1. Approach to Patients with Medically Unexplained Symptoms / Illnesses Jeffrey P Schaefer MSc MD FRCPC Rural Physician Video Conference Program March 31, 2009

2. website dr.schaeferville.com

3. Conflicts of Interest none

4. Objectives Medically Unexplained Symptoms Session participants shall: –be able to define MUS –know that MUS are common –have considered psychobiological framework –become aware of management strategies

5. Case 42 yr old female administrator total body pain and extreme fatigue x 5 years previously assessed by GIM, Neurology, Gastroenterology investigations  normal

6. What is the probability that you will find a condition that risks loss of life or limb? 0% 50% 100%

7. What are your feelings at this point? Negative Neutral Positive -10 0 +10

8. Problem List –daily occipitofrontal headache CT – negative  amitriptyline –chest pain, episodic, at work EST / echo - negative –abdominal pain GI assess / colonoscopy / endoscopy / CT – negative –dysuria with ‘blood in the urine’ U/A usually normal / low CFU but no blood –fatigue CBC, lytes, renal, ESR, ANA, ferritin, TSH, ECG, CXR - normal –poor concentration & dizziness neurology consult  no disease –work issues disability questionnaire anticipated

9. PMH –cholecystectomy for abdo pain 7 years ago (pain returned) Meds –citalopram 20 mg po od –amitriptyline 25 mg po qhs –gabapentin 400 mg tid –fentanyl disk 50 ug/hr –Tylenol #4 tablets, 2 po qid, prn –lorazepam 2 mg po qhs –pantoloc 40 mg po od –multivitamin Family History –two teenage children Psycho-social –‘perfectionist traits’, not much social contact anymore, supportive husband, non-smoker, no alcohol or street drugs

10. Examination –normal except tender to palpation in all areas examined Investigations within last 2 years – all NORMAL –CBC and SPE –electrolytes, calcium, mg, phos, creatinine –liver enzymes, albumin, INR –glucose, TSH, and she has regular menstrual cycles –ESR, ANA –urinalysis –ECG and echo –CXR –CT head –Colonoscopy / Gastroscopy / CT Abdomen and Pelvis

11. What is the probability that you will find a condition that risks loss of life or limb? 0% 50% 100%

12. What’s your diagnosis? Diagnosis: ______________________

13. Hopefully, uptodate.com has something…

14. Diagnosis Menu What’s your diagnosis / diagnoses? –Chronic Fatigue Syndrome / Idiopathic Chronic Fatigue –Fibromyalgia –Tension Headache –Irritable Bowel Syndrome –Multiple Chemical Sensitivity Syndrome –Interstitial Cystitis –Hematuria Loin-pain Syndrome –Depression and Anxiety –Conversion Disorder –Somatization

15. Medically Unexplained Symptoms Physical symptoms that prompt the sufferer to seek health care but remain unexplained after an appropriate medical evaluation.

16. Medically Unexplained Symptoms Physical symptoms that prompt the sufferer to seek health care but remain unexplained after an appropriate medical evaluation. Chest Pain Headache Fibromyalgia Irritable BowelChronic Fatigue Infertility Dizziness

17. Are Medically Unexplained Symptoms Common?

18. MUS Prevalence 30% of primary care visits 13.6 visits in the previous year Psychosomatic Med 2005;67:123-9

19. Most Frequent Visitors 5 th percentile GI…………….54% Neuro……..50% Rheum…….33% ENT………….27% GIM………… 10%

20. If only… ‘an actual email’ Dear Dr. Schaefer, This is great! I'm much relieved and grateful for your care. Thank you THANK YOU! Michelle

21. This is a problem!

22. This is a big problem!

23. Unhappiness is… Patients Feel Unheard –physician centered approach 69% of MD’s interrupt at 18 sec into the interview Ann Int Med 1984:101 –MD patient incongruence longer the patient talks  more likely to prescribe Psychosomatic Med 2007;69:571-7 – Why reassurance fails? PLOS Medicine 2006

24. MUSDepressedControls P(Disease)15%10%5% 25

26. One condition or many?

27. Chronic Fatigue Syndrome Fibromyalgia Irritable Bowel Syndrome Multiple Chem Sensitivity Syndrome Sick Building Syndrome Hypoglycemia Gulf War Syndrome Undocumented Labels Headache Syndromes Asthma Painful Conditions Various Bodily Distress Disorder

28. Do functional symptoms cluster in a way that support multiple conditions? –Cross sectional survey of patients with functional symptoms –Screened 2,300 patients  978 were judged functional

29. Median Number of Symptoms Men  4 Women  6 Men & Women  5

30. “Bodily Distress Disorder” Fink et al. Psychosom Med 2007 Chest Pain Group GI Symptoms Group Musculoskeletal Group < 3% of patients had symptoms confined to their predominant group 3 group model explained 36% of the variance

31. associated with anxiety preoccupied with symptoms preoccupied with illness low threshold to request consultation difficult / impossible to reassure Multiplicity of diagnostic labels is an artifact of medical specialization.

32. Psychobiology ‘the mind-body connection’

33. Psychobiological Framework

36. Left: Areas of the brain that ‘light-up’ during strong emotion. These correlate to Vagus Nerve mediated Heart Rate Variability. Below: HPA axis Mind Body Connection: neural and hormonal

37. Acute Stress and MI Mortality in Widowers –40% increase within 6 mo of spouses death Myocardial Infarction Onset Study –incidence of AMI 14X among recent widows / widowers

38. Self-report AMI Trigger 412 reports from 849 AMI

42. Chronic Stress & Immune Dysfunction Influenza Vaccination Difference between stressed and non- stressed group. –Lancet 1999

43. Stress and Wound Healing

44. Punch Biopsies 13 Care Givers vs 13 Controls Complete wound healing –Caregivers 48.7 vs 39.3 days (9 day diff) –Age and income did not effect outcome

45. So now what?

46. Several Approaches…

47. The Approach… Exclude bio-medical disease –neoplasm –infection –auto-immune –metabolic

48. The Approach… Exclude bio-medical disease –Adrenal Insufficiency –Hemochromatosis –Hypercalcemia –Amytrophic Lateral Sclerosis –Multiple Sclerosis –Alcoholism –Temporal arteritis –Subacute bacterial endocarditis –Sleep Apnea

49. Assess the impact of known conditions Conditions Underestimated (e.g.) –Chronic Cardiac Disease –Chronic Respiratory Disease –Chronic Sinusitis –Recurrent genital herpes –Diabetes mellitus –Obesity –Osteoarthritis –Medication Effect –Physical deconditioning

51. RCT: n = 200 OR  1.92 (95%CI 1.08 – 3.4) NNT to improve @ 12 months = 6.4

52. Smith’s Treatment Model Cognitive – Behavioural Model Establish an information base & motivate Obtain patient commitment –be clear about risk of somatic intervention –stop addicting medications & alcohol –start lifestyle interventions Negotiate a specific plan –follow-up –lifestyle

53. Key Components 50

54. Interpersonal Therapy Scott Stuart Somatization –distress owing to physical symptoms –maladaptive illness behaviour –the distress and behaviour impairs function Attachment Style –insecure attachment & failure of reassurance –seeking health care is a coping mechanism IPT –communication analysis –interpersonal incidents –role playing

55. www.calgaryhealthregion.ca/cmbm/

57. CMBM Approach Principles –symptoms are psychobiological real & explainable & diagnosable –management cognitive reassurance is insufficient uncovering a psychological trauma is insufficient psychotropic medications are counterproductive success lays in self-regulation

58. Self-regulation Somatic Awareness –experiential –link emotional state with body symptoms –effortless breathing Medication Reduction / Elimination Group Therapy –education –HeartmathHeartmath –guided imagery Appleguided imageryApple

59. Talk about Stress...

60. Acute Stress Response Fight, Fright, Flight, Frolic Response

61. Hans Selye (1907-1982) General Adaptation Response –Alarm –Failure to adapt –Exhaustion

62. Absolute Stress

63. Relative Stress Interpretation of the world

64. Recipe for Stress Novelty Unpredictability Threat to ego Loss of control

65. Stress & Recovery

66. Allostatic Load

67. 21 Program Completers

69. Unscheduled Visits (ED / UCC) PeriodVisits Prev 36563 During17 Post 36521 Admissions Arising from Unscheduled Visits PreviousDuringAfter 821

70. Questions Discussion Experiences to share