Session Ten (Persistent Physical Symptoms) Flashcards
What are Persistent Physical Symptoms?
New term for Medically Unexplained Symptoms
Essentially:
- Persistent bodily symptoms
- With functional disability
- But no explanatory pathology
N.B. Even if symptoms aren’t real, distress is very real and therefore must be managed appropriately.
Give some examples of PPS?
Symptoms:
- Dizziness
- Headaches
- Chest pain
- Lower back pain
- Limb weakness
Recognised as conditions:
- Fibromyalgia
- IBS
- Chronic Fatigue
- Functional Neurological disorder
- Non-Cardiac chest pain
- Irritable bladder syndrome
- Non-epileptic seizures
What terms are used clinically for persistent physical symptoms?
- MUS
- Functional conditions e.g. functional dyspepsia
- Idiopathic
- Somatisation
- Miscellaneous specific terms such as IBS, CFS
How does DSM-5 define Somatic Symptom Disorder (another term for PPS)?
3 Criteria:
- Symptoms are distressing and impairing
- Must persist for 6 months +
- Must be associated with abnormal and excessive thoughts, feelings, behaviours (e.g. anxiety, illness behaviour, catastrophising)
Name some common characteristics of PPSs?
- Symptoms are often as debilitating as those caused by organic disease
- Have similar accompanying distress and impaired functioning
- Patients often have underlying long term health conditions (e.g. diabetes or inflammatory diseases)
- Presentations vary widely
- More common in women (3 : 1)
- Poor prognosis if simply ignored
How prevalent are PPS/MUS?
- 90% of people experience some sort of MUS every week
- 1/5 new consultations in primary care are relating to a somatic symptom with no organic pathology
- One of the most common reasons for outpatient referrals
- 50% have co-morbid anxiety and depression
Name some conditions where the vast majority of presentations are unexplained?
- Chest pain
- Fatigue
- Dizziness
- Headache
- Back pain
- SoB
What did Stone and Carson’s 2015 5 year follow up study on MUS show?
- PPS can and does get better
- Treatment can be effective
- Prognosis is poor if left untreated
- No greater risk of missing underlying pathology than just dismissing the patient, therefore shouldn’t shy away from the diagnosis
- Many patients have an overlap with similar physical health conditions e.g. Asthmatics may develop difficult breathing outside of their asthma, Epileptics may develop NE seizures, non-cardiac chest pain after MI
What form of therapy for PPS has the most supporting evidence?
CBT.
Kleinstauber et al, 2011:
- Demonstrates both long and short term efficacy in the management of MUS
White et al, 2011:
- Larger treatment effects seen in specific syndromes such as CFS
Physiotherapy has also shown to be highly effective for people with functional neuro disorder
Why is finding effective therapy for PPS of such vital importance?
Immense burden on health care services:
- More than a quarter of primary care patients present with unexplained pain, IBS, chronic fatigue
- People with a PPS are 2/3 times more likely to have mental health problems
- PPS + mental health issues raises health care costs upon to 45%
What is the trans diagnostic approach in PPS?
The idea that there are essential shared commonalities between different PPS, for instance:
- Fatigue and Pain in CFS, IBS
- Avoidance, Misappraisals and All or Nothing thinking are also very commonly seen
TD approach states we should focus on the similarities and differences between these cases rather than lumping them together or splitting them up.
Outline the rationale for the trans diagnostic approach to PPS?
Chalder et al, 2017:
- There is significant symptom overlap and sharing of cognitive and behavioural processes behind various PPS
- However there are also processes which are stronger in some conditions than others, e.g. embarrassment in IBS
- So, any approach needs to be flexible enough to also consider condition specific and individual differences
- An individualised Cognitive Behavioural formulation can achieve this, by addressing similarities and differences between conditions
What is the underlying focus of the trans diagnostic approach?
Identifying the core and common, maladaptive:
- Temperamental
- Psychological
- Cognitive
- Emotional
- Interpersonal
- Behavioural
…processes which underlie conditions
What factors might predispose someone to developing a PPS?
- Genetic factors
- High neuroticism scores
- Chronic stress
- Perfectionism
- Maternal overprotection
- Paternal hostility or rejection
- Childhood experiences of illness (either self or parental)
- Learning in childhood that any symptom is dangerous or catastrophic
What factors may precipitate the development of PPS?
- Adverse life events
- Infections or other health problems
- Illness and stress combo
