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Approach to Patients with Medically Unexplained Symptoms / Illnesses. Jeffrey P Schaefer MSc MD FRCPC Rural Physician Video Conference Program March 31, 2009. website dr.schaeferville.com. Conflicts of Interest. none. Objectives Medically Unexplained Symptoms. Session participants shall:

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approach to patients with medically unexplained symptoms illnesses

Approach to Patients withMedically Unexplained Symptoms / Illnesses

Jeffrey P Schaefer MSc MD FRCPC

Rural Physician Video Conference Program

March 31, 2009

objectives medically unexplained symptoms
ObjectivesMedically Unexplained Symptoms
  • Session participants shall:
    • be able to define MUS
    • know that MUS are common
    • have considered psychobiologicalframework
    • become aware of management strategies
slide5
Case
  • 42 yr old female administrator

total body pain and extreme fatigue x 5 years

previously assessed by GIM, Neurology, Gastroenterology

investigations  normal

what are your feelings at this point
What are your feelings at this point?

Negative Neutral Positive

-10 0 +10

slide8

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
slide9
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
slide10

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
what s your diagnosis
What’s your diagnosis?

Diagnosis: ______________________

slide13

Hopefully,

uptodate.com

has something…

diagnosis menu
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
medically unexplained symptoms
Medically Unexplained Symptoms
  • Physical symptoms that prompt the sufferer to seek health care but remain unexplained after an appropriate medical evaluation.
medically unexplained symptoms16
Medically Unexplained Symptoms

Physical symptoms that prompt the sufferer to seek health care but remain unexplained after an appropriate medical evaluation.

Headache

Chest Pain

Fibromyalgia

Irritable Bowel

Chronic Fatigue

Dizziness

Infertility

mus prevalence
MUS Prevalence
  • 30% of primary care visits
  • 13.6 visits in the previous year

Psychosomatic Med 2005;67:123-9

slide19

Most Frequent Visitors 5th percentile

GI……………. 54%

Neuro…….. 50%

Rheum……. 33%

ENT…………. 27%

GIM………… 10%

if only an actual email
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
unhappiness is
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
slide27

Chronic Fatigue Syndrome

Fibromyalgia

Irritable Bowel Syndrome

Multiple Chem Sensitivity Syndrome

Sick Building Syndrome

Hypoglycemia

Gulf War Syndrome

Undocumented Labels

Headache Syndromes

Asthma

Painful Conditions

Various

Bodily Distress Disorder

slide28
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
slide29

Median Number of Symptoms

Men  4

Women  6

Men & Women  5

slide30

Chest Pain Group

GI Symptoms Group

Musculoskeletal Group

< 3% of patients had symptoms

confined to their predominant group

3 group model explained 36% of the variance

“Bodily Distress Disorder”

Fink et al. Psychosom Med 2007

slide31

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.

slide36

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

acute stress and mi
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
chronic stress immune dysfunction
Chronic Stress & Immune Dysfunction
  • Influenza Vaccination
  • Difference between stressed and non-stressed group.
    • Lancet 1999
slide44

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
the approach
The Approach…
  • Exclude bio-medical disease
    • neoplasm
    • infection
    • auto-immune
    • metabolic
the approach48
The Approach…
  • Exclude bio-medical disease
    • Adrenal Insufficiency
    • Hemochromatosis
    • Hypercalcemia
    • Amytrophic Lateral Sclerosis
    • Multiple Sclerosis
    • Alcoholism
    • Temporal arteritis
    • Subacute bacterial endocarditis
    • Sleep Apnea
assess the impact of known conditions
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
slide51
RCT: n = 200
  • OR  1.92 (95%CI 1.08 – 3.4)
  • NNT to improve @ 12 months = 6.4
smith s treatment model cognitive behavioural model
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
interpersonal therapy scott stuart
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
cmbm approach
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
self regulation
Self-regulation
  • Somatic Awareness
    • experiential
    • link emotional state with body symptoms
    • effortless breathing
  • Medication Reduction / Elimination
  • Group Therapy
    • education
    • Heartmath
    • guided imageryApple
acute stress response
Acute Stress Response

Fight, Fright, Flight, Frolic Response

hans selye 1907 1982
Hans Selye (1907-1982)

General Adaptation Response

  • Alarm
  • Failure to adapt
  • Exhaustion
relative stress
Relative Stress

Interpretation of the world

recipe for stress
Recipe for Stress
  • Novelty
  • Unpredictability
  • Threat to ego
  • Loss of control
slide70

Questions

  • Discussion
  • Experiences to share