Cardiff - Understanding Medically & Neurologically Unexplained Symptoms (Apr08)

Understanding & TreatingMedically Unexplained Symptoms

Alex Mitchell alex.mitchell@leicspart.nhs.ukConsultant in Liaison Psychiatry

Medicine for Psychiatrists Conference Cardiff 2008

RecognisedUnrecognised

Uncertain

Clinical Features

Pathology

Contents

• Diagnostic Methods– Assumptions vs Diagnostic Accuracy

• Classification of Medically Unexplained Symptoms– Common or rare?– Somatoform Disorders in DSMIV and ICD10

• The Clinical Significance of MUS– MUS in Primary Care– MUS in Secondary Care

• Prognosis & Treatment of MUS– What do we know

1. Introduction

Uncertain

Clinical Features

Pathology

Basic concept - MUS

• Medically unexplained symptoms– Are physical (somatic) complaints that are noted by the

patient but which seem to have no satisfactory medical explanation according to the health professional

– They may or may not be linked with psychological symptoms– They may or may not be linked with underlying disease– They should warrant further help/advice from clinicians

Uncertain

Clinical Features

Pathology

Main MUS Syndromes

• Somatization disorder (8 symptoms)

• Undifferentiated/abridged somatoform disorder

• Conversion disorder (1 symptom)

• Hypochondriasis

• Body dysmorphic disorder

• ? Pain disorder

Uncertain

Clinical Features

Pathology

Related MUS Symptoms/Syndromes

Multiple chemical sensitivityOccupational Medicine

MUS HypoglycemiaEndocrinology

Irritable bowel syndromeGastroenterology

Chronic Fatigue SyndromeInternal Medicine

FibromyalgiaRheumatology

TMJ syndromeDentistry

Hyperventilation, dyspneaPulmonary

Atypical chest painCardiology

Dizziness, headacheNeurology

TinnitusENT

Pelvic pain, PMSOb/Gyn

Lower back painOrthopedics

2. Scientific Principles of Diagnosis

How to establish a cause?

How to establish a syndrome?

Uncertain

Clinical Features

Pathology

Example: A Clear Disease [#1]

Disorder

Number ofIndividuals

False +veFalse +ve

True -veTrue -ve

Point of Partial Rarity

Test Result

No Disorder

False -veFalse -ve

True +veTrue +ve

Uncertain

Clinical Features

Pathology

Example: A Probable Syndrome [#2]

Disorder

False +veFalse +ve False -veFalse -ve

True -veTrue -ve

True +veTrue +ve

MMSE Cognitive Score

No Disorder

Uncertain

Clinical Features

Pathology

Example: A Normally Distributed Trait [#3]

Disorder

False +veFalse +ve False -veFalse -ve

True -veTrue -ve

True +veTrue +ve

MMSE Cognitive Score

No Disorder

Example: Dementia

DiseaseSyndromeTrait

Uncertain

Clinical Features

Pathology

Hubbert et al (2005) BMC Geriatrics

MMSE scores for dementia (n=72)and non-dementia (n=2735)

Huppert et al BMC Geriatrc 2005

Example: Depression

DiseaseSyndromeTrait

Uncertain

Clinical Features

Pathology

Mitchell, Coyne et al (2008)

Early Pregnancy3months Post-Partum12months Post-Partum

Scores on the CES-D during Pregnancy, 3 and 12 months Post-partum in 947 Women

Depressive Symptoms Moderate to Severe DepressionHealthy Mild Depression

Uncertain

Clinical Features

Pathology

Thompson et al (2001) n=18,414

Zero One

TwoThree Four

Five SixSev

TenEleve

nTwelv

eThirt

Fourtee

nFifte

enSixtee

nEightee

3. MUS – Any there Valid Criteria?

Uncertain

Clinical Features

Pathology

• 1952 DSM - Conversion reaction • 1968 DSM-II - Hysterical neurosis (conversion type) • 1980 DSM-III - Conversion disorder • 1987 DSM-III-R - Conversion disorder • 1994 DSM-IV - Conversion disorder • 1992 ICD-10 - Dissociative (conversion) disorder

Uncertain

Clinical Features

Pathology

DSMIV Diagnostic criteria Somatization disorder• A. A history of many physical complaints beginning before age 30 years that occur over a period of several

years and result in treatment being sought or significant impairment in social, occupational, or other important areas of functioning.

• B. Each of the following criteria must have been met, with individual symptoms occurring at any time during the course of the disturbance: 1. Four pain symptoms: a history of pain related to at least 4 different sites or functions (for example, head, abdomen, back, joints, extremities, chest, rectum, during menstruation, during sexual intercourse, or during urination).

– 2. Two gastrointestinal symptoms: a history of at least 2 gastrointestinal symptoms other than pain (for example, nausea, bloating, vomiting other than during pregnancy, diarrhea, or intolerance of several different foods).

– 3. One sexual symptom: a history of at least 1 sexual or reproductive symptom other than pain (for example, sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding, vomiting throughout pregnancy).

– 4. One pseudoneurological symptom: a history of at least 1 symptom or deficit suggesting a neurological condition not limited to pain (conversion symptoms such as impaired coordination or balance, paralysis or localized weakness, difficulty swallowing or lump in throat, aphonia, urinary retention, hallucinations, loss of touch or pain sensation, double vision, blindness, deafness, seizures; dissociative symptoms such as amnesia; or loss of consciousness other than fainting).

• C. Either (1) or (2):– 1. After appropriate investigation, each of the symptoms in Criterion B cannot be fully explained by a known general

medical condition or the direct effects of a substance (for example, a drug of abuse, a medication).– 2. When there is a related general medical condition, the physical complaints or resulting social or occupational

impairment are in excess of what would be expected from the history, physical examination, or laboratory findings.

• D. The symptoms are not intentionally produced or feigned (as in factitious disorder or malingering).

Not specifiedDoes not meet criteria for any other somatoform disorder

Can be <6 mo duration

Somatoform symptomsSomatoform disorder, NOS

Not specifiedNot better accounted for by other mental disorder

Not applicablePreoccupation with imagined defect in appearance or excessive concern about slight physical anomaly

Body dysmorphic disorder

Not of delusional intensity; not restricted to circumscribed concern about appearance

Not exclusively during obsessive compulsive disorder (OCD), generalized anxiety, panic disorder, major depressive episode, separation anxiety, or other somatoform disorder

Duration >6 moPreoccupation with fear of having or idea that one has serious disease based on misinterpretation of bodily symptoms; persistent fear and idea despite medical evaluation and reassurance

Hypochondriasis

Not specifiedNot better accounted for by mood, anxiety, or psychotic disorder; does not meet criteria for dyspareunia

Psychological factors in important role

Pain is predominant focus; severe enough to warrant clinical attention

Pain disorder

Not intentionally produced or feigned; not explained by other neurologic or medical condition, substance effect, or culturally sanctioned behavior and/or experience

Not limited to pain or sexual dysfunction; not exclusively during course of somatizationdisorder; not better accounted for by other mental disorder

Associated psychological factors

Symptoms affecting voluntary motor and/or sensory function suggesting neurologic and/or medical condition

Conversion disorder

Not explained by medical condition or pathophysiologicmechanism

Not accounted for by another mental disorder

Duration >6 moOne or more physical complaintsUndifferentiated somatoform disorder

Not explained by general medical condition or substance effect

Not specifiedOnset <30 y of age

History of many physical complaints; 4 pain sites or functions: 2 nonpain GI, 1 sexual or reproductive, 1 pseudoneurologic

Somatizationdisorder

Other ExclusionsExclusions By Other Psychiatric Illness

Temporal and Other

Requirements

General DescriptionSomatoform Disorder

(DSM-IV)

Uncertain

Clinical Features

Pathology

Somatization Disorder - SimplifiedDiagnostic Criteria:

1. History: onset before 30yo, symptoms lasting years, Impairment in function or pursuit of medical treatment

2. Symptoms [all four of the following]:a. Pain (four sites)b. Gastrointestinal (two non-pain symptoms)c. Sexual (one non-pain symptom)d. Neurological (one non-pain symptom)

3. Medical explanations inadequate4. Rule out other conditions

Uncertain

Clinical Features

Pathology

• One or more symptoms suggesting a medical condition• Psychological factors associated with symptoms

• Not intentionally produced• Symptoms are self-limited not progressive disabilities

– Subtypes: (1) motor (2) sensory (3) seizures or convulsions (4) mixed

• “La Belle Indifference”• Primary or secondary gain

Conversion Disorder - Simplified

Uncertain

Clinical Features

Pathology

MUS Definitions – Rule of Thumb

• Somatization– Multiple physical complaints, no medical explanation– Common

• Conversion Disorder– Single physical complaint, a psychological explanation– Rare

Uncertain

Clinical Features

Pathology

Somatisation, factitious or malingering?

Intentionality

Insight

Motivation conscious

Motivation unconscious

Symptoms Conscious

Symptoms unconscious

MalingeringFactitiousSomatoform

4. MUS – What about Diagnostic features

Uncertain

Clinical Features

Pathology

Possible Diagnostic Factors - Patient

SometimesPsychosocial Difficulties

UsuallyUnsatisfied with care

YesRequests more tests

Not intentionalIntentionality

Inferred by doctorGain?

SometimesIndifference

YesNo abnormal test

YesPhysical complaints

Present?Classic MUS

Uncertain

Clinical Features

Pathology

Possible Diagnostic Factors - Patient

SometimesPsycho-social difficulties

Usually satisfiedUnsatisfied with care

NoRequests more tests

Not intentionalIntentionality

Usually overlookedGain?

SometimesIndifference

YesNo abnormal test

YesPhysical complaints

Physical DisorderClassic MUS

Uncertain

Clinical Features

Pathology

Stone et al, 2006

Uncertain

Clinical Features

Pathology

Psychiatric disorder, life events and difficulties in functional bowel disordersCreed et al 1988

30%13%Marked relationship difficulties

14%3%Psychiatric disorder

38%24%Chronic difficulties

Not inflamed n=56

Acute inflamed n=63

Appendicectomy patients

Uncertain

Clinical Features

Pathology

Possible Diagnostic Factors - Doctor

NoWorking with patient

UncertainRequests more tests

YesLow Dr Satisfaction

YesLow Ther Relationship

YesLittle to offer

YesTo many appointments

YesToo much time

Present?Classic MUS

Uncertain

Clinical Features

Pathology

Salmon et al (2007)

Uncertain

Clinical Features

Pathology

With Psychiatric Symptoms

Medically ExplainedMedically Unexplained

Medically ExplainedPsychiatrically Unexplained

Medically UnexplainedPsychiatrically Explained

Medically UnexplainedPsychiatrically Unexplained

ExplainedUnexplainedFunctional

UnexplainedUnexplainedUnclear

UnexplainedExplainedOrganic

PsychiatricallyMedicallyModel

Dichotomous Model – Organic vs Functional

Uncertain

Clinical Features

Pathology

Unresolved Questions• How to establish conscious? Intentional?

• Where is partly explained?

• Where are rare conditions?

• Where are future conditions?

Uncertain

Clinical Features

Pathology

MUS Model

Unexplained75%

Initially Explained

Later Explained

Initially Explained

Mostly Psycholo

gically Explained

Theoretically

Explained15%

Impossible to

Explain20%

With time

5. MUS – Clinical Significance

Uncertain

Clinical Features

Pathology

MUS Frq in Primary Care

Kroenke K, Mangelsdorff AD. Am J Med. 1989;86:262-266.

16% = organic; 10% psychological; 75% = unclear

Abdom-inalPain

N o o r g a n i c c a u s e i d e n t i f i e dO r g a n i c c a u s e

DizzinessChestPain

Fatigue Head-ache

Edema BackPain

Dyspnea

Insomnia Numb-ness

Uncertain

Clinical Features

Pathology

DSM-IV Criteria in Primary Care Patients

MUS DSM-IV Criteria in Primary Care Patients (n=206)

ric (M

RC Smith et al (2005) Exploration of DSM-IV Criteria in Primary Care Patients With Medically Unexplained Symptoms Psychosomatic Medicine 67:123–129

(60.2%) had any “psychiatric” (23%) any psychosomatic

Uncertain

Clinical Features

Pathology

Self rated anxiety and depression (HAD - max 21 - a lower score is ‘better’)

0 5 10 15 20

HAD score

Completely explained by diseaseLargely explained by diseaseSomewhat explained by diseaseNot at all explained by disease

Uncertain

Clinical Features

Pathology

Diagnosis of MUS by GPs, N=667• 20% of high scorers

Rosendal M, Bro F, Fink P, Christensen KS, Olesen F.Diagnosis of somatisation: effect of an educational intervention in a cluster randomised controlled trial. British Journal of General Practice 2003; 53:917–922.

Uncertain

Clinical Features

Pathology

MUS accuracy, Becker, 2004

n = 431 False positives False negatives

Somatization/MUS 34.6% 44.1%

Depression 10.5% 55.1%

Uncertain

Clinical Features

Pathology

MUS in Secondary Care (Neurology)

Uncertain

Clinical Features

Pathology

Frequency of MUS Episodes in Frequent Attenders by Specialty

0.540.5

0.34 0.330.3

0.17 0.16 0.150.12 0.11

Gastro

logyCard

iologyRheu

matology

Orthopae

dics ENTGyn

aecolog

eral su

Chest m

edicine

almology

General

Dermato

MUS in Frq Attenders

Uncertain

Clinical Features

Pathology

Prevalence of MUS syndromes by clinic% Cases Accounted for by MUS from Hospital Clinics (n=550)

Nimnuan et al (2001) J Psychosom Res Medically Unexplained SymptomsAn Epidemiological Study in Seven Specialities

Uncertain

Clinical Features

Pathology

Prevalence of MUS syndromes by clinic

Chest Cardio Gastro Rheum Neuro Gynae

NCCPIBSFMGCF

Nimnuan et al (2001) J Psychosom Res Medically Unexplained SymptomsAn Epidemiological Study in Seven Specialities

Uncertain

Clinical Features

Pathology

Lempert T, Dieterich M, Huppert D, et al. Psychogenic disorders in neurology: frequency and clinical spectrum. Acta Neurol Scand 1990;82:335–40.

MUS in Neurology

Uncertain

Clinical Features

Pathology

Referrals for MUS from NeurologyReferra l Bias from Neurologica l W ards vs Non-Neurologica l W ards

11.40%

15.10%15.50%

12.00%

7.30%7.90%

15.10%

11.90%

18.80%

19.60%

13.90%

-3.00%

12.00%

17.00%

22.00%

Neurological Wards (837)

Non-Neurological Wards (n=8705)

Peter de Jonge et al. (2001) Referral pattern of neurological patients to psychiatric consultation-Liaison Services in 33 European hospitals. General Hospital Psychiatry 23: 152–157

Uncertain

Clinical Features

Pathology

What do Neurologists Think?

Uncertain

Clinical Features

Pathology

To what extent can the patient’s symptoms be explained by organic disease? (n=4180)

Not at allExplainedBy Disease

LargelyExplainedBy Disease

CompletelyExplainedBy Disease

SomewhatExplainedBy Disease

12% 18% 25% 45%

Carson et al (2002)

Regional variation: Inverness 11% Stranraer- 100%!

6. MUS – Prognosis

Uncertain

Clinical Features

Pathology

Consequences of somatisation

– “Unnecessary” use of healthcare• Investigations• Admissions for treatment / operations

– Often making matters worse

– Prescribed drug misuse and dependence– Disability and loss of earnings

• Social disability payments– Poor quality of life

• Impact on family / social network

Uncertain

Clinical Features

Pathology

Is a negative test benign?

27Anti-anginal medication

13Cardiac-related admission in the last year

19Impaired work

51Limitation of physical activity

70Continuing chest discomfort

%Outcome

Papanicolau et al (1986),Chest pain with normal coronary arteries: outcome at 6 years

Uncertain

Clinical Features

Pathology

MUS and Prognosis

University of Kansas Medical Center (routine)2825892005Ziegler (unpublished

University Department of Neurology00301998Binzer

Wards of National Hospital for Neurological Diseases43731998Crimlisk

Wards of National Hospital for Neurological Diseases1511731996Mace

University Department of Neurology42561995Couprie

Wards of National Hospital for Neurological Diseases4415351986Marsden

Wards of National Hospital for Neurological Diseases4222521965Slater

Source of Cases%#FoundOrganic

#CasesFollowed

YearSeniorAuthor

7. MUS – Treatment

Uncertain

Clinical Features

Pathology

Treatment (Allen et al, 2002)

Uncertain

Clinical Features

Pathology

Uncertain

Clinical Features

Pathology

Uncertain

Clinical Features

Pathology

Fibromyalgia

Uncertain

Clinical Features

Pathology

Kroenke (2007)

Uncertain

Clinical Features

Pathology

Uncertain

Clinical Features

Pathology

Uncertain

Clinical Features

Pathology

Summary

Uncertain

Clinical Features

Pathology

Smith et al (2006)• 206 patients who had 8 or more

visits per year for the last 2 years to any providers.

• no documented organic disease to explain symptoms of at least 6 months duration.

• Combination approach by GPs

• => improved depression and function at 12 months

Uncertain

Clinical Features

Pathology

Whiteley -7 Scale

Fink P, Ewald H, Jensen J, Engberg M, Holm M, Munk-Jorgensen P. Screening for somatization and hypochondriasis in primary care and neurological inpatients. A 7-item scale for hypochondriasis and somatization. J Psychosom Res1999;46:261–73.

Uncertain

Clinical Features

Pathology

Rosendal et al• Educational program designed to improve

care for somatizing patients in primary care.

• Evaluation was performed during routine clinical care in a cluster randomized controlled trial.

• Follow-up was conducted 3 months (response rate=0.74) and 12 months

• Self-reported health improved in both intervention and control groups during follow-up for patients with a high score for somatization, but changes were small.

• Satisfaction 35%• GP diagnosed 20% of 911 high scorers

8. Extras

Uncertain

Clinical Features

Pathology

Model of MUS

Uncertain

Clinical Features

Pathology

Establish Cause?• Bradford Hill criteria for causation

– Temporal relationship– Dose-response gradient– Strength of association– Biological plausibility– Consistency– Specificity– Coherence of evidence

Uncertain

Clinical Features

Pathology

Increase in Sophistication

ExplainedUnexplainedFunctional

UnexplainedUnexplainedUnclear

UnexplainedExplainedOrganic

PsychiatricallyMedicallyModel

Unexplained

Explained(contributory)

Complicating(effect)

Explained

Unexplained

Psychiatrically

TEAExplained(cause)

Symptomatic

Fear of SeizuresExplained(contributory)

Combination

PNESUnexplainedFunctional

Atypical fitUnexplainedUnclear

Epileptic seizureExplainedOrganic

ExampleMedicallyModel

Cardiff - Understanding Medically & Neurologically Unexplained Symptoms (Apr08)

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