Week 7 Lecture 7 - Medically Unexplained symptoms Flashcards
Kroenke & Price (1993) conducted a large community sample of the lifetime prevalence of 26 common symptoms
They asked what the explanation for symptoms was
What did they find?
- 50.5% due to medically condition or injury
- 16.4% minor or transient symptoms
- 2.1% due to medication/substance use
31% no medical diagnosis or explanation!!
What are medically unexplained symptoms?
Symptoms for which no medical diagnosis or explanation can be found
What are medically unexplained syndromes?
When symptoms occur together regularly in clusters to form a recognisable illness, this may be defined as a “syndrome”
A study looked at consecutive referrals to 7 clinics in 2 London hospitals
What was the percentage of cases for which no medical diagnosis or explanation could be found?
- Dental –> M=50, F=33
- Chest –> M=26, F=53
- Neurology –> M=55, F=66
- Gynaecology –> F=66
around a 1/3 to 2/3 of cases referred to secondary care did not receive a diagnosis
What are the different groups of symptoms that are present in MUS?
- gynaecological symptoms e.g. heavy/painful periods
- neurological symptoms e.g. seizures, dizziness
- regional pain presentations e.g. atypical chest pain, headaches
- musculoskeletal symptoms e.g. low back pain
- widespread pain/fatigue e.g. chronic fatigue, fibromyalgia
- gastrointestinal symptoms e.g. abdominal pain
True or false?
MUS often tend to persist for a long time
True
A Dutch primary care study (n=254) was conducted with patients with unexplained fatigue, abdominal or musculoskeletal complaints
What was found?
43% still had unexplained symptoms 1 year later
People with lots of persistent MUS tend to consult the doctor a lot
What are these people called?
“frequent attenders”
What is the problem of MUS?
- MUS violate the biomedical model which conflates disease and illness
(disease > symptoms > diagnosis > intervention > cure) - But MUS are symptoms or illness without disease…
- 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 medical/psychiatric response to MUS violating the biomedical model?
- Somatization
What is somatization?
- psychological difficulty through somatic symptoms
- unaccounted for by pathological findings
- to attribute them to physical illness
- seek medical help
What is the difference between somatization and somatization disorder?
- Somatization: “The process by which psychological distress is expressed as physical symptoms.”
- “Somatization disorder” a diagnostic label for people with multiple medically unexplained symptoms.
Is somatization as a construct satisfactory?
- no
- Patients hate it as they feel that it delegitimizes 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
What are MUS often accompanied by
psychological symptoms or distress
What did a study of co-occurrence of MUS and psychiatric symptoms in large community sample find?
More MUS, greater likelihood of anxiety and depression symptoms
Why is “medically unexplained” an unsatisfactory term?
- Diagnosis by exclusion.
- Continued concern ‘have we missed something?’
- indicates failure of medical system
- Patients can feel dismissed
Are the symptoms real in MUS?
yes
What is an alternative approach to try and explain MUS?
Alternative approaches try to explain the experience of symptoms in terms of interacting biological, psychological and (to a lesser extent) social factors, and help people to manage them.
What is a symptom?
- Bodily sensations (e.g. Dizziness, pain)
- Bodily signs (e.g. Raised temperature)
which are attributed to illness
How do we perceive bodily sensations?
- by noticing sensations
- and then attending to sensations
How do we interpret bodily sensations (cognitive factors)?
- Context important
- Beliefs and personal models of illness, illness prototypes
- May use heuristics – e.g. stress, age
- Interpretations affected by emotional factors
What did a community study find about how emotion interacts with cognition?
In the community, emotion is positively correlated with physical symptoms e.g. fatigue
In what ways does emotion interact with cognition?
- Fear of being ill – more vigilant to bodily sensations
Physical sensations of anxiety:
- Sweating, shaking, dry throat, dizzy, nausea, stomach cramps, butterflies
Physical sensations of depression:
- Weight/appetite change, sleeplessness, early waking
- Tiredness, aches and pains
Is the interaction between emotion and cognition directional?
is bidirectional
How are MUS managed in clinical practice?
Many doctors don’t know what to do, so they try:
- ‘Reassurance’ (effective for approx 24 hours)
- Referral to secondary care departments –> 30-70% no physical pathology
- Physical investigation e.g. blood tests
- Symptomatic treatment e.g. analgesia
Surgery:
- e.g. proportion of appendectomies have normal histology
Qualitative study (N=68).
Interviewed patients with persistent MUS about the different explanations they had received from GPs and other health professionals
What was found?
Typology:
Rejecting:
- Denies reality of symptom
- Implies imaginary disorder
Implications:
- Unresolved explanatory conflict
- GP is distrusted with future symptoms
Colluding:
GP sanctions patient’s own explanation
Implications:
- Questioning GP’s openness and competence
Empowering:
- Tangible mechanism
- Exculpation
- Opportunity for self-management
Implications:
- Legitimises patient’s suffering and removes blame from patient
- Allies GP and patient
- Allows for discussion of psychological features
- Empowering
What are the consequences of the current medical approach to MUS?
- Excessive investigation and treatment
- Iatrogenesis* – e.g. unnecessary treatment
- Heightened awareness of symptoms
The lack of an explanation causes distress:
- Patient feels disbelieved
- ‘heartsink’ patients
- Breakdown of therapeutic relationship
What does iatrogenesis mean?
harm caused by healthcare
What are psychological approaches to managing MUS?
- Based on the idea that beliefs (cognitions), emotions, and behaviour interact with the body to maintain symptoms
How can CBT be used to treat patients with MUS?
- Identifies patients’ interpretations of sensations and beliefs about symptoms
- Helps patients to develop alternative models
- Promotes behavioural changes
- Behavioural changes improve symptoms
- Symptom improvement feeds back into beliefs
Kroenke & Swindle (2000) conducted a systematic review of 31 controlled trials (29 RCT) of CBT for MUS
What was found?
12 month improvement compared with treatment as usual (TAU) in:
- Physical symptoms
- Functional status
- Emotional distress
What are some issues in engaging MUS patients with 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
- Sheer volume of individuals with MUS and limited capacity of CBT-trained therapists
CBT was adapted to primary care (MUS). What was this called?
Reattribution therapy
What is reattribution therapy?
Stages of Reattribution Therapy
1. Feeling understood
- Explore illness belief, respond to emotional cues
- Broadening the agenda
- Exploration of emotional factors - Making the link
- e.g. Stress response, muscle tensions - Collaborating on a treatment or management approach
Morriss & Gask, 2002 compared patients before GPs trained on reattribution therapy with patients after training was completed.
What was found?
- Improvements in patient satisfaction and a decrease in patient somatizing beliefs
- Patients with trained GPs less likely to still believe that the cause of their symptoms was purely physical
But
- No benefit of reduction in healthcare use
Morriss et al, 2007 replicated Morriss & Gask, 2002 study with 141 MUS patients in a RCT
What was found?
Trained GPs had:
1. Improved GP communication behaviour
- Feeling understood (p<.001)
- Broadening the agenda (p<.001)
- Making the link (p<.001)
- Negotiating treatment (p<.001)
- Increased patient satisfaction (p<.05)
- No increase in consultation length
What conclusions have been made about reattribution therapy?
- ‘simplified’ cognitive behavioural intervention (Reattribution) 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 effectiveness compared with CBT.
- Unlikely to be as effective as full CBT for some patients with complex presentations
