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1 BMJ LEARNING PODCAST TRANSCRIPT File: FINAL medically unexplained symptoms.mp3 Duration: 0:16:13 Date: 20/02/2014 Typist: TC6 START AUDIO Recording: You re listening to an audio module from BMJ Learning. Hello. I m Dr Alison Walker, a clinical editor at BMJ Learning. Welcome to this audio module, recorded on 18 th July 2013, on the diagnosis and management of medically unexplained symptoms. Here to talk to us is Dr Chris Burton, academic GP and senior lecturer at the Centre of Academic Primary Care at the University of Aberdeen. Hello Chris. Good to see you, and thanks for coming along. Afternoon. Okay. To begin with, then, what are medically unexplained symptoms? At the simplest level, medically unexplained symptoms are just physical symptoms where there isn t, or you think there isn t, any physical pathology to explain them. That includes both physical symptoms that don t fit a specific syndrome label, and also a wide range of syndromes that we re familiar with; things

2 like fibromyalgia, chronic pelvic pain, irritable bowel syndrome, tension-type headache. In fact, you name a clinical speciality; they ll have a clinical syndrome that fits within this umbrella of medically unexplained symptoms. Okay. Is there any particular way you could group and define these sorts of symptoms? I think people have tried lots of different ways. We tend to use the term medically unexplained symptoms, but if you re like me, you probably don t use it with patients, but we use it among professionals. Psychiatrists looking at this have defined things like somatisation and somatoform disorders. I sometimes find it s useful to think of these as functional symptoms; functional somatic syndromes, we sometimes use the term. The idea is that these are problems with function in the body, rather than structure, and I think that s a useful way to start thinking about these problems, and to start making sense of them for patients. How often would a doctor see patients with symptoms like these in primary care? Roughly one in six consultations with a GP is for a physical symptom that s not just a minor illness, probably isn t part of a major illness, so if you think about it that way, potentially a medically unexplained symptom. That s one in six; that s one patient an hour in an ordinary clinic. 2

3 If you look at people who are a bit more bothered, then it looks like about 2% of the population. If you look at the number of patients who repeatedly go to a GP three or more times over a year with a symptom that s probably medically unexplained, it s about 2%. If you look at the proportion of patients who have at least two hospital referrals for a medically unexplained symptom or an all tests were normal referral over about five years, again, it comes out at about 2%. I think that 2% of the population is a good ballpark figure for people who are significantly affected. I think there s another group, much smaller; maybe two per thousand, who ve got much more severe and disabling medically unexplained symptoms, and often they re the people that spring to mind when we start to talk about these. But in terms of people for whom GPs can make a difference, they re probably not the most important group; it s probably the middle group who we should be focusing on. Okay, so amongst that middle group, then, what are the most common conditions that a GP might come across? A lot of them are going to be the pain disorders: persistent pain, pain that s part of irritable bowel syndrome, pain as part of fibromyalgia or chronic widespread pain, muscular-skeletal pain, headaches. A lot of pain symptoms are in there. But there are also autonomic symptoms; things like palpitations, lightheadedness, dizziness; these commonly crop up. Of course, there s the abdominal function things; the bloating, the dyspepsias, the changes in bowel habit that go with irritable bowel syndrome; these kinds of things. 3

4 Okay. Shall we look at some case examples, then, to illustrate the management of these sorts of patients? Sure. I think when we re thinking about management, it s important to remember that this is such a broad spectrum that trying to give a single plan of management would be overambitious. What I d like to do is think of three different situations in relation to medically unexplained symptoms. The first one would be where somebody s presenting with fairly new symptoms; perhaps the symptoms are still evolving, but you re suspicious that this might turn out to be medically unexplained, or functional. Okay. What sort of case, then, would we be thinking of there? Let s use an example of a 35-year old male; maybe he works as an engineer. He comes to see you with colicky abdominal pain. He s got some mild looseness of his bowels some days. It s been going on for maybe six weeks, but it hasn t been going on for six months or anything, and it didn t all start suddenly. He s had something a bit similar in the past, but never quite as troublesome as this. In the past, about five years ago, he had trouble with persistent headaches, and attended half a dozen times over a year, before ending up being referred for a neurologist and having a normal CT scan. You notice in his records that last year, he turned up at the emergency department with palpitations that was just a sinus tachycardia; possibly a panic attack. 4

5 That s the kind of, it s somebody who s had, got symptoms that would fit with the early part of what might be irritable bowel syndrome. Relatively low-risk by nature of age and the symptoms, and with a past history of, again, consulting, perhaps repeatedly, about symptoms that turn out not to be anything serious. Great, so you ve painted a very nice scenario there, and what might come out in a history. How would you approach carrying out any investigations in a patient such as this? When you ve got an evolving picture such as this, it s really important to manage this as a symptom that might be medically unexplained, and might be a sign of significant pathology. It s absolutely appropriate to do proper physical examinations, to take a proper clinical history, and to do your standard investigations. In this case, it might be full blood count, CRP, perhaps coeliac antibodies; an appropriate workup for somebody with IBS-type symptoms. Once the symptoms, or the investigations etc. come back negative, how do you then approach a patient such as this in making a diagnosis? What would you say? Well, I think I d be trying to do this before the investigations came back negative. One of the things I think s really valuable is when you re doing tests and there s a low probability of disease, to actually say in advance, I think these tests are going to be normal. I think that these symptoms are caused by your intestines just not functioning properly, rather than there 5

6 being any disease here, but I m running the tests just to check that there isn t something else; just to be sure, to be thorough. But I expect them to be normal. By doing that, you re creating an environment where, when he checks up to get the test results, they re what was anticipated. Because otherwise people get, Well, we didn t find anything, or, Your tests were negative, and aren t quite sure what that means. I think it s really important, when we re setting tests up when we expect them to be negative, to be very explicit about that expectation. Is there anything more you could say to the patient, to help them, then, with their diagnosis, and maybe further management? I think at that point, what we want to be doing is trying to explain these symptoms as probably due to intestinal function. I would probably say that, Normally the intestine, which is an incredibly complex thing, does everything on autopilot, without you really being aware of it. But sometimes it just gets a bit uncoordinated; sometimes it just gets things a bit wrong. It will do that for a while, and sometimes it needs a little nudge just to settle back down to working normally, but work normally again it will, and if that s the case, things will settle. I might help that along by a prescription for an anti-spasmodic, but I would also say, If that s what this is, then I would expect this to settle down over the next few weeks, certainly begin improving, and I certainly wouldn t expect to see it getting worse, or giving you more diarrhoea every day, or associated with bleeding or anything. I d already have checked that he didn t have those before. We re simultaneously signposting the 6

7 expected route to recovery, but also putting in a bit of safety netting, just to make sure if the picture changes, then we know about it. Okay then, onto our second case example. What about when a patient has already had that diagnostic work up and the investigations have all come back negative, and they come back again to see you? Okay, let s change the scenario a little bit, but again, somebody I guess everybody s seen, had to manage. We ll take a 48-year old woman this time. She had her gall bladder taken out a year or two ago. They found some stones but no inflammation or obstruction, but she s carried on having abdominal pain, often in her right upper quadrant, since then, and wonders what it is. Again, in the past, she had a laparoscopy for suspected endometriosis ten or more years ago, and a couple of years ago she saw a rheumatologist who thought she d got fibromyalgia. Her pain isn t typically anything; it does lots of different things. Sometimes it moves around, sometimes it grips her in the right upper quadrant. Sometimes it s just there. When you sit and listen to her a little bit and recognising that she has a problem involves sitting and listening and making sure that she knows that you re sitting and listening she says, You know what? Sometimes it just gets so severe I think it s going to burst. She then says, But when I ask the doctors at the hospital what it is and she s been to see two different specialists and had a whole bunch of investigations They just say, It s alright, it s not cancer. 7

8 When you look at that situation, when you re dealing with that situation, what the patient is often saying is: Please, give me some explanation; tell me what s going on. It s all very well saying what I haven t got, but could you make sense of it, please? I think if we don t start to make sense of it, in terms of what the body s doing, then it s very difficult to move on from there. Again, there s the recognition component listening to the patient, acknowledging the severity and the nature of their problem and also acknowledging their fear. That s exactly the sort of patient that I m sure many of our listeners will be familiar with. What would you advise as the management of a patient like this? I think there s no single thing, but what you want to be doing here is not just saying, Yes, I understand, but also starting to think about what the patient might do to try and minimise symptoms. Now, that might be some behavioural techniques, like learning how to use some relaxation exercises and using them when the pain comes on. It might be about using medication, because if she s got persistent pain, one in three people with persistent pain will respond to a tricyclic antidepressant in a low dose, or to an anticonvulsant. Now, if you just prescribe her some amitriptyline and she goes away and looks it up and finds that it s an anti-depressant, and, Well, they just think it s in my head, she s probably not going to take it for very long, if at all. But if you explain, with pain-modifying drugs, about how they change the pain pathways, how they rebuild natural pain barriers, help people 8

9 to switch pain off again, then it becomes sensible to try these things. But I think the key thing is that for a lot of patients, there needs to be that coherent explanation that then moves on to doing something, so the explanation precedes the action. Shall we move onto our third case example, then? What about a scenario where it becomes intractable? These symptoms are associated with a profound sort of disability. I wonder if we could think about an example like that? I m sure that everybody has one. Let s paint a picture of a guy in his late 50s who s had a couple of negative coronary angiograms. He s breathless despite having normal lung function, he has fibromyalgia, and he walks slowly and breathlessly into the consulting room with a stick, telling you that he s now got headaches as well. This is a guy who s got multiple symptoms, and may well have had multiple symptoms for quite a long time, and we re not going to fix him in primary care. I think there are two lines of approach. The first one is: if it s available; if you have a service that offers cognitive behavioural therapy for people with severe medically unexplained symptoms, then there s good evidence from trials that proper cognitive behavioural therapy can be effective for these people in significantly improving symptoms and quality of life. Some areas have these services; some don t. The second strand is to contain this guy; to not overinvestigate, and also to not over-prescribe, bearing in mind that a lot of people with painful medically unexplained 9

10 symptoms often end up on large and potentially toxic doses of strong painkillers. Well, thanks very much; those are three very good illustrative examples. I note that you haven t used in any of them the possibility that the symptoms are down to stress; is that something that you ve done on purpose? Yes. What we know from the trials of studies that have attempted to use reattribution, where doctors take people with medically unexplained symptoms and try and make the link between those symptoms and stress or depression or whatever, when that s done in primary care on a short contact basis, we know that that doesn t work. In fact, we know that patients find it threatening and destructive and unhelpful, so we shouldn t be doing it. Instead, what we should be doing is listening just that little bit more, giving the patients the space to bring out their own attributions. Some people will say, like the woman in the middle, I worry that it s going to burst. Anxieties are always there, or a feeling that they can t cope will be there, but patients don t take very much prompting to volunteer that themselves, and the key thing: if the patient volunteers it themselves, they own it, and it s available for discussion later. Even in that discussion, it s important, I think, to think of these things as either associated things or possibly consequences of the symptoms, and not to make them the primary cause. Just avoiding that idea that these things are caused by stress, even if they may be associated with them, is really important, because again, what happens is patients will often then say, Well, you say it s due to stress, but actually I was really 10

11 relaxed on my holiday, and that s when the symptoms were worst. It only takes one argument like that to just burst the case that you re building, so I find that it s often safer just not to start, and to leave it to the patient to bring these things up. Thanks very much. I wonder if you ve got any final comments you d like to leave us with? I think that using that sort of framework of recognition, explanation and action gives us a structured way of dealing with a wide range of patients with medically unexplained symptoms, and potentially makes them less difficult to deal with. Many thanks to Dr Chris Burton. For further useful resources, please follow the links on the next page. Recording: Thank you for listening to this audio module from BMJ Learning. END AUDIO 11