medically unexplained symptoms amanda howe ma med md frcgp professor of primary care university of...

Medically Unexplained Symptoms

Amanda HoweMA MEd MD FRCGP

Professor of Primary CareUniversity of East Anglia, Norwich, U.K.

13th international Course, Slovenia EURACT

‘MUS’• patients who present in primary care with a variety of physical

symptoms, for whom we find it difficult to arrive at a clear diagnosis

• a challenge / threat to the doctor?Spectrum of presentations linked with • Some ‘frequent attenders’ / ‘heart sink’• Functional disorders – symptoms best explained by

abnormalities of function, in the absence of disease• Physical presentations of anxiety and / or depression• Somatisation – the physical presentation of psychological

distress • Somatoform disordersApproaches relate to consultation skills / reattribution



What do we already know?

1. How are symptoms caused?

2. What are the underlying physiological mechanisms?

3. Give examples of physical conditions known to be influenced by psychological states

4. How do we learn to understand our experiences?

5. What is the role of health beliefs in illness experience?

6. How do patients present distress to clinicians?


Some more questions...

1. What proportion of people have significant psychological distress when they consult in a UK primary care population?

2. How do sociodemographic factors influence presentation and diagnosis?

3. What are the difficulties of discussing the mind – body continuum with patients?

4. What are the difficulties of conceptualising the mind – body continuum anyway?

5. Or is it a mind – body split?! .....


Context

• 1 in 4 – 5 people consulting are significantly more psychologically distressed than the population ‘norm’

• Based on ‘match’ of views with measures e.g. GHQ• ‘High’ and ‘low’ pickup by clinicians appears based on their

consultation style and ?? beliefs / expectations• Detection and discussion of psychological aspects commoner

if ->– Clinical ‘antennae’ are working– Patients themselves raise emotions / psychological aspects– Women > men, life events > none, midlife > older / young– Varying cultural expectations (on both sides)

Consulting across the body – mind divide – some (contestable) claims

• All experiences have psychological aspects• All illnesses have a psychological impact, because illness is a

threat to self• Symptoms common (‘iceberg’), often unexplained• Cultural awareness and acceptance of the mind – body are

conditioned through emotional expressiveness and insight• Insight into, knowledge of, and effective coping responses for

illhealth are useful adaptive mechanisms for us all• Effective intra – and interpersonal communication is essential to

dealing with illness effectively, both for management AND diagnosis

• Doing this well involves skills and attitudes as well as knowledge


What patient features are known to be associated with MUS?

1. Adverse social circumstances

• Anxious reaction• Hyperattention to

symptoms• Difficulty expressing

feelings• Poor peer relationships• Previous illness prolonged• Other behavioural or

functional problems• Intermittent or atypical

pattern• Minor physical signs

2. Learned behaviour• Psychological gain• Emotional gain• Attention seeking• Introversion• Excessive sensitivity to

physical sensation• Anxiety / depression• Previous illness and lack

of care increase dysfunctional response to adversity

School of Medicine, Health Policy and Practice


Why do patients differ in their experience and expression of symptoms?

• Children learn from the relationship between their own behaviours and the responses of others

• the early ‘mother’ - infant relationship as ‘a homeostatic regulatory system that facilitates the emergence of a primitive mind from the bodily functions of the infant’ (Mahler, 1972)1

• Move over time from external to internal regulation, with development of independence

• Loss/separation always a threat to self identity• Link to MUS – constitutional and learned ways of dealing with

emotion, embodied through neurophysiological pathways



Factors influencing this pathway


Genetic / constitutional factors Home / child rearing

Socioeconomic factors Developmental stage

Life events Significant others

Cultural and socialenvironment

Explanatory concepts - self esteem, coping and resilience

• Psychological resilience ‘the ability to adjust successfully to major life changes’ – a stable personality trait that minimises negative effects of stress and promotes adaptation2

• Coping mechanisms3 – cognitive and emotional appraisal: rethinking the problem, reconsidering your reactions

• Extroversion (expression of feelings) - linked with less physical symptoms and better sense of wellbeing - ‘the correlation between potential health problems and inhibition of behaviour and emotional expression is seen by the (age of) 2 years old’4

• Self esteem – dependent on successful attachments

* Constructive psychological approaches in adult life are correlated with stable caring relationships in childhood, and

weakened by disruptions in emotional security*


Consulting with patients with MUS

• Key components to detecting

Consultation skills

Establishing a rapport

Open questions

Cueing

Exploring ideas, concerns and expectations (ICE)

Checking understanding

Full history and examination

• Key components to managing

Respect and acceptance

Time

Choices

Focused explanation

Linking mind and body *reattribution*

Clear expectations of next steps

Multilevel management




Reattribution

Four crucial stages in the consultation process:• Feeling understood: The general practitioner elicits a history of the

physical symptoms, explores the patient’s beliefs about these symptoms and associated psychosocial and lifestyle factors, and makes a brief focussed physical examination

• Broadening the agenda beyond the presenting physical symptoms. The doctor feeds back the results of the examination and any recent investigations, and explains the lack of serious underlying pathology. The doctor explicitly acknowledges the reality of the patient’s physical symptoms, and explores the extent of the patient’s acceptance that psychosocial or lifestyle factors may be inked to these symptoms

• Making the link: The doctor links the physical symptoms to an underlying psychosocial or lifestyle explanation, using physiological and/or temporal links that are compatible with the patient’s symptom beliefs

• Negotiation over further management. Various, including exploring patient’s views about treatment, promoting problem solving and coping strategies, appropriate use of relaxation, appropriate treatment for depression, and agreeing specific plans for follow-up.

Challenges

• Maintaining a positive therapeutic relationship• Keeping continuity• Pursuing a dual agenda• Containing anxiety / referrals• Time management• Threat to self perception for doctor and patient• Early preventive interventions • Population perspective• Media perspective• Cultural variations


Implications

• For the practice – case discussion, attendance audits, true picture of all health care inputs

• For the practitioner – further training, appropriate use of time and resources, reflection and psychological insight

• For the service – collective approach, simple psychological therapies, liaison psychiatry

• For society – therapeutic support in early years, psychological health, self help

• For cross cultural situations • Other ........


Medically Unexplained Symptoms

Amanda HoweMA MEd MD FRCGP

Professor of Primary CareUniversity of East Anglia, Norwich, U.K.


medically unexplained symptoms amanda howe ma med md frcgp professor of primary care university of...

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