medically unexplained physical symptoms for gp trainees dr sarah burlinson consultant in liaison...

Medically Unexplained Physical Symptoms

for GP trainees

Dr Sarah BurlinsonConsultant in Liaison

PsychiatryRoyal Oldham HospitalPennine Care NHS Trust

Aims

Appreciate how common these areIncrease assessment skillsRecognise associated psychiatric diagnosesStrategies to manage in primary care

Simple scenariosComplex patients

List 8 common physical symptoms which are often medically unexplained?

Common Medically Unexplained Symptoms

PainFatigueDizzinessHeadache

Ankle swellingBreathlessnessInsomniaNumbness

What % of these are found to have a medical cause when followed up for 1 year?

76%-100%51%-75%25%-50%0-24%

These common symptoms…..

At 1 year: only 10-15% due to organic cause (Katon 1998)

Prompt < 50% of primary care consultations

10% of patients with ‘MUS’ diagnosed with organic disease at 18 months FU (Morriss 2007)

How common are MUS in NP in Primary Care?

76%-100%51%-75%25%-50%0-24%

Are they more or less common inSecondary Care OP clinics?

How common are MUS?

Primary Care20% of new GP consultations 1/3 of these persist

Secondary Care25-50% of new medical out-patients

Chronic MUPS/ somatisation disorder0.5-4 % community prevalence

Impact of MUS

PatientsPsychologicalPhysicalSocial

StaffFrustration/ demoralisation‘Heart sink’ patient

ResourcesInvestigations/ admissions/clinics/medication

Possible mechanisms

Autonomic arousalMuscular tensionHyperventilationHyper-vigilanceMood disorderDe-conditioning

Predisposing/ precipitating & maintaining factors

FemaleParental ill-health/ childhood adversityLife eventsPast/ current psychiatric illnessHealth care responseSecondary gain

Name 6 psychiatric disorders which are associated with or which cause MUS.

Associated Psychiatric Disorders

Anxiety/ depressive illnessSomatoform disorders

Somatisation disorderSomatoform pain disorderHypochondriacal disorder

Dissociative disorder (Hysteria)Factitious disorder (Munchausen’s)Delusional disorderSubstance misuse

Detecting Depression in MUPS

HOPELESSHELPLESSWORTHLESSPervasive low moodLack of enjoymentPoor concentrationIrritabilityGuilty feelings

Sleep disturbancePoor appetiteDiurnal variationLow libidoReduced energy

Anxiety: Physical Symptoms

PalpitationsDizziness‘Butterflies’NauseaTremorTinglingDry mouth

Wanting the toiletMuscle tensionHyperventilationChest painLump in throat

Somatisation Disorder

>2 years multiple and variable medically unexplained physical symptomsPreoccupation & distressRepeated consultationsRefusal to accept medical reassurance> 6 from a listUndifferentiated SD & Somatoform Pain Disorder

Hypochondriacal disorder

Persistent belief of the presence of a serious diseasePreoccupation/ distress/ disabilityRefusal to accept medical reassurance

Dissociative Disorder(Hysteria)

Sudden loss of functionTemporal link with stressful event/ situation

• No medical explanation

Delusional Disorder

• Single or set of related delusions• Hallucinations/ thought disorder

rare• Relatively well functioning• Themes include

– Hypochondriacal– Erotomanic– Persecutory

Factitious Disorder

• Intentional feigning of symptoms• Aim is to receive medical care• Often marked personality disorder

& interpersonal difficulties• (Malingering- different motive e.g:

– Financial– Avoid court/ conscription)

Management

• Case note review • Clinical assessment and Ix• Will simple explanation work?• Is this depression/ anxiety?• Is there another psychiatric

disorder?

Management

• Reattribution– Acknowledging reality of symptoms– Feeling understood– Making the link

• Antidepressant– May reduce symptoms even if not

depressed

• Psychotherapy– Cognitive behaviour therapy– Psychodynamic interpersonal therapy

Management of Chronic Somatisation

• Regular fixed intervals• Bio-psychosocial approach• Reduce drugs• Treat mood disorder• Limit referrals / investigations• Reduce expectation of cure

Summary

• MUS: – common and treatable– associated with mood disorders

• Mild/ recent onset:– Reattribution techniques– Antidepressants/ psychotherapy

• Chronic (somatisation disorder):– Complex/ time consuming– Clear management plan

Resources

• http://www.rcpsych.ac.uk/expertadvice/problems/medicallyunexplainedsymptoms.aspx

• http://www.neurosymptoms.org/