotion regulation/problem focused coping)
What is somatising (causal attribution)?
Maybe I’m coming down with something? (see doctor)
How does mood affect symptoms?
Fear of being ill – more vigilant to bodily sensations
Physical sensations of anxiety: sweating, shaking, dry throat, dizzy, nausea, cramps
Physical sensations of depression: weight/appetite change, sleeplessness
Many patients with unexplained symptoms depressed/anxiety (85%)
In community emotion positively correlated with physical sensations
Fatigue symptoms positively correlate with distress
How do GPs deal with patients with MUS?
Many GPs don’t know what to do, so they try
Reassurance (effective approx. 24 hours)
Referral to secondary care departments
Physical investigation: blood tests, scans, endoscopy
Symptomatic treatment: analgesia, antibiotics, antidepressants
Surgery (15-40% appendectomies have normal histology
What are 3 diff types of received explanations?
Rejecting Explanations: denies reality of symptoms, implies imaginary disorder
Implications: unresolved explanatory conflict, GP distrusted w/ future symptoms
Colluding Explanations: GP sanctions patient’s own explanation
Implications: questioning GP’s openness/experience
Empowering Explanations: tangible mechanism, exculpation, opportunity for self-management (eg. “He explained about tensing myself up so neck kept hurting”)
Legitimises patient’s suffering/removes blame from patient, allies GP + patient, allows for discussion of psychological features
What are consequences of current medical approach?
Excessive investigation/treatment, iatrogenesis (unnecessary treatment, harm caused by healthcare), heightened awareness of symptoms, lack of explanation causes distress (feel disbelieved), breakdown of therapeutic relationship
How does CBT work in those with MUS?
Identifies patient’s interpretations of sensations/beliefs about symptoms
Helps patients develop alternative models: not indicative of disease, can manage it
Promotes behavioural changes (increase activity, reduce checking/help seeking)
Changes improve symptoms, symptom improvement feeds back into beliefs
Kroenke/Swindle (2000): 31 controlled trials of CBT for MUS
12 month improvement compared w/ treatment as usual in physical symptoms, functional status, emotional distress
What are issues in engaging patients with psychological therapy?
Disenchanted w/ medical care, suspicious of mental health services, beliefs symptoms caused by disease, feel symptoms not believed, important to explain rationale convincingly, sheer volume of individuals
What are the stages of reattribution therapy?
Feeling understood: explore illness belief, respond to emotional cues
Broadening agenda: explore emotional factors
Making the link: stress response, muscle tensions
Collaborating on treatment/management approach
(Benefits found in studies of MUS in Dutch/UK primary care)
What are conclusions about reattribution therapy?
‘Simplified’ cognitive behavioural intervention can be delivered by non-psych trained health professionals + still be feasible/acceptable
No studies compared full cost effectiveness with CBT yet, unlikely to be as effective for complex patients
