approach to medically unexplained symptoms jeffrey p schaefer msc md frcpc canadian society of...
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Approach toMedically Unexplained
SymptomsJeffrey P Schaefer MSc MD FRCPC
Canadian Society of Internal MedicineAnnual Meeting – Workshop #13
October 16, 2008http://dr.schaeferville.com
Conflicts of Interest
• none
ObjectivesMedically Unexplained Symptoms
• Session participants shall: – be able to define MUS– know that MUS are common– have considered psychobiological framework– become aware of management strategies– know about the Clinic for Mind-Body Medicine
Medically Unexplained Symptoms
• Physical symptoms that prompt the sufferer to seek health care but remain unexplained after an appropriate medical evaluation.
Case Presentations
What’s your diagnosis?
Diagnosis: ______________________
Hopefully, uptodate.comhas something…
Diagnosis Menu
• What’s your diagnosis / diagnoses?– Chronic Fatigue Syndrome– Fibromyalgia– Tension Headache– Irritable Bowel Syndrome– Multiple Chemical Sensitivity Syndrome– Interstitial Cystitis– Hematuria Loin-pain Syndrome– Depression and Anxiety– Conversion Disorder– Somatization
Are Medically Unexplained Symptoms Common?
Prevalence of MUS Factoids
• ~30% of visits to primary care are MUS
• MUS averaged 13.6 MD visits in prev yearPsychosomatic Med 2005;67:123-9
Most Frequent Visitors 5th percentile
GI…………….54%
Neuro…….. 50%
Rheum……. 33%
ENT………….27%
GIM………… 10%
This is a problem!
This is a big problem!
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
• dissatisfaction relates to communication style• Soc Sci Med. 2001 Jun;52(12):1859-64
– Why reassurance fails?• PLOS Medicine 2006
MUS Depressed Controls
P(Disease) 15% 10% 5%
One condition or many?
Chronic Fatigue SyndromeFibromyalgia
Irritable Bowel SyndromeMultiple Chem Sensitivity Syndrome
Sick Building SyndromeHypoglycemia
Gulf War Syndrome
Undocumented LabelsHeadache Syndromes
AsthmaPainful Conditions
Various
Bodily Distress Disorder
• 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
Median Number of SymptomsMen 4
Women 6Men & Women 5
“Bodily Distress Disorder”Fink et al. Psychosom Med
2007
Chest Pain GroupGI Symptoms Group
Musculoskeletal Group
< 3% of patients had symptomsconfined to their predominant group
3 group model explained 36% of the variance
• 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.
Psychobiology‘the mind-body connection’
Psychobiological Framework
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
Self-report AMI Trigger412 reports from 849 AMI
Chronic Stress & Immune Dysfunction
• Influenza Vaccination
• Difference between stressed and non-stressed group.
– Lancet 1999
Stress and Wound Healing
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
So now what?
Several Approaches…
• RCT: n = 200
• OR 1.92 (95%CI 1.08 – 3.4)
• NNT to improve @ 12 months = 6.4
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
Key Components
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
www.calgaryhealthregion.ca/cmbm/
Rockyview General Hospital, Calgary
CMBM Approach
• Principles– symptoms are psychobiological
• real & explainable & diagnosable
– management is experiential• cognitive reassurance is insufficient• uncovering a psychological trauma is insufficient• psychotropic medications are counterproductive• success lays in self-regulation
Self-regulation• Somatic Awareness
– link emotional state with body symptoms– effortless breathing
• Medication Reduction / Elimination
• Group Therapy– education– Heartmath– guided imagery
Role of Internist
• Compassionate Listener
• Expert– data gatherer and review– explicit address of patient fears– health promotion– co-morbidity manager– educator
• Exclude bio-medical disease– Adrenal Insufficiency (hyper K / hypo Na)– Hemochromatosis (ferritin screen)– Hypercalcemia (calcium)– Amytrophic Lateral Sclerosis (twitches)– Multiple Sclerosis (neurological deficit)– Alcoholism (CAGE, MCV, GGT)– Temporal arteritis (ESR)– Subacute bacterial endocarditis– Sleep Apnea
Assess the impact of known conditions
• Conditions Underestimated– Chronic Cardiac Disease– Chronic Respiratory Disease– Chronic Sinusitis– Recurrent genital herpes– Diabetes mellitus– Obesity– Osteoarthritis – Medication Effect– Physical decondition
Talk about Stress...
Acute Stress Response
Fight, Fright, Flight, Frolic Response
Stimulus
Reaction
• Hormones• Neurochemistry• Immunochemistry
• Organ dysfunction
Physiological Response
Experience of thePhysiological Response
Hans Selye (1907-1982)
General Adaptation Response
– Alarm– Failure to adapt– Exhaustion
Absolute Stress
Relative Stress
Interpretation of the world
Recipe for Stress• Novelty
• Unpredictability
• Threat to ego
• Loss of control
Stress & Recovery
Allostatic Load
Summary
• MUS– common in the population– many challenges– psychobiological framework– multidisciplinary approach shows promise
• Questions
• Discussion
• Experiences to share