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Mental health and Wellbeing > Week 7 Lecture 7 - Medically Unexplained symptoms > Flashcards

Week 7 Lecture 7 - Medically Unexplained symptoms Flashcards

1
Q

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?

A
  • 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!!

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2
Q

What are medically unexplained symptoms?

A

Symptoms for which no medical diagnosis or explanation can be found

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3
Q

What are medically unexplained syndromes?

A

When symptoms occur together regularly in clusters to form a recognisable illness, this may be defined as a “syndrome”

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4
Q

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?

A
  • 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

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5
Q

What are the different groups of symptoms that are present in MUS?

A
  • 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
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6
Q

True or false?

MUS often tend to persist for a long time

A

True

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7
Q

A Dutch primary care study (n=254) was conducted with patients with unexplained fatigue, abdominal or musculoskeletal complaints

What was found?

A

43% still had unexplained symptoms 1 year later

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8
Q

People with lots of persistent MUS tend to consult the doctor a lot

What are these people called?

A

“frequent attenders”

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9
Q

What is the problem of MUS?

A
  • 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?
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10
Q

What is the medical/psychiatric response to MUS violating the biomedical model?

A
  • Somatization
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11
Q

What is somatization?

A
  • psychological difficulty through somatic symptoms
  • unaccounted for by pathological findings
  • to attribute them to physical illness
  • seek medical help
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12
Q

What is the difference between somatization and somatization disorder?

A
  • Somatization: “The process by which psychological distress is expressed as physical symptoms.”
  • “Somatization disorder” a diagnostic label for people with multiple medically unexplained symptoms.
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13
Q

Is somatization as a construct satisfactory?

A
  • 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
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14
Q

What are MUS often accompanied by

A

psychological symptoms or distress

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15
Q

What did a study of co-occurrence of MUS and psychiatric symptoms in large community sample find?

A

More MUS, greater likelihood of anxiety and depression symptoms

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16
Q

Why is “medically unexplained” an unsatisfactory term?

A
  • Diagnosis by exclusion.
  • Continued concern ‘have we missed something?’
  • indicates failure of medical system
  • Patients can feel dismissed
17
Q

Are the symptoms real in MUS?

A

yes

18
Q

What is an alternative approach to try and explain MUS?

A

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.

19
Q

What is a symptom?

A
  • Bodily sensations (e.g. Dizziness, pain)
  • Bodily signs (e.g. Raised temperature)

which are attributed to illness

20
Q

How do we perceive bodily sensations?

A
  • by noticing sensations
  • and then attending to sensations
21
Q

How do we interpret bodily sensations (cognitive factors)?

A
  • Context important
  • Beliefs and personal models of illness, illness prototypes
  • May use heuristics – e.g. stress, age
  • Interpretations affected by emotional factors
22
Q

What did a community study find about how emotion interacts with cognition?

A

In the community, emotion is positively correlated with physical symptoms e.g. fatigue

23
Q

In what ways does emotion interact with cognition?

A
  • 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

24
Q

Is the interaction between emotion and cognition directional?

A

is bidirectional

25
Q

How are MUS managed in clinical practice?

A

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

26
Q

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?

A

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

27
Q

What are the consequences of the current medical approach to MUS?

A
  • 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
28
Q

What does iatrogenesis mean?

A

harm caused by healthcare

29
Q

What are psychological approaches to managing MUS?

A
  • Based on the idea that beliefs (cognitions), emotions, and behaviour interact with the body to maintain symptoms
30
Q

How can CBT be used to treat patients with MUS?

A
  • 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
31
Q

Kroenke & Swindle (2000) conducted a systematic review of 31 controlled trials (29 RCT) of CBT for MUS

What was found?

A

12 month improvement compared with treatment as usual (TAU) in:
- Physical symptoms
- Functional status
- Emotional distress

32
Q

What are some issues in engaging MUS patients with psychological therapy?

A
  • 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
33
Q

CBT was adapted to primary care (MUS). What was this called?

A

Reattribution therapy

34
Q

What is reattribution therapy?

A

Stages of Reattribution Therapy
1. Feeling understood
- Explore illness belief, respond to emotional cues

  1. Broadening the agenda
    - Exploration of emotional factors
  2. Making the link
    - e.g. Stress response, muscle tensions
  3. Collaborating on a treatment or management approach
35
Q

Morriss & Gask, 2002 compared patients before GPs trained on reattribution therapy with patients after training was completed.

What was found?

A
  • 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
36
Q

Morriss et al, 2007 replicated Morriss & Gask, 2002 study with 141 MUS patients in a RCT

What was found?

A

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)

  1. Increased patient satisfaction (p<.05)
  2. No increase in consultation length
37
Q

What conclusions have been made about reattribution therapy?

A
  • ‘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

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