Medically Unexplained

Medically Unexplained

SymptomsSymptoms

how to tell whether symptoms are organic or not

how to tell whether symptoms are organic or not

Dr. Ramesh Mehay

Dr. Ramesh Mehay

Programme Director (Bradford VTS),

Programme Director (Bradford VTS),

20112011

Why

do t

hese

Why

do t

hese

pati

ents

irri

tate

pati

ents

irri

tate

us?us?

1.1. ‘‘I am worried about

I am worried about missing missing

somethingsomething’’2.2. ‘‘I don’t want to do

I don’t want to do unnecessary

unnecessary

teststests’’3.3. ‘‘Getting them

Getting them onto your way of

onto your way of

thinking thinking is a nightmare’

is a nightmare’

4.4. ‘‘And I don’t want to

And I don’t want to wind them up

wind them up’’

5.5. ‘‘I feel I feel helpless

helpless. How do I help them.

. How do I help them.

There’s no focus

There’s no focus in the in the

consultation’

consultation’6.6. ‘‘And yet I still feel I have a

And yet I still feel I have a sense of sense of

responsibility

responsibility or or moral obligation

moral obligation

to make things better’

to make things better’To tackle 1 & 2

To tackle 1 & 2 you need to create a

you need to create a

bit more certainty out of uncertainty

bit more certainty out of uncertainty

make better decisions

make better decisions

To tackle 3-6

To tackle 3-6 The art of Reattribution.

The art of Reattribution.

Getting certainty out of uncertainty

1. ‘I am worried about missing something’2. ‘I don’t want to do unnecessary tests’

• These two worries come from being: uncertain/unsure/insecure/unconfident in your

diagnosis

• The diagnosis is simply whether there is something organic or not.

• But it’s not surprising as MUS patients come with vague symptoms.

Getting certainty out of uncertainty

• The aim is not to get rid of uncertainty

• The aim is not to simply tolerate the current level of uncertainty

• The aim is to reduce it to a point where what is left is acceptable and manageable.

There is always an element of uncertainty when patients present with MUS.

Therefore:

final level of uncertainty

initial level of uncertainty

To g

et

to t

he

To g

et

to t

he

poin

t w

here

you

poin

t w

here

you

can s

ay:

can s

ay:

‘‘In my heart and in my

In my heart and in my

mind, I really don’t get

mind, I really don’t get

the feeling that there is

the feeling that there is

anything physically

anything physically

wrong with this patient’.

wrong with this patient’.

The real question: ‘How can we tell if this is something organic or not?’

• We don’t need a fancy diagnostic name.

• We simply need to answer this question of whether it is organic or not.

• You can’t never be 100% definitive about this but you need to reduce the level of uncertainty to tolerable levels.

• And here’s how to do it…

The real question: ‘How can we tell if this is something organic or not?’

Doing loads of investigations is not the answer…. there’s a lot more you can do before doing that. Inappropriate use is wasteful (in terms of costs), creates a load of unnecessary work for others in the NHS (and thus waiting lists) and creates anxiety in the patient. Here are some simple things you can do.i.Take a good enough historyii.Good examinationiii.Look at the notesiv.ICEv.PSO

It’s not rocket science! It doesn’t need to be.Two other things throughout the process…1.Don’t be too swayed by others.2.Be prepared to change your view at any point.

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 RBS and ESR 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 psycho-social-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• What do they think is going on?- Is there evidence of crooked thinking that needs rectifying? Is this a way into

discussions?- Do they make links to life problems?• What are their concerns?• What they are 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 track of thinking rather than them hoping 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).

PSO• What are relationships like?• Think work and home.• Domestic violence, sexual/physical/emotional abuse, bullying,

isolation/lonliness, poverty.

I would be less worried about headaches:In a patient who is the victim of domestic violence (unless they’re being

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? Surely 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, RBS (and perhaps one or more of vit D, HIV test, cortisol, coeliac Abs, auto-antibodies, prolactin if suspicious).

Case 1—the most common: mild MUSA 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 MUSA 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 MUSA 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.

Normal to mild ~80% Moderate ~15% Severe ~5% Very severe† <1%

Common name “Worried well” DSM-negative; MAI ASD; MSD SD

Freq. of attendance Low High High High Age of onset Any Any Any <30 years 18

Body systems/Physical symptoms involved Any Any Musculoskeletal, GI, nervous, or

ill-defined systems

Musculoskeletal, GI, nervous, or ill-defined systems.Often Pain, GI, sexual, neurological

Symptom duration “Acute” days to weeks “Subacute” < 6 m “Chronic” >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 it abates ?

Yes 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%

Severity of MUS

The Normal-MildBruce 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-IVSomatization 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

Final w

ord

…Fi

nal w

ord

…

Don’t forget to

Don’t forget to build a picture

build a picture of of

things. things. Think of it

Think of it like a jigsaw puzzle.

like a jigsaw puzzle.

Where all the things I’ve

Where all the things I’ve

mentioned in blue are the

mentioned in blue are the

individual pieces.

individual pieces. Do not rely on any one jigsaw

Do not rely on any one jigsaw

piece. piece. In other words, do not

In other words, do not

make judgements just on ONE or

make judgements just on ONE or

TWO bits of information.

TWO bits of information.

You have to build up a picture.

You have to build up a picture.

You will probably never build a

You will probably never build a

complete picture.

complete picture. The aim is to build up a

The aim is to build up a good good

enough and fairly reliable

enough and fairly reliable

picture picture (even if one or two pieces

(even if one or two pieces

are missing).

are missing).

R Jones.

W

hen n

o

dia

gnost

ic la

bel i

s applie

d;

BM

J (2

010)

“When pattern recognition and iterative

diagnosis do not give an

answer, when symptoms

are vague, or when a

clear diagnosis does not

“crystallise” from investigations or tests of

time or of treatment,

patients will need to be

managed without having

a diagnostic label.”

In these set of slidesWe mainly talked about getting to that point of deciding whether we think something is organic or not. To reduce uncertainty to a tolerable level so that we don’t feel the following:1.‘I am worried about missing something’2.‘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…3.‘Getting them onto your way of thinking is a nightmare’4.‘And I don’t want to wind them up’5.‘I feel helpless. How do I help them. There’s no focus in the consultation’6.‘And yet I still feel I have a sense of responsibility or moral obligation to make things better’

Tackling 36 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/medically-

unexplained-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.