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Medically Unexplained
(or Functional) Symptoms:
An Enhanced Clinical
Formulation &
Management Approach
Dr M Griffiths
Lead Consultant Clinical Psychologist
Head of Services
Clinical Health Psychology Services
Aintree University Hospital NHS Foundation Trust
15/06/2016 1
“Medically unexplained/ Functional symptoms
are ‘persistent bodily complaints for which
adequate (medical) examination does not reveal
sufficient explanatory structural or other
specified pathology”
(RC Psych, 2011)
Definition
15/06/2016 2
Functional Neurological
SymptomsE.g. Functional weakness/ NEAD
Heart Palpitations
Stomach/ Bowel SymptomsBloatedness/ constipation/ diarrhoea/
nausea
Assessment fourYour text here. Your text goes here. Your text goes
here. Place your text here. Your text here. Place your
text here. Your text goes here.
Fatigue (Physical/ Cognitive)
PainBack pain/ Chest pain/ Headaches/
Stomach Pain/ Muscle Pain
Common Functional Symptoms
15/06/2016 3
(UK) Primary Care – FS Prevalence
15-20% of GP consultations regard FS
2% of the general practice population repeatedly
present with FS, accounting for 4-6% of total GP
consultations
10-20% of adults will experience FS over their life
course
15/06/2016 4
(UK) Secondary Care – FS prevalence (Rolfe & Burton, 2013)
Cardiology- 53%
Gastroenterology- 58%
Neurology- 66%
Respiratory- 41%
Rheumatology- 45%
More generally, within a hospital clinic,
25% patients will be likely to present with functional symptoms15/06/2016 5
15/06/2016 6
715/06/2016 7
Chronic Pain: A Highly Complex Phenomenon
“Pain is mediated
by sensory, physiological, interpersonal and environmental-situational factors”
(Dennis Turk, Professor, Department of Anaesthesiology & Pain Medicine, UW Medicine)
15/06/2016
Recurrent FS experience: Psychosocial Risk Factors
•Life history of adversity or trauma
•FS more common in patients from poorer
backgrounds
(Common Thread – Greater exposure to
recurrent stressors, the greater the risk )
•FS more common in families with FS
histories (Genetics v Learning Theory)
15/06/2016 8
Recurrent FS experience: Psychosocial Risk Factors
• High rates of mental health/ FS co-morbidity
• Anxiety and Depression – both more common
in patients with FS than in counterparts living
with medically-explainable physical LTCs
• Approx. 75% of patients with FS will report
symptoms of depression +/- anxiety (2x the
rate of patients with equivalent physical
disability explainable by organic disease)
15/06/2016 9
“The key aspect of all functional disorders is that
they are:
• Long term/ Enduring & Fixed conditions
• Underpinned by a baseline of “impaired
adaptedness…...that limits the capacity to
adapt successfully to the demands of life….”
Oken (2000)
The Human Factor
15/06/2016 10
Pre-morbid personality and coping styles are highlighted as
integral precursors to how patients developing persistent FS are
able to:
a) negotiate the world around them
b) how they understand, cope with, and respond to stress
provoked (at unconscious and physiological levels)
c) how these relationships drive health symptom patterns and
responses/ health behaviours
The Human Factor
15/06/2016 11
Body & Mind – A Dynamic Equilibrium
• Pain science
• Fatigue & Immune system Fx
• Bodily systemic inflammation and Depression
evidence
(i.e. BMC Medicine, 2013: Suggestion of physiological process
leading to depression causation by bodily immflamation)
15/06/2016 12
Activity Limitation
Illness Behaviours
Environmental Restriction
Sickness in the society
Impairment
Neurophysiological disorder
Health
Experienced
Biological
Psychological Sociological
The Biopsychosocial Model of Health
15/06/2016 13
• Neglected recognition of the underlying and key
psychological issues – missed opportunities for intervention
to improve clinical management
• Compromised medical care & clinical outcomes
• Iatrogenic affects –Exacerbating negative psychological
factors, then re-enforcing persistent healthcare seeking
(increasing healthcare dependency)
• Increasing costs of (ongoing) care
Risks posed by ‘usual care’
15/06/2016 14
Healthcare Cost
RCPsych (2011):
• Annual NHS healthcare cost of FS across the UK – Exceeds
£3.1 billion
• Patients presenting with FS commonly having:
• higher rates of onward medical referral and medical
investigations
• more protracted patient journeys
• less likely to be followed up within specialist care
• more likely to be referred back for GP management15/06/2016 15
How can medical management gains best be made?
15/06/2016 16
Principles of Effective MUS management
The PPP model (Walker,
Unutzer & Katon, 1998)-
Seek to Understand:
Biopsychosocial predisposing
factors
Childhood illness history/ social stress/ lack of social support/
childhood trauma/ psychological
problem history/ coping resource
deficits
Precipitating Factors
Current MH issues; stressors (social,
relational, occupational, financial) Perpetuating
Factors
Ongoing stress cycles; social
isolation; relational secondary gains
15/06/2016 17
Commissioning Support for enhanced models of medical care at
primary and secondary levels -
• Striving for an holistic approach from the ground up;
• Supporting an enhanced, holistic model of care & treatment,
starting at primary care, but across all care stages
Commissioning considerations
15/06/2016 18
Adoption of a biopsychosocial clinical formulation
approach – moving away from a reductionist
position
Commissioners & Services must seek to
acknowledge and consider biopsychosocial
relationships as having pertinence to medical
presentations routinely, under systematic care
Paradigm Shift required
15/06/2016 19
An Enhanced Management Approach
– What might this look like?
15/06/2016 20
• A protocol to support GPs in providing enhanced care of patients with
FS (and FS/ mixed with medically explained symptoms)
• Supporting enhanced primary care management, through an
enhanced and holistic clinical management model
• ‘Diagnosis’ of FS NOT NEEDED to apply these care principles (which
may offer management benefits early on)
Primary Care/ GP FS management:
An Enhanced case management approach (Rimmer & Griffiths, 2016)
15/06/2016 21
Provide regular
support within a
structured planAvoiding risk of
responding to
reactive behaviours
Invest in extended
appointmentsSupporting time for
rapport development
Named GP
allocatedWho can provide
regular contact and
a consistent
approach
Provide
compassionate
listening
Encourage
behavioural &
social activation To facilitate social
support
Promote a
biopsychosocial
understanding of
symptomswith the patient
Principles
Of
Enhanced
Clinical
Management
15/06/2016 22
Be cautious in
prescription of
opiates and similar Which may otherwise
mask key underpinning
issues to be tackled
May also lead to
psychological addiction
issues, further
complicating clinical
issues to be managed)
Explain basic CBT
or mindfulness
principles to aid
coping and
symptom
management
(Seek ing support
to if needed )
Support by advice by
prescription
Liaise with
colleagues from
local IAPT, Clinical
Health Psychology
Services and
Psychological
Medicine services
– to support
primary care case
management
Principles
Of
Enhanced
Clinical
Management
15/06/2016 23
Avoid secondary
care
investigations unless clear medical
rationale can be
seen
Avoid referring
onwards for
reassurance
Communicate the
need for a
consistent
approachTo practice
colleagues
Secondary care
colleagues
Seek to support
patient symptom
management as
early as possible
once medical ‘red
flags’ ruled out
Principles
Of
Enhanced
Clinical
Management
15/06/2016 24
General core principle
Provision of psychologically/psychosocially
-informed medical care within the
patients’ understanding that this is part of
a medical (physical symptom) treatment
plan
15/06/2016 25
• Very high burden on emergency care of frequent
attenders
• E.g. 2012-13: more than 12,000 people made 10+
visits to A&E, with over 150 of these attending 50+
times (BBC, 2014)
• Most A&E attenders presenting with pain of some sort
(Loveridge, 2000) –with a high percentage of
presentations being for functional pain
Acute Care: An Enhanced Approach
15/06/2016 26
• Chest pain (anxiety and panic manifesting as queried
heart disease)
• NEAD/ pseudo seizures/ conversion disorder presentations
• Acute/ Chronic pain (often co-morbid to ‘medical’
conditions)
• COPD attack fuelled by anxiety/ panic attack
• Neurological symptoms (numbness/ Neuralgia)
Common A&E presentations:
complex presentations where psychological issues
significantly affect / confuse clinical presentation
15/06/2016 27
Holistic MDT model of enhanced AED care:
CH Psychologist on ‘shop floor’ with AED team
Biopsychosocial position to routine MDT assessment, facilitated by the
presence of a clinical psychologist within the A&E acute MDT
Facilitating identification and management of:
- crucial psychological factors (amenable to change) and pertinent to
physical health presentation
- Via professional consultation and direct patient contact/ advice/
treatment (including access to F/U treatment clinic)
An enhanced A&E approach –
the Aintree Model
15/06/2016 28
Service Aims :
• Improved patient journey/ experience
• Support integrated clinical formulation & care planning
• Reduced rates of avoidable admissions
• Improved patient flow
• Improved care
15/06/2016 29
15/06/2016 30
Outcomes (so far – 6 months in…..)
• Clear evidence of reduced rates of A&E attendance following
psychologist contact or influence on care
• 40% reduction of A&E attendances
(Comparing A&E behaviours 3 months before psychology input v 3
months post input into care)
Also - Medical team feedback :
• Admissions that would otherwise have occurred being avoided
by this enhanced approach
• Added value to medical management15/06/2016 31
Other innovative MUS
management examples
NES Scotland Primary Care Support Model
• Development of an interactive online resource to help inform
optimised FS and physical LTC management
CSL ‘”Whole systems approach to MUS management’
• 2011 report outlining a stepped care model to support
optimised MUS identification and management, across
medical and psychological pathways (e.g building up from a
polyclinic and collaborative approach model)
15/06/2016 32
Significant clinical outcome and financial opportunity gains raised
due to high proportional problem prevalence , across steps of care. With
high levels of health service use (and burden) associated with these
patients (at all levels)
A different; enhanced; integrated; holistic clinical management approach
is needed (from primary care upwards) to optimally manage patients
suffering with FS/ MUS/ psychosomatic symptoms and realise gains
possible –
Innovative clinical commissioning and service design is needed
(learning from examples out there)– being the key to achieving gains
possible
In Summary
15/06/2016 33
Reference –
Medically Unexplained Symptoms:
Understanding and Managing the Clinical Phenomena
Guidance for Clinicians & Commissioners (Griffiths, M, 2016)
North West Coast Strategic Clinical Network
(Currently being finalised)
Further information and references
15/06/2016 34