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Medically Unexplained Symptoms Dr Rebecca Jacob Consultant Psychiatrist Fulbourn Hospital Cambridge Background MUS are defined as physical symptoms which are not or insufficiently explained by somatic disease.1 Clinically, conceptually and emotionally difficult area. Patients referred to in pejorative terms: ‘Frequent fliers’,‘heard sink’ patients, ‘thick folder patients’ or ‘somatisers’. Clinical presentations vary: frequent attender to GP with minor complaints versus bed bound chronic fatigue patient Common symptoms include chest, abdominal, or back pain, tiredness, dizziness, headache ankle swelling, shortness of breath, insomnia and numbness2 Studies show that MUS are presenting problem of 35-53% specialist medical clinics and 10-33% in primary care clinics.3,4 In those with MUS rates of mental and physical dysfunction are high, disability and poor work records common and relationships poor.6 MUS is also associated with excessive health costs and utilisation- investigations, doctor appointments, admissions and indirect costs such as lost working days, carer input etc.7 One study suggests the cost to NHS is 3 billion/year.8 Classification of MUS Divided into different but overlapping groups including: Functional somatic syndromes, which classically describes Irritable bowel syndromes, Fibromyalgia and Chronic fatigue (post viral fatigue). Somatoform disorders-main features is repeated presentation of physical symptoms together with persistent request for medical investigations, in spite of repeated negative finding and reassurance that the symptoms have no physical basis. Functional somatic syndromes Somatoform disorders Medically Unexplained symptoms Creed et al 2011 Functional Somatic Syndromes according to medical specialty Medical specialty Functional somatic syndromes Gastroenterology IBS Rheumatology Fibromyalgia, chronic back pain Cardiology Non cardiac chest pain Neurology Non-epileptic Seizures, tension headache ENT Globus syndrome Infectious Disease Chronic Fatigue Syndrome Psychiatry Somatoform disorders, conversion Can you define: Somatisation Disorder Conversion Disorder Hypochondriasis Factitious Disorder Malingering Risk Factors for MUS Fewer years of formal education Parental illness Lack of care in childhood Assessment Why now and what is the agenda? Assess presentation Is there associated pathology? Does the patient have an anxiety or depressive disorder? Is this some other emotional distress presenting as physical distress Could there be associated pathology? Systematic review : 4% patients diagnosed with a conversion disorder develop illness that could explain presenting symptom Follow up study of 73 patient with unexplained motor symptoms suggest psych disorders most commonly missed: 33 had undetected psych disorder (mainly anxiety and depression. Reassurance, explanation and use of investigations Reassurance- deal with fears, encourage patient to express feelings as well as history of symptoms Explanation: encourage talk about psychosocial problems, integrate physical and pschological i.e. stress can make your muscles tense lead to pain, tense chest muscles can cause chest pain etc. Use of investigations: before ordering, explain what a normal result means, other possible reasons for symptoms, and what happens if test is normal and symptoms persist. Signs/Tests: Unexplained weakness and Non epileptic seizures Hoovers sign Videotelemetry- beware true and ‘pseudoseizures’. Raised serum prolactin (at least double of baseline Risks of Iatrogenic Damage Over investigation and over treatment can be damaging Being given a dx may cause abnormal illness behaviour Longitudinal study those with Chronic Fatigue termed as ‘myalgic encephalomyelitis’ had a worse prognosis than those whose doctors termed illness CFS. Emotional Distress presenting as Physical Distress? Where there is no evidence of mental illness, consider: Patients model of illness Role of predicaments – are there are dilemmas that patient is facing where all choices have negative consequenses? Role of allies- people who encourage patient to get help from medical profession, they may need to be involved in solutions. Management Non psychiatric settings, in primary care, regular scheduled visits brief physical exam, avoiding repeated Ix, improve outcome Anti-depressant help- systematic reviewed of 94 RCT’s showed significant improvement RCT’s show activity rather than rest helpful for CF/Fibromyalgia Psychiatric Management Systematic review 29 RCT’s CBT vs other Rx (secondary care): (1)CBT more effective for somatisation (2)physical symptoms more responsive to treatment than psychological. Psychodynamic therapy effective for chronic pain and IBS. Referral to Psychiatrist? Reasonable in patients not improving with structured explanation, graded activity and a trail of antidepressants. Beware interpretation by patient ‘the doctor thinks I’m making this up’ Be honest- not able to find a cure but we need to find a way for your to learn to live with these symptoms. Prognosis Few robust studies, but literature suggests one quarter of patients in primary care continue to have symptoms after 12 months Secondary care a study of people presenting to neurologists-58% continued to have unexplained symptoms 12 years later. References 1. Fink P, Toft T et al .Symptoms and syndromes of bodily distress: An exploratory study of 978 internal medical, neurological, and primary care patients. Psychosomatic medicine 2007; 69:30-9 2. Nimnuan C, Hotopf M et al. Medically unexplained symptoms: how often and why are they missed? QJM Monthly Journal of the Associations of Physicians 2000;93 3. Mangwana S, Burlinsons S et al. medically unexplained symptoms presenting at secondary care. International Journal of psychiatry in Medicine 2009;39:33-40 4. Peveler R, Kilkenny L et al. Medically unexplained physical symptoms in primary care. Journal of Psychosomatic Research 1997; 42: 245-52 5. Wessely S, Nimnuan C et al. Function somatic syndromes: one or many? Lancet 1999; 354:93609 6. Dirkzwager A & Verhaak P (2007) Patients with persistent medically unexplained symptoms in general practice: characteristics and quality of care. BMC Family Practice, 8:33 7. Dwamena F, Lyles J, Frankel R & Smith R (2009) In their own words: qualitative study of high-utilising primary care patients with medically unexplained symptoms. BMC Family Practice, 10 8.Bermingham S, Cohen A, Hague J & Parsonage M (2010) The cost of somatisation among the working-age population in England for the year 2008-2009. Mental Health in Family Medicine, 7, 71-84 9. Hatcher S, Arrol B (2008) Assessment and management of MUS. BMJ 336;335-1124. 10.Carson AJ et al (2003). Outcome of neurology outpatient with MUS. J Neurol Neurosourg Psychiatry;74; 884 11. Henningzen S eta l (2007). Management of functional somatic syndromes. Lancet ;369: 946-55