Approach to Patients withMedically Unexplained Symptoms / Illnesses

Jeffrey P Schaefer MSc MD FRCPCRural Physician Video Conference Program

March 31, 2009

website

dr.schaeferville.com

Conflicts of Interest

• none

ObjectivesMedically 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-10 0 +10

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.comhas 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 SymptomsPhysical symptoms that prompt the sufferer to

seek health care but remain unexplained after an appropriate medical evaluation.

Chest Pain

Headache

Fibromyalgia

Irritable Bowel

Chronic Fatigue

InfertilityDizziness

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 5th percentile

GI…………….54%

Neuro…….. 50%

Rheum……. 33%

ENT………….27%

GIM………… 10%

If only… ‘an actual email’

• 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

MUS Depressed Controls

P(Disease) 15% 10% 5%

25

One condition or many?

Chronic Fatigue SyndromeFibromyalgia

Irritable Bowel SyndromeMultiple Chem Sensitivity Syndrome

Sick Building SyndromeHypoglycemia

Gulf War Syndrome

Undocumented LabelsHeadache Syndromes

AsthmaPainful 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 SymptomsMen 4

Women 6Men & Women 5

“Bodily Distress Disorder”Fink et al. Psychosom Med

2007

Chest Pain GroupGI Symptoms Group

Musculoskeletal Group

< 3% of patients had symptomsconfined 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 Trigger412 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 improve @ 12 months = 6.4

Smith’s Treatment ModelCognitive – 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 TherapyScott 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

www.calgaryhealthregion.ca/cmbm/

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– Heartmath– guided imagery Apple

Talk about Stress...

Acute Stress Response

Fight, Fright, Flight, Frolic Response

Hans Selye (1907-1982)

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)

Period Visits

Prev 365 63During 17Post 365 21

Frequency of Unscheduled Visits in the year prior and the year subsequent to attendance at the Clinic for Mind Body Medicine for 39 patients.

-10 -8 -6 -4 -2 0 2 4

123456789

101112131415161718192021222324252627282930313233343536373839

Uniq

ue S

ubje

cts

Sum of visits prior to attendance (negative) and subequent to attendance (positive) at CMBM

Prev365

Post365

Admissions Arising from Unscheduled Visits

Previous During After

8 2 1

• Questions

• Discussion

• Experiences to share