THE PATIENT WITH MEDICALLY UNEXPLAINED

SYMPTOMSProf. Trudie Chalder

Dr. Rina Dutta

• Medically unexplained symptoms (MUS) / Medically unexplained physical symptoms (MUPS) (symptoms not explained by the medical model)

• Functional (e.g. “functional dyspepsia”; affecting physiological or psychological functions but not due to structural / physical / chemical disorder)

• Idiopathic (e.g. idiopathic chest pain – means ‘unknown cause’)

• Somatisation (usually implies physical symptoms are expression of emotional distress)

• DSM-IV somatoform disorders (criticised for containing mixture of relatively specific categories such as somatisation disorder and hypochondriasis, and vague non-specific categories such as undifferentiated somatoform disorder)

• Miscellaneous specific terms (e.g. irritable bowel syndrome (IBS), chronic fatigue syndrome (CFS)

Different terms for medically unexplained symptoms

Gastroenterology: Irritable bowel syndromeRheumatology: FibromyalgiaInfectious diseases: Chronic fatigue syndromeNeurology: Headache/Non-epileptic

seizuresHand surgery: Repetitive strain injuryDental: Atypical facial painCardiology: Non-cardiac chest painGynaecology: Chronic pelvic painUrology: Irritable bladder syndrome

Which clinics see patients with MUS?

What is the prevalence of MUS in medical clinics (Nimnuan et al., 2001)

Clinic Prevalence (95% CI)

Chest 59% (46-72)

Cardiology 56% (46-67)

Gastroenterology 60% (45-73)

Rheumatology 58% (47-69)

Neurology 55% (45-65)

Dental 49% (37-61)

Gynaecology 57% (50-68)

Total 56% (52-60)

• Fatigue is the principal symptom. Fatigue is severe, disabling, and affects physical & mental functioning

• Definite onset that is not lifelong

• Fatigue has been present for a minimum of 6 months, during which time it has been present for more than 50% of the time

• Other symptoms may be present, particularly myalgia, mood, and sleep disturbance

• Exclusion criteria include presence of medical conditions that produce chronic fatigue & certain psychiatric disorders (substance abuse, eating disorders, organic brain disease)

What is Chronic Fatigue Syndrome: Oxford Criteria (Sharpe et al., 1991)

Chronic Fatigue Syndrome (“ME”)

• More common in women than men• Prevalence estimates vary widely.

o Can be difficult to differentiate CFS from depressive & anxiety disorders. Estimates that do not exclude those diagnoses are much higher than those that do.

o Depends on criteria used. o Prevalence in adults perhaps 0.3-1.0%.

• 50%+ have psychiatric disorders, especially depression

• IBS is a clinical diagnosis• A symptom complex for which no organic

cause has been found• No physical test by which to identify the

syndrome• Identified by symptoms• Usually ESR and full blood count exclude

other diagnoses

Diagnosis

• At least 12 weeks (not necessarily consecutive), in the preceding 12 months of abdominal discomfort or pain that has 2 out of 3 features:

1) Relieved with defecation; and/or 2) Onset associated with a change in frequency of stool; and/or 3) Onset associated with a change in form (appearance) of stool.

Other symptoms that are not essential but support the diagnosis of IBS: • Abnormal stool frequency (greater than 3 bowel movements/day or less

than 3 bowel movements/week);

• Abnormal stool form (lumpy/hard or loose/watery stool);

• Abnormal stool passage (straining, urgency, or feeling of incomplete evacuation);

• Passage of mucus;

• Bloating or feeling of abdominal distension.

Irritable bowel syndrome: Rome II criteria

• Symptoms that might indicate another disorder and hence further investigation necessary include; rectal bleeding, unintended weight loss, frequent awakening by symptoms, fever, anaemia.

• Very common, 9-12% of population (up to 30% have some features), small minority get disability

• More common in women than men• In gastroenterology clinics about 40-60% have

psychiatric disorders, mainly anxiety & depression

Irritable Bowel Syndrome (IBS)

• CBT generally found to be significantly better than standard medical care / group psychoeducation / pacing

(e.g. Sharpe et al., 1996; Deale et al., 1997; Prins et al., 2001; White et al 2011)

• Graded exercise therapy (e.g. Fulcher & White, 1997; Powell et al., 2001; White et al 2011)

Treatments with little or no supportive evidence include:

- Antidepressants; Nutritional supplements

- Extended rest; Complementary / alternative therapies

Evidence from RCTs: CFS

Evidence from RCTs: IBS

• CBT:

- More effective than control conditions (Greene & Blanchard, 1994; Dulmen et al. 1996) [although Boyce et al. (2003) found no diffs between CBT & relaxation training & routine medical care]

- Group CBT is superior to psycho-education or usual medical care (Toner et al., 1998)

- CBT in combination with antispasmodic drugs is superior to drugs alone (Kennedy et al., 2005).

More evidence from RCTs: IBS

•Hypnotherapy (e.g. Whorwell et al., 1984) and psychodynamic interpersonal therapy (Guthrie et al., 1993; Creed et al. 2003) effective in reducing symptoms / ↑ quality of life in secondary care.

• Antidepressants – most effective drugs for treating IBS; modify gut motility and alter visceral nerve responses, reduce pain.

•Antispasmodics (e.g. mebeverine hydochloride) are associated with improvement in symptoms for some people.

Engagement

• Be empathic • Explicitly convey belief in reality of physical

symptoms; doesn’t mean ‘all in the mind’• Shift focus from “cause” to “symptom

management”• Avoid physical versus psychological discussions• Use physical illness analogies to illustrate

approach• Reinforce any helpful responses patient is

already using• Elicit concerns and expectations

Assumes multiple contributory factors

• Predisposing factors

• Precipitating events or triggers

• Maintaining factors

(Physiological, behavioural, cognitive, emotional, social)

Use information from assessment to develop individualised model of the different contributory factors

Modifying predisposing & maintaining factors can help to:

- reduce symptoms and impairment

- decrease risk of future relapse

Presenting CBT approach

• Guided by individual conceptualisation

• Rationale for every aspect of treatment

• Expanding understanding of contributory factors

• Physiological explanations where possible

• Begin with behaviour change

• Cognitive work on unhelpful thinking patterns & underlying beliefs

• Normalising and acceptance of symptoms

CBT for unexplained symptoms: Basic components

• Pain does not necessarily mean damage / harm

• Work on other psychological issues if necessary (e.g. low self-esteem, lack of assertiveness).

• Be aware how underlying beliefs may affect therapy

• Recovery defined in terms of concrete behaviour, not necessarily symptom free or returning to previous lifestyle

• Relapse prevention

• Close liaison with all practitioners (party line)• Deal with reassurance seeking (provide rationale

/ liaise with those providing reassurance)• Suspend further investigations or agreeing a

compromise• Rationalise medication• Reduce drugs with adverse side effects

Other aspects of treatment

• Establishment of consistent baseline activity level- Use activity diaries at beginning of

treatment

• Balance between activity and rest

• Identify activity targets (exercise, social, work-related, leisure)

Components specific to fatigue

•Break down targets into specific manageable steps•Increase activity level if managed at least 75% of time over past fortnight•Don’t increase exercise time more than about 10% at a time•Address high action proneness

Sleep Management Programme

• Sleep diaries for assessment • Set getting-up time• No sleeping in the day-time• Stay in bed only for amount of time sleep for • (e.g. if patient usually sleeps 8 hours in total,

don’t go to bed at 10pm & get up at 8am)• If sleeping excessively, gradually reduce• Sleep hygiene

- Check caffeine, use bedroom for sleep only, wind down before bedtime, make sleep environment comfortable etc.

• Address unhelpful beliefs about sleep

Example of initial activity programme for underactive person with CFS

Someone who is resting for 6 hours a day:

• Get up at 8 a.m.

• Housework for 15 mins twice a day

• Paperwork or other chores for 15 mins twice a day

• Read for ten minutes a day

• Email for ten minutes a day

• Two 10-minute walks each day

• Rest for six 1-hour periods, spaced through day

• Talk to friends on phone for 10 mins, every other day

• Sally: 30-year old woman with a 3-year history of severe fatigue, concentration / memory difficulties, muscle and joint pain.

• Believes that a virus was the cause of her problems as has never been well since she had a bout of gastroenteritis three years ago. At that time there were also stresses at work and her relationship with her partner was breaking down.

• Unable to walk for more than about ten minutes without becoming extremely fatigued and experiencing more muscle pain.

• Reduced from full-time to part-time work because of her symptoms.

Presenting the model with a Case Study

• Goes to bed at 9pm and gets up at 7.30am. Often has trouble getting to sleep or staying asleep. Quite often sleeps in the daytime.

• Limited social life - it is fatiguing to be with people or staying out late.

• Lives with her mother who does most of the housework and shopping.

• Believes that her mood has become low because her quality of life has decreased. Is sure that depression is not the cause of her problems and is fed up with doctors assuming that she is simply depressed.

• Reluctant to see a psychologist but is offered no alternatives.

DISCUSSION

• Familiarise self with anatomy & functioning of the digestive system

• Education about bowel functioning to challenge misconceptions such as:• “I should have a bowel movement every day”

• Everyone’s bowel habits are different; normal bowel movements may occur as often as three times a day to as few as three a week.

• IBS is a problem with how the digestive system functions but is not a disease

Components specific to IBS

Brain-gut connection

• Bowel is a segmented tube

• Food is propelled down by the sequential squeezing of each segment.

• Nerves from the brain control this motion.

• If the nervous control is disrupted, problems with this movement can result.

• Stress and other psychological factors cause bowel symptoms by affecting this nervous control.

• Effects that stress can have (general population):- Spasms in muscles in gut wall, resulting in pockets of high pressure, gas or painful contractions - Decreased gastric emptying and accelerated colonic transit.

• Results in symptoms such as cramps, diarrhoea etc.• These gut responses to stress are enhanced in IBS patients.• IBS patients report greater pain response to distension of the bowel (e.g. in experiments with inflatable balloon)• Any intervention that helps the person to manage stress more effectively is likely to help

Stress and intestinal functioning

Components specific to IBS (con)

• Avoiding foods can:- result in increased sensitivity & - make it more difficult to get nutritionally balanced diet

• Re-introduce avoided foods

• Address other safety-seeking behaviours around bowel functioning (e.g. not eating for long periods of time before an important event) assess carefully, there may be many!

PATIENTS LOG BOOK

Monday Tuesday Wednesday

Thursday Friday Saturday

• Healthy, varied diet (not too much of one food)

• Eat regularly; chew food slowly and thoroughly

• Drink 6-8 cups of water daily

• Maintain a regular program of physical exercise and activity

• Avoid delaying the urge to have a bowel movement

• Avoid straining / forcing

• Dealing with pain (e.g. accepting, not trying to suppress or focussing on pain excessively)

Establish healthy bowel routine

• Beliefs about needing to avoid particular foods, places to eat• Beliefs about needing to avoid

particular activities that use up energy or result in increase in symptoms• Perfectionism

Behavioural experiments – examples of beliefs to target

• Self help materials• IAPT• Primary care• Specialist care – CBT

Stepped Care

Key Assessment Tools

• Chalder Fatigue Scale (Chalder et al., 1993)• Work and Social Adjustment Scale (Mundt et al.,

2002)• Beliefs about emotions scale (Rimes & Chalder

2009)• SF-36; Physical functioning subscale (Ware &

Sherbourne, 1992).• Measures of anxiety & depression e.g. Hospital

Anxiety & Depression Scale (Zigmond & Snaith, 1983)

Questionnaires for use in CFS: examples

• IBS Symptom Severity Scale (Francis et al., 1997)

• Behavioural Scale for IBS (Reme et al 2010)

• Work and Social Adjustment Scale (Mundt et al., 2002)

• Measures of anxiety and depression (HAD)

Questionnaires for use in IBS: examples

The CBT model of MUS

Deary V, Chalder T & Sharpe M. (2007)

One of the Resources for Self-Study on Moodle

Key Points

• Assessment• Treatment• Evidence• Where to refer

It’s good to talk CBT style of course!