Medically Unexplained Physical Symptoms for GP trainees

Dr Sarah Burlinson Consultant in Liaison Psychiatry

Royal Oldham Hospital Pennine Care NHS Trust

Aims Appreciate how common these are Increase assessment skills Recognise associated psychiatric diagnoses Strategies to manage in primary care Simple scenarios Complex patients

List 8 common physical symptoms which are often medically unexplained?

Common Medically Unexplained Symptoms Pain Fatigue Dizziness Headache Ankle swelling Breathlessness Insomnia Numbness

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 in Secondary Care OP clinics?

How common are MUS?

Primary Care 20% of new GP consultations 1/3 of these persist Secondary Care 25-50% of new medical out-patients Chronic MUPS/ somatisation disorder 0.5-4 % community prevalence

Impact of MUS Patients Psychological Physical Social Staff Frustration/ demoralisation ‘Heart sink’ patient Resources Investigations/ admissions/clinics/medication

Possible mechanisms Autonomic arousal Muscular tension Hyperventilation Hyper-vigilance Mood disorder De-conditioning

Predisposing/ precipitating & maintaining factors Female Parental ill-health/ childhood adversity Life events Past/ current psychiatric illness Health care response Secondary gain

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

Associated Psychiatric Disorders Anxiety/ depressive illness Somatoform disorders Somatisation disorder Somatoform pain disorder Hypochondriacal disorder Dissociative disorder (Hysteria) Factitious disorder (Munchausen’s) Delusional disorder Substance misuse

Detecting Depression in MUPS HOPELESS HELPLESS WORTHLESS Pervasive low mood Lack of enjoyment Poor concentration Irritability Guilty feelings Sleep disturbance Poor appetite Diurnal variation Low libido Reduced energy

Anxiety: Physical Symptoms Palpitations Dizziness ‘Butterflies’ Nausea Tremor Tingling Dry mouth Wanting the toilet Muscle tension Hyperventilation Chest pain Lump in throat

Somatisation Disorder >2 years multiple and variable medically unexplained physical symptoms Preoccupation & distress Repeated consultations Refusal to accept medical reassurance > 6 from a list

Undifferentiated SD & Somatoform Pain Disorder

Hypochondriacal disorder Persistent belief of the presence of a serious disease Preoccupation/ distress/ disability Refusal to accept medical reassurance

Dissociative Disorder (Hysteria) Sudden loss of function Temporal 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/expertadvi ce/problems/medicallyunexplainedsym ptoms.aspx

http://www.neurosymptoms.org/