medically-unexplained symptoms

Question 1

what happened in Kroenke & Price (1993) study

Answer 1

– 31% no medical diagnosis or explanaion

Question 2

what is a medically unexplained symptom?

Answer 2

Symptoms for which no medical diagnosis or explanaion can be found are often called
“medically unexplained symptoms”

– This can be shortened to MUS

Question 3

what is a medically unexplained syndrome?

Answer 3

When symptoms occur together regularly inclusters to form a recognisable illness, this
may be deined as a “syndrome”
• So we also have “medically unexplained syndromes”

Question 4

name 3 examples of medically unexplained symptoms

Answer 4

irritable bowel syndrome
chronic fatigue synrome
non-specific chest pain

Question 5

From Nimnuan, Hotopf & Wessely, 2001, J Psychosom Res 51, 361-7

Answer 5

Around a third to a half of pps presenting in secondary care there is no medical diagnosis or explanation for the symptoms that have been significantly impactful or severe enough for them to be referred to secondary care

Question 6

what are gynaecological symptoms

Answer 6

heavy/painful periods

Question 7

what are neurological symptoms

Answer 7

seizures and dizziness

Question 8

what are reginal pain presentations

Answer 8

atypical chest pain, headaches

Question 9

what are musculoskeletal symptoms

Answer 9

low back pain

Question 10

what is widespread pain and fatigue

Answer 10

chronic fatigue or fibromyalgia

Question 11

what are gastrointestinal symptoms

Answer 11

abdominal pain

Question 12

do MUS persist for a long time

Answer 12

Dutch primary care study (n=254) of patients with unexplained fatigue, abdominal or musculoskeletal complaints. 
• 43% still had unexplained symptoms 1
year later (Koch et al, 2009)
• People with lots of persistent MUS tend to consult the doctor a lot – “frequent attenders”

Question 13

what is the problem of MUS

Answer 13

it violates the biomedical model which conflates disease and illness

If (according to the biomedical model) illness is a sign of disease and a person is ill without a disease, what can be going on?

Question 14

what is the biomedical model

Answer 14

disease - symptoms- diagnosis - intervention - cure

Question 15

what are MUS

Answer 15

symptoms or illness without disease

Question 16

what is the medical/psychiatric response

Answer 16

“Somatizaion is the manifestaion of psychological difficulty or distress through somatic symptoms, a tendency to experience and communicate somatic distress and symptoms unaccounted for by pathological findings and to atribute them to physical illness and seek medical help”

Question 17

the definition of somatiziation

Answer 17

the process by which psychological disresss is expressed as physical symptoms

Question 18

the definition of somatization disorder

Answer 18

a diagnosic label for people with muliple medically unexplained symptoms.

Question 19

why is somatization an unsatisfactory construct

Answer 19

Patients hate it as they feel that it delegiimizes their symptoms

Question 20

• What does it mean for “psychological distress” to “come out” as bodily symptoms?

Answer 20

• There is scant evidence that having lots of bodily symptoms is related to denying emotional problems – in fact the opposite is true

Question 21

is distress common in people with MUS

Answer 21

MUS are often accompanied by psychological symptoms or distress
• Study of co-occurrence of MUS and psychiatric symptoms in large community
sample
• More MUS, greater likelihood of anxiety and depression symptoms. (Simon &
Vonkorff, 1991)

Question 22

More symptoms you have the more likely you are to also present with psychological symptoms

Answer 22

true

Question 23

why is medically unexplained unsatisfactory

Answer 23

“Somaizaion” is unsaisfactory
• “Medically unexplained” is unsaisfactory – Diagnosis by exclusion. Coninued concern ‘have we missed something?’; indicates failure of medical system. Paients can feel dismissed.

• Symptoms are real. They are not imaginary, they are not made up.
• Alternaive approaches try to explain theexperience of symptoms in terms of interacting biological, psychological and (to a lesserextent) social factors, and help people to manage them.

Question 24

what is a symptom

Answer 24

What is a symptom?
– Bodily sensaions (e.g. Dizziness, pain)
– Bodily signs (e.g. Raised temperature)
which are atributed to illness

Question 25

what is perception of bodily sensations

Answer 25

noticing sensations attending to sensations experiencing sensations

Question 26

what is the interpretation of sensations

Answer 26

Interpretaion of sensaions – Context important – Beliefs and personal models of illness, illness prototypes – May use heurisics – e.g. stress, age - rule of thumb – Interpretations afected by emotional factors - personal experiences- illness in the family - makes you think a certain way

Question 27

how does emotion interact with cognition

Answer 27

In the community, emoion is posiively correlated with physical symptoms e.g. faigue (Pawlikowska et al, 1994) higher distress higher fatigue bidirectional

Question 28

what are the ways emotion interacts with cognition

Answer 28

• Fear of being ill – more vigilant to bodily sensations • Physical sensations of anxiety – Sweating, shaking, dry throat, dizzy, nausea, stomach cramps, buterlies • Physical sensations of depression – Weight/appeite change, sleeplessness, early waking – Tiredness, aches and pains

Question 29

is emotion positively correlated with physical symptoms

Answer 29

yes

Question 30

do MUS challenge the biomedical model

Answer 30

yes

Question 31

what is involved with the maintenance of symptoms

Answer 31

Cogniive and emoional processes are involved in the maintenance of symptoms

Question 32

are MUS common

Answer 32

Yes Medically unexplained symptoms are a common reason to present to health care services • They can be long-lasing, disabling and very distressing to live with

Question 33

how are MUS managed in clinical practice

Answer 33

Many doctors don’t know what to do, so they try – ‘Reassurance’ (efecive for approx 24 hours; Lucock et al, 1997) – Referral to secondary care departments • 30-70% no physical pathology – Physical investigaion • e.g. blood tests, scans/x-rays, endoscopy, laparoscopy – Symptomatic treatment • e.g. analgesia, anibioics, anidepressants * Surgery * e.g. proporion of appendectomies have normal histology

Question 34

how do doctors explain MUS to patients - 3 ways

Answer 34

1. rejecting 2. colluding 3. empowering

Question 35

what does rejecting explanations consist of and its implications

Answer 35

denies realits of symptom implies imaginary disorder unresolved axplanatory conflict gp is distrusted with future symptoms

Question 36

what does colluding explanations consist of and its implications

Answer 36

gp sanction patients own explanation - ' i think your right i agree' questioning gps openness and competence

Question 37

what does empowering explanations consist of and its implications

Answer 37

tangible mechanisms excuplation opportunity for self-management Implicaions are: – Legitimises paient’s sufering and removes blame from paient – Allies GP and patient – Allows for discussion of psychological features – Empowering

Question 38

Consequences of current medical approach

Answer 38

• Excessive investigation and treatment • Iatrogenesis* – e.g. unnecessary treatment - harm caused by healthcare • Heightened awareness of symptoms • The lack of an explanation causes distress – Paient feels disbelieved – ‘heartsink’ paients (O’Dowd, 1988) • Breakdown of therapeuic relaionship

Question 39

what is the psychological approach to MUS

Answer 39

Based on the idea that beliefs (cognitions),emotions, and behaviour interact with the body to maintain symptoms

Question 40

what happens

Answer 40

bodily sensation interpreted as symptom rest - seek treatment - continued checking worry preoccupation- hypervigilance - bodily changes- sleep disturbance bodily sensation

Question 41

what does CBT do

Answer 41

identifies paients’ interpretations of sensations and beliefs about symptoms (their explanatory models) Helps patients to develop alternative models – e.g. This pain is not indicative of disease – I can manage it – It is normal so I can live a normal life Promotes behavioural changes (increasing acivity, reducing checking, help seeking) Behavioural changes improve symptoms Symptom improvement feeds back into beliefs

Question 42

CBT change to model

Answer 42

normalised reduction in worry sleep better - less preoccupied- less diabled - fitter

Question 43

does CBT work

Answer 43

Systemaic review of 31 controlled trials (29 Randomised controlled trials) of cognitive behavioural therapy (CBT) for MUS • 12 month improvement compared with treatment as usual (TAU) in: – Physical symptoms – Funcional status – Emoional distress

Question 44

what are the issues in engaging patients in psychological therapy

Answer 44

• Disenchanted with medical care • Suspicious of mental health services • Beliefs that symptoms are caused by disease • Feel symptoms are not believed • It is important to be able to explain the rationale for treatment convincingly - limited CBT trained therapists

Question 45

adaption of CBT to primary care - reattribution therapy | what are the 4 stages

Answer 45

Stages of Reatribuion Therapy 1. Feeling understood – Explore illness belief, respond to emotional cues 2. Broadening the agenda – Exploraion of emotional factors 3. Making the link e.g. Stress response, muscle tensions - physical and emotional relationships 4. Collaboraing on a treatment or management approach

Question 46

does reattribution therapy work

Answer 46

improvement in patient satisfaction decrease in somatizing beliefs no benefit of reduction in healthcare use less likely to believe the cause of symptom was purely physical

Question 47

trained GPS

Answer 47

improved GP communication behaviour

Question 48

what is reattribution therapy

Answer 48

‘simpliied’ cogniive behavioural intervention (Reattribuion) can be delivered by non- psychology trained health professionals in a way that is feasible and acceptable to patients and NHS  But no studies have yet compared the full cost effeciveness compared with CBT.  Unlikely to be as effective as full CBT for some patients with complex presentaions (Gask, 2011)

Question 49

does CBT have a strong evidence base

Answer 49

yes

Question 50

who is reattribution therapy delivered by

Answer 50

non-psychologist health professionals