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Medically Unexplained Symptoms

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Medically Unexplained Symptoms. LWCC . New Orleans, LA. October 13, 2011. David Randolph, MD, MPH. Trang Nguyen MD, PhD – PowerPoint PPT presentation

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Title: Medically Unexplained Symptoms


1
Medically Unexplained Symptoms
  • LWCC
  • New Orleans, LA
  • October 13, 2011
  • David Randolph, MD, MPH
  • Trang Nguyen MD, PhD

2
What is meant by Medically Unexplained
Symptoms???
  • This term is applied to a clinical presentation
    which cannot be explained through contemporary
    medical, anatomic, physiologic and/or scientific
    methods.
  • We will be discussing clinical scenarios and
    issues which address potential explanations for
    medically unexplained symptoms.
  • It is our goal to have you consider these in your
    clinical practices as you approach patients with
    pain complaints.
  • A panel discussion will follow, so please write
    down your questions.

3
Case presentation MUS
  • John is a 47 year old truck driver. In May, 2006
    he slipped (no fall)exiting his truck and felt
    pain in his low back. He has had multiple
    diagnostic studies with no clear etiology of his
    complaints(MRI shows multilevel degenerative
    changes with no neurologic impingement).
  • Multiple interventions have produced no change in
    his symptoms. Repeated exams have shown no
    evidence of radiculopathy, he repeatedly
    references aching in his low back. He has
    remained off work. He has unsuccessfully applied
    for SSDI.
  • He complains of generalized discomfort in his low
    back, with normal reflexes, sensation, motor
    strength and no atrophy.

4
A few terms
  • OBJECTIVE
  • SUBJECTIVE
  • PAIN
  • VALIDITY
  • RELIABILITY
  • INTER-RATER vs. INTRA-RATER RELIABILITY
  • COIN TOSS
  • SPASMS/TRIGGER POINTS, TENDERNESS
  • RADICULOPATHY
  • SYNDROME (HUMPTY DUMPTY)

5
IPSE DIXIT
  • Its true because I say so is not science
  • Eminence vs. Evidence based practices
  • Nothing wrong with using experience to guide
    treatments, but experience should consider peer
    reviewed literature
  • George Washington (bled to death)
  • James Garfield (Sepsis from GSW)

6
CAUSATION ANALYSIS
  • A science
  • Used to establish cause of pathology/disease
    processes
  • Utilizes history, exam findings, objective
    medical findings to systematically address
    clinical processes leading to a disease state
  • Hills Criteria named for Sir Austin
    Bradford-Hill, British Epidemiologist (smoking
    and lung cancer)

7
Hills Criteria
  • 1-Temporal Relationship
  • 2-Strength of Association
  • 3-Dose Response
  • 4-Replication of Findings
  • 5-Biologic Plausibility
  • 6-Consideration of Alternate Explanations
  • 7-Cessation of Exposure
  • 8-Consistency
  • 9-Specificity

8
To Establish Causation
  • Use 1, 2, 3, 4, and 7 to ESTABLISH
  • 1-Temporal Relationship
  • 2-Strength of Association
  • 3-Dose Response
  • 4-Replication of Findings
  • 7-Cessation of Exposure
  • C. Ralph Buncher Sc.D.

9
To Establish Causation
  • Temporal Relationship
  • Cause before effect is essential. (It is not
    possible for an effect to precede its cause)
  • The other four are helpful but not one is
    essential. One can conclude causation even if
    one or two are not available as information.
  • C. Ralph Buncher Sc.D.

10
To EXPLAIN Causation
  • Use 5, 6, 8, 9 to EXPLAIN
  • 5-Biologic Plausibility
  • 6-Consideration of Alternate Explanations
  • 8-Consistency
  • 9-Specificity
  • C. Ralph Buncher Sc.D.

11
So What?
  • Human aspects of ineffective medical care
  • What have we done for this person?
  • What have we done to this person?
  • What are the consequences of disability?
  • See Black Box Warning for disability
  • If the patient becomes disabled then this should
    be deemed as a failure on our part as
    physicians.
  • Gordon Waddell

12
Hypothetical new prescription medicationBlack
Box Warning
  • This drug (DIASBILITY)
  • Can be detrimental to a persons mental health
  • Can be associated with elevated rates of
    substance abuse
  • Can be associated with higher incidence of
    depression, anxiety and suicide.
  • Can be associated with abuse, domestic violence
    and family breakdown
  • References available on request

13
SWITCHING GEARS A FEW WORDS ABOUT ANXIETY
  • Generalized anxiety disorder is characterized by
    excessive anxiety and worry about a variety of
    topics (such as work, school, family, health)
    occurring more days than not for at least six
    months. People with GAD find it difficult to
    control their worry, and often experience other
    related symptoms including restlessness,
    irritability, and muscle tension.

14
TYPES OF ANXIETY
  • anxiety disorders include generalized anxiety
    disorder (GAD), social anxiety disorder (also
    known as social phobia), specific phobia, panic
    disorder with and without agoraphobia,
    obsessive-compulsive disorder (OCD),
    posttraumatic stress disorder (PTSD), anxiety
    secondary to medical condition, acute stress
    disorder (ASD), and substance-induced anxiety
    disorder.

15
PREVALENCE OF ANXIETY
  • Anxiety is one of the most prevalent of all
    psychiatric disorders in the general population.
    Simple phobia is the most common anxiety
    disorder, with up to 49 of people reporting an
    unreasonably strong fear and 25 of those people
    meeting criteria for simple phobia. Social
    anxiety disorder is the next most common disorder
    of anxiety, with roughly 13 of people reporting
    symptoms that meet the DSM criteria. PTSD, which
    is often unrecognized, afflicts approximately
    7.8 of the overall population and 12 of women,
    in whom it is significantly more common. In
    victims of war trauma, PTSD prevalence reaches
    20.

16
ANXIETY RISK FACTORS
  • Genetic risk factors are being studied, and
    researchers have found genetic predisposition for
    two broad groups of anxiety disorders a
    panic-generalized anxiety-agoraphobia group and a
    specific phobias group.4 More clinically
    important risk factors include co morbid
    substance abuse and family history. One 20-year
    study of the offspring of depressed parents found
    a threefold increase in anxiety disorders,
    including greater substance abuse, younger onset,
    and more significant physical health concerns

17
SOMATOFORM DISORDERS
  • According to the Diagnostic and Statistical
    Manual of Mental Disorders IV (DSM-IV),
    somatoform disorders are characterized by "the
    occurrence of one or more physical complaints for
    which appropriate medical evaluation reveals no
    explanatory physical pathology or
    pathophysiologic mechanism, or, when pathology is
    present, the physical complaints or resulting
    impairment are grossly in excess of what would be
    expected from the physical findings." Pain
    disorder is one of the somatoform disorders.

18
ANXIETY Physical Manifestations
  • Stress affects immune responses through the
    hypothalamus-pituitary-adrenal axis and the
    sympathetic nervous system.
  • Emotional distress can cause muscular pains and
    headaches through increased muscular tension.
  • Psychologically induced changes in behavior, such
    as compulsive activity or prolonged bed rest,
    lead to secondary physiologic changes and
    attendant symptoms.

19
ANXIETY REFERENCES
  • Kessler R, Demier O, Frank R, et al Prevalence
    and treatment of mental disorders 1990-2003. N
    Engl J Med. 2005, 352 2515-2523.
  • Hettema J, Prescott C, Meyers J, et al The
    structure of genetic and environmental risk
    factors for anxiety disorders in men and women.
    Arch Gen Psychiatry. 2005, 62 182-189.
  • Weissman M, Wickramaratne P, Nomura Y, et al
    Offspring of depressed parents 20 years later.
    Am J Psychiatry. 2006, 163 1001-1008.
  • Hoehn-Sark R, McLeod D, Funderburk F, et al
    Somatic symptoms and physiologic responses in
    generalized anxiety disorder and panic disorder.
    Arch Gen Psychiatry. 2004, 61 913-921.
  • Rapaport M, Clary C, Fayyad R, Endicott J.
    Quality of life impairment in depressive and
    anxiety disorders. Am J Psychiatry. 2005, 162
    1171-1178.

20
DEPRESSION
  • NO DIAGNOSIS OF DEPRESSION IN DSM-IV-TR
  • MDD
  • MAJOR DEPRESSIVE EPISODE
  • BIPOLAR
  • DEPRESSION is a normal human response to
    unfortunate circumstances.

21
MAJOR DEPRESSIVE DISORDER
  • Major Depressive Disorder is a condition
    characterized by one or more Major Depressive
    Episodes without a history of Manic, Mixed, or
    Hypomanic Episodes. These Major Depressive
    Episodes are not due to a medical condition,
    medication, abused substance, or Psychosis. If
    Manic, Mixed, or Hypomanic Episodes develop, the
    diagnosis is changed to Bipolar Disorder.

22
CAUSE/COMORBIDITIES
  • Alcoholism and illicit drug abuse dramatically
    worsen the course of this illness, and are
    frequently associated with it. Dysthymic Disorder
    often precedes the onset of this disorder for
    10-25 of individuals. This disorder also
    increases risk of also having Panic Disorder,
    Obsessive-Compulsive Disorder, Anorexia Nervosa,
    Bulimia Nervosa, and Emotionally Unstable
    (Borderline) Personality Disorder.

23
BEESDO (J soc psych epi 2010, 4589-104
  • Among those with any lifetime unexplained pain
  • symptoms (UPS)
  • 1055 (65.0) have lifetime UPS only
  • 575 (35.0) have any lifetime PD
  • 445 (24.2) have any 12-month anxiety disorder
  • 307 (17.8) have any 12-month depressive disorder

24
BEESDO
  • Among those with any 12-month anxiety disorder
  • 671 (92.6) have any significant lifetime pain
  • 445 (60.9) have any lifetime UPS
  • 199 (27.9) have any lifetime PD
  • 243 (33.5) have any 12-month depressive disorder

25
BEESDO
  • Among those with any 12-month depressive
    disorder
  • 468 (91.3) have any significant lifetime pain
  • 307 (59.8) have any lifetime UPS
  • 149 (28.8) have any lifetime PD
  • 243 (44.6) have any 12-month anxiety disorder

26
BEESDO
  • Pain is strongly associated with specific
    anxiety and depressive disorders. In light of the
    individual and societal burden due to pain, and
    the demonstrated role of co morbid anxiety or/and
    depression, our results call for further
    investigation of the underlying mechanisms for
    this association as well as targeted treatments
    for these co morbidities.
  • When patients have subjective complaints and a
    lack of objective findings, and fail to respond
    to normal and standard interventions, a non
    physical source of symptoms should be considered.

27
(No Transcript)
28
MEDICALLY UNEXPLAINED SYMPTOMS
  • Sooooowhen someone has a normal physical exam,
    does not respond to standard interventions,
    continuously demonstrates behaviors not
    consistent with physical pathology.maybe we
    should consider other interventions before
    medicalization
  • Keep in mind, just as digitalis will not help
    appendicitis, opiates, muscle relaxers,
    injections and more PT will not help anxiety
    and/or depression
  • Such interventions would be considered
    ineffective and unnecessary.

29
Case 1 (LBP)
  • Mrs. B (a 52 yo F schoolteacher)was injured in a
    MVA on 12/21/04. She was the restrained driver of
    a Chevy suburban traveling on an interstate at
    about 15 mph in heavy but slowed traffic near a
    large shopping mall. She was rear ended by a
    Toyota Celica traveling at 20 mph. No air bag
    deployment occurred. Due to traffic, both drivers
    exchanged information and a police report not
    immediately filed.

30
Case 1
  • 10 days after the accident, Mrs. B noted LBP. She
    was seen by her FP. Xrays showed arthritis. She
    was given opiates and a muscle relaxer and sent
    for PT. He refilled her Fosamax, Cymbalta and
    Geodon and placed her off work. After 4 weeks of
    PT, she was seen by a Chiropractic Doctor who
    ordered an MRI. This was interpreted as showing
    DDD at L3-4, L4-5, L5-S1 with spondylosis at
    these levels, and minimal spondylolisthesis of
    L5 on S1. No herniations were described, and no
    neurologic impingement noted.

31
Case 1
  • She then underwent a six week course of spinal
    decompression. This was accompanied by HP, US,
    EGS, and manipulation. Worsening symptoms were
    described. Mrs. B was referred to a surgeon and a
    pain specialist.
  • A PE showed painful ROM and no neurologic
    abnormalities. A discogram showed concurrent pain
    at all 3 levels and a fusion from L3 to S1
    recommended if a trial of facet blocks and ESI
    series proved unsuccessful.

32
TIME OUT!!
  • YOU are the Treating Physician (TP), Reviewing
    Physician (RP), or consulting physician (CP)
  • Most physicians here will assume more than one
    role
  • Be prepared to change hats
  • Sooooooo.what do you think about treatment to
    date?

33
TIME OUT!!!
  • What about the mechanics of the accident?
  • How would you differ from these treatments
    (TP,RP, CP)
  • What about the meds? (Opiates, muscle relaxers,
    Geodon, Cymbalta?)
  • Discuss the intervention (PT, chiropractic
    treatment, PT/Chiropractic modalities, MRI)
  • Discogram?
  • Surgery?

34
Red Flags
  • Fosamax
  • The drug can cause bone pain, arthralgia, joint
    swelling and myalgia.
  • This can be severe and incapacitating.
  • Bisphosphonates should be considered a cause for
    any patient who presents with severe severe
    musculoskeletal or joint pain.

35
Red Flags
  • Why is she taking Fosamax?
  • First-line therapy for postmenopausal
    osteoporosis
  • Approved for prevention in postmenopausal women

36
Red Flags Osteopenia and Osteoporosis
  • Osteoporosis Disease of decreased bone mass and
    change in microarchitecture of the skeleton
  • Diagnosed
  • Acute fracture
  • Generalized osteopenia
  • Etiologies Bone marrow disorders
    Endocrinopathy Liver disease GI disease Drugs

37
Red Flags (?MUS)
  • Geodon (ziprasidone)
  • Atypical antipsychotic
  • FDA approved
  • - Acute psychosis
  • - Agitation
  • - Bipolar disorder
  • - Mania
  • - Schizophrenia

38
Case1
  • Her pain physician increased her medications to
    include Oxycontin, 80mg 3x/d, Methadone for
    breakthrough pain, Lyrica for neuropathic
    pain. No exam was documented. Facet blocks and
    ESI at L3-4, 4-5 and 5-1 bilaterally were
    provided with no benefit. A fusion procedure was
    performed. She remains off work and had
    successfully applied for retirement benefits.

39
Discussion on Case 1
  • She presents to your office with dilated pupils
    and diffuse psychomotor slowing. She complains of
    increasing pain complaints and wants you to
    increase her Oxycontin. An exam shows no focal
    neurologic abnormalities, but extremely limited
    function in terms of range of motion, ADLs .
  • Your review of records shows no physical exam
    for the past 6 months, no UDS, her current meds
    include Oxycontin (80 mg tid), Methadose (10 mg
    tid for breakthrough pain, Amitryptyline,
    Risperdal, Norvasc, Zocor, Soma (tid)

40
Discussion case 1
  • What is her daily Morphine equivalent dose?
  • www.globalrph.com/narcoticonv.htm
  • 360112.5472.5 MEQ/day
  • What is the recommended maximum for benign pain?
  • Discuss the medication combination and potential
    interactions
  • What drug-drug interactions are possible here?
  • CYP450 inhibitions may become irreversible, QT
    interval (methadone)

41
Discussion Case1
  • A UDS shows the following positives opiates,
    opioids, benzoylecognine.
  • What does this mean?
  • What do you want to do now?

42
Red Flag !!!
  • Was methadone positive?

43
Discussion Case1
  • How do you determine the need for detox?
  • How do you accomplish this?
  • Where is the evidence this treatment is helping?

44
MEDICALLY UNEXPLAINED SX
  • BE CAUTIOUS when confronted with multiple
    subjective complaints without objective
    correlation
  • Death rate from prescribed narcotics is climbing
  • Always consider alternate non physical
    explanation
  • THANK YOU VERY MUCH !!
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