Lecture 9 - Medically Unexplained Symptoms

Question 1

What are medically unexplained symptoms?

Answer 1

No medical diagnosis/explanation can be found for these symptoms (MUS)

Question 2

What are medically unexplained syndromes?

Answer 2

Symptoms occur together regularly in clusters to form recognisable illness

Question 3

What are some examples of medically unexplained syndromes?

Answer 3

Irritable bowel syndrome, chronic fatigue syndrome, tension, tinnitus, premenstrual syndrome

Question 4

How much of the population experiences medically unexplained symptoms?

Answer 4

80-90% per week (general)
19-25% (in primary care)
30-70/avg 53% (secondary care)

Question 5

How is fatigue distributed in the community?

Answer 5

Normally distributed

Question 6

What are some groups of symptoms?

Answer 6

Gynaecological symptoms, neurological symptoms, regional pain presentations, musculoskeletal symptoms, etc.

Question 7

What did a Dutch primary care study find about persistence of symptoms?

Answer 7

43% still had symptoms 1 year later

Question 8

What is the “problem” of MUS?

Answer 8

MUS violates biomedical model which conflates disease and illness

Disease>symptoms>diagnosis>intervention>care

But there isn’t disease so what’s happening?

Question 9

What is somatisation?

Answer 9

Manifestation of psychological difficulty/distress through somatic symptoms

Unaccounted for by pathology, attribute them to physical illness + seek help

Point: MUS caused by distress

Question 10

What is somatisation unsatisfactory?

Answer 10

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

Question 11

Why is medically unexplained unsatisfactory?

Answer 11

Diagnosis by exclusion, continued concern “have we missed something?”

Indicates failure of medical system, patients feel dismissed

Symptoms are real, not imaginary

Question 12

What are other approaches?

Answer 12

Explain experience in therms of interacting biological/psychological/social factors + help people manage them

Question 13

What is a symptom?

Answer 13

Bodily sensations/signs attributed to illness

Question 14

How do we perceive bodily sensations?

Answer 14

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

Question 15

How to we interpret sensations as symptoms?

Answer 15

Context important, beliefs/personal models of illness (illness prototypes), may use heuristics, interpretations affected by emotional factors

Question 16

What is normalising (causal attribution)?

Answer 16

The room is too hot (open window), out late last night (early night)

Question 17

What is psychologising (causal attribution)?

Answer 17

I’m stressed and wound up (emotion regulation/problem focused coping)

Question 18

What is somatising (causal attribution)?

Answer 18

Maybe I’m coming down with something? (see doctor)

Question 19

How does mood affect symptoms?

Answer 19

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

Question 20

How do GPs deal with patients with MUS?

Answer 20

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

Question 21

What are 3 diff types of received explanations?

Answer 21

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

Question 22

What are consequences of current medical approach?

Answer 22

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

Question 23

How does CBT work in those with MUS?

Answer 23

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

Question 24

What are issues in engaging patients with psychological therapy?

Answer 24

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

Question 25

What are the stages of reattribution therapy?

Answer 25

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)

Question 26

What are conclusions about reattribution therapy?

Answer 26

‘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