1. Medically Unexplained Physical Symptoms for GP trainees
Dr Sarah Burlinson
Consultant in Liaison Psychiatry
Royal Oldham Hospital
Pennine Care NHS Trust

2. Aims Appreciate how common these are Increase assessment skills
Recognise associated psychiatric diagnoses
Strategies to manage in primary care
Simple scenarios
Complex patients

3. List 8 common physical symptoms which are often medically unexplained?

4. Common Medically Unexplained Symptoms
Ankle swelling
Breathlessness
Insomnia
Numbness
Pain
Fatigue
Dizziness
Headache
The term ‘Functional disorders’ refers to a number of related syndromes that have been characterised by the reporting of physical symptoms and resultant disability rather than on the evidence of an underlying conventional disease process
These symptoms may have a medical cause but commonly turn out to be medically unexplained

5. What % of these are found to have a medical cause when followed up for 1 year?
76%-100%
51%-75%
25%-50%
0-24%

6. These common symptoms…..
At 1 year: only 10-15% due to organic cause (Katon 1998)
Prompt < 50% of primary care consultations
10% of patients with ‘MUS’ diagnosed with organic disease at 18 months FU (Morriss 2007)
organic origin in only % in pts fu for 1 year..Katon ’98
These symptoms prompt almost half of all primary care consultations,
Patients Dx with Mups after appropriate assessment and Ix unlikely to show later evidence of underlying organic disease that might account for the presenting symps……but they may do so MUS best viewed as a ‘working hypothesis’
Morris 14/141 patients…only 1 life threatening
(Crimlisk 1998 FU 73 patients with MUPs (following full examintion/ investigation) for 6 yrs….only 3 developed organic disease which could have accounted for their symps
Jackson et al 2006…500 consec patients in a medical clinic in US with physical symptoms
At 5 yrs symptoms were still present in 50%, and 1/3 of the symptoms remained medically unexplained
(patients with SD had most symptoms and less likely 2 improve))

7. How common are MUS in NP in Primary Care?
76%-100%
51%-75%
25%-50%
0-24%
Are they more or less common in
Secondary Care OP clinics?

8. How common are MUS? Primary Care Secondary Care
20% of new GP consultations
1/3 of these persist
Secondary Care
25-50% of new medical out-patients
Chronic MUPS/ somatisation disorder
0.5-4 % community prevalence
New GP consultations :20% (Peveler 1997)
Jackson et al 2006…500 consec patients in a medical clinic in US with physical symptoms
At 5 yrs symptoms were still present in 50%, and 1/3 of the symptoms remained medically unexplained
(patients with SD had most symptoms and less likely 2 improve))…ie approx 17% of original 500 with symptoms were MUS at 5 years

9. Impact of MUS Patients Staff Resources Psychological Physical Social
Frustration/ demoralisation
‘Heart sink’ patient
Resources
Investigations/ admissions/clinics/medication
Patients
psychological-angry, frightened, depressed, confused (ecg N but try this to see if any help) emphatic language>>>misreporting
physical-reduced activity…deconditioning/checking behaviours/SE meds/ iatrogenic ..adhesions from surgery, hypervigilance etc
social-job loss, financial diffs, loss of role & relationships
Staff
Often feel pressurised to do something such as Ix or refer on…patients frequently use emotive language to describe symptoms and emphasize their disabling effectsf
One study showed that GPs felt the patient wanted to be referred to secondary care….but actually that wasn’t what the patient was after
Frustration/ demoralisation
Patient relationship….’heart sink’ patient
Resources
Reid and wessley freq attenders with MUPS have higher usage and costs for medical investigations than frequent attenders without mups
Investigations/ admissions/clinics/medication

10. Possible mechanisms Autonomic arousal Muscular tension
Hyperventilation
Hyper-vigilance
Mood disorder
De-conditioning
The following may heighten bodily sensation…which may be felt as symptoms…
Autonomic arousal…inc HR, palpatations, trmor sweating
Muscular tension
Hyperventilation…may induce chest pain, dizziness, tingling
Hyper-vigilance
Mood disorder
De-conditioning
Mood disorder….alt pain threshold….50% of patients with MUPS meet DSM criteria for anxiety or depression kroenke 94 simon 96
neuroendocrine changes could also be implicated…dec cortisol in CFs, red responsiveness of HPA axis in FM, gut may be overactivated by corticotrophin releasing hormone in IBS etc…hard 2 know if primary or secondary
Meds effecting noradrenaline transmission….seem to help pain irrespective of whether depressed of not….eg amitrip, venlafaxine,duloxetine

11. Predisposing/ precipitating & maintaining factors
Female
Parental ill-health/ childhood adversity
Life events
Past/ current psychiatric illness
Health care response
Secondary gain
Female..found in gen pop, primary and secondary care , not explained by inc anx/ depr (wesleys study of MUPS in secondary care)
Parental ill-health ..childhood experience of
Childhood abdominal pain
Childhood adversity including illness, abuse etc
Recent ‘life events’…..high rates of recent LE in period predating onset of MUPS…..similar to that seen b4 onset of depressive illness
High rates of Recent LE in period predating onset of MUS….30% of CFS patienst experienced ‘dilemmas in months preceding onset of symptoms (cf none of the controls)
For SD..high rates of PD…small stidy of 25 female patienst suggested 72%...passive dependanet, histrioninc, sensitive aggressive
GP’s often feel under pressure to refer
Some will be attending several secondary care facilities at once…GP may have arranged this or due to inter-speciality referrals….separate labels eg fibromyalgia, Patient may get conflicting messages
Often patients may be v sceptical about referral to a psychiatrist
Patients with MUPS more likely to have been told its all in your mind
Once patients feels discredited ‘all in your mind’ opportunity to explore psycho-social factors is lost..no face saving way of getting better
Treatment..iatrogenic damage….opiods/ benzos/ cardiac angioplasty/ exploratory surgey/ adhesions
Secondary gain….spared stress of returning to a difficult work environment/ caring for an ill child/ may help to continue a fragile relationship….carer/ patients role preventing separation/ DLA/ litigation/ tribunal/ retirement on ill health grounds

12. Name 6 psychiatric disorders which are associated with or which cause MUS.

13. Associated Psychiatric Disorders
Anxiety/ depressive illness
Somatoform disorders
Somatisation disorder
Somatoform pain disorder
Hypochondriacal disorder
Dissociative disorder (Hysteria)
Factitious disorder (Munchausen’s)
Delusional disorder
Substance misuse
Anxiety/ depressive illness
Somatoform disorders
Somatisation disorder…..>2ys of multiple and changing MUPS, persistant refusal to accept advice, seeking reassurance from docs, impaired functioning.
+ undifferentiated
Somatoform pain disorder
Hypochondriacal disorder
Dissocciative disorder (Hysteria)….motor or sensory loss of function often in the context of ++LE or unresolved conflict
Factitious disorder (Munchausen’s)…conscious feigning of symps to be a patient
In gen med clinics prev of SD or hypochondriacal disorder is as high as 12% (com prev %)
May also occur in patients with physical disease –can be very diff to assess and manage
Malingering…not a ‘medical disorder….put on symps for finacial benefit/ avoid court appearance/ conscroption etc

14. Detecting Depression in MUPS
HOPELESS
HELPLESS
WORTHLESS
Pervasive low mood
Lack of enjoyment
Poor concentration
Irritability
Guilty feelings
Sleep disturbance
Poor appetite
Diurnal variation
Low libido
Reduced energy
When to consider
Delayed recovery, poor compliance, physical symptoms more severe than expected, irritability, previous history, poor social interaction eg doesn’t respond to relatives visiting, suicidal ideas
Cognitive aspects are more discriminating……Hopeless, helpless, worthless
50% of depression missed in primary care

15. Anxiety: Physical Symptoms
Palpitations
Dizziness
‘Butterflies’
Nausea
Tremor
Tingling
Dry mouth
Wanting the toilet
Muscle tension
Hyperventilation
Chest pain
Lump in throat

16. Somatisation Disorder
>2 years multiple and variable medically unexplained physical symptoms
Preoccupation & distress
Repeated consultations
Refusal to accept medical reassurance
> 6 from a list
Undifferentiated SD & Somatoform Pain Disorder
Undifferentiated Somatisation Disorder…below the threshold for Dx of SD…in fact most of my somatisers meet this Dx
1 or more medically unexplained physical symptom
Distress and impaired functioning

17. Hypochondriacal disorder
Persistent belief of the presence of a serious disease
Preoccupation/ distress/ disability
Refusal to accept medical reassurance

18. Dissociative Disorder (Hysteria)
Sudden loss of function
Temporal link with stressful event/ situation
No medical explanation
Motor/ sensory/ memory
Often present how the pat thinks they would manifest

19. Delusional Disorder Single or set of related delusions
Hallucinations/ thought disorder rare
Relatively well functioning
Themes include
Hypochondriacal
Erotomanic
Persecutory

20. Factitious Disorder Intentional feigning of symptoms
Aim is to receive medical care
Often marked personality disorder & interpersonal difficulties
(Malingering- different motive e.g:
Financial
Avoid court/ conscription)
Or self infliction of wounds

21. Management Case note review Clinical assessment and Ix
Will simple explanation work?
Is this depression/ anxiety?
Is there another psychiatric disorder?
Docs who can detect and respond to verbal and non-verbal cues, who use empathic statements are more likely to det whether a pat has psych or social probs that could be linked to symps.
When were you last completely well?
What’s the worst thing about all this for you?
When the symptoms really bad what do you do?
Prioritise a problem list…bio-psych and social….drain the symptoms dry
Ask spec about low mood and biological symps of depr ie sleep app fatigue…use of rating scale
Ask what the patient thinks might be wrong
Don’t sweep this away with reassurance esp if long standing

22. Management Reattribution Antidepressant Psychotherapy
Acknowledging reality of symptoms
Feeling understood
Making the link
Antidepressant
May reduce symptoms even if not depressed
Psychotherapy
Cognitive behaviour therapy
Psychodynamic interpersonal therapy
RECOG
Can’t say MUPS until appropriate asess and Ix
Review case notes in detail
Inc hx examin tests,psych and social issues from outset
REATTRIB
Esp for recent onset and milder symps, demonstrate understanding by taking Hx of related physical, mood and social facs, making pat feel understood with help of supportive listening, acceptance and interest, making link betw symps and psych probs eg overbreathing and anxiety, dec pain threshold and depr
Training GPs helps pats, red depr is cost effect and red refs to secondary care.
Offer expl if poss
Enc self help
Aim to inc coping than cure seeking
Reduce unnec drugs
Fu consultations with 1 doc
CBT-brief self help Rx
Group or individual
….71% of studies show greater improvement in physical symptoms in treatment group Kroenke 2000
Generally studies show reduced psychological distress and increased functioning…but benefits can occur whether or not psych distress is ameliorated
What is it>>>
Helping patients to overcome identified problems/ attain goals
Self help techniques such as self mx of stress and anxiety
Diary of symptoms thoughts and evidence for and against there being a serious physical cause for symps
discourages maintaining facseg checking and challenges false beliefs
Re-at-dev to help practiotioners manage these symps- esp recent onest and milder symptoms

23. Management of Chronic Somatisation
Regular fixed intervals
Bio-psychosocial approach
Reduce drugs
Treat mood disorder
Limit referrals / investigations
Reduce expectation of cure
Proactive approach
Receiving health care is not contingent on the development of new symptoms
Problem list
Involve relative
Involve colleagues
Red drugs..often opiods , benzos interaction, side effects
Red expec of cure…patients will become less demanding

24. Summary MUS: Mild/ recent onset: Chronic (somatisation disorder):
common and treatable
associated with mood disorders
Mild/ recent onset:
Reattribution techniques
Antidepressants/ psychotherapy
Chronic (somatisation disorder):
Complex/ time consuming
Clear management plan

25. A final reminder that people with medically unexplained symptoms are as likely as you or I to develop a serious medical disease
Spike Milligans Gravestone
‘I told you I was ill’ (in Gaelic)

26. Resources