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

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

List 8 common physical symptoms which are often medically unexplained?

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

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

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 10-15 % 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))

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?

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

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 2002..freq attenders with MUPS have higher usage and costs for medical investigations than frequent attenders without mups Investigations/ admissions/clinics/medication

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

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

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

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 0.1-0.7%) 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

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

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

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

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

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

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

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

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

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

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

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

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)

Resources http://www.rcpsych.ac.uk/expertadvice/problems/medicallyunexplainedsymptoms.aspx http://www.neurosymptoms.org/