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At the heart of general practice since 1960

I can't afford to work as a clinical assistant

Professor Francis Creed advises on managing patients who repeatedly present and for whom there is no simple diagnosis

Every GP knows that patients with medically unexplained symptoms are commonplace ­ indeed they account for 10-20 per cent of consultations1. Some doctors experience difficulties with managing a minority of these patients. There are a number of problems that may contribute to their difficulties:

· GPs' confidence in managing these patients varies greatly. This partly reflects the absence of undergraduate training in the relevant skills. It may also result from difficulties in the past with particular patients. A doctor who lacks confidence is not well placed to reassure a worried patient, especially when the symptom cannot be readily explained.

· The importance of detecting organic diseases, such as cancer, and the increasingly intense societal expectation that doctors will never make mistakes.

· Patients' fears may be increased by the internet or other sources, where serious illnesses are listed as possible causes of common symptoms.

· Investigations for possible organic disease may lead to increased worry rather than reassurance.

· The difficulties that arise in managing a very few patients with medically unexplained symptoms may influence the management of less complicated cases.

· Many articles explain the frequency and nature of these symptoms in clinical practice but few offer practical help.

· Research relevant to the severe 'somatoform disorders' may not be not relevant to the majority of patients seen in primary care (eg, belief that patients refuse to accept a psychosocial explanation).

· Medically unexplained symptoms are common in people with organic disease.

Are medically unexplained

symptoms really 'unexplained'?

The term 'medically unexplained symptoms' is rejected by some doctors as it is negative and unhelpful. On the other hand it is accurate ­ the medical model, which seeks to explain symptoms on the basis of underlying organic disease or pathophysiology, does not explain why these symptoms develop or persist. Unfortunately, management strategies are often determined by the medical model, with its emphasis on investigations for possible medical diseases, rather than by the psychological and social models.

Persistent symptoms ­

a psychosocial model

Recent research has focused less on why medically unexplained symptoms develop ­ they are universal ­ but has sought to explain why such symptoms persist and lead to numerous consultations.

There are background factors which may make the persistence of medically unexplained symptoms more likely but, in themselves, are insufficient to explain persistence. These include childhood experiences.

Exposure to adversity, family conflict and illness or death in the family may have a lasting effect, although this tendency may not be apparent unless the person also experiences a recent stress, such as those listed in the next paragraph2,3. Personality, notably neuroticism, predisposes an individual to develop medically unexplained symptoms.

The onset or exacerbation of symptoms may occur at a time of recent stress such as conflict within a close relationship or other stressors in work or home life. In addition, the onset may be triggered by a recent physical or psychiatric illness.

A viral or gastrointestinal illness that leaves the person fatigued or a physical illness that produces frightening bodily symptoms is a potent starting point for persistent symptoms. Similarly, the onset of an anxiety or depressive disorder may be important. Classically, the combination of a threatening life event ­ serious heart attack in a brother for example ­ with a viral infection leads to persistent symptoms. The underlying anxiety is likely to present with chest pain and fears of a heart attack.

Psychological processes

A cognitive-attentional syndrome, which draws heavily on the psychological processes that occur in anxiety, has been highlighted by recent research.

If a patient attributes undiagnosed bodily symptoms, such as fatigue or diarrhoea, to a serious physical disease this may lead to complete avoidance of physical exercise for fear of irreversible harm, and avoidance of going out for fear of severe diarrhoea.

Such 'catastrophic' beliefs are often accompanied by a heightened awareness of, and selective attention towards, bodily symptoms. Some patients believe that constantly thinking about their health and hypervigilance towards bodily symptoms are necessary and effective coping strategies, although they actually lead to increased disability.

It is thought that persistent symptoms arise when both cognitive aspects (beliefs concerning the origin of symptoms) and perceptual ones (hypervigilance and amplification of bodily sensations) occur together4.

It is thought that the background factors listed above make such a combination more likely. In addition, there may be reinforcement if the symptoms provide the person with respite from a difficult work situation or difficult relationship problem.

Psychological and social reasons for frequent seeking of medical help

Although approximately 14 per cent of the general population may be affected by irritable bowel syndrome (IBS), only a proportion seek help from the doctor; the latter is associated with greater pain, anxiety and depression and more worries about the symptoms5. Primary care IBS patients who choose to consult specialists are least likely to see a link between stress and their symptoms.

There are numerous reasons why a small proportion of patients visit their GP frequently2,3. These include:

· the presence of chronic physical and psychiatric illnesses

· current distress

· marked worry about symptoms and illness

· numerous bodily symptoms.

The most frequent attenders in primary care report, in addition:

· exposure to serious illnesses during childhood (either in themselves or close family members)

· childhood adversity, eg neglect and abuse.

Although one might feel little can be done to help people who have experienced childhood adversity, there is evidence they may respond particularly well to interpersonal psychotherapy with improved health-related quality of life and reduced health care utilisation6. Such intensive treatments are rarely available in primary care which is one reason why such treatments tested in secondary care appear to be more successfu · 7.

The other main option is cognitive behaviour therapy ­ the leading treatment for medically unexplained symptoms8.

Recent research highlights two aspects of medically unexplained symptoms, which doctors may usefully use in their management of patients: increased worry about health ('health anxiety')9 and increased number of bodily symptoms ('somatisation')1.

A step-by-step approach

1. Make up your own mind whether symptoms are unlikely to be due to organic disease. Take a complete history and elicit widespread bodily symptoms: if the patient presents with chest pain ask, in addition to the usual questions about cardiac or gastrointestinal causes of chest pain, about headaches, light-headedness, tightness of the throat, bowel disturbance, tiredness, menstrual and urinary symptoms, sleep pattern, concentration, libido, anxiety and depression. If there are multiple symptoms in several bodily systems the chances of an underlying organic disease causing them all is reduced.

Don't think in 'either/or' terms. There may be organic disease but that does not mean it is the cause of the presenting symptoms. Organic disease increases the chances of medically unexplained symptoms developing.

Do examine the patient to demonstrate that you have taken the symptom seriously and also to look for signs of increased anxiety (increased respiratory and heart rates and increased tension of muscles).

2. Be confident, when it is appropriate, about the nature of the phenomenon being presented. The power of a positive statement from a doctor that the symptoms are unlikely to be due to physical illness is a starting point of a helpful encounter. This means, however, that the doctor must go on to provide a plausible positive explanation for the symptoms. Doctors may find this easier for a localised symptom (abdominal pain) than fatigue but a brief version of the model outlined previously is helpful. Most people accept that flu, or similar viral infection, is followed by fatigue that gradually improves spontaneously. If it becomes protracted the cause is more likely to be psychological or social rather than a physical illness.

3. Assess worries about the symptom and its causes ­ ask how much the person is worried about the symptom, what they think causes it and whether it leads to worrying thoughts in their mind. The discussion can then move towards why the patient is so worried.

Use a scale; the most pertinent investigation may be a simple measure of bodily symptoms (SCL-90 somatisation scale or somatic symptom inventory www.pearsonassessments.com/tests/sc · 90r.htm), a measure of anxiety and depression such as HADS http://chipts.ucla.edu/assessment/ Assessment_Instruments/Assessment_files_new/assess_hads.htm or a scale of illness worry (Whitely scale http://www.uib.no/med/avd/ med_a/gastro/ wilhelms/whiteley.html).

4. Identify the real problem and be direct. The problem may not be the presenting symptom(s). The problem may be the large number of bodily symptoms experienced by the patient or the difficulty you have in reassuring the patient. If these are openly stated as the problem the doctor and patient can work towards a joint solution. Remember patients with medically unexplained symptoms are usually seeking support.

Try to be honest ­ do you really think it is necessary to investigate the symptom or are you only considering it because of pressure?

5. Detect and treat anxiety or depressive disorders. This is essential and often overlooked. Many patients with painful symptoms may respond to a low dose of antidepressants but explain fully that the emotional and painful symptoms overlap10.

Francis Creed is professor of psychological medicine, University of Manchester

What I say to patients

'I have heard you describe your symptoms and I have examined you. I do not think your symptoms are due to a serious physical illness. It is important to check that you do not have anaemia or thyroid disturbance but I think these will be normal.'

'These symptoms are common. They usually resolve without medical treatment. I need to keep them under review until they do recede. If they change or get worse you should come back and tell me.'

'People often attribute symptoms to stress but before we do that we need to know exactly what stress(es) might be involved and examine whether the symptoms have come and gone as the stress waxes and wanes. Will you keep a diary of the symptoms and your stress levels?'

'It is clear you are very worried about this pain. Why are you so worried?' (You cannot reassure until you understand fully the patient's concerns).

'You have had all the investigations relevant to your symptoms. I do not think medical science will explain adequately the cause of your symptoms. We need to look at them in a different way and understand why they are causing so much difficulty. We can work together to try to reduce the impact they are having on your life.'

Two GP dilemmas

A rather threatening man is convinced he has HIV. He has had loads of tests (all negative) and has no clear risk factors. He brings in internet articles saying tests are unreliable. He is contained by one partner but every now and then it all resurfaces and the whole cycle resumes ­ including visits to every GUM clinic within a day's travel ­ and we obviously can't stop this. He has seen the psychologist and realises he is anxious. The psychiatrists say he is somatising and is not delusional; he has various aches, sweats, says he is losing weight (but isn't) and regularly brings in tiny palpable reactive lymph nodes as evidence.

Arrange a long interview with this patient and be direct about the core problem. The problem is: he cannot be reassured that he does not have a serious illness underlying his symptoms. Such illness worry is an uncommon, but well-recognised problem. It is related to influences in the past, such as a difficult relationship in the family during childhood, current interpersonal problems and illness in close relatives. Some people are lifelong worriers about their health. Which of these factors is relevant to him?

When he comes to the doctor, what are his expectations? It is clear that appointments do not satisfy him. He is probably seeking more tests in the hope that 'this time they will find what is wrong and it can be put right'. In fact, the opposite happens. The test result comes back normal which is frustrating ­ 'what is causing this then?'.

We now understand that becoming anxious about bodily symptoms leads to a person paying more and more attention to their bodily sensations, like anxious people pay attention to their heart beat. This can make the person more anxious and actually induce increased heart rate. The only way you can break this cycle is to see the psychologist again for cognitive behaviour therapy.

Repeated tests make the situation worse. SSRI antidepressants can be helpful provided he keeps on taking them even if they have side-effects.

A medical student has typical irritable bowel symptoms, tension headaches and multiple other symptoms suggestive of hyperventilation. She seems to accept an explanation of the symptoms but then uses her partner's private health insurance to access a specialist. She now has non-radicular sensory loss in a limb and is convinced she has MS, which makes sense of all her previous symptoms. What should I do?

Her current symptoms suggest to her that she has MS. Why? Does that diagnosis explain her previous symptoms? In fact, a detailed exploration of her symptoms will indicate that there are many outside of the nervous system that cannot be accounted for by that diagnosis. Ask her to complete a somatisation scale (e. PHQ-1511). Ask in detail about anxiety and depressive symptoms12.

Ask in detail about the timing and onset of the current symptoms and her previous ones. State that you have an open mind and the underlying explanation might be a physical illness or a psychological disorder ­ somatisation.

The main management plan is to observe her carefully and see whether the symptoms change and, if so, whether the pattern follows that of MS or that of multiple somatic symptoms. The aim at this stage is to get her to develop an open-minded approach also. If she will not then the reasons for her fixed view must be explored ­ a feared diagnosis because of a relative or other? What are the consequences of such a diagnosis in terms of her current job or relationship? Does she show signs of unhappiness with either of these spheres of her life?

The aim is to get her to view her symptoms in an open-minded way so, eventually, she might adopt a psychological view if this is appropriate. Continuity of appointments with one GP and a medium-term timescale is indicated.

Limit investigations to those you feel are justified, and predict normal results if you feel this is likely.

References

1 Creed FH, Barsky AJ. A systematic review of the epidemiology of somatisation disorder and hypochondriasis.

J Psychosom Res. 2004; 56:391-408

2 Kapur N et al. Childhood experience and health care use in adulthood: nested case-control study. British Journal of Psychiatry 2004; 185:134-9

3 Fiddler M et al. Childhood adversity and frequent medical consultations. General Hospital Psychiatry 2004; 26:367-7

4 Barsky AJ et al. Predictors of remission in DSM hypochondriasis. Comprehensive Psychiatry 2000;41:179-83

5 Creed FH. The relationship between psychosocial parameters and outcome in the irritable bowel syndrome. American Journal of Medicine 1999;

107(5A);74S-80S

6 Creed F et al. North of England IBS Research Group. The cost-effectiveness of psychotherapy and paroxetine for severe irritable bowel syndrome.

Gastroenterology 2003; 124:303-17

7 Raine R et al. Systematic review of mental health interventions for patients with common somatic symptoms: can research evidence from secondary care be extrapolated to primary care?

BMJ 2002;325:1082

8 Kroenke K, Swindle R. Cognitive-behavioural therapy for somatisation and symptom syndromes: A critical review of controlled clinical trials. Psychotherapy & psychosomatics 2000; 69: 205-25

9 Lucock MP et al. Responses of consecutive patients to reassurance after gastroscopy: results of self-administered questionnaire survey. BMJ 1997;315,7108:572-5

10 O'Malley PG et al. Antidepressant therapy for unexplained symptoms and symptoms syndromes. J Fam Pract 1999; 48: 980-90

11 Kroenke K etal. The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosomatic Medicine.2002;64:258-66

12 Kroenke K et al. The PHQ-9: validity of a brief depression severity measure.

Journal of General Internal Medicine. 2001;16:606-13

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