1. Anita R. Webb, PhD JPS Health Network Fort Worth, Texas

2.  Medically unexplained symptoms are common.  Costly due to repeated testing and treatments  Frustrating to physicians and patients  Psychological and sociological theories  Precursors: Childhood and family illness  Treatment: Collaborative Care

3.  “Symptoms with no clear organic cause”  Which cause suffering: Pain, fatigue, disability  Recent Examples  Chronic Fatigue Syndrome  Fibromyalgia  Gulf War Syndrome

4.  “Extremely Common”  ( DeAngelis 2013)  Up to 50% of new patient visits  Pain: esp. abdominal, head, back, joint, chest  Dyspepsia, palpitations, fatigue, etc.  Associated with considerable disability  (Margalit 2008)

5.  General Practice  Testing: Attempts to identify diagnosis  Relationship: Supporting the patient  Conservative approach is recommended  Referral  Collaborative Care  Psychiatry, Neurology  Psychology: Cognitive Behavioral Therapy (CBT)

6.  Typically: Increased costs  Multiple laboratory tests  Multiple “trial treatments”  Risk of iatrogenic complications  Annual costs > $6500 per affected patient

7.  National Survey of Health and Development  Goal: Identify childhood influences on adult health  Cumulative body of research  http://www.nshd.mrc.ac.uk  “Lifelong Health & Ageing”: LHA  Example: Prospective birth cohort study  National sample: 1946 to age 36  N = 3107  GOAL: Identify and track  5% most common symptoms

8.  Childhood correlations of adult symptoms  1. Increased rate of physical illness in family during patient’s childhood  2. Patient’s “defined” physical illness  Conclusion:  “May reflect a learned process whereby illness experience leads to symptom monitoring”

9.  “Society does not grant permission to be ill in the absence of disease.”  Issues  Implies malingering?  Morality (“pejorative overtones”)  Chaos  Ambivalence  (Bauman 1991) 

10.  Patients with unexplained motor symptoms  48%: with absence of function  52%: with abnormal activity (e.g. tremor)  Were referred to hospital  For “neurological disorder”  N=73  Six year follow-up  N=64 (88%)  Hatcher (2008)

11.  Diagnosis  Psychiatric Disorder  75% (44/59)  Most common psychiatric diagnosis  “Personality Disorder”  45% (31/59)  (continued)

12.  25% of patients diagnosed with  Chronic pain  Irritable bowel syndrome  Chronic fatigue  New neurology cases explained by disease  33% cases “Not at all”  or “Only somewhat”  Hatcher (2008)

13.  “Unexplained Pain”  Neurology outpatients  N=18  Qualitative Interview study  Conclusion: “The patients were  “Resistant to psychological explanations”  (Nettelton 2006: Sociology)

14.  May feel their competence is being challenged  (Hatcher 2008)  Suggest continued professional development  Personal and interpersonal skills  Good communication habits  Self Awareness: especially your stress level  Stress Management Skills

15.  Referral with vague diagnoses:  Somatization  Hypochondriasis  Pain disorder  Patients with identified medical disease plus  Identified depression and/or anxiety  And/or with significantly more medical symptoms

16.  Most common comorbid psychiatric diagnoses  Depression  Anxiety  Personality Disorder

17.  HOWEVER:  “Many patients do not have a psychiatric disorder.”  “A multicausal aetiology is most likely”  Physical and psychological factors interacting  Factors that predispose to somaticizing:  Greater awareness and  Even misinterpretation  Of minor physical perceptions  (continued)

18.  Personality  Previous experience of illness  Life stress  Attitudes toward medical care  Expectations  Behavior  (Mayou 1991)

19.  “Pejorative overtones”?  Most symptoms are transient  Employ straightforward management  “If initial assessment does not suggest  “A serious underlying physical cause,  “Then eventually uncovering one  “Is extremely unlikely.”

20.  AGENDA:  Identify childhood influences on adult health  Body of research on physical illness in children  National Survey of Health and Development  NSHD: N = 3107  Prospective birth cohort study to age 36  Identify and track 5% most common symptoms

21.  “Powerful relationship” between  Poor reported health of parents  When subjects were age 15  Predicted subjects’ symptoms  At age 36

22.  Two groups: 21 patients in each group  “Biopsychosocial” group vs. control group  Results for intervention group:  Clinic visits decreased from baseline (N=32)  To 13 visits after first year  And 15 visits after two years  ER visits decreased from 33.5  To 4 year one  And 3.5 year two

23.  “Usual care” results  No changes in number of visits  To clinic  Or to ER  Five year mortality  Control group = 17 patient deaths  Intervention group = 6 patient deaths Margalit (2008)

24.  Biopsychosocial intervention decreased  Number of visits  Care utilization  Expense  Mortality

25.  Dual Approach  Investigate somatic symptoms, plus  Recognize and manage psychological factors  Goal: “Damage limitation” [vs. cure]  Consider:  Referral for Cognitive Behavioral Therapy  Goal: Identify and change erroneous health beliefs  (Matou 1991)

26.  Relaxation Training  Pre-planned distraction activities  Regular and often deep breathing exercises  Health “diary”  Gradual, stepped increase in physical activity  Gradually limit over-use of medical resources  Including unnecessary investigation  Goal: Cost-effective treatment

27.  And/Or: You can initiate discussion of the patient’s erroneous health beliefs.  “Most [patients] are satisfied by simple:  Explanation,  Discussion, and  Reassurance.”  (Ibid)

28.  Only ONE physician for all medical care  Pre-scheduled medical appointments  Weekly initially  Eventually tapering gradually  Patient satisfaction?  Probably not realistic goal  Physician satisfaction?  Ineffective, unsatisfying consultation?

29.  Most such symptoms are transient.  Use “straightforward management”  “If initial assessment does not suggest a serious underlying physical cause,  “Then eventually uncovering one,  “Is extremely unlikely.”  (Mayou 1999)

30.  Unexplained medical symptoms are a common clinical problem.  Organic explanations are rare.  “High level of psychiatric comorbidity”  Avoid repeat investigation(s).  (Crimlisk et al 1998)

31.  Questions?  Comments?  Suggestions?  Your experiences?  Residents’ attitudes?  Faculty attitudes?