An introduction to medically unexplained persistent physical symptoms
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1 An introduction to medically unexplained persistent physical symptoms Professor Trudie Chalder Department of Psychological Medicine King s Health Partners Trudie Chalder 2014
2 IMPARTS Integrating Mental and Physical Health Care: Research Training and Services IMPARTS is funded by King s Health Partners Academic Health Science Centre, with the overall aim to improve integration of mental and physical healthcare in general hospital settings. Trudie Chalder 2014
3 Different terms for persistent physical symptoms Functional (e.g. functional dyspepsia ; affecting physiological or psychological functions but not due to structural / physical / chemical disorder) Medically unexplained symptoms (MUS) / Medically unexplained physical symptoms (MUPS) (symptoms not explained by the medical model) Idiopathic pain (e.g. idiopathic chest pain means unknown cause) Bodily distress disorder (Fink & Schroder 2010) Somatisation (usually implies physical symptoms are expression of emotional distress) Trudie Chalder 2014
4 Two surveys : Same answer Survey of healthy population preferred term was Persistent Physical Symptoms (PPS) (Hunter et al accepted) Survey of CFS patients in specialist clinic in secondary care preferred term was PPS, then Complex Physical Symptoms (Picariello et al in prep) Trudie Chalder 2014
5 Hospital Specialists Gastroenterology: Irritable bowel syndrome Rheumatology: Fibromyalgia Infectious diseases: Chronic fatigue syndrome Neurology: Headache / Non-epileptic seizures Hand surgery: Repetitive sprain injury Dental: Atypical facial pain Cardiology: Non-cardiac chest pain Gynaecology Chronic pelvic pain Urology: Irritable bladder syndrome Trudie Chalder 2014
6 DSM-IV somatoform disorders Criticised for containing mixture of relatively specific categories such as somatisition disorder and hypochondriasis, and vague non-specific categories such as undifferentiated somatoform disorder Trudie Chalder 2014
7 Somatoform Disorders Body Dysmorphic Disorder Conversion Disorder Hypochondriasis Somatisation Disorder Somatoform Pain Disorder Undifferentiated Somatoform Disorder Trudie Chalder 2014
8 DSM-V Somatic Symptoms Disorders Complex somatic symptom disorder Simple somatic symptom disorder Health anxiety disorder Functional neurological symptom disorder Factitious disorder Trudie Chalder 2014
9 Somatic symptom disorder (SSD) (Dimsdale & Levenson 2014) The diagnosis of SSD is established when three criteria are met: distressing and impairing somatic symptoms are present the symptoms are persistent (i.e., >6 months) associated with abnormal and excessive thoughts, feelings, and behaviors, typically manifested by disproportionate catastrophizing, high levels of anxiety, and illness behavior Trudie Chalder 2014
10 More questions than answers! Research has demonstrated that in many medical disorders, psychological factors account for more of the variance in physical symptoms than objective measures of disease severity BUT Is it right to group together patients with medically explained and unexplained symptoms? How do we operationalize disproportionate thoughts, feelings, and behaviors? Trudie Chalder 2014
11 Clinical and research implications When it comes to research we will still make the distinction between those with pathology and those without In practice it is easy to see how treatment protocols can be adapted It is important to include physiological as well as cognitive, behavioural and affective mechanisms in information for patients Trudie Chalder 2014
12 Symptoms in US primary care Kroenke & Mangelsdorff, 1989 Trudie Chalder 2011
13 Prevalence of unexplained symptoms in medical clinics Nimnuan et al., 2001 Clinic Prevalence (95% CI) Chest 59% (46-72) Cardiology 56% (46-67) Gastroenterology 60% (45-73) Rheumatology 58% (47-69) Neurology 55% (45-65) Dental 49% (37-61) Gynaecology 57% (50-68) Total 56% (52-60) Trudie Chalder 2011
14 Models Cognitive behavioural model (most supporting evidence) Differs from bio-psycho-social model Psychodynamic models (little evidence, an exception being treatment efficacy in IBS e.g. Creed et al., 2003) Trudie Chalder 2011
15 Genetic factors Predisposing factors (CFS: Buchwald et al., 2001; IBS: Saito et al., 2005) Neuroticism & chronic stress (CFS; Kato et al., 2008; IBS: Gwee et al., 1996, 1999) Perfectionism (relating to personality and learning; linked to avoidance of criticism) (CFS/IBS: Spence & Moss-Morris, 2006; Deary & Chalder 2009) Maternal overprotection (CFS: Fisher & Chalder, 2003) Paternal rejection or hostility (IBS: Lackner et al., 2004) Childhood experience of illness in self or parent (Craig et al., 1993; see next slide) Learning in childhood that symptoms are dangerous or catastrophic (Hotopf et al 1999) Trudie Chalder 2011
16 South London Somatisation Study: Childhood Risk Factors for Somatisation in Primary Care. Craig et al 1993 Psychologisers Physical illness Somatisers Physical illness before 17 years 18% 20% 55% (0.001) Parental physical illness before 17 years Parental lack of care 9% 23% 41% (0.05) 34% 2% (0.001) 36% Trudie Chalder 2011
17 Precipitating Factors Life events Infections or other health problems Combination of illness and stress Trudie Chalder 2011
18 Maintaining factors - examples Behaviours Boom-or-bust (all-or-nothing) behaviour Excessive avoidance / precaution taking Disturbed sleep routine Repeated investigations (NHS, privately or alternative practitioners) Repeatedly seeking external cure Medications which can produce side-effects Trudie Chalder 2011
19 Perpetuating factors Emotional: Stress, anxiety, frustration, low mood, hopelessness Cognitive Unhelpful beliefs about symptoms Unhelpful beliefs about general performance, standards, asking for help Rumination and worry Symptom-focusing and monitoring Trudie Chalder 2011
20 Maintaining factors (continued) Physiological Hypothalamic-pituitary-adrenal axis disturbance (low levels of cortisol) Social Too much or too little Unhelpful advice (e.g. rest) or lack of specific advice / explanation Cultural Mind / body dualism Stigma around psychological problems Trudie Chalder 2011
21 Efficacy of short term psychotherapy for MUS: A meta analysis (Kleinstauber et al 2011 Clin Psy Rev) 27 studies Small to moderate between group effect sizes (0.40) for disorder specific outcomes, Small effect sizes for depressive symptoms and functional impairment and health care utilisation Small to large within group effect sizes (0.80) Trudie Chalder 2011
22 Moderators of effect More therapy sessions, younger age, higher % of women were associated with better effect sizes for depression Control of concomitant treatments, higher quality assessment, more sessions and MHP involvement were associated with change in cognitions and behaviours In patient treatment, non MHP & less sessions related to reduced health care utilisation Trudie Chalder 2011
23 THANK YOU FOR LISTENING Trudie Chalder 2014
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