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