Medically Unexplained Physical Symptoms for GP trainees Dr Sarah Burlinson Consultant in Liaison...
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Transcript of Medically Unexplained Physical Symptoms for GP trainees Dr Sarah Burlinson Consultant in Liaison...
Medically Unexplained Physical Symptoms
for GP trainees
Dr Sarah BurlinsonConsultant in Liaison
PsychiatryRoyal Oldham HospitalPennine Care NHS Trust
Aims
Appreciate how common these areIncrease assessment skillsRecognise associated psychiatric diagnosesStrategies to manage in primary care
Simple scenariosComplex patients
List 8 common physical symptoms which are often medically unexplained?
Common Medically Unexplained Symptoms
PainFatigueDizzinessHeadache
Ankle swellingBreathlessnessInsomniaNumbness
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 inSecondary Care OP clinics?
How common are MUS?
Primary Care20% of new GP consultations 1/3 of these persist
Secondary Care25-50% of new medical out-patients
Chronic MUPS/ somatisation disorder0.5-4 % community prevalence
Impact of MUS
PatientsPsychologicalPhysicalSocial
StaffFrustration/ demoralisation‘Heart sink’ patient
ResourcesInvestigations/ admissions/clinics/medication
Possible mechanisms
Autonomic arousalMuscular tensionHyperventilationHyper-vigilanceMood disorderDe-conditioning
Predisposing/ precipitating & maintaining factors
FemaleParental ill-health/ childhood adversityLife eventsPast/ current psychiatric illnessHealth care responseSecondary gain
Name 6 psychiatric disorders which are associated with or which cause MUS.
Associated Psychiatric Disorders
Anxiety/ depressive illnessSomatoform disorders
Somatisation disorderSomatoform pain disorderHypochondriacal disorder
Dissociative disorder (Hysteria)Factitious disorder (Munchausen’s)Delusional disorderSubstance misuse
Detecting Depression in MUPS
HOPELESSHELPLESSWORTHLESSPervasive low moodLack of enjoymentPoor concentrationIrritabilityGuilty feelings
Sleep disturbancePoor appetiteDiurnal variationLow libidoReduced energy
Anxiety: Physical Symptoms
PalpitationsDizziness‘Butterflies’NauseaTremorTinglingDry mouth
Wanting the toiletMuscle tensionHyperventilationChest painLump in throat
Somatisation Disorder
>2 years multiple and variable medically unexplained physical symptomsPreoccupation & distressRepeated consultationsRefusal to accept medical reassurance> 6 from a listUndifferentiated SD & Somatoform Pain Disorder
Hypochondriacal disorder
Persistent belief of the presence of a serious diseasePreoccupation/ distress/ disabilityRefusal to accept medical reassurance
Dissociative Disorder(Hysteria)
Sudden loss of functionTemporal 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/expertadvice/problems/medicallyunexplainedsymptoms.aspx
• http://www.neurosymptoms.org/