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Medically Unexplained Symptoms (MUS) A spectrum of disorders ranging from mild transitory illness to chronic disorders with severe disability.

The scope of medically unexplained physical symptoms 1)Physical symptoms of anxiety and depression 2)Anxiety or depression secondary to physical illness 3)Acute somatisation 4)Chronic somatisation (usually multiple symptoms and systems) 5)Functional somatic syndromes 6)Fabricated symptoms – factitious disorder and malingering 6)Symptoms with organic pathophysiology which has yet to be discovered/understood

1)The first group may be relieved to talk about psychosocial issues. Communication with patients with MUPS needs to be flexible as they are a heterogeneous group: 1)The first group may be relieved to talk about psychosocial issues. 2) The second group may be angered and offended: ‘‘making it up’’. 3) The third group are uncertain of the role of psychological factors.

Rule-out medicine 1)Rapid rule out 2)This has clear advantages to the patients with disease ruled in, in that further care can be planned and implemented much more quickly 3)Within rapid rule-out paradigms, the number of patients ruled out considerably exceeds the number ruled in.

The patient may be left with the rather unsatisfactory explanation that ‘‘we don’t know what is wrong with you, but we do know what it isn’t’’, or given pseudodiagnoses such as ‘‘non-cardiac chest pain’’ or ‘‘swollen calf, Doppler negative’’

Unfortunately, this is not always done well or even at all. The logic of protocol-based rule-out medicine can be unthinkingly applied and explained to patients as ‘‘there is nothing (seriously) wrong with you, you can go home’’. Careful consideration needs to be given to the explanation of negative results in order to avoid creating iatrogenic anxiety.

Explaining negative results: 1) Rejection 2) Collusion 3) Empowerment Empowering explanations are clearly the ideal as they legitimise the patient’s suffering and ally rather than alienate the patient and doctor.

Pandora’s box

Normalization Reassurance Central; to effective management counterproductive; negative investigation results without appropriate explanation

Effective normalization: Acknowledge and validate patients’ sense of suffering. Provide tangible mechanisms to explain symptoms arising from patients’ expressed concerns. Offer opportunity for linkage between psychological factors and physical mechanisms.

The reattribution model - how to talk to somatizating patients and how to deal - Stage 1: Feeling understood Take a full history of the symptoms Explore emotional cues Explore social and family factors Explore health beliefs Brief focused physical examination Practice tips Treatment goal is relief of complaints, not cure. Regular appointments, e.g. every 14 days, is recommended. For treatment in primary care, the following 3-step model has proven helpful: Step 1: ▪ Empathic, trusting doctor-patient relationship ▪ Questioning about the subjective understanding of disease: “The laboratory tests, ultrasound and computer tomography have not shown evidence of an organic disease. I would like to examine your abdomen… Your abdomen is sensitive in the middle area, but I don’t find anything else remarkable. But I can imagine that you suffer a lot from your complaints.” Step 2: ▪ Development of an alternative model of disease by explaining psychophysiological relationships, such as between fear and physical symptoms. “In frightened people, the body excretes more adrenalin. That’s why their hearts beat faster in situations of fear.” Or explanation of the relationship between depressive mood and physical symptoms: “If people are worried, or are depressed, the intestines can contract and that causes abdominal pain.” Everyday body-related expressions are especially helpful, such as “when the heart skips a beat, makes you sick to your stomach, gets under one’s skin”. ▪ Influence the cognitive processing of complaints, such as the vicious circle model or exercises in body perception ▪ Verbalization of stressful emotions Step 3 ▪ Relationship between onset of physical symptoms and lifestyle ▪ Reduction of protective and avoidance behavior ▪ Development of alternative behaviors on the job and in private life. Motivation for specialist psychotherapeutic treatment

Engage the patient / their problem is being taken seriously. Enquiry regarding primary care and hospital attendance/ physical symptoms. A physical examination Empathic statements, acknowledging the reality of the symptoms, and normalization (explaining that such problems are commonly seen) Enquiring about disability and self care activities, and encouraging the patient to discuss their presenting problems without interruption or premature closure by the doctor.

Stage 2: broadening the agenda Feed back the results of the examination Acknowledge the reality of the symptoms Reframe the complaints: link physical, psychological, and life events

One technique that can be used is the ‘‘switch’’ The doctor suggests that the physical symptoms might be making the patient feel depressed or anxious. Any positive response is then followed up on with a more detailed enquiry screening for anxiety and depression. If the response is negative, the patient is less likely to feel undermined than if the doctor had suddenly changed the subject to their mood.

Stage 3: making the link Simple explanation Three-stage explanation for anxiety How depression lowers the pain threshold Demonstration Practical Link to life events „Here and Now“

Finally, it is suggested to the patient that psychosocial factors may help to explain their physical symptoms. These should be presented to the patient as suggestions, rather than dogmatically. Give some examples It may be helpful to ask if anyone else in the family experiences similar symptoms, and, if so, what brings them on, as it may be easier for people to see the ‘‘link’’ in other people. Tension headache and period pain are good examples that can be used to demonstrate that pain does not necessarily mean pathology. In these ways, a positive explanation may be provided for physical symptoms in the absence of physical pathology.

Approach to the patient who has unexplained physical symptoms

Communication Techniques for Physicians

Improve listening and understanding Improve listening and understanding. Summarize the patient’s chief concerns. Interrupt less. Offer regular, brief summaries of what you are hearing from the patient. Reconcile conflicting views of the diagnosis or the seriousness of the condition.

Improve partnership with patient Discuss the fact that the relationship is less than ideal; offer ways to improve care

Improve skills at expressing negative emotions Decrease blaming statements Increase “I” messages. Example: “I feel” as opposed to “You make me feel…

Increase empathy; ensure understanding of patient’s emotional responses to condition and care. Attempt to name the patient’s emotional state; check for accuracy and express concern.

Negotiate the process of care Clarify the reason for the patient seeking care Indicate what part the patient must play in caring for his or her health Revise expectations if they are unrealistic

Reassurance: Controversial role Simple reassurance does not work well in patients with MUPS. The narrow focus on the somatic aspects of a complex problem may reinforce their concerns about having a physical disease.

Patients factors: chronicity, severity of symptoms, personality characteristics and also to attitudes and treatment style of the therapist.

Reassurance Elements of Effective Reassurance: Thorough examination of medical records and history

Acceptance of the patient, his or her complaints, and their legitimacy

Using clear and simple language with unambiguous terms

Providing relevant information and explanations

Fostering the patient's responsibility for his or her treatment

Shifting attention from physical symptoms to underlying psychological and social problems and focusing on patient assets.

Adjusting a reassuring style in a way that is effective for a given patient Providing repeated reassurance

Scheduling regular visits with a clear goal Performing appropriate examinations and tests with adequate explanation

One common cause for failure of reassurance was referred: ‘‘wild card effects’’. If we don’t find out: “what they fear”.

The keys to success Not to expect miracles Develop rapport Any change is positive Caring rather than a curing approach Develop rapport What is it that they want More willing to discuss his or her psychosocial world