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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
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Conflicts of Interest
• none
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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
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Medically Unexplained Symptoms
• Physical symptoms that prompt the sufferer to seek health care but remain unexplained after an appropriate medical evaluation.
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Case Presentations
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What’s your diagnosis?
Diagnosis: ______________________
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Hopefully, uptodate.comhas something…
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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
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Are Medically Unexplained Symptoms Common?
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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
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Most Frequent Visitors 5th percentile
GI…………….54%
Neuro…….. 50%
Rheum……. 33%
ENT………….27%
GIM………… 10%
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This is a problem!
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This is a big problem!
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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
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MUS Depressed Controls
P(Disease) 15% 10% 5%
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One condition or many?
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Chronic Fatigue SyndromeFibromyalgia
Irritable Bowel SyndromeMultiple Chem Sensitivity Syndrome
Sick Building SyndromeHypoglycemia
Gulf War Syndrome
Undocumented LabelsHeadache Syndromes
AsthmaPainful Conditions
Various
Bodily Distress Disorder
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• 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
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Median Number of SymptomsMen 4
Women 6Men & Women 5
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“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
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• 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.
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Psychobiology‘the mind-body connection’
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Psychobiological Framework
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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
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Self-report AMI Trigger412 reports from 849 AMI
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Chronic Stress & Immune Dysfunction
• Influenza Vaccination
• Difference between stressed and non-stressed group.
– Lancet 1999
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Stress and Wound Healing
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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
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So now what?
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Several Approaches…
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• RCT: n = 200
• OR 1.92 (95%CI 1.08 – 3.4)
• NNT to improve @ 12 months = 6.4
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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
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Key Components
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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
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www.calgaryhealthregion.ca/cmbm/
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Rockyview General Hospital, Calgary
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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
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Self-regulation• Somatic Awareness
– link emotional state with body symptoms– effortless breathing
• Medication Reduction / Elimination
• Group Therapy– education– Heartmath– guided imagery
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Role of Internist
• Compassionate Listener
• Expert– data gatherer and review– explicit address of patient fears– health promotion– co-morbidity manager– educator
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• 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
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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
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Talk about Stress...
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Acute Stress Response
Fight, Fright, Flight, Frolic Response
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Stimulus
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Reaction
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• Hormones• Neurochemistry• Immunochemistry
• Organ dysfunction
Physiological Response
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Experience of thePhysiological Response
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Hans Selye (1907-1982)
General Adaptation Response
– Alarm– Failure to adapt– Exhaustion
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Absolute Stress
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Relative Stress
Interpretation of the world
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Recipe for Stress• Novelty
• Unpredictability
• Threat to ego
• Loss of control
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Stress & Recovery
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Allostatic Load
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Summary
• MUS– common in the population– many challenges– psychobiological framework– multidisciplinary approach shows promise
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• Questions
• Discussion
• Experiences to share
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