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Approach to Patients withMedically Unexplained Symptoms / Illnesses
Jeffrey P Schaefer MSc MD FRCPCRural Physician Video Conference Program
March 31, 2009
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website
dr.schaeferville.com
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Conflicts of Interest
• none
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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
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Case
• 42 yr old female administrator
total body pain and extreme fatigue x 5 years
previously assessed by GIM, Neurology, Gastroenterology
investigations normal
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What is the probability that you will find a condition that risks loss of life or limb?
0% 50% 100%
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What are your feelings at this point?
Negative Neutral Positive-10 0 +10
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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
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• 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
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• 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
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What is the probability that you will find a condition that risks loss of life or limb?
0% 50% 100%
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What’s your diagnosis?
Diagnosis: ______________________
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Hopefully, uptodate.comhas something…
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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
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Medically Unexplained Symptoms
• Physical symptoms that prompt the sufferer to seek health care but remain unexplained after an appropriate medical evaluation.
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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
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Are Medically Unexplained Symptoms Common?
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MUS Prevalence
• 30% of primary care visits
• 13.6 visits in the previous year
Psychosomatic Med 2005;67:123-9
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Most Frequent Visitors 5th percentile
GI…………….54%
Neuro…….. 50%
Rheum……. 33%
ENT………….27%
GIM………… 10%
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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
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This is a problem!
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This is a big problem!
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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
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MUS Depressed Controls
P(Disease) 15% 10% 5%
25
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One condition or many?
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Chronic Fatigue SyndromeFibromyalgia
Irritable Bowel SyndromeMultiple Chem Sensitivity Syndrome
Sick Building SyndromeHypoglycemia
Gulf War Syndrome
Undocumented LabelsHeadache Syndromes
AsthmaPainful Conditions
Various
Bodily Distress Disorder
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• 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
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Median Number of SymptomsMen 4
Women 6Men & Women 5
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“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
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• 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.
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Psychobiology‘the mind-body connection’
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Psychobiological Framework
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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
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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
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Self-report AMI Trigger412 reports from 849 AMI
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Chronic Stress & Immune Dysfunction
• Influenza Vaccination
• Difference between stressed and non-stressed group.
– Lancet 1999
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Stress and Wound Healing
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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
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So now what?
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Several Approaches…
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The Approach…
• Exclude bio-medical disease–neoplasm
–infection
–auto-immune
–metabolic
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The Approach…
• Exclude bio-medical disease– Adrenal Insufficiency– Hemochromatosis– Hypercalcemia– Amytrophic Lateral Sclerosis – Multiple Sclerosis– Alcoholism– Temporal arteritis– Subacute bacterial endocarditis– Sleep Apnea
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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
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• RCT: n = 200
• OR 1.92 (95%CI 1.08 – 3.4)
• NNT to improve @ 12 months = 6.4
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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
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Key Components
50
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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
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www.calgaryhealthregion.ca/cmbm/
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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
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Self-regulation• Somatic Awareness
– experiential– link emotional state with body symptoms– effortless breathing
• Medication Reduction / Elimination
• Group Therapy– education– Heartmath– guided imagery Apple
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Talk about Stress...
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Acute Stress Response
Fight, Fright, Flight, Frolic Response
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Hans Selye (1907-1982)
General Adaptation Response
– Alarm– Failure to adapt– Exhaustion
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Absolute Stress
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Relative Stress
Interpretation of the world
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Recipe for Stress• Novelty
• Unpredictability
• Threat to ego
• Loss of control
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Stress & Recovery
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Allostatic Load
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21 Program Completers
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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
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• Questions
• Discussion
• Experiences to share
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