1. Quality Education for a Healthier Scotland Explaining MUS (PPP? FS? PS?) Aims Being clear about MUS General sense of the literature Finding out what your difficulties are Provide “hints and tips” Resources to tap into.. Hope to avoid the “thanks anyway” response..

2. Quality Education for a Healthier Scotland Explaining MUS (PPP? FS? PS?) What problems as GPs and trainers do you see?

3. Quality Education for a Healthier Scotland Explaining MUS (PPP? FS? PS?) Stats 20% of PC consults Up to 50% in Secondary Care High levels of distress and disability 60% also have diagnoses LTC 2% of PC patients attend persistently £3.1B cost annually in UK

4. Quality Education for a Healthier Scotland Explaining MUS (PPP? FS? PS?) “MUS” label is problematic PPP or FS often preferable to patients “Persistent and distressing somatic symptoms for which adequate somatic explanation does not reveal sufficient explanatory organic pathology” (Shaefert et al 2013) Vague symptoms, polypharma, high distress, insistent and frequent attendees. IBS/CFS/FM.

5. Quality Education for a Healthier Scotland Explaining MUS (PPP? FS? PS?) What works and what doesn’t? Evidence to support CBT-based interventions Enhanced generalist care may be helpful (Rosendal et al 2013) Reassurance/Psychosomatic ideas may not be helpful Biopsychosocial perpetuation…(formulation vs diagnosis) Personally relevant, mechanical explanations best (Burton (Ed) 2014) Major Cochrane review of NP interventions coming.. (Van Dessel et al 2014)

6. Quality Education for a Healthier Scotland Explaining MUS (PPP? FS? PS?) What not to say..and why “Good news, there’s nothing wrong with you!” “The results of the tests have ruled out anything bad” “There is not much we can do with these symptoms” “There could be psychological reasons for all this” “I’m not sure your symptoms are as bad as you say” “I’m going to refer you one more time for reassurance” “You’re absolutely fine, it’s going to be ok”

7. Quality Education for a Healthier Scotland Explaining MUS (PPP? FS? PS?) Initial thoughts You can’t do everything “(Personally relevant) Explanations can be therapeutic Providing physiological pathways may help Keeping and re-appointing the patient can help No one is advocating the “T” in CBT.. The trials of moving from “diagnosis” to “formulation” Without core comm skills there’s little point..

8. Quality Education for a Healthier Scotland Explaining MUS (PPP? FS? PS?) Core Comm skills Empathy Checking Summarising Reflecting Validating Checking the patient has picked YOU up correctly Getting personally relevant information to USE

9. Quality Education for a Healthier Scotland Explaining MUS (PPP? FS? PS?) Stuff that comes best from GPs Full Physical exams Physiological aspects of the explanation (1 st ) Eg; Pain Mechanisms (sensitisation) Gut Motility Vestibular aspects of dizziness Probably best way of engaging patients initially. Link in with perpetuating aspects.

10. Quality Education for a Healthier Scotland Explaining MUS (PPP? FS? PS?) Interaction issues Most HP encounters involve “expert” and “patient” Problems arise when explanations don’t sit well Tendency for many HPs to push the same message Frustration when the patient resists explanations Presumption that patient has heard what you’ve said

11. Quality Education for a Healthier Scotland Explaining MUS (PPP? FS? PS?) Perpetuating factors - Cause vs Perpetuation How symptoms interpreted Avoidance of activity Low mood and anxiety Create “vicious cycle” – not a cause, but maintenance Consequences add to the suffering of the patient

12. Quality Education for a Healthier Scotland Explaining MUS (PPP? FS? PS?) Perpetuating factors Use “4 systems” model “So what do you notice when you’re doing less?” “How hard is it to cope when you feel down?” “How can you end up feeling with these worries?” “What’s happened to your motivation?” “So one thing affects another, affects another?” (Might not need to link back to symptoms..)

13. Quality Education for a Healthier Scotland Explaining MUS (PPP? FS? PS?) Perpetuating Factors Good way to validate the patient experience Can be used to identify intervention strategies Reflect on success of trying to look for cause “What do you think might help based on this idea?”

14. Quality Education for a Healthier Scotland Explaining MUS (PPP? FS? PS?) Round up.. Move away from psychological cause Don’t expect to do it all in one session Explanations which favour physiological elements and are personally-relevant may work best initially Recognise the difference between cause and perpetuation. Reject, collude or empower?

15. Quality Education for a Healthier Scotland “..complex interactions of physiological and cognitive processes. Neither simple disease syndromes nor a general somatisation disorder are adequate to describe the diversity seen in primary care. Somatisation is too restrictive a label; ‘functional somatic symptoms’ is a more appropriate term.” (Burton, C. BJGP 2003)

16. Quality Education for a Healthier Scotland Explaining MUS (PPP? FS? PS?) Useful refs 1. ABC of Medically Unexplained Symptoms. Burton (Ed). 2013. Wiley-Blackwell. 2. Health Behaviour Change (2 nd ed.). Mason, P. & Butler, C. (2010). 3. Overcoming Functional Neurological Disorders – A Five Systems Approach. Williams, C. (2011). Hodder Arnold 4. Deary, V., Chalder, T. And Sharpe, M. (2007). The cognitive behavioural model of medically unexplained symptoms: A theoretical and empirical review. Clinical Psychology Review, 27, 781-797. 5. Rosendal M, Blankenstein AH, Morriss R, Fink P, Sharpe M, Burton C. (2013). Enhanced care by generalists for functional somatic symptoms and disorders in primary care (Review). The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

17. Quality Education for a Healthier Scotland David Craig NES Psychology Directorate 2 Central Quay 89 Hydepark St. G5 3BW David.craig@nes.scot.nhs.uk