medically-unexplained symptoms Flashcards
what happened in Kroenke & Price (1993) study
– 31% no medical diagnosis or explanaion
what is a medically unexplained symptom?
Symptoms for which no medical diagnosis or explanaion can be found are often called
“medically unexplained symptoms”
– This can be shortened to MUS
what is a medically unexplained syndrome?
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”
name 3 examples of medically unexplained symptoms
irritable bowel syndrome
chronic fatigue synrome
non-specific chest pain
From Nimnuan, Hotopf & Wessely, 2001, J Psychosom Res 51, 361-7
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
what are gynaecological symptoms
heavy/painful periods
what are neurological symptoms
seizures and dizziness
what are reginal pain presentations
atypical chest pain, headaches
what are musculoskeletal symptoms
low back pain
what is widespread pain and fatigue
chronic fatigue or fibromyalgia
what are gastrointestinal symptoms
abdominal pain
do MUS persist for a long time
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”
what is the problem of MUS
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?
what is the biomedical model
disease - symptoms- diagnosis - intervention - cure
what are MUS
symptoms or illness without disease
what is the medical/psychiatric response
“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”
the definition of somatiziation
the process by which psychological disresss is expressed as physical symptoms
the definition of somatization disorder
a diagnosic label for people with muliple medically unexplained symptoms.
why is somatization an unsatisfactory construct
Patients hate it as they feel that it delegiimizes their symptoms
• What does it mean for “psychological distress” to “come out” as bodily symptoms?
• There is scant evidence that having lots of bodily symptoms is related to denying emotional problems – in fact the opposite is true
is distress common in people with MUS
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)
More symptoms you have the more likely you are to also present with psychological symptoms
true
why is medically unexplained unsatisfactory
“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.
what is a symptom
What is a symptom?
– Bodily sensaions (e.g. Dizziness, pain)
– Bodily signs (e.g. Raised temperature)
which are atributed to illness
what is perception of bodily sensations
noticing sensations
attending to sensations
experiencing sensations
what is the interpretation of sensations
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
how does emotion interact with cognition
In the community, emoion is posiively correlated with physical symptoms e.g. faigue (Pawlikowska et al, 1994)
higher distress higher fatigue
bidirectional
what are the ways emotion interacts with cognition
• 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
is emotion positively correlated with physical symptoms
yes
do MUS challenge the biomedical model
yes
what is involved with the maintenance of symptoms
Cogniive and emoional processes are involved in the maintenance of symptoms
are MUS common
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
how are MUS managed in clinical practice
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
how do doctors explain MUS to patients - 3 ways
- rejecting
- colluding
- empowering
what does rejecting explanations consist of and its implications
denies realits of symptom
implies imaginary disorder
unresolved axplanatory conflict
gp is distrusted with future symptoms
what does colluding explanations consist of and its implications
gp sanction patients own explanation - ‘ i think your right i agree’
questioning gps openness and competence
what does empowering explanations consist of and its implications
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
Consequences of current medical approach
• 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
what is the psychological approach to MUS
Based on the idea that beliefs (cognitions),emotions, and behaviour interact with the body to maintain symptoms
what happens
bodily sensation
interpreted as symptom
rest - seek treatment - continued checking
worry
preoccupation- hypervigilance - bodily changes- sleep disturbance
bodily sensation
what does CBT do
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
CBT change to model
normalised
reduction in worry
sleep better - less preoccupied- less diabled - fitter
does CBT work
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
what are the issues in engaging patients in psychological therapy
• 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
adaption of CBT to primary care - reattribution therapy
what are the 4 stages
Stages of Reatribuion Therapy
1. Feeling understood – Explore illness belief, respond to emotional cues
- Broadening the agenda – Exploraion of emotional factors
- Making the link e.g. Stress response, muscle tensions - physical and emotional relationships
- Collaboraing on a treatment or management approach
does reattribution therapy work
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
trained GPS
improved GP communication behaviour
what is reattribution therapy
‘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)
does CBT have a strong evidence base
yes
who is reattribution therapy delivered by
non-psychologist health professionals
