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Medically Unexplained Physical Symptoms

Medically Unexplained Physical Symptoms. Aims: where are we going today?. Recognise and understand the significance of MUPS Reduce anxiety about them Consider some work done in the management of MUPS Equip us with tools for negotiation with patients

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Medically Unexplained Physical Symptoms

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  1. Medically Unexplained Physical Symptoms

  2. Aims: where are we going today? • Recognise and understand the significance of MUPS • Reduce anxiety about them • Consider some work done in the management of MUPS • Equip us with tools for negotiation with patients • Ensure you will never want to say ‘mups’ again

  3. Aims: where are we NOT going today • You will not leave with all the answers • You will not leave with a protocol for the management of all MUPS • BUT basic tools discussed today are central to management of these conditions

  4. Symptom

  5. History and examination

  6. Diagnostic tests

  7. Specific Treatment

  8. Or is it like this..

  9. Or maybe…

  10. Disease cured

  11. MUPS:A problem in Primary Care? • 20% of new consultations in primary care are by patients with physical symptoms for which no specific organic cause is found • Bridges KW, Goldberg DP 1985 • many transient • >33% persist  Distress and disability • Craig et al 1993

  12. MUPS: A problem in Primary Care? • Physical symptoms such as headache and dizziness prompt almost 50% of all primary care consultations. • Shown to have organic origin in only 10-15% of patients followed up for 1 year • Katon J Clin Psychiatry 1998;59 (suppl 20):15-21 • Patient diagnosed with MUPs after appropriate assessment unlikely to show later evidence of underlying organic disease

  13. MUPS: A problem in Primary Care? • 73 patients with medically unexplained motor symptoms • Followed up for 6 years • 3 patients in whom a new organic neurological disorder was diagnosed – could partly/fully explain presenting symptoms • Crimlisk BMJ 1998;316:582-6

  14. MUPS: A problem in Secondary Care • Medically unexplained symptoms in frequent attenders of secondary health care: retrospective cohort study Steven ReidBMJ 2001;322:767 • Frequent attenders consume large amounts of healthcare • Top 5% attenders South Thames Region • Randomly selected 400 notes • Consultation episode = initial consultation to discharge from clinic

  15. Prevalence of medically unexplained episodes in frequent attenders categorised by referral complaint (stratified by age). Figures are number of medically unexplained symptoms/number of referrals Reid S BMJ 2001;322:767

  16. Prevalence of medically unexplained episodes in frequent attenders categorised by specialty.* number of medically unexplained symptoms/number of referrals Reid S BMJ 2001;322:767

  17. MUPS: A problem in Secondary Care • Kingham and Dawson 1985 • 22 patients • chronic upper abdominal pain reproduced by distension of the colon with a balloon • Seen 76 consultants • Normal investigations • 72 pancreatico-biliary procedures • 53 barium xrays • 25 endoscopies • 12 IVUs

  18. MUPS: A problem in Secondary Care • 38 operations without long term success • 12 appendicectomies • 10 cholecystectomies • 16 gynaecological / exploratory abdominal operations • Only consistently abnormal investigation: • Hamilton rating scale for depression

  19. MUPS: A problem for primary and secondary care • Increased specialisation – defined boundaries • “All your tests are negative” • “You don’t have any of ‘my’ diseases” • “I’m discharging you” • “If you have any more problems – see your GP” • Problem solved!?

  20. What does a negative test do?Chest pain with normal coronary arteries: outcome at 6 years(adapted from Papanicolau et al, 1986)

  21. The Spectrum of MUPS No. of Sx: one multiple Duration: transient persistent Insight: good none Disability: none severe

  22. Types of MUPS Somatic presentation among patients with depression or anxiety Functional Symptoms Hypochondriacal Worry

  23. Who gets MUPS?Factors associated with MUPS • Being older • Being female • Living alone, isolation • Having a co-morbid psychiatric disorder • e.g. anxiety or depression • Childhood sexual abuse

  24. What is going on?example of non cardiac atypical chest pain Physical perceptions: Physiological pathological Emotional arousal: personality stress psychiatric disorder Illness experience: heart disease other illness Interpretation Maintaining factors: iatrogenic reaction of others psychiatric Symptoms: psychological physical Disabilty

  25. Attribution of symptoms • The cognitive process whereby somatic sensations are interpreted in the context of the body and its physical and social environment. • I’m tired because… • I’m overworking and unfit (normalising) • My muscles have been weakened by a virus (somatic) • I have depression (psychological)

  26. Attribution of symptoms among frequent attenders Patients asked to write down possible causes for each of 10 common physical symptoms Psychol Med 1996;26:575-589, 641-646

  27. Attribution of symptoms among frequent attenders • Frequent attenders were no more likely than controls to see symptoms as serious but were less able to come up with reasons why they might be benign. • May explain why reassurance that rules out problems but does not offer alternative tangible explanations often fails. • C Burton BJGP 2003;53:233-241

  28. Somato-sensory awareness • Irritable bowel syndrome • Hypersensitive to rectal balloon distension • Visceral hypersensitivity only reported on 60% • Others developed hypersensitivity after repeated distension • Anticipation • Distension with increasing magnitude • Lower pain threshold than control • Distension with random variation in magnitude • No significant differences

  29. Psychological distress • 20% of patients with one MUPS have a current psychological illness • 30% with 4 symptoms • >80% with 10 or more symptoms have a current psychological illness

  30. What we say matters • Randomised trial of positive attitude • Positive consultation with prescription • Firm diagnosis, told it WILL get better • Positive consultation with out prescription • Negative consultation with prescription • “I cannot be certain…” “not sure if treatment will work” • Negative consultation without prescription • “I cannot be certain…therefore I will give no treatment” • 200 patients, URTIs, pains in arm/head/chest/back etc

  31. What we say matters NNT = 4

  32. MUPS: A balanced perspective • Studies exploring prevalence of MUPS demonstrate… • “While MUPS are common, and often associated with psychiatric morbidity, many patients with MUPS have no definite psychological illness, and patients with multiple symptoms and a refusal to acknowledge a severe mental health problem are rare.” • C Burton BJGP 2003;53:233-241

  33. What are we going to do? • Discuss 8 questions to open up some of the important issues we need to consider in our practice • 8 Groups of 5 - 2 questions each. • Definitely feedback on the highlighted question • Be prepared to feedback on the other question • Looking at how to manage MUPS later • 2 case studies to help us start

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