Medically Unexplained

(or Functional) Symptoms:

An Enhanced Clinical

Formulation &

Management Approach

Dr M Griffiths

Lead Consultant Clinical Psychologist

Head of Services

Clinical Health Psychology Services

Aintree University Hospital NHS Foundation Trust

15/06/2016 1

“Medically unexplained/ Functional symptoms

are ‘persistent bodily complaints for which

adequate (medical) examination does not reveal

sufficient explanatory structural or other

specified pathology”

(RC Psych, 2011)

Definition

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Functional Neurological

SymptomsE.g. Functional weakness/ NEAD

Heart Palpitations

Stomach/ Bowel SymptomsBloatedness/ constipation/ diarrhoea/

nausea

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Fatigue (Physical/ Cognitive)

PainBack pain/ Chest pain/ Headaches/

Stomach Pain/ Muscle Pain

Common Functional Symptoms

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(UK) Primary Care – FS Prevalence

15-20% of GP consultations regard FS

2% of the general practice population repeatedly

present with FS, accounting for 4-6% of total GP

consultations

10-20% of adults will experience FS over their life

course

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(UK) Secondary Care – FS prevalence (Rolfe & Burton, 2013)

Cardiology- 53%

Gastroenterology- 58%

Neurology- 66%

Respiratory- 41%

Rheumatology- 45%

More generally, within a hospital clinic,

25% patients will be likely to present with functional symptoms15/06/2016 5

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Chronic Pain: A Highly Complex Phenomenon

“Pain is mediated

by sensory, physiological, interpersonal and environmental-situational factors”

(Dennis Turk, Professor, Department of Anaesthesiology & Pain Medicine, UW Medicine)

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Recurrent FS experience: Psychosocial Risk Factors

•Life history of adversity or trauma

•FS more common in patients from poorer

backgrounds

(Common Thread – Greater exposure to

recurrent stressors, the greater the risk )

•FS more common in families with FS

histories (Genetics v Learning Theory)

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Recurrent FS experience: Psychosocial Risk Factors

• High rates of mental health/ FS co-morbidity

• Anxiety and Depression – both more common

in patients with FS than in counterparts living

with medically-explainable physical LTCs

• Approx. 75% of patients with FS will report

symptoms of depression +/- anxiety (2x the

rate of patients with equivalent physical

disability explainable by organic disease)

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“The key aspect of all functional disorders is that

they are:

• Long term/ Enduring & Fixed conditions

• Underpinned by a baseline of “impaired

adaptedness…...that limits the capacity to

adapt successfully to the demands of life….”

Oken (2000)

The Human Factor

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Pre-morbid personality and coping styles are highlighted as

integral precursors to how patients developing persistent FS are

able to:

a) negotiate the world around them

b) how they understand, cope with, and respond to stress

provoked (at unconscious and physiological levels)

c) how these relationships drive health symptom patterns and

responses/ health behaviours

The Human Factor

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Body & Mind – A Dynamic Equilibrium

• Pain science

• Fatigue & Immune system Fx

• Bodily systemic inflammation and Depression

evidence

(i.e. BMC Medicine, 2013: Suggestion of physiological process

leading to depression causation by bodily immflamation)

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Activity Limitation

Illness Behaviours

Environmental Restriction

Sickness in the society

Impairment

Neurophysiological disorder

Health

Experienced

Biological

Psychological Sociological

The Biopsychosocial Model of Health

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• Neglected recognition of the underlying and key

psychological issues – missed opportunities for intervention

to improve clinical management

• Compromised medical care & clinical outcomes

• Iatrogenic affects –Exacerbating negative psychological

factors, then re-enforcing persistent healthcare seeking

(increasing healthcare dependency)

• Increasing costs of (ongoing) care

Risks posed by ‘usual care’

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Healthcare Cost

RCPsych (2011):

• Annual NHS healthcare cost of FS across the UK – Exceeds

£3.1 billion

• Patients presenting with FS commonly having:

• higher rates of onward medical referral and medical

investigations

• more protracted patient journeys

• less likely to be followed up within specialist care

• more likely to be referred back for GP management15/06/2016 15

How can medical management gains best be made?

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Principles of Effective MUS management

The PPP model (Walker,

Unutzer & Katon, 1998)-

Seek to Understand:

Biopsychosocial predisposing

factors

Childhood illness history/ social stress/ lack of social support/

childhood trauma/ psychological

problem history/ coping resource

deficits

Precipitating Factors

Current MH issues; stressors (social,

relational, occupational, financial) Perpetuating

Factors

Ongoing stress cycles; social

isolation; relational secondary gains

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Commissioning Support for enhanced models of medical care at

primary and secondary levels -

• Striving for an holistic approach from the ground up;

• Supporting an enhanced, holistic model of care & treatment,

starting at primary care, but across all care stages

Commissioning considerations

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Adoption of a biopsychosocial clinical formulation

approach – moving away from a reductionist

position

Commissioners & Services must seek to

acknowledge and consider biopsychosocial

relationships as having pertinence to medical

presentations routinely, under systematic care

Paradigm Shift required

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An Enhanced Management Approach

– What might this look like?

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• A protocol to support GPs in providing enhanced care of patients with

FS (and FS/ mixed with medically explained symptoms)

• Supporting enhanced primary care management, through an

enhanced and holistic clinical management model

• ‘Diagnosis’ of FS NOT NEEDED to apply these care principles (which

may offer management benefits early on)

Primary Care/ GP FS management:

An Enhanced case management approach (Rimmer & Griffiths, 2016)

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Provide regular

support within a

structured planAvoiding risk of

responding to

reactive behaviours

Invest in extended

appointmentsSupporting time for

rapport development

Named GP

allocatedWho can provide

regular contact and

a consistent

approach

Provide

compassionate

listening

Encourage

behavioural &

social activation To facilitate social

support

Promote a

biopsychosocial

understanding of

symptomswith the patient

Principles

Of

Enhanced

Clinical

Management

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Be cautious in

prescription of

opiates and similar Which may otherwise

mask key underpinning

issues to be tackled

May also lead to

psychological addiction

issues, further

complicating clinical

issues to be managed)

Explain basic CBT

or mindfulness

principles to aid

coping and

symptom

management

(Seek ing support

to if needed )

Support by advice by

prescription

Liaise with

colleagues from

local IAPT, Clinical

Health Psychology

Services and

Psychological

Medicine services

– to support

primary care case

management

Principles

Of

Enhanced

Clinical

Management

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Avoid secondary

care

investigations unless clear medical

rationale can be

seen

Avoid referring

onwards for

reassurance

Communicate the

need for a

consistent

approachTo practice

colleagues

Secondary care

colleagues

Seek to support

patient symptom

management as

early as possible

once medical ‘red

flags’ ruled out

Principles

Of

Enhanced

Clinical

Management

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General core principle

Provision of psychologically/psychosocially

-informed medical care within the

patients’ understanding that this is part of

a medical (physical symptom) treatment

plan

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• Very high burden on emergency care of frequent

attenders

• E.g. 2012-13: more than 12,000 people made 10+

visits to A&E, with over 150 of these attending 50+

times (BBC, 2014)

• Most A&E attenders presenting with pain of some sort

(Loveridge, 2000) –with a high percentage of

presentations being for functional pain

Acute Care: An Enhanced Approach

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• Chest pain (anxiety and panic manifesting as queried

heart disease)

• NEAD/ pseudo seizures/ conversion disorder presentations

• Acute/ Chronic pain (often co-morbid to ‘medical’

conditions)

• COPD attack fuelled by anxiety/ panic attack

• Neurological symptoms (numbness/ Neuralgia)

Common A&E presentations:

complex presentations where psychological issues

significantly affect / confuse clinical presentation

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Holistic MDT model of enhanced AED care:

CH Psychologist on ‘shop floor’ with AED team

Biopsychosocial position to routine MDT assessment, facilitated by the

presence of a clinical psychologist within the A&E acute MDT

Facilitating identification and management of:

- crucial psychological factors (amenable to change) and pertinent to

physical health presentation

- Via professional consultation and direct patient contact/ advice/

treatment (including access to F/U treatment clinic)

An enhanced A&E approach –

the Aintree Model

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Service Aims :

• Improved patient journey/ experience

• Support integrated clinical formulation & care planning

• Reduced rates of avoidable admissions

• Improved patient flow

• Improved care

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Outcomes (so far – 6 months in…..)

• Clear evidence of reduced rates of A&E attendance following

psychologist contact or influence on care

• 40% reduction of A&E attendances

(Comparing A&E behaviours 3 months before psychology input v 3

months post input into care)

Also - Medical team feedback :

• Admissions that would otherwise have occurred being avoided

by this enhanced approach

• Added value to medical management15/06/2016 31

Other innovative MUS

management examples

NES Scotland Primary Care Support Model

• Development of an interactive online resource to help inform

optimised FS and physical LTC management

CSL ‘”Whole systems approach to MUS management’

• 2011 report outlining a stepped care model to support

optimised MUS identification and management, across

medical and psychological pathways (e.g building up from a

polyclinic and collaborative approach model)

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Significant clinical outcome and financial opportunity gains raised

due to high proportional problem prevalence , across steps of care. With

high levels of health service use (and burden) associated with these

patients (at all levels)

A different; enhanced; integrated; holistic clinical management approach

is needed (from primary care upwards) to optimally manage patients

suffering with FS/ MUS/ psychosomatic symptoms and realise gains

possible –

Innovative clinical commissioning and service design is needed

(learning from examples out there)– being the key to achieving gains

possible

In Summary

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Reference –

Medically Unexplained Symptoms:

Understanding and Managing the Clinical Phenomena

Guidance for Clinicians & Commissioners (Griffiths, M, 2016)

North West Coast Strategic Clinical Network

(Currently being finalised)

Further information and references

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