Medically unexplained symptoms and syndromes Flashcards
1
Q
Define medically unexplained symptoms (MUS)
A
Symptoms for which no medical diagnosis or explanation can be found are often called
2
Q
Symptoms for which no medical diagnosis or explanation can be found are often called
This is known as…?
A
Medically unexplained symptoms (MUS)
3
Q
Define syndrome
A
When symptoms occur together regularly in clusters to form a recognisable illness
4
Q
When symptoms occur together regularly in clusters to form a recognisable illness
This is known as…?
A
Syndrome
5
Q
Name 5 syndromes classed as medically unexplained
A
- Irritable bowel syndrome
- Fibromyalgia (chronic widespread pain)
- Premenstrual syndrome
- Repetitive strain injury
- Chronic pelvic pain
6
Q
What % of people in the general population experience physical medically unexplained symptoms?
A
80-90% per week
7
Q
What is the distribution of fatigue in the community?
A
Normal distribution
8
Q
Fatigue is normally distributed in the community
What does this mean?
A
Most people have some fatigue, a few people have a lot or a little
9
Q
True or False?
Fatigue is a common experience in the communtity
A
True
10
Q
What is the average fatigue score in a study by Pawlikowska et al (1994) on 15,000 adults
A
12
11
Q
What % of people who go into primary care experience medically unexplained symptoms?
A
19-25%
12
Q
What % of people who go into secondary care (hospital outpatient) experience medically unexplained symptoms?
A
30-70%, average 53%
13
Q
After consecutive referrals to 7 clinics and 2 London hospitals, what % of dental cases had no medical diagnosis?
A
Male = 50%
Women = 33%
14
Q
After consecutive referrals to 7 clinics and 2 London hospitals, what % of chest cases had no medical diagnosis?
A
Male = 26%
Women = 53%
15
Q
After consecutive referrals to 7 clinics and 2 London hospitals, what % of rheumatology cases had no medical diagnosis?
A
Male = 31%
Women = 52%
16
Q
After consecutive referrals to 7 clinics and 2 London hospitals, what % of cardiology cases had no medical diagnosis?
A
Male = 42%
Women = 63%
17
Q
After consecutive referrals to 7 clinics and 2 London hospitals, what % of gastroenterology cases had no medical diagnosis?
A
Male = 50%
Women = 63%
18
Q
After consecutive referrals to 7 clinics and 2 London hospitals, what % of neurology cases had no medical diagnosis?
A
Male = 55%
Women = 66%
19
Q
After consecutive referrals to 7 clinics and 2 London hospitals, what % of gynaecology cases had no medical diagnosis?
A
66%
20
Q
For many, Medically Unexplained Symptoms are fleeting and self- limiting
What does this mean?
A
These symptoms often resolve themselves
21
Q
Describe the study by Koch et al (2009) on primary care patients and unexplained symptoms
A
Dutch primary care study (n=254) of patients with unexplained fatigue, abdominal or musculoskeletal complaints.
22
Q
Dutch primary care study (n=254) of patients with unexplained fatigue, abdominal or musculoskeletal complaints.
Describe the results of this study
A
43% still had unexplained symptoms 1 year later
23
Q
What % of Dutch primary care study of patients with unexplained fatigue, abdominal or musculoskeletal complaints. still had unexplained symptoms 1 year later
A
43%
24
Q
What is the main problem of Medically Unexplained Symptoms?
A
MUS violates the biomedical model which conflates disease and illness
25
Violates the biomedical model which conflates disease and illness
This is known as...?
Medically Unexplained Symptoms
26
Describe the biomedical model which conflates disease and illness
List 5 points
1. Disease
2. Symptoms
3. Diagnosis
4. Intervention
5. Cure
27
Symptoms or illness without disease
This is known as...?
Medically Unexplained Symptoms
28
What is the medical/psychiatric response to Medically Unexplained Symptoms?
List 4 points
1. MUS is due to psychological difficulty
2. MUS is due to somatic distress and symptoms unaccounted for by pathological findings
3. MUS is somatic distress and symptoms attributed to physical illness (somatized manifestations to a physical illness)
4. MUS is belief that the cause of these experiences is because there is a physical illness going on
29
Wy is somatization an unsatisfactory construct?
List 3 reasons
1. Patients hate it as they feel that it delegitimizes their symptoms
2. What does it mean for “psychological distress” to “come out” as bodily symptoms?
3. There is scant evidence that having lots of bodily symptoms is related to denying emotional problems – in fact the opposite is true
30
What are Medically Unexplained Symptoms often accompanied by?
Psychological symptoms or distress
31
The more Medically Unexplained Symptoms, the ____ distress you have
a. Less
b. More
b. More
32
Medically Unexplained Symptoms expresses distress in the form of ...?
Physical illness
33
True or False?
“Somatization” is unsatisfactory
True
34
True or False?
“Medically unexplained” is satisfactory
False
“Medically unexplained” is unsatisfactory
35
Why is “Medically unexplained” unsatisfactory?
List 4 reasons
1. Diagnosis by exclusion
2. Continued concern ‘have we missed something?’
3. indicates failure of medical system
4. Patients can feel dismissed because they are told that nothing is the matter
36
True or False?
Medically Unexplained Symptoms are real, they are not imaginary or made up
True
37
Alternative approaches try to explain the experience of Medically Unexplained Symptoms in terms of interacting _____, _____ and (to a lesser extent) _____ factors, and help people to manage them
1. Biological
2. Psychological
3. Social
38
What are the perceptual factors of MUS (perceptions of bodily sensations)?
List 3 points
1. Noticing sensations (by attending to the sensation)
2. Attending to sensations
3. Competition of cues
39
Describe the study by Pennebaker & Lightner (1980) on competition of cues
2 groups
- G1: External focus group (listened to music before reporting their fatigue levels)
- G2: Internal focus group (listened to their own breathing before reporting their fatigue levels)
40
Describe the results of the study by Pennebaker & Lightner (1980) on competition of cues
Internal focus group (listened to their own breathing before reporting their fatigue levels) reported feeling more fatigue, pain and effortful
41
Internal focus group (listened to their own breathing before reporting their fatigue levels) reported feeling more fatigue, pain and effortful
Why?
Because they attend to their internal sensations
42
How can we interpret sensations as symptoms?
List 4 ways
1. Context important
2. Beliefs and personal models of illness, illness prototypes
3. May use heuristics – e.g. stress heuristic, age heuristic
4. Interpretations affected by emotional factors
43
How can we use stress heuristics to interpret sensations as symptoms?
During times of stress you are more likely to attribute symptoms due to stress rather than other influences
44
Who proposed the attributional style of explaining MUS (e.g. Tiredness)?
Kirmayer & Robbins (1991)
45
What are the 3 types of attribution?
1. Normalising
2. Psychologising
3. Somatising
46
What types of attribution does this apply to?
"I’m stressed and wound up"
a. Normalising
b. Psychologising
c. Somatising
b. Psychologising
47
What types of attribution does this apply to?
"The room is too hot
I was out late last night"
a. Normalising
b. Psychologising
c. Somatising
a. Normalising
48
What types of attribution does this apply to?
"Maybe I’m coming down with something?"
a. Normalising
b. Psychologising
c. Somatising
c. Somatising
49
What types of attribution does this behaviour apply to?
The room is too hot
I was out late last night
- open window
- have an early night
a. Normalising
b. Psychologising
c. Somatising
a. Normalising
50
What types of attribution does this behaviour apply to?
Maybe I’m coming down with something?
- See a doctor or treat symptoms
- Feeling ill, with a virus
a. Normalising
b. Psychologising
c. Somatising
c. Somatising
51
What types of attribution does this behaviour apply to?
I’m stressed and wound up
- Emotion regulation or problem focused coping
- Feeling upset, having a lot on your plate
a. Normalising
b. Psychologising
c. Somatising
b. Psychologising
52
List 5 ways out mood can affect our symptoms
1. Fear of being ill
2. Physical sensations of anxiety
3. Physical sensations of depression
4. Many patients with unexplained symptoms are depressed or anxious
5. In the community, emotion is positively correlated with physical symptoms
53
How can fear of being ill affect our symptoms?
We become more vigilant to bodily sensations
54
How can physical sensations of anxiety affect our symptoms?
When we are anxious, we experience sweating, shaking, dry throat, dizzy, nausea, stomach cramps, butterflies, etc. which can be interpreted as illness symptoms
55
How can physical sensations of depression affect our symptoms?
When we are depressed, we experience weight/appetite change, sleeplessness, early waking, tiredness, aches and pains, which can be interpreted as illness symptoms
56
What % of patients with unexplained symptoms are depressed or anxious?
Approx 85%
57
What is emotion positively correlated with?
Physical symptoms
58
According to Pawlikowska et al (1994), what are fatigue symptoms positively correlated with?
Distress
59
According to Pawlikowska et al (1994), fatigue symptoms _____ correlated with distress
a. Negatively
b. Positively
b. Positively
60
True or False?
The more distress you have, the less fatigue you report experiencing
False
The more distress you have, the more fatigue you report experiencing
61
The more distress you have, the more fatigue you report experiencing
What might explain this relationship?
List 3 points
1. Excess cortisol can manifest itself into physical symptoms
2. We might overthink things
3. Having to work har to keep going when you are ill can lead to fatigue
62
Describe a potential process of being "diagnosed" with Medically Unexplained Symptoms from having abdominal pain
List 8 points
1. Feeling abdominal pain
2. Mother died of bowel cancer. Worried symptoms are same
3. Vigilant about abdominal sensations
4. Notices more discomfort
5. Increased worry and monitoring of symptoms
6. Attends GP describing her symptoms of bowel cancer
7. Sent to hospital for tests
8. Tests are clear, but GP tells her to return if any further symptoms
63
How do GPs deal with patients with Medically Unexplained Symptoms?
List 5 ways
1. Provide reassurance
2. Refer them to secondary care departments
3. Conduct a physical investigation
4. Give symptomatic treatment
5. Perform surgery
64
When GPs provide reassurance for patients with MUS, how long is it effective for
24 hours
Patients may leave the GP feeling better but will worry and concern once they get back and might revisit the GP
65
What % of MUS patients get referred to secondary care departments by GPS?
30-70% no physical pathology
66
What physical investigations do GPs conduct on MUS patients?
List 4
1. Blood tests
2. Scans/x-rays
3. Endoscopy
4. Laparoscopy
67
What symptomatic treatment do GPs given to MUS patients?
List 3
1. Analgesia
2. Antibiotics
3. Antidepressants
68
What % of MUS patients underwent surgery even when having normal histology?
15-40%
69
Describe the qualitative study by Salmon et al. (1999) on how doctors explain MUS to patients
List 2 points
1. Qualitative study on patients with persistent MUS
2. Interviewed about the different explanations they had received from GPs and other health professionals
70
What were the 3 typologies in Salmon et al.'s (1999) qualitative study on how doctors explain MUS to patients
1. Rejecting (explanations)
2. Colluding (explanations)
3. Empowering (explanations)
71
How do doctors reject explanations when dealing with MUS patients?
List 2 points
1. Denies reality of symptom
2. Implies imaginary disorder
72
How do doctors collude explanations when dealing with MUS patients?
GP sanctions patient’s own explanation (they agree with the patient)
73
How do doctors empower explanations when dealing with MUS patients?
List 3 ways
1. Through tangible mechanisms (understanding of what was going on and what the potential causes could be)
2. Exculpation (does not blame the patient)
3. Opportunity for self-management
74
What are the implications of GPs rejecting explanations to MUS patients?
List 2
1. Unresolved explanatory conflict (getting into an argument about whether the symptoms are real)
2. GP is distrusted with future symptoms
75
What are the implications of GPs colluding explanations to MUS patients?
Patient might question. the GP’s openness and competence
76
What are the implications of GPs empowering explanations to MUS patients?
List 4
1. Legitimises patient’s suffering and removes blame from patient
2. Allies GP and patient
3. Allows for discussion of psychological features
4. Empowering
77
Which of these explanations does this statement apply to?
“It’s not bloody psychological. I’m not off my trolley. She thinks it’s all in the mind”
a. Empowering (explanations)
b. Colluding (explanations)
c. Rejecting (explanations)
c. Rejecting (explanations)
78
Which of these explanations does this statement apply to?
"I don’t tell her now, I think she’ll just laugh"
a. Empowering (explanations)
b. Colluding (explanations)
c. Rejecting (explanations)
c. Rejecting (explanations)
79
Which of these explanations does this statement apply to?
‘He explained about tensing myself up so the neck kept hurting’
a. Empowering (explanations)
b. Colluding (explanations)
c. Rejecting (explanations)
a. Empowering (explanations)
80
Which of these explanations does this statement apply to?
"I have clinical depression. The Dr explained it to me quite well.. In these synapses something goes awry...an imbalance.. Everything that hurts, I know that it’s because of the brain cells not quite working"
a. Empowering (explanations)
b. Colluding (explanations)
c. Rejecting (explanations)
a. Empowering (explanations)
81
Which of these explanations does this statement apply to?
Denies reality of symptom
a. Empowering (explanations)
b. Colluding (explanations)
c. Rejecting (explanations)
c. Rejecting (explanations)
82
Which of these explanations does this statement apply to?
Implies imaginary disorder
a. Empowering (explanations)
b. Colluding (explanations)
c. Rejecting (explanations)
c. Rejecting (explanations)
83
Which of these explanations does this statement apply to?
Allows for discussion of psychological features
a. Empowering (explanations)
b. Colluding (explanations)
c. Rejecting (explanations)
a. Empowering (explanations)
84
Which of these explanations does this statement apply to?
Allies GP and patient
a. Empowering (explanations)
b. Colluding (explanations)
c. Rejecting (explanations)
a. Empowering (explanations)
85
Which of these explanations does this statement apply to?
GP sanctions patient’s own explanation
a. Empowering (explanations)
b. Colluding (explanations)
c. Rejecting (explanations)
b. Colluding (explanations)
86
Which of these explanations does this statement apply to?
Empowering
a. Empowering (explanations)
b. Colluding (explanations)
c. Rejecting (explanations)
a. Empowering (explanations)
87
Which of these explanations does this statement apply to?
GP is distrusted with future symptoms
a. Empowering (explanations)
b. Colluding (explanations)
c. Rejecting (explanations)
c. Rejecting (explanations)
88
Which of these explanations does this statement apply to?
Legitimises patient’s suffering and removes blame from patient
a. Empowering (explanations)
b. Colluding (explanations)
c. Rejecting (explanations)
a. Empowering (explanations)
89
Which of these explanations does this statement apply to?
Opportunity for self-management
a. Empowering (explanations)
b. Colluding (explanations)
c. Rejecting (explanations)
a. Empowering (explanations)
90
Which of these explanations does this statement apply to?
Unresolved explanatory conflict
a. Empowering (explanations)
b. Colluding (explanations)
c. Rejecting (explanations)
c. Rejecting (explanations)
91
Which of these explanations does this statement apply to?
Tangible mechanism
a. Empowering (explanations)
b. Colluding (explanations)
c. Rejecting (explanations)
a. Empowering (explanations)
92
Which of these explanations does this statement apply to?
Questioning GP’s openness and competence
a. Empowering (explanations)
b. Colluding (explanations)
c. Rejecting (explanations)
b. Colluding (explanations)
93
Which of these explanations does this statement apply to?
Exculpation
a. Empowering (explanations)
b. Colluding (explanations)
c. Rejecting (explanations)
a. Empowering (explanations)
94
What are the consequences of the current medical approach?
List 5
1. Excessive investigation and treatment
2. Iatrogenesis (harm caused by healthcare) – e.g. unnecessary treatment
3. Heightened awareness of symptoms
4. The lack of an explanation causes distress
5. Breakdown of therapeutic relationship (partnership between patient and doctor)
95
How can the lack of an explanation causes distress?
List 2 ways
1. Patient feels disbelieved (which can be worse than the symptoms itself)
2. Heartsink patients (patient would repeatedly visits the doctor, often with multiple or non-specific symptoms, and whose complaints are impossible to treat)
96
What are psychological approaches to managing MUS based on?
Based on the idea that beliefs (cognitions), emotions, and behaviour interact with the body to maintain symptoms
97
Psychological approaches to managing MUS are based on the idea that ___, ____ and ___ interact with the body to maintain symptoms
1. Beliefs (cognitions)
2. Emotions
3. Behaviour
98
How can beliefs (cognitions), emotions, and behaviour interact with the body to maintain symptoms?
List 5 points
- Feel bodily sensations
- These are interpreted as symptoms
- They may worry
or
- They may rest, seek treatment and continued checking
- They experience preoccupation, hypervigilance, bodily changes, sleep disturbance
99
How can CBT help MUS patients?
It identifies patients’ interpretations of sensations and beliefs about symptoms (their explanatory models)
100
What does CBT help patients with MUS identify?
List 2 points
1. Patients' interpretations of sensations
2. Beliefs about symptoms (their explanatory models)
101
What therapy helps MUS patients to develop alternative models?
e.g. This pain is not indicative of disease
I can manage it
It is normal so I can live a normal life
CBT
102
What therapy promotes behavioural changes (increasing activity, reducing checking, help seeking)?
CBT
103
What does CBT help promote?
Behavioural changes (increasing activity, reducing checking, help seeking)
104
True or False?
Behavioural changes improve symptoms
True
105
True or False?
Symptom improvement feeds back into beliefs
True
106
CBT promotes behavioural changes (increasing activity, reducing checking, help seeking)
How does this help patients with MUS?
Patients become more motivated to change their behaviours
Behavioural changes improve symptoms
Symptom improvement feeds back into beliefs
107
How can patients with MUS reduce their symptoms by changing beliefs and behaviour?
Describe the 5-step process
1. Bodily sensations
2. Normalised attribution
3. Stay active, don’t go to doctor, don’t check (not losing fitness)
+ reduced worry
4. Less preoccupied, sleep better, less disabled, fitter
5. Reduction in sensations
108
Describe the findings of Kroenke & Swindle's (2000) systematic review of 31 controlled trials of CBT for MUS
Patients experienced a 12 month improvement compared with treatment as usual in:
- Physical symptoms
- Functional status
- Emotional distress
109
Patients experienced a 12 month improvement with CBT compared with other usual treatments
What are the 3 areas patients improved in?
1. Physical symptoms
2. Functional status
3. Emotional distress
110
What are the issues in engaging patients with psychological therapy?
List 6
1. Disenchanted with medical care
2. Suspicious of mental health services
3. Beliefs that symptoms are caused by disease
4. Feel like symptoms are not believed
5. It is important to be able to explain the rationale for treatment convincingly
6. Sheer volume of individuals with MUS and limited capacity of CBT-trained therapists
111
Engaging MUS patients with psychological therapy may make them disenchanted with medical care
Why?
Patients who had negative experiences with healthcare feel dismissed and disbelieved
112
Engaging MUS patients with psychological therapy may make them feel like their symptoms are not believed
Why?
If they see a clinical psychologist instead of an actual doctor, they may feel like their symptoms are not taken seriously
113
What is the adaptation of CBT used in primary care?
Reattribution Therapy
114
What is Reattribution Therapy?
The adaptation of CBT used in primary care
115
What are the 4 stages of Reattribution Therapy?
1. Feeling understood
2. Broadening the agenda
3. Making the link
4. Collaborating on a treatment or management approach
116
How can MUS patients in primary care feel understood through Reattribution Therapy?
Reattribution Therapy explores illness belief and respond to emotional cues
117
How can Reattribution Therapy broaden the agenda?
It explores emotional factors
118
How can Reattribution Therapy make the link between emotional factors and MUS?
Links symptoms with stress response and muscles tensions
119
Benefits of Reattribution Therapy are found in 2 studies
What are they?
MUS in Dutch primary care (Blankenstein et al, 2001)
MUS in UK primary care (Morriss et al, 2002, 2007; 2010)
120
MUS in Dutch primary care (Blankenstein et al, 2001)
MUS in UK primary care (Morriss et al, 2002, 2007; 2010)
What therapy do these study provide support for?
Reattribution Therapy
121
1. Feeling understood
2. Broadening the agenda
3. Making the link
4. Collaborating on a treatment or management approach
These are the stages of...?
Reattribution Therapy
122
Arrange these stages in order:
Making the link
Collaborating on a treatment or management approach
Broadening the agenda
Feeling understood
1. Feeling understood
2. Broadening the agenda
3. Making the link
4. Collaborating on a treatment or management approach
123
Describe the Randomised Controlled Trial with 141 MUS patients conducted by Morriss et al (2010) on trained vs untrained GPs
Compared Trained GPs (underwent training for Reattribution Therapy) vs Control GPs
124
Describe the results of the Randomised Controlled Trial with 141 MUS patients conducted by Morriss et al (2010) on trained vs untrained GPs
List 3 points
1. Improved GP communication behaviour
- Feeling understood (p<.001)
- Broadening the agenda (p<.001)
- Making the link (p<.001)
- Negotiating treatment (p<.001)
2. Increased patient satisfaction (p<.05)
3. No increase in consultation length
125
The ‘simplified’ cognitive behavioural intervention is known as...?
Reattribution therapy
126
True or False?
The 'simplified’ cognitive behavioural intervention (Reattribution Therapy) can be delivered by non- psychology trained health professionals
True
127
The 'simplified’ cognitive behavioural intervention (Reattribution Therapy) can be delivered by non- psychology trained health professionals in a way that is ____ and ____ to patients and NHS
1. Feasible
2. Acceptable
128
True or False?
Studies have compared the full cost effectiveness of Reattribution Therapy compared with CBT and found it to be significantly more effective
False
But no studies have yet compared the full cost effectiveness of Reattribution Therapy compared with CBT
129
True or False?
It is unlikely that Reattribution Therapy would be as effective as full CBT
True
130
It is unlikely that Reattribution Therapy would be as effective as full CBT for some patients with...?
Complex presentations
131
MUS are a challenge to the _____ model
Biomedical
132
____ and ____ processes are involved in the maintenance of symptoms
1. Cognitive
2. Emotional
