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

website dr.schaeferville.com

Conflicts of Interest none

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

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

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

What are your feelings at this point? Negative Neutral Positive

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

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

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

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

What’s your diagnosis? Diagnosis: ______________________

Hopefully, uptodate.com has something…

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

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

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

Are Medically Unexplained Symptoms Common?

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

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

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

This is a problem!

This is a big problem!

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

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

One condition or many?

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

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

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

“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

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.

Psychobiology ‘the mind-body connection’

Psychobiological Framework

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

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

Self-report AMI Trigger 412 reports from 849 AMI

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

Stress and Wound Healing

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

So now what?

Several Approaches…

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

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

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

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

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

Key Components 50

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

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

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

Talk about Stress...

Acute Stress Response Fight, Fright, Flight, Frolic Response

Hans Selye ( ) General Adaptation Response –Alarm –Failure to adapt –Exhaustion

Absolute Stress

Relative Stress Interpretation of the world

Recipe for Stress Novelty Unpredictability Threat to ego Loss of control

Stress & Recovery

Allostatic Load

21 Program Completers

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

Questions Discussion Experiences to share