Presentation on theme: "Different terms for medically unexplained symptoms"— Presentation transcript:
0 THE PATIENT WITH MEDICALLY UNEXPLAINED SYMPTOMS Prof. Trudie Chalder Dr. Rina Dutta
1 Different terms for medically unexplained symptoms Medically unexplained symptoms (MUS) / Medically unexplained physical symptoms (MUPS) (symptoms not explained by the medical model)Functional (e.g. “functional dyspepsia”; affecting physiological or psychological functions but not due to structural / physical / chemical disorder)Idiopathic (e.g. idiopathic chest pain – means ‘unknown cause’)Somatisation (usually implies physical symptoms are expression of emotional distress)DSM-IV somatoform disorders (criticised for containing mixture of relatively specific categories such as somatisation disorder and hypochondriasis, and vague non-specific categories such as undifferentiated somatoform disorder)Miscellaneous specific terms (e.g. irritable bowel syndrome (IBS), chronic fatigue syndrome (CFS)
3 What is the prevalence of MUS in medical clinics (Nimnuan et al Clinic Prevalence (95% CI) Chest 59% (46-72) Cardiology 56% (46-67) Gastroenterology 60% (45-73) Rheumatology 58% (47-69) Neurology 55% (45-65) Dental 49% (37-61) Gynaecology 57% (50-68) Total 56% (52-60)
4 What is Chronic Fatigue Syndrome: Oxford Criteria (Sharpe et al Fatigue is the principal symptom. Fatigue is severe, disabling, and affects physical & mental functioningDefinite onset that is not lifelongFatigue has been present for a minimum of 6 months, during which time it has been present for more than 50% of the timeOther symptoms may be present, particularly myalgia, mood, and sleep disturbanceExclusion criteria include presence of medical conditions that produce chronic fatigue & certain psychiatric disorders (substance abuse, eating disorders, organic brain disease)
5 Chronic Fatigue Syndrome (“ME”) More common in women than menPrevalence estimates vary widely.Can be difficult to differentiate CFS from depressive & anxiety disorders. Estimates that do not exclude those diagnoses are much higher than those that do.Depends on criteria used.Prevalence in adults perhaps %.50%+ have psychiatric disorders, especially depression
6 Diagnosis IBS is a clinical diagnosis A symptom complex for which no organic cause has been foundNo physical test by which to identify the syndromeIdentified by symptomsUsually ESR and full blood count exclude other diagnoses
7 Irritable bowel syndrome: Rome II criteria At least 12 weeks (not necessarily consecutive), in the preceding 12 months of abdominal discomfort or pain that has 2 out of 3 features:1) Relieved with defecation; and/or ) Onset associated with a change in frequency of stool; and/or ) Onset associated with a change in form (appearance) of stool.Other symptoms that are not essential but support the diagnosis of IBS:Abnormal stool frequency (greater than 3 bowel movements/day or less than 3 bowel movements/week);Abnormal stool form (lumpy/hard or loose/watery stool);Abnormal stool passage (straining, urgency, or feeling of incomplete evacuation);Passage of mucus;Bloating or feeling of abdominal distension.
8 Irritable Bowel Syndrome (IBS) Symptoms that might indicate another disorder and hence further investigation necessary include; rectal bleeding, unintended weight loss, frequent awakening by symptoms, fever, anaemia.Very common, 9-12% of population (up to 30% have some features), small minority get disabilityMore common in women than menIn gastroenterology clinics about 40-60% have psychiatric disorders, mainly anxiety & depression
9 Evidence from RCTs: CFS CBT generally found to be significantly better than standard medical care / group psychoeducation / pacing(e.g. Sharpe et al., 1996; Deale et al., 1997; Prins et al., 2001; White et al 2011)Graded exercise therapy (e.g. Fulcher & White, 1997; Powell et al., 2001; White et al 2011)Treatments with little or no supportive evidence include:- Antidepressants; Nutritional supplements- Extended rest; Complementary / alternative therapies
10 Evidence from RCTs: IBS CBT: More effective than control conditions(Greene & Blanchard, 1994; Dulmen et al. 1996) [although Boyce et al. (2003) found no diffs between CBT & relaxation training & routine medical care]- Group CBT is superior to psycho-education or usual medical care (Toner et al., 1998)- CBT in combination with antispasmodic drugs is superior to drugs alone (Kennedy et al., 2005).
11 More evidence from RCTs: IBS Hypnotherapy (e.g. Whorwell et al., 1984) and psychodynamic interpersonal therapy (Guthrie et al., 1993; Creed et al. 2003) effective in reducing symptoms / ↑ quality of life in secondary care.Antidepressants – most effective drugs for treating IBS; modify gut motility and alter visceral nerve responses, reduce pain.Antispasmodics (e.g. mebeverine hydochloride) are associated with improvement in symptoms for some people.
12 Engagement Be empathic Explicitly convey belief in reality of physical symptoms; doesn’t mean ‘all in the mind’Shift focus from “cause” to “symptom management”Avoid physical versus psychological discussionsUse physical illness analogies to illustrate approachReinforce any helpful responses patient is already usingElicit concerns and expectations
13 Presenting CBT approach Assumes multiple contributory factorsPredisposing factorsPrecipitating events or triggersMaintaining factors(Physiological, behavioural, cognitive, emotional, social)Use information from assessment to develop individualised model of the different contributory factorsModifying predisposing & maintaining factors can help to:- reduce symptoms and impairment- decrease risk of future relapse
14 CBT for unexplained symptoms: Basic components Guided by individual conceptualisationRationale for every aspect of treatmentExpanding understanding of contributory factorsPhysiological explanations where possibleBegin with behaviour changeCognitive work on unhelpful thinking patterns & underlying beliefsNormalising and acceptance of symptoms
15 Pain does not necessarily mean damage / harm Work on other psychological issues if necessary (e.g. low self-esteem, lack of assertiveness).Be aware how underlying beliefs may affect therapyRecovery defined in terms of concrete behaviour, not necessarily symptom free or returning to previous lifestyleRelapse prevention
16 Other aspects of treatment Close liaison with all practitioners (party line)Deal with reassurance seeking (provide rationale / liaise with those providing reassurance)Suspend further investigations or agreeing a compromiseRationalise medicationReduce drugs with adverse side effects
17 Components specific to fatigue Establishment of consistent baseline activity level- Use activity diaries at beginning of treatmentBalance between activity and restIdentify activity targets (exercise, social, work-related, leisure)
18 Break down targets into specific manageable steps Increase activity level if managed at least 75% of time over past fortnightDon’t increase exercise time more than about 10% at a timeAddress high action proneness
19 Sleep Management Programme Sleep diaries for assessmentSet getting-up timeNo sleeping in the day-timeStay in bed only for amount of time sleep for(e.g. if patient usually sleeps 8 hours in total, don’t go to bed at 10pm & get up at 8am)If sleeping excessively, gradually reduceSleep hygiene- Check caffeine, use bedroom for sleep only, wind down before bedtime, make sleep environment comfortable etc.Address unhelpful beliefs about sleep
20 Example of initial activity programme for underactive person with CFS Someone who is resting for 6 hours a day:Get up at 8 a.m.Housework for 15 mins twice a dayPaperwork or other chores for 15 mins twice a dayRead for ten minutes a dayfor ten minutes a dayTwo 10-minute walks each dayRest for six 1-hour periods, spaced through dayTalk to friends on phone for 10 mins, every other day
21 Presenting the model with a Case Study Sally: 30-year old woman with a 3-year history of severe fatigue, concentration / memory difficulties, muscle and joint pain.Believes that a virus was the cause of her problems as has never been well since she had a bout of gastroenteritis three years ago. At that time there were also stresses at work and her relationship with her partner was breaking down.Unable to walk for more than about ten minutes without becoming extremely fatigued and experiencing more muscle pain.Reduced from full-time to part-time work because of her symptoms.
22 Goes to bed at 9pm and gets up at 7. 30am Goes to bed at 9pm and gets up at 7.30am. Often has trouble getting to sleep or staying asleep. Quite often sleeps in the daytime.Limited social life - it is fatiguing to be with people or staying out late.Lives with her mother who does most of the housework and shopping.Believes that her mood has become low because her quality of life has decreased. Is sure that depression is not the cause of her problems and is fed up with doctors assuming that she is simply depressed.Reluctant to see a psychologist but is offered no alternatives.
24 Components specific to IBS Familiarise self with anatomy & functioning of the digestive systemEducation about bowel functioning to challenge misconceptions such as:“I should have a bowel movement every day”Everyone’s bowel habits are different; normal bowel movements may occur as often as three times a day to as few as three a week.IBS is a problem with how the digestive system functions but is not a disease
26 Brain-gut connection Bowel is a segmented tube Food is propelled down by the sequential squeezing of each segment.Nerves from the brain control this motion.If the nervous control is disrupted, problems with this movement can result.Stress and other psychological factors cause bowel symptoms by affecting this nervous control.
28 Stress and intestinal functioning Effects that stress can have (general population):- Spasms in muscles in gut wall, resulting in pockets of high pressure, gas or painful contractions- Decreased gastric emptying and accelerated colonic transit.Results in symptoms such as cramps, diarrhoea etc.These gut responses to stress are enhanced in IBS patients.IBS patients report greater pain response to distension of the bowel (e.g. in experiments with inflatable balloon)Any intervention that helps the person to manage stress more effectively is likely to help
29 Components specific to IBS (con) Avoiding foods can:- result in increased sensitivity &- make it more difficult to get nutritionally balanced dietRe-introduce avoided foodsAddress other safety-seeking behaviours around bowel functioning (e.g. not eating for long periods of time before an important event)assess carefully, there may be many!
31 Establish healthy bowel routine Healthy, varied diet (not too much of one food)Eat regularly; chew food slowly and thoroughlyDrink 6-8 cups of water dailyMaintain a regular program of physical exercise and activityAvoid delaying the urge to have a bowel movementAvoid straining / forcingDealing with pain (e.g. accepting, not trying to suppress or focussing on pain excessively)
32 Behavioural experiments – examples of beliefs to target Beliefs about needing to avoid particular foods, places to eatBeliefs about needing to avoid particular activities that use up energy or result in increase in symptomsPerfectionism
33 Stepped Care Self help materials IAPT Primary care Specialist care – CBT
35 Questionnaires for use in CFS: examples Chalder Fatigue Scale (Chalder et al., 1993)Work and Social Adjustment Scale (Mundt et al., 2002)Beliefs about emotions scale (Rimes & Chalder 2009)SF-36; Physical functioning subscale (Ware & Sherbourne, 1992).Measures of anxiety & depression e.g. Hospital Anxiety & Depression Scale (Zigmond & Snaith, 1983)
36 Questionnaires for use in IBS: examples IBS Symptom Severity Scale (Francis et al., 1997)Behavioural Scale for IBS (Reme et al 2010)Work and Social Adjustment Scale (Mundt et al., 2002)Measures of anxiety and depression (HAD)
37 The CBT model of MUSDeary V, Chalder T & Sharpe M. (2007) One of the Resources for Self-Study on Moodle
38 Key PointsAssessmentTreatmentEvidenceWhere to refer