An Individualized, Evidence-Based Approach To Medically Unexplained

Symptoms

Francesca C. Dwamena, MD MSRobert C. Smith, MD ScM

Michigan State University

AACH Research and Teaching Forum, Scottsdale, Arizona

October 17, 2010

Learner Objectives

Video Presentation:

• A 34 year old female with intractable diarrhea, nausea/vomiting, abdominal pain

Workshop Objectives

Participants will be able to:1. Describe steps required to diagnose “Medically

Unexplained Symptoms” (MUS) in primary care.

2. assist MUS patients in– understanding their illnesses

– committing to participate in their care.

– setting and achieving realistic goals

3. negotiate treatment plans with patients with MUS

What do we mean by MUS?

• Symptoms that are not adequately explained by the presence of organic disease (metaphor for psychic distress)

Becomes a problem when there is high utilization

How do MUS arise?

o Often understandable in context of patient history and circumstances

o Mechanism --- patient avoids emotion

o Psychodynamic – ineffective emotional expression

o Behavioral – reinforcement of illness behaviors

o Socio-cultural – emotional suppression

o Biological – gate control theory

DSM-IV Classification of MUS

• Somatoform disorders: not used in primary care– Somatization disorder (SD) – very rare– Hypochondriasis– Chronic pain– Conversion disorder– Miscellaneous

Only SD validated; Overlapping definitions limit use for classification

Syndromes of MUS in Medicine

• Chronic Fatigue Syndrome

• Fibromyalgia

• Irritable Bowel Syndrome

• Chronic pain: back, pelvic, head, neck, abdominal, chest etc. for each specialty

Overlapping definitions limit use for classification, but useful for labeling; not useful for diagnosing mild MUS / minor acute illness

Proposed Classification

• Better to think of MUS as one entity on a continuum with 3 parameters:

–Severity

–Duration

–Co-morbidity

Normal-Mild (~80% MUS pts.)

Characterized by:

Low severity (low

utilization, few symptoms)

Acute (days –weeks)

Co-morbidity not studied

Diagnose by:

H&P + observation for weeks (e.g., eye

problem) - months (e.g., back pain).

Avoid unnecessary testing

Treatment:

Reassurance, positive PPR, symptomatic

treatment

Moderate (~15% MUS pts.)

Characterized by:

High utilization, >2 symptoms

Sub-acute (1-6 months)

20% depression, anxiety or other psych disorder. Neurotic personality

structure

Diagnose by:

H&P + observation initially; Definitive work-up with increased utilization or recurrence

• Organic disease rare after negative definitive work-up

Diagnosis of co-morbid psychiatric disease

Severe MUS (~5-6% MUS pts.)

Characterized by:

High Utilization; multiple, persistent

symptoms

Chronic (>6 months)

>67% with psychiatric disorder. 61-72% Personality

Disorder

Diagnose with:

Definitive lab and/or consultation

• MRI, or CT for chronic back pain

• CT, colonoscopy for chronic abdominal pain with altered bowel habits

• Laparoscopy for chronic pelvic pain

• Observation over time

• No need to repeat if definitive work-up was negative

Diagnose co-morbid psychiatric disease

Differential / Co-morbidity

Organic diseases• rare (e.g. Wilson’s Disease),

• vague, unusual presentations (e.g. MS, Lyme, porphyria, celiac sprue)

• prominent psych symptoms (e.g. carcinoma of pancreas, subdural hematoma or ulcerative colitis)

Factitious Disorders

• no external incentive

Malingering

• external incentive

Psychiatric• Depression, anxiety

• Panic disorder

• PTSD; also, sexual, physical abuse

• Personality disorder

• Substance abuse/dependence

Our Case – Ms G

• MUS was characterized by:

– High utilization, Multiple symptoms

– Chronic; recent acceleration

– Both medical and psychiatric co-morbidity

• Type 2 DM, OSA, depression, anxiety, dependent personality, obesity

Our Case – Ms G

To rule out organic disease,

• We reviewed med records

– CT scan abdomen (2 non-obstructing stones), EGD, colonoscopy (2 years prior), cholecystectomy

• Ordered the following in hospital

– stool studies, antiendomyseal antibodies, repeat CT (same), 240 urine VIP, 5-HIAA, ERCP with sphincterotomy, repeat colonoscopy with terminal ileum visualization (mild anemia)

• And followed her over time

Questions?

(Smith et al. JGIM, 2006;21:671-677)

206 high utilizing patients with MUS

•Primary care Nurse Practitioners

Intervention vs. Usual care

•Evidence-based Patient centered approach

•ECGN (education, commitment, goals, negotiation)

•Symptomatic treatment

•Antidepressant (usually)

Improved mental function

(OR : 1.92, CI = 1.08 – 3.40)

•Improved patient satisfaction, physical disability (p<0.001, p=0.02 respectively)

•Decreased use of narcotics and benzodiazepines (p = 0.043)

•Increased use of full dose antidepressants (p = 0.037)

Primary Care Physicians Assisted by Case Manager Can Also Treat MUS

What is the patient’s perspective?

Qualitative Methods - Sampling

Random sample of high utilizing

patients (n=103)

Purposive on spectrum of

severity

Recruited till no new themes

(n=19)

Sample - Characteristics• 16 (84%) were females• 9 (47%) married• 14 (74%) > 2 years of college• Mean age 48years (31 – 65)• >11 visits/year; 69.6% medically unexplained per

chart review• Only 7 (37%) diagnosed MUS (5 fibromyalgia, 2

IBS)

So, typical primary care patients with a lot of visits (or symptoms); many not recognized by doc as having MUS --- need to diagnose to treat.

Qualitative Methods – Long Interview (60 – 90 minutes)

Open-ended 30 – 45 minutes

Iteratively developed list of topics

• Explanatory models, locus of control, health-seeking behavior, abuse, gender effects, relationships, expectations for future

Taped and transcribed verbatim

Qualitative Methods – Grounded Theory

Read 5 transcripts

each

Prelim Themes by consensus

Tested themes

in another

5

Working themes by consensus

Tested working themes in rest

Reread all 19

transcripts

Major categories, relationships

Results• There were 3 different types of patients

• The 3 types wanted different things from their visits

Coping (n=4) Classic (n=9) Worried (n=6)

Mean age (SD) 54.5 (9.8) 47.0 (10.9) 53.2 (6.9)

# Female (% group) 3 (75) 8 (89) 5 (83)

≤ 12 years school 3 2 0

14 years 1 4 1

≥ 16 years 0 3 5

# Severe MUS (%) 1 (11) 5 (56) 3 (33)

# Moderate MUS (%) 3 (30) 4 (40) 3 (30)

Mean # visits/year (SD) 11.0 (2.7) 11.4 (3.1) 16.0 (9.6)

Mean % visits MUS (SD) 0.68 (0.24) 0.66(0.22) 0.74 (0.02)

Coping High Utilizers

Insight

Mind-body

Had therapy

Symptoms

Not disabled

Not focused on them

High utilization

Multiple tests

Follow-up visits

What they want:

to understandtheir

symptoms

Do not want unnecessary

tests, treatments

☼None had been diagnosed with MUS by their doctors

Classic Somatizers

No insight

Still raw from past trauma

Symptoms

Disability

Focus

High utilization

Symptoms

Ineffective treatments

What they want

Support

Management of symptoms, not

drugs

☼Most had been diagnosed with MUS, but no specific treatment

for MUS; patient with impression nothing could be/was done.

Worried High Utilizers

Combination

Insight

Symptoms focus

Not much disability

Worried

Knew docs make

mistakes

Not told their docs

Complained

Access to docs

Time spent with them

Healthcare system

What they want

Taken seriously

Sure

☼Only 1 had been diagnosed with MUS

Bottom Line

• Patients with MUS want and need different things from encounter– Explanation

– Support

– Treatment (not necessarily drugs)

– Respect/Reassurance

• Individualize by assessing their unique needs and meeting them.

Skills Needed To Treat MUS

1. Establish and maintain a successful doctor-patient relationship

2. Help patient to understand his/her illness (Education)

3. Help patient to Commit to actively participate in his/her care

4. Help patient to set realistic Goals

5. Negotiate and agree on pharmacologic and non-pharmacologic treatment elements

1: Establish & Maintain a Successful Doctor-Patient Relationship

• Awareness of Self

• Relationship-Building Skills

– Listen

– Ask about emotions

– Express empathy

Developing Self Awareness• Mindfulness

– paying attention, on purpose, to one's own mental and physical processes during everyday tasks, so as to act with clarity and insight

– a set of habits of mind and habits of practice in the moment

• Can be enhanced by:– Meditation

– Journaling

– Balint Groups

– Advanced Communication Training with Personal Awareness Component

• American Academy on Communication in Healthcare (AACH)– www.aachonline.org

– Finding Meaning in Medicine Groups– www.meaninginmedicine.org

Relationship-Building Skills

ASK ABOUT

EMOTION

1.Direct

2. Indirect• impact

• belief

• self-

disclosure

EXPRESS EMPATHY

1. Name

2. Understand

3. Respect

4. Support

LISTEN

1. Non-focusing

•silence

•nonverbal

encouragement

•neutral utterances

2. Focusing

•echoing

•requests

•summarizing

Express Empathy

• “NURS” often

Name: “You say being disabled by this knee pain makes you angry.”

Understand: “I can understand your feeling this way.”

Respect: “This has been a difficult time for you. You show a lot of courage.”

Support: “I want to help you to get better.”

2: Help Patients Understand

ASKWhat they fear

What do you think (fear) might be wrong?

TELLConfidently

•Good news is no life threatening disease

•We do not need any more tests

•Illness is real, “not in your head”

•It is common, it has a name, and I have experience

•We think it is caused by…

•Bad news is it cannot be cured

•But you can feel better and get on with your life

ASKIf they understand

This is a lot to throw at you. Can you tell me

what you understand so far?

What can you say to help patients understand…

• Chronic pain

• Irritable bowel syndrome

3: Help Patients to Commit

ASK for

commitment

I am committed to helping you feel better, but

I can’t do it alone. A lot of effort, especially

from you. We can go at your pace, but you

have to be on board. Are you ready?

ASK again

and again

•Are you really committed to walking? On

scale 1 to 10 where would you put yourself?

What would it take to do better?

•What 1 or 2 things can you commit to doing

by our next visit?

•You thought that walking 15 minutes 2X/week

was possible for you. What got in the way?

What would you say to following patients?

• Multiple no-shows

• Not making progress in changing unhealthy behavior

Commitment DOs and DON’TsDO

– Ask for commitment again and again; key to success

– Acknowledge patient’s plight and obstacles

– Praise small victories

– Express curiosity and be patient

– Use contracts to emphasize plan and partnership

DON‘T– Use language that blames the patient

– Give up when success is elusive or fleeting

NURS!

“You can’t keep doing the same things expecting different results…”

4: Help Patients Set Goals

ASKWhat would you be doing if you did not

have these symptoms?

e.g.,

•Better relationships

•Improved work/school record

•Improved functioning

•Improved symptoms

ASK for

Long-term goals

Even though there is no cure, you can

do/have some of these. What would

you like to have/do in the next 6 to 12

months?

Assess and celebrate progress at each visit

ASK What can you accomplish by next visit?

To Operationalize Long Term Goals

e.g.,

•Walk 3 blocks 3X/week for 2 weeks

•Meditate for 10 minutes everyday

•Swim for 30 minutes 3X/week

SUMMARIZE

and record

•You will stretch for 10min each day and

walk outside for 30 minutes on Mon,

Wed, and Fri, right?

•What will you do if it rains?

Review, revise, update goals each visit

5. Negotiate – a) Non-Pharmacologic Treatment

• Regular Visits

• Agreement not to self-refer

• Exercise

• Physical Therapy

• Relaxation techniques

• Involvement of significant other

5. Negotiate – b) Pharmacologic Treatment

1. Antidepressants

•Anyone going through this would be depressed.

•The test shows that you have major depression.

•X helps significantly to improve pain.

•We can stay away from X and try Y.

•It can help the pain and also help you to sleep.

•We can start low dose so you can get used to it.

•Would that be alright with you?

Negotiate – b) Pharmacologic Treatment

2. Wean Narcotics and benzodiazepines

•Z doesn’t work very well in the long run.

•As X builds up in your system, we can wean Z.

•Don’t worry; if we have to, we can add it right

back.

•I want to help you feel better, not worse.

•Take Z the same way everyday. Don’t skip or

take more no matter how you feel.

•Think this week about which dose you can drop.

How would you negotiate with a patient who

• Refuses to wean narcotics, instead wants to escalate use.

• Is reluctant to use antidepressants.

Demonstration: Development of Initial Plan

• Discussion (assign components)

1. How did he establish/maintain relationship? NURS (Name, Understand, Respect, Support)?

2. How did he educate (what were elements?)

3. How did he help patient to commit?

4. How did he help patient to set goals (long-term, short-term)?

5. How did he negotiate?

Our Case – Ms G

• Video• Long term goals achieved:

– Better work record (missed 63 days in 5 months vs. 5 days in 5 years)

– Successful marriage– Two beautiful babies– Able to anticipate and control exacerbations

Low utilization (from every 2 to 3 weeks to 2-3 times per year)

Consultation and Hospitalization

• Chose consultants who

– understand MUS and after appropriate evaluation are willing to tell patient - “no organic disease”

• Prepare

– consultants to prevent excessive testing and reinforcement of patient fears

– patient to avoid feelings of abandonment

• Consult psychiatrist for unstable/suicidal patients, refractory symptoms

• Hospitalize only for physical/psychiatric instability

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