Download Medically Unexplained Symptoms

Getting certainty out of uncertainty
1.
2.
‘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
• But it’s not surprising as MUS patients come with vague symptoms.
• In terms of diagnosis  simply determine whether organic or not.
Getting certainty out of uncertainty
There is always an element of uncertainty when patients present with
MUS.
Therefore:
• The aim is not to get rid of
uncertainty entirely (impossible!)
• The aim is not to simply tolerate
the current level of uncertainty
(too risky)
• The aim is to reduce it to a point
where what is left is acceptable
and manageable.
initial level of uncertainty
final level of
uncertainty
In summary…
• We don’t need a fancy diagnostic name.
• We simply need to answer this question of whether this is organic or not.
• You can never be 100% about this but you need to reduce the level of
uncertainty to tolerable levels.
• And here’s how to do it…
‘How can we tell if this is something
organic or not?’
Doing loads of investigations is not the answer….
• It is wasteful (in terms of resources and costs)
• It creates a whole load of unnecessary work for other in the NHS
• It promotes patient anxiety.
Some simple things you can do.
i.
Take a good enough history
ii.
Good examination
iii. Look at the notes – what’s gone on before?
iv. ICE
v.
PSO
It’s not rocket science and it doesn’t need to be!
Throughout the process…
1. Don’t be too swayed by other professionals.
2. Be prepared to change your view at any point (really impt).
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’.
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%.
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, HBA1C, ESR and Vit D levels 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 psychosocial-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).
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
Exploring ICE
• IDEAS: What do they think is going on?
1. Is there evidence of crooked thinking that needs rectifying? Is
this a way into discussions?
2. Do they make links to life problems?
• What are their CONCERNS?
• Expectations: What are they 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 thinking track rather than forcing them 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).
Explore the PSO
•
•
•
•
Think home, social and work
Home: Domestic violence, sexual/physical/emotional abuse
Social: loneliness/isolation, poverty, debt
Work: bullying, harassment, stress, being overworked
I would be less worried about headaches:
In a patient who is the victim of domestic violence (unless they were 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? Perhaps the hidden agenda is the domestic violence, and I need to
do something about that.
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?
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, HBA1C, Vit D levels
(and perhaps one or more of HIV test, cortisol, coeliac Abs, auto-antibodies, prolactin if
suspicious).
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.
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
Age of onset
Low
Any
High
Any
High
Any
Body systems/Physical
symptoms involved
Any
Any
Symptom duration
“Acute” days to weeks
“Subacute” < 6 m
“Chronic” >6 m
Number of symptoms
Few
Any
Around >3 (men) & >5 (women) >7
Symptoms occur and recur with
external stress and clear when Yes
it abates ?
Yes, but recur frequently
No, but worsen with stress
No, but worsen with stress
Depression, anxiety, dysthymia,
and other psychiatric problems ?
present?
In 20%
In 70%
In 90-100%
Personality structure
“Normal”
?
Personality disorder
60-70% Personality disorder ;
rarely, psychotic
Prevalence, community
~100%
?
5%
0.03–0.7%
Prevalence, all outpatients
?
?
35%
5%
Prevalence, inpatients
?
?
?
10%
High
<30 years 18
Musculoskeletal, GI, nervous, or
ill-defined systems.
Musculoskeletal, GI, nervous, or
Often Pain, GI, sexual,
ill-defined systems
neurological
“Chronic” >6 m
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.
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
In these set of slides
We mainly
organic or
following:
1.
2.
3.
talked about getting to that point of deciding whether we think something is
not. To reduce uncertainty to a tolerable level so that we don’t feel the
‘I am worried about missing something’
‘I don’t get sued’
‘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…
4.
‘Getting them onto your way of thinking is a nightmare’
5.
‘And I don’t want to wind them up’
6.
‘I feel helpless.
7.
There’s no focus in the consultation’
8.
‘And yet I still feel I have a sense of responsibility or moral obligation to
make things better’
Tackling 48 involves the art of Reattribution. Please move onto those set of slides.
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), 689-95.
• Nottingham has a fab site on MUS:
http://iapt.nmhdu.org.uk/special-interest/special-interest/medicallyunexplained-symptoms/the-nottingham-tool/
• Loads more on www.bradfordvts.co.uk click ‘online resources’ and then
‘02 The GP Consultation’ then ‘somatisation and medically unexplained
symptoms’ folder.