Medically Unexplained Physical Symptoms

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Medically Unexplained Physical Symptoms
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Aims where are we going today?

• Recognise and understand the significance of MUPS
• Reduce anxiety about them
• Consider some work done in the management of MUPS
• Equip us with tools for negotiation with patients
• Ensure you will never want to say mups again

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Aims where are we NOT going today

• You will not leave with all the answers
• You will not leave with a protocol for the
  management of all MUPS
• BUT basic tools discussed today are central to
  management of these conditions

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Symptom
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History and examination
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Diagnostic tests
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Specific Treatment
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Or is it like this..
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Or maybe
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Disease cured
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MUPSA problem in Primary Care?

• 20 of new consultations in primary care are by
  patients with physical symptoms for which no
  specific organic cause is found
• Bridges KW, Goldberg DP 1985
• many transient
• gt33 persist ? Distress and disability
• Craig et al 1993

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MUPS A problem in Primary Care?

• Physical symptoms such as headache and dizziness
  prompt almost 50 of all primary care
  consultations.
• Shown to have organic origin in only 10-15 of
  patients followed up for 1 year
• Katon J Clin Psychiatry 199859 (suppl 20)15-21
• Patient diagnosed with MUPs after appropriate
  assessment unlikely to show later evidence of
  underlying organic disease

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MUPS A problem in Primary Care?

• 73 patients with medically unexplained motor
  symptoms
• Followed up for 6 years
• 3 patients in whom a new organic neurological
  disorder was diagnosed could partly/fully
  explain presenting symptoms
• Crimlisk BMJ 1998316582-6

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MUPS A problem in Secondary Care

• Medically unexplained symptoms in frequent
  attenders of secondary health care retrospective
  cohort study Steven Reid BMJ 2001322767
• Frequent attenders consume large amounts of
  healthcare
• Top 5 attenders South Thames Region
• Randomly selected 400 notes
• Consultation episode initial consultation to
  discharge from clinic

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Prevalence of medically unexplained episodes in
frequent attenders categorised by referral
complaint (stratified by age). Figures are number
of medically unexplained symptoms/number of
referrals
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Prevalence of medically unexplained episodes in
frequent attenders categorised by specialty.
number of medically unexplained symptoms/number
of referrals
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MUPS A problem in Secondary Care

• Kingham and Dawson 1985
• 22 patients
• chronic upper abdominal pain reproduced by
  distension of the colon with a balloon
• Seen 76 consultants
• Normal investigations
• 72 pancreatico-biliary procedures
• 53 barium xrays
• 25 endoscopies
• 12 IVUs

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MUPS A problem in Secondary Care

• 38 operations without long term success
• 12 appendicectomies
• 10 cholecystectomies
• 16 gynaecological / exploratory abdominal
  operations
• Only consistently abnormal investigation
• Hamilton rating scale for depression

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MUPS A problem for primary and secondary care

• Increased specialisation defined boundaries
• All your tests are negative
• You dont have any of my diseases
• Im discharging you
• If you have any more problems see your GP
• Problem solved!?

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What does a negative test do?Chest pain with
normal coronary arteries outcome at 6
years(adapted from Papanicolau et al, 1986)
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The Spectrum of MUPS
No. of Sx one multiple
Duration transient persistent
Insight good none
Disability none severe
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Types of MUPS
Somatic presentation among patients with
depression or anxiety
Functional Symptoms
Hypochondriacal Worry
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Who gets MUPS?Factors associated with MUPS

• Being older
• Being female
• Living alone, isolation
• Having a co-morbid psychiatric disorder
• e.g. anxiety or depression
• Childhood sexual abuse

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What is going on?example of non cardiac atypical
chest pain
Physical perceptions Physiological pathological
Emotional arousal personality stress psychiatric
disorder
Illness experience heart disease other
illness
Interpretation
Maintaining factors iatrogenic reaction
of others psychiatric
Symptoms psychological physical Disabilty
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Attribution of symptoms

• The cognitive process whereby somatic sensations
  are interpreted in the context of the body and
  its physical and social environment.
• Im tired because
• Im overworking and unfit (normalising)
• My muscles have been weakened by a virus
  (somatic)
• I have depression (psychological)

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Attribution of symptoms among frequent attenders
Patients asked to write down possible causes for
each of 10 common physical symptoms
Psychol Med 199626575-589, 641-646
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Attribution of symptoms among frequent attenders

• Frequent attenders were no more likely than
  controls to see symptoms as serious but were less
  able to come up with reasons why they might be
  benign.
• May explain why reassurance that rules out
  problems but does not offer alternative tangible
  explanations often fails.
• C Burton BJGP 200353233-241

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Somato-sensory awareness

• Irritable bowel syndrome
• Hypersensitive to rectal balloon distension
• Visceral hypersensitivity only reported on 60
• Others developed hypersensitivity after repeated
  distension
• Anticipation
• Distension with increasing magnitude
• Lower pain threshold than control
• Distension with random variation in magnitude
• No significant differences

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Psychological distress

• 20 of patients with one MUPS have a current
  psychological illness
• 30 with 4 symptoms
• gt80 with 10 or more symptoms have a current
  psychological illness

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What we say matters

• Randomised trial of positive attitude
• Positive consultation with prescription
• Firm diagnosis, told it WILL get better
• Positive consultation with out prescription
• Negative consultation with prescription
• I cannot be certain not sure if treatment
  will work
• Negative consultation without prescription
• I cannot be certaintherefore I will give no
  treatment
• 200 patients, URTIs, pains in arm/head/chest/back
  etc

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What we say matters
NNT 4
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MUPS A balanced perspective

• Studies exploring prevalence of MUPS demonstrate
• While MUPS are common, and often associated with
  psychiatric morbidity, many patients with MUPS
  have no definite psychological illness, and
  patients with multiple symptoms and a refusal to
  acknowledge a severe mental health problem are
  rare.
• C Burton BJGP 200353233-241

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What are we going to do?

• Discuss 8 questions to open up some of the
  important issues we need to consider in our
  practice
• 8 Groups of 5 - 2 questions each.
• Definitely feedback on the highlighted question
• Be prepared to feedback on the other question
• Looking at how to manage MUPS later
• 2 case studies to help us start