Medically unexplained symptoms Persistent physical symptoms Chronic mental illness. Dr Philippa Bolton

Transcription

1 Medically unexplained symptoms Persistent physical symptoms Chronic mental illness Dr Philippa Bolton

2 QUIZ

3 The Drivers NHS Five Year Forward View Urgent Care Demand Parity of Esteem

4 Current example: GP Gen surgery Gynae Mental health Patient Gastro Pain clinic A and E

5 The problem patient GP 3-12 bn

6 What does this patient look like in your practice?

7 How to identify them Frequent attenders. Patients on repeat prescriptions for opiate like analgesics / pregabalin / gabapentin etc. Certain diagnoses may have MUS elementfibromyalgia, CFS/ME, IBS, chronic pelvic pain, atypical facial pain, back pain. Multi- symptom presentations with normal investigations. MUS should be considered if you see a patient with Physical Symptoms For 3 months Affecting functioning Cannot be readily explained

8 What do we know now?

9 Everyone gets functional symptoms What functional symptoms have you experienced?

10 Not all MUPS patients are the same

11 Where is the mind?

12 The Science bit

13 Shell Shock

14 Pain video

15 The internal model of illness We all have an internal model which helps make predictions based on sensory information and probabilities. The internal predictions that arise can drive sensory perception to somewhere very different from reality.

16 Memory and expectation Many of our illness behaviours and symptoms come from memory and expectation, both personal and cultural. Placebo effect In countries where there is no expectation of chronic disabling neck pain after whiplash there are very low levels of whiplash. Gluten intolerance anyone? Events that trigger memory can trigger symptoms looking at a food that previously was linked to sickness can cause nausea.

17 The role of trauma There are a high level of threat events in patients with conversion disorder (2/3rds). Alcoholic fathers for women with somatic symptom disorder. Affects emotional regulation hyperarousal to emotions. In Non epileptic seizures, this abnormally links to motor initiation the amygdala is overactive and then the SMA becomes activated producing abnormal movements.

18 Window of tolerance

19 The role of upbringing Modelling parents / siblings with chronic illness Lack of ability to self soothe Lack of ability to recognise / identify emotions

20 The role of Attention These expectations, memories and internal models can give rise to increased attention to a particular area of the body, inducing or worsening symptoms. This increase in attention is often triggered by a common illness / injury. The more attention to a symptom the worse it gets.

21 System 1 and 2 System 2 - Automatic movement have to do a thing 10,000 times - breathing, walking, moving System 1 - Conscious driven movement or voluntary movement movements that are less familiar and thought about. If something interferes with these systems, such as a physical trigger, then something that was system 2 enters system 1 and the person can not do it anymore in an automatic natural way. Sports people / actors choking in their performance.

22 In NEAD there is a major shift of attention TO self just prior to a seizure. If you can then use grounding techniques to shift attention back away from self, you can avert the seizure. In Parkinsons, there is a reduction in normal voluntary movement, leading to increase attention to movement so increase in functional symptoms at the start of the illness

23 Physical Trigger Novel Sensory data Anxiety Stress Increased salience of data Background of trauma Expectation Increased self focus Symptoms

24 Ovulation Pelvic pain Anxiety Stress Aunt had cyst and almost died Expectation that needs hospital treatment Told it is a cyst on scan - Increased self focus Stops work, demands scans, investigations, medications, increasing symptoms due to increased self focus

25 Pain system Persistent pain changes the central nervous system and sometimes even if there was an original cause, the nervous system gets stuck and continues to tell you there is pain even when the original problem has gone. It can become hypersensitive to pain and magnify the pain present.

26 Physical Trigger Ankylosing spondylitis Novel Sensory data fall Unable to stand leading to panic Increased salience of data hospital say might be dystonia Expectation effortful gait gets a stick/ Wheelchair/ splints Increased self focus - conscious control takes over Symptoms worsened and then deconditioning and chronic change occurs

27 Physiotherapy In FND physio is helpful as it can retrain a patient s poor gait. Get patient to sway / dance not walk as a way back into walking. Use mirrors work with third person perspective, not first person thus drawing attention away from self. Therapeutic sedation ry.aspx?videoid=128&autoplay=false

28 Links to long term conditions Patients with long term conditions account for 77% of bed days and 70bn a year in NHS. Often cross over with MUPS increased attention gives rise to functional overlay and additional functional symptoms. In MUPS inactivity leads to deconditioning and development of long term conditions eg back pain.

29 Fear Avoidance Patients with chronic symptoms often end up fearful of activities and avoid, so become housebound, unemployed, depressed and anxious. High rates of disability, anxiety and depression. Increased attention on symptoms Also maintenance factors influence DLA, change of role, family dynamics.

30 Cortisol the stress hormone When raised can cause: Problems with sleep, the immune system, digestion, memory, sex drive, tiredness. Problems with making you more sensitive to pain Problems with mood Problems with periods Autonomic nervous system In chronic conditions it becomes deconditioned causing fatigue, postural hypotension, palpitations, dizziness, IBS etc.

31 How does all this link to treatment? You are key in managing and determining expectation and therefore the salience of and focus on symptoms Lots of tests increase anxiety and attention to symptom making it worse. Do what is necessary but then stop additional tests. Encourage a different approach symptoms management with behavioural activation don t treat chronic conditions the same as acute.

32 Work is therapeutic it takes attention away from the condition thus lessening it. Psychological therapy can treat underlying predisposing factors in some cases. Treat anxiety and depression Use physio and OT early on to advise on safe graded and paced exercises CBT helpful BUT for some Behavioural activation can work better than CBT link to social prescribing.

33 Functional disorders Video Functional Conditions on Vimeo

34 Do s and Don ts in MUPS

35 Do s and Don t s in MUPS One session of good psycho-education can CURE 10% of patients. You have the power to do this! Given that cost to the NHS is 3bn a year, this can save 300 million a year. For most patients prognosis is GOOD IF medicine doesn t make it WORSE. 70% recover in 6 months. So use this to instil early therapeutic optimism. DO THE RIGHT AMOUNT OF INVESTIGATIONS FOR THAT SYMPTOM AND NO MORE. What is regarded as appropriate for that symptom? Stick to guidelines.

36 DON T HARM THE PATIENT FROM OVERINVESTIGATION. Remember, the more tests you do the more likely it is that you will get a false positive and the less likely you are to get engagement with alternative models of treatment. Employ a positive risk taking approach only investigate NEW symptoms or significant deteriorations in previous symptoms

37 Manage expectations early if sending for investigations introduce the concept that they might come back negative and then need to look at symptom management ensure ONE OR TWO GP s ONLY manage that patient. The relationship is key to recovery, don t have them seeing lots of different GP s / locums/ juniors. DON T abandon the patient. They have symptoms. Move to a symptom management / quality of life approach

38 Acknowledge the truth that medicine isn t that good and our tests do not provide answers for lots of patients Don t make up diagnoses or give medicine just for the sake of it. Help patients come to a place of ACCEPTANCE of their symptoms and then shift the focus to how can we help you get the best quality of life WITH these symptoms Remember, functional symptoms love attention, shifting attention away from them will starve them of the attention and they will naturally reduce, sometimes disappearing completely.

39 Remember you can raise psychosocial issues alongside doing investigations- so can initiate a conversation early on about other factors affecting pain etc. Listen for cues- patients often do refer to other concerns and will mention psycho-social problems if encouraged- eg I always get my headaches on Mondays when I am going to work... Set out your stall- I always feel it is important to consider ALL factors affecting health, so thats why I am asking you about stress/mood etc.

40 What you say and what your patient thinks Good news, everything is normal (it clearly isnt, something is wrong!) There is nothing wrong on tests (you cant have done the right tests) Everything is fine, we will discharge you (everything is not fine, I ll have to find another doctor who will take me seriously)

41 Role play One of you is a patient will chronic abdominal pain. You are going to the GP to get your test results back. They are normal. Role play a consultation of how to take this forward.

42 Managing patients with MUPS Sometimes it is about changing perception of symptoms that is more important than changing the symptoms themselves.

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44 Preserve and restore functioning Low intensity: Behavioural activation Group Psychoeducation OT and Physio IAPT level 2 Social Prescribing Support back to work

45 Moderate intensity Multi-professional MUS clinics in primary care Psychological therapy CBT IAPT Medication

46 High complexity Frequent attenders Poor engagers Multiple physical and psychiatric problems Joint consultations Clear systemic management plans across GP s, NEAS and 111, A and E and the acute services Long term complex psychological intervention Primary care MUS clinics and joint working with secondary care mental health services

47 Stress bucket model

48 Using an anonymised patient with MUPS from your practice, come up with a treatment plan for that patient

49 TIME You don t have much time as a GP to see patients. This stuff can take longer than 10 minutes However, is it better to bottom out the problem and come up with a treatment plan in 30 minutes, than to have 12 x 10 minute ineffective consultations?

50 Get involved! We want to identify some practices that would be happy for the informatics team to pull the data from there systems to start to develop a picture of the prevalence and incidence of MUPS in general practice Following this work we would be looking at a case for change to be shared with our executive team around future management of the client group, depending upon the need which is identified.

51 QUIZ!!! And Any Questions?