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Medically Unexplained Physical Symptoms

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Consider some work done in the management of MUPS ... Cardiology. 6/39. Chest medicine. 20/40 (50%) Neurology. 15/50 (30%) Orthopaedics. 32/59 (54 ... – PowerPoint PPT presentation

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Title: Medically Unexplained Physical Symptoms


1
Medically Unexplained Physical Symptoms
2
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

3
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

4
Symptom
5
History and examination
6
Diagnostic tests
7
Specific Treatment
8
Or is it like this..
9
Or maybe
10
Disease cured
11
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

12
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

13
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

14
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

15
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
16
Prevalence of medically unexplained episodes in
frequent attenders categorised by specialty.
number of medically unexplained symptoms/number
of referrals
17
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

18
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

19
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!?

20
What does a negative test do?Chest pain with
normal coronary arteries outcome at 6
years(adapted from Papanicolau et al, 1986)
21
The Spectrum of MUPS
No. of Sx one multiple
Duration transient persistent
Insight good none
Disability none severe
22
Types of MUPS
Somatic presentation among patients with
depression or anxiety
Functional Symptoms
Hypochondriacal Worry
23
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

24
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
25
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)

26
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
27
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

28
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

29
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

30
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

31
What we say matters
NNT 4
32
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

33
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
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