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Medically Unexplained Medically Unexplained Symptoms (MUS)Symptoms (MUS)

A spectrum of disorders A spectrum of disorders ranging from mild transitory ranging from mild transitory illness to chronic disorders illness to chronic disorders with severe disabilitywith severe disability..

The scope of medically unexplained physical symptoms

1)Physical symptoms of anxiety and depression2)Anxiety or depression secondary to physical illness

3)Acute somatisation4)Chronic somatisation )usually multiple symptoms

and systems)5)Functional somatic syndromes

6)Fabricated symptoms – factitious disorder and malingering

6)Symptoms with organic pathophysiology which has yet to be discovered/understood

Communication with patients with MUPS needs to be flexible as they are a heterogeneous group:

1)The first group may be relieved to talk about psychosocial issues.

2 )The second group may be angered and offended: ‘‘making it up.’’

3 )The third group are uncertain of the role of psychological factors.

Rule-out medicine

1)Rapid rule out

2)This has clear advantages to the patients with disease ruled in, in that further care can be planned and implemented much more quickly

3)Within rapid rule-out paradigms, the number of patients ruled out considerably exceeds

the number ruled in .

The patient may be left with the rather unsatisfactory explanation that ‘‘we don’t know what is wrong with you, but we do know what it isn’t’’, or given pseudodiagnoses such as ‘‘non-cardiac chest pain’’ or ‘‘swollen calf, Doppler negative’’

Unfortunately, this is not always done well or even at all .

The logic of protocol-based rule-out medicine canbe unthinkingly applied and explained to patients as ‘‘there is nothing )seriously) wrong with you, you can

go home.’’

Careful consideration needs to be given to the explanation of negative results in order to avoid creating iatrogenic anxiety.

Explaining negative results:

1 )Rejection

2 )Collusion

3 )EmpowermentEmpowering explanations are clearly the ideal as they legitimise the patient’s suffering and ally rather than alienate the patient and doctor.

Pandora’s box

Normalization

ReassuranceCentral; to effective management

counterproductive; negative investigation results without appropriate explanation

Effective normalization:

Acknowledge and validate patients’ sense of suffering .

Provide tangible mechanisms to explain symptoms arising from patients’ expressed concerns.

Offer opportunity for linkage between psychological factors and physical mechanisms.

The reattribution modelThe reattribution model- how to talk to somatizating patients and how to deal- how to talk to somatizating patients and how to deal- -

Take a full history of the symptomsTake a full history of the symptoms

Explore emotional cuesExplore emotional cues

Explore social and family factorsExplore social and family factors

Explore health beliefsExplore health beliefs

Brief focused physical examinationBrief focused physical examination

Stage 1: Feeling understood

Engage the patient / their problem is being taken seriously .

Enquiry regarding primary care and hospital attendance/ physical symptoms.

A physical examination

Empathic statements, acknowledging the reality of the symptoms, and normalization )explaining that such problems are commonly seen)

Enquiring about disability and self care activities, and encouraging the patient to discuss their presenting problems without interruption or premature closure by the doctor.

Feed back the results of the examinationFeed back the results of the examination

Acknowledge the reality of the symptomsAcknowledge the reality of the symptoms

Reframe the complaints: link physical, Reframe the complaints: link physical, psychological, and life eventspsychological, and life events

Stage 2: broadening the agenda

One technique that can be used is the ‘‘switch’’

The doctor suggests that the physical symptoms might be makingthe patient feel depressed or anxious .

Any positive response is then followed up on with a more detailed enquiry screening for anxiety and depression.

If the response is negative, the patient is less likely to feel undermined than if the doctor had suddenly changed the subject to their mood.

Simple explanationSimple explanation

Three-stage explanation for anxietyThree-stage explanation for anxiety

How depression lowers the pain thresholdHow depression lowers the pain threshold

DemonstrationDemonstration

PracticalPractical

Link to life eventsLink to life events

„„Here and NowHere and Now““

Stage 3: making the link

Finally, it is suggested to the patient that psychosocial factorsmay help to explain their physical symptoms. These should be presented to the patient as suggestions, rather than dogmatically .

Give some examples

It may be helpful to ask if anyone else in the family experiences similar symptoms, and, if so, what brings them on, as it may be easier for people to see the ‘‘link’’ in other people.

Tension headache and period pain are good examples that can be used to demonstrate that pain does not necessarily mean pathology .

In these ways, a positive explanation may be provided for physical symptoms in the absence of physical pathology.

Approach to the patient who has unexplained physical symptoms

Communication Techniques for Physicians

Improve listening and understanding.Improve listening and understanding. Summarize the patient’s chief concernsSummarize the patient’s chief concerns..

Interrupt lessInterrupt less..

Offer regular, brief summaries of what youOffer regular, brief summaries of what you

are hearing from the patientare hearing from the patient..

Reconcile conflicting views of the diagnosisReconcile conflicting views of the diagnosis

or the seriousness of the conditionor the seriousness of the condition..

Improve partnership with patientImprove partnership with patient

Discuss the fact that the Discuss the fact that the relationship is less than ideal; relationship is less than ideal; offer ways to improve careoffer ways to improve care

Improve skills at expressing Improve skills at expressing negative emotionsnegative emotions

Decrease blaming statementsDecrease blaming statements

Increase “I” messages. Example: Increase “I” messages. Example: “I feel” as opposed to “You make “I feel” as opposed to “You make

me feelme feel … …

Increase empathy; ensure Increase empathy; ensure understanding of patient’s emotional understanding of patient’s emotional responses to condition and careresponses to condition and care..

Attempt to name the patient’s Attempt to name the patient’s emotional state; check for accuracy emotional state; check for accuracy and express concernand express concern..

Negotiate the process of careNegotiate the process of care

Clarify the reason for the patientClarify the reason for the patient

seeking careseeking care

Indicate what part the patient must play Indicate what part the patient must play in caring for his or her healthin caring for his or her health

Revise expectations if they are Revise expectations if they are unrealisticunrealistic

Reassurance:Reassurance: Controversial roleControversial role

Simple reassurance does not work Simple reassurance does not work well in patients with MUPSwell in patients with MUPS..

The The narrow focusnarrow focus on the somatic on the somatic aspects of a complex problem may aspects of a complex problem may reinforce their concerns about reinforce their concerns about having a physical diseasehaving a physical disease..

Patients factorsPatients factors: chronicity, : chronicity, severity of symptoms, severity of symptoms, personality characteristics and personality characteristics and also to attitudes and treatment also to attitudes and treatment style of the therapiststyle of the therapist..

ReassuranceReassurance Elements of Effective Reassurance:Elements of Effective Reassurance:

Thorough examination of Thorough examination of medical records and historymedical records and history

Acceptance of the patientAcceptance of the patient, , his or her complaints, and his or her complaints, and their legitimacytheir legitimacy

Using Using clear and simple clear and simple languagelanguage with unambiguous with unambiguous termsterms

Providing relevant information Providing relevant information and explanationsand explanations

Fostering the patient's Fostering the patient's responsibilityresponsibility for his or her for his or her treatmenttreatment

Shifting attention from Shifting attention from physical symptoms to physical symptoms to underlying psychological and underlying psychological and social problems and focusing social problems and focusing on patient assets.on patient assets.

Adjusting a reassuring style in Adjusting a reassuring style in a way that is effective for a a way that is effective for a given patientgiven patient

Providing repeated Providing repeated reassurancereassurance

Scheduling regular visitsScheduling regular visits with with a clear goala clear goal

Performing appropriate Performing appropriate examinations and tests with examinations and tests with adequate explanationadequate explanation

One common cause for failure of reassurance was referred :

‘‘wild card effects.’’

If we don’t find out :

“what they fear.”

The keys to successThe keys to success

Not to expect miraclesNot to expect miraclesAny change is positiveAny change is positiveCaring rather than a curing approachCaring rather than a curing approach

Develop rapportDevelop rapportWhat is it that they wantWhat is it that they wantMore willing to discuss his or her psychosocial worldMore willing to discuss his or her psychosocial world