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Dr. Ramesh Mehay Programme Director (Bradford VTS), 2011

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1 Dr. Ramesh Mehay Programme Director (Bradford VTS), 2011
Medically Unexplained Symptoms how to tell whether symptoms are organic or not Dr. Ramesh Mehay Programme Director (Bradford VTS), 2011

2 Why do these patients irritate us?
‘I am worried about missing something’ ‘I don’t want to do unnecessary tests’ ‘Getting them onto your way of thinking is a nightmare’ ‘And I don’t want to wind them up’ ‘I feel helpless. How do I help them. There’s no focus in the consultation’ ‘And yet I still feel I have a sense of responsibility or moral obligation to make things better’ To tackle 1 & 2  you need to create a bit more certainty out of uncertainty  make better decisions To tackle 3-6  The art of Reattribution. Why do these patients irritate us?

3 Getting certainty out of uncertainty
‘I am worried about missing something’ ‘I don’t want to do unnecessary tests’ These two worries come from being: uncertain/unsure/insecure/unconfident in your diagnosis The diagnosis is simply whether there is something organic or not. But it’s not surprising as MUS patients come with vague symptoms.

4 Getting certainty out of uncertainty
There is always an element of uncertainty when patients present with MUS. Therefore: initial level of uncertainty The aim is not to get rid of uncertainty The aim is not to simply tolerate the current level of uncertainty The aim is to reduce it to a point where what is left is acceptable and manageable. final level of uncertainty

5 To get to the point where you can say:
‘In my heart and in my mind, I really don’t get the feeling that there is anything physically wrong with this patient’. To get to the point where you can say:

6 The real question: ‘How can we tell if this is something organic or not?’
We don’t need a fancy diagnostic name. We simply need to answer this question of whether it is organic or not. You can’t never be 100% definitive about this but you need to reduce the level of uncertainty to tolerable levels. And here’s how to do it…

7 It’s not rocket science! It doesn’t need to be.
The real question: ‘How can we tell if this is something organic or not?’ Doing loads of investigations is not the answer…. there’s a lot more you can do before doing that. Inappropriate use is wasteful (in terms of costs), creates a load of unnecessary work for others in the NHS (and thus waiting lists) and creates anxiety in the patient. Here are some simple things you can do. Take a good enough history Good examination Look at the notes ICE PSO It’s not rocket science! It doesn’t need to be. Two other things throughout the process… Don’t be too swayed by others. Be prepared to change your view at any point.

8 Good History Detailed enough history – don’t be swayed too early by what others have written before Red flags – fever, weight loss, anorexia and night sweats Especially the ‘review of systems’ – make sure nothing is there Effect of symptoms on daily living - explore to right depth PMH - especially depression, anxiety, drugs or alcohol. I would be less worried about headaches which: Didn’t have any alarm features, which had been going on for years, didn’t fall into a particular pattern (i.e. a bit weird), in a patient who repeatedly attended surgery for minor things, always seemed anxious, used over-expressive terminology which did not marry with her physical presentation(e.g. ‘it’s absolutely killing doctor all the time and has been for the last 2 years’), yet didn’t take anything over the counter because she just ‘coped with it’.

9 Good examination You should be prepared to be FLEXIBLE with your working diagnosis (the working diagnosis here being whether something is organic or not). For instance, if you’ve taken a history and are thinking ‘non-organic’, you must be prepared to ‘switch tracks’ if anything abnormal is found on examination. Abnormal examination should make you exclude the organic. Remember, in most cases, history gives you 90% of the working diagnosis and the examination just adds another 10%.

10 Look at the notes What have other GP colleagues said?
What prev. Ix have been done? Great if someone has done FBC U&E LFTs TFTS RBS and ESR within symptom duration. Consultation behaviour / freq of attendance Look at the letters section. I would be less worried about headaches which: Previous GPs had looked at in quite some detail and didn’t think there was anything organic. And even more so if they’d made links to things in the patient’s psycho-social-occupational history (e.g. loneliness, bullying, abuse, domestic violence etc). And even more so if I could see from the notes that a) the patient comes into surgery every other week for various vague ailments and b) has been referred to loads of different specialties in the past with nothing much fruitful in the end (or there is collusion of anonymity).

11 How often do they come to surgery and how many symptoms?
Look at the notes How often do they come to surgery and how many symptoms? Visits to the surgery How many medically unexplained symptoms? NORMAL - MILD 2 visits/year 2-3 symptoms MODERATE 8 visits/year for at least 2y 5 symptoms SEVERE 15 visits/year for many years 8 MU symptoms in last year alone

12 Exploring ICE What do they think is going on?
- Is there evidence of crooked thinking that needs rectifying? Is this a way into discussions? - Do they make links to life problems? What are their concerns? What they are hoping for from the consultation or from me? Sometimes, these patient’s do not come up with crazy beliefs. Sometimes, what they say is quite reasonable. And therefore, sometimes, you may need to hop onto their track of thinking rather than them hoping onto yours! I would be less worried about organic stuff in the patient who did have crazy ideas, crooked thinking or unrealistic expectations. But remember, I don’t just rely on this – I look at the bigger picture and see how their ICE fits in with other markers which point to a MUS diagnosis (covered in other slides).

13 PSO What are relationships like? Think work and home.
Domestic violence, sexual/physical/emotional abuse, bullying, isolation/lonliness, poverty. I would be less worried about headaches: In a patient who is the victim of domestic violence (unless they’re being bashed in the head). May be their physical symptom is an expression of emotional distress. May be I need to start working on the emotion rather than the physical? Surely the hidden agenda is the domestic violence, and I need to do something about that.

14 Remember, MUS often accompanies…
(Co-morbid conditions) Depression, anxiety, OCD, Anorexia/Bulimia Nervosa, Dysthymia, Personality Disorders Fibromyalgia/Chronic Fatigue Syndrome/Irritable Bowel Syndrome Severe psycho-social-occupational upset? (domestic violence, sexual/physical/emotional abuse, bullying, isolation, poverty) Obstructive Sleep Apnoea syndrome Drugs & Alcohol (be sensitive, decide on the right moment to ask, don’t ignore in elderly) ARE ANY OF THESE PLAYING A PART?

15 But equally, the following can be mistaken for MUS
(Differential Diagnosis for MUS / Somatisation) LEVEL 1 Anaemia (whatever the cause); Folic acid or Iron deficiency (FBC, folate, ferritin ) Addison’s Disease (U&E – low Na, high K, low serum cortisol at 0800h) Diabetes (RBS) Hypercalcaemia (LFTs will give a Ca) Hypo or hyperthyroidism (TFTs) LEVEL 2 Vitamin D deficiency/Secondary hyperparathyroidism - esp. asian women/ladies in hijab with total body pain and vague symptoms (Vit D levels) AIDS (HIV test) Coeliac Disease (coeliac antibodies) SLE (autoantibodies, lupus anticoagulant) Hyperprolactinaemia (prolactin levels) Multiple Sclerosis (CSF) Cancer of Ovary/Pancreas (don’t often cause clear cut symptoms). LEVEL 3 Rare  Myasthenia Gravis, Wilson’s, MS, Porphyria (just keep in back of your mind) Minimum tests in moderate-severe MUS: FBC, folate, ferritin, U&E, LFTs, TFTs, RBS (and perhaps one or more of vit D, HIV test, cortisol, coeliac Abs, auto-antibodies, prolactin if suspicious).

16 Case 1—the most common: mild MUS
A 32-year-old man with controlled hypertension presented with the new onset of fatigue and distracting headaches, and he mentioned the threat of being laid off work. Physical examination was negative, and you empathized, supported, reassured, ordered no tests, and recommended ibuprofen. He reported 2 weeks later the symptoms had cleared, and that he was back to work. Case 2—less common: moderate MUS A 44-year-old woman presented with yet another episode of low back pain without radicular symptoms. Her diabetes also was poorly controlled, and she had gained weight. The pain interfered with work, and she had been in the clinic with recurrences 7 times in the preceding 12 months. She was not enjoying her life and said that she had difficulty sleeping, but did not feel depressed. Physical exam revealed no neurologic deficits and mild paraspinal muscle spasm. You obtained an MRI of the spine that provided no explanation for the pain (small disc without neurologic compromise), and you implemented a program of treatment for her MUS and depression, advised exercise and weight control, and increased her metformin dose. Case 3—least common: severe MUS A 50-year-old man related a long history of severe neck pain and headaches, virtually constant over the last 5 years. He wanted a “new approach” because he was “not getting better,” even though he went to 4 doctors and 2 pain clinics in the last year. His COPD was somewhat worse recently as well. He denied depression but did have anhedonia (lack of enjoyment), insomnia, difficulty concentrating, and weight gain over the preceding year. Physical exam was negative except for changes of COPD. You did not repeat the neck and brain MRI his previous doctor had obtained 3 months earlier but reviewed it with the radiologist and learned that several minor abnormalities (a few white matter changes and mild disc protrusion without neurologic compromise) were unrelated to his symptoms. You initiated treatment for his MUS and depression and advised a short trial of antibiotics for his COPD.

17 Severity of MUS Normal to mild ~80% Moderate ~15% Severe ~5%
Very severe† <1% Common name “Worried well” DSM-negative; MAI ASD; MSD SD Freq. of attendance Low High Age of onset Any <30 years 18 Body systems/Physical symptoms involved Musculoskeletal, GI, nervous, or ill-defined systems Musculoskeletal, GI, nervous, or ill-defined systems. Often Pain, GI, sexual, neurological Symptom duration “Acute” days to weeks “Subacute” < 6 m “Chronic” >6 m Number of symptoms Few Around >3 (men) & >5 (women) >7 Symptoms occur and recur with external stress and clear when it abates ? Yes Yes, but recur frequently No, but worsen with stress Depression, anxiety, dysthymia, and other psychiatric problems present? ? In 20% In 70% In % Personality structure “Normal” Personality disorder 60-70% Personality disorder ; rarely, psychotic Prevalence, community ~100% 5% 0.03–0.7% Prevalence, all outpatients 35% Prevalence, inpatients 10%

18 The Normal-Mild Bruce Thomas, a general practitioner in Hampshire, UK, pointed out in the 1970s that in up to 40% of patients in general practice no diagnostic label could be attached. These patients did not require, and generally were not given, specific treatment, and most recovered spontaneously.

19 The others – according to DSM-IV
Somatization disorder is of many years duration, begins before age 30, is more common in women, and has (over a lifetime) at least four pain symptoms, two gastrointestinal symptoms, one sexual symptom, and one pseudoneurological symptom. Undifferentiated somatoform disorder, the vast majority of persistent somatizers, is a residual category for patients who do not meet criteria for other somatoform disorders, is of at least 6 months duration, has no gender or age limit, and has at least one symptom. Conversion disorder usually occurs acutely and lasts about 2 weeks but may be recurring or chronic, is most frequent in women before age 35, and exhibits one or more motor, sensory, or seizure (pseudoneurological) symptoms. Pain disorder occurs at any age, more often in women, usually is chronic and persistent, and has one or more pain symptoms that are the predominant focus of the presentation and that are not restricted to dyspareunia. Hypochondriasis occurs at any age in males and females, may be more common in early adulthood, is at least 6 months duration and often chronic and persistent, and has one or more symptoms that provoke an unwarranted fear (which is not delusional or restricted to concerns about appearance) of organic disease even after reassurance and appropriate investigation. Body dysmorphic disorder begins in adolescence, occurs in males and females equally, is chronic and persistent, and is suggested by preoccupation with an alleged defect in appearance that causes patients to feel ugly (anorexia nervosa is classified elsewhere); when of delusional intensity, an additional diagnosis of delusional disorder, somatic type is made. Somatoform disorder not otherwise specified includes disorders with somatoform symptoms that do not meet the above criteria, such as pseudocyesis and symptoms of less than 6 months duration

20 Final word… Don’t forget to build a picture of things.
Think of it like a jigsaw puzzle. Where all the things I’ve mentioned in blue are the individual pieces. Do not rely on any one jigsaw piece. In other words, do not make judgements just on ONE or TWO bits of information. You have to build up a picture. You will probably never build a complete picture. The aim is to build up a good enough and fairly reliable picture (even if one or two pieces are missing). Final word…

21 R Jones. When no diagnostic label is applied; BMJ (2010)
“When pattern recognition and iterative diagnosis do not give an answer, when symptoms are vague, or when a clear diagnosis does not “crystallise” from investigations or tests of time or of treatment, patients will need to be managed without having a diagnostic label.” R Jones. When no diagnostic label is applied; BMJ (2010)

22 In these set of slides We mainly talked about getting to that point of deciding whether we think something is organic or not. To reduce uncertainty to a tolerable level so that we don’t feel the following: ‘I am worried about missing something’ ‘I don’t want to do unnecessary tests’ Now that we are more sure that things are not organic, the next step is to get the patient on board with that. The problem with this is that… ‘Getting them onto your way of thinking is a nightmare’ ‘And I don’t want to wind them up’ ‘I feel helpless. How do I help them. There’s no focus in the consultation’ ‘And yet I still feel I have a sense of responsibility or moral obligation to make things better’ Tackling 36 involves the art of Reattribution. Please move onto those set of slides.

23 Other articles worth reading
When no diagnostic label is applied. R Jones. BMJ2010;340;(Published 25 May 2010) The treatment of somatization: teaching techniques of reattribution. Goldberg D, Gask LL, O'Dowd T. (1989). J Psychosom Res, 33( 6), Nottingham has a fab site on MUS: Loads more on click ‘online resources’ and then ‘02 The GP Consultation’ then ‘somatisation and medically unexplained symptoms’ folder.

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