Mus primhe


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  • Frank has come to consult with me about his stomach pain. He finds it hard to pin down exactly where it is. ‘It starts with my tummy button but spreads all over one side.’ It has been off-and-on for about 18 months. It lasts around a day at a time, sometimes longer. He finds it hard to get to sleep because he has to try to lie in a way that eases the pain. When it flares up he feels very low, thinking ‘oh no, this is starting again’. When it’s not happening he feels anxious that that it might start again. He has found himself noticing other problems lately, although he is aware how busy I am today and not sure whether I will want to hear about them as well as his stomach pain. He had a migraine the other day. He used to get them a lot but has been free of them for a few years. He has also had bad acne for about three months. Whatever he does, the spots won’t go away. He has a mole on his arm which might have grown a little over the last few months. At night he has throbbing in his leg sometimes. He is worried what it all might be. He has tried to work out what the cause of his stomach pain is. It doesn’t seem to link to diet. He has talked to people about it. A previous doctor suggested he had bruised his ribs. Another doctor had suggested gall-stones. In the past two years, he has had blood tests and scans of his gall-bladder and liver but these were all normal. Friends have suggested it could be his appendix, and his grandmother thinks it is probably his ‘nerves’. He had ‘flu last year and is wondering if he might have a lingering virus. He also wonders if stress might be involved. His wife had an affair three years ago but they have moved house since then and are trying to put those problems behind them. But the pain is horrible, so it can’t just be stress.
  • Persistent MUS: Persistent or recurrent (at least monthly) for at least six months Fink et al: 58% on DSM-IV abridged criteria! Arnold et al: cut-off 5 UPS: 50% had these at baseline, but 16% had somatoform disorder…..
  • Returning to our study of doctors and patients influence on outcomes of consultations in primary care: Quantitative analysis of 420 consultations: Patients almost always provided cues for the doctors to develop psychosocial dimensions of the consultation: 61% indicated emotional or social problems, either by direct disclosure (41%) or by suggesting psychosocial explanations for their physical symptoms (41%). 70% patients requested explanation for symptoms Only 38 (9%) did neither
  • Mus primhe

    1. 1. Medically unexplained symptoms: how can doctors help, not hinder? Christopher Dowrick Professor of Primary Medical Care University of Liverpool
    2. 2. Frank <ul><li>stomach pain </li></ul><ul><ul><li>‘ Oh no, it’s starting again’ </li></ul></ul><ul><li>headache </li></ul><ul><li>mole on arm </li></ul><ul><li>throbbing leg </li></ul>
    3. 3. Kroenke et al Am J Med 1989
    4. 4. Persistence in primary care <ul><li>19% MUS >3 months </li></ul><ul><ul><ul><ul><ul><li>Peveler et al, J Psychosom Res 1997 </li></ul></ul></ul></ul></ul><ul><li>21% somatoform disorders persistent </li></ul><ul><ul><ul><ul><ul><li>Jackson & Kroenke, Psychosom Med 2008 </li></ul></ul></ul></ul></ul>
    5. 5. <ul><li>Do doctors help, or hinder? </li></ul>
    6. 6. Mismatch of help seeking and care <ul><li>Liverpool Primary Care Study </li></ul><ul><ul><li>Psychosocial agendas voiced </li></ul></ul><ul><ul><ul><li>61% patients referred to emotional or social problems </li></ul></ul></ul><ul><ul><ul><li>70% requested explanations for symptoms </li></ul></ul></ul><ul><ul><li>But often unheard </li></ul></ul><ul><ul><ul><li>In 67% consultations, GPs indicated physical disease could be present </li></ul></ul></ul><ul><ul><ul><li>In only 16% did GPs make empathic statements </li></ul></ul></ul><ul><ul><ul><ul><li>Ring et al, Soc Sci Med 2005 </li></ul></ul></ul></ul>
    7. 7. GPs more likely to propose symptomatic management Z=12.19, P<0.001 %
    8. 8. Why this mismatch? <ul><li>Examining the role of doctors </li></ul>
    9. 9. Distancing <ul><li>Somatic outcomes directly associated with </li></ul><ul><ul><li>length of consultation </li></ul></ul><ul><ul><ul><li>t 2.742, p 0.007 </li></ul></ul></ul><ul><ul><li>patient elaboration </li></ul></ul><ul><ul><ul><li>t 1.990, p 0.047 </li></ul></ul></ul><ul><ul><li>NB not associated with </li></ul></ul><ul><ul><ul><li>Patients’ reference to physical disease </li></ul></ul></ul><ul><ul><ul><li>Patients’ proposal for somatic management </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Salmon et al, Psychosom Med 2007 </li></ul></ul></ul></ul></ul>
    10. 10. Attachment styles <ul><li>GP somatic interventions related to </li></ul><ul><ul><li>negative view of self </li></ul></ul><ul><ul><li>positive view of others </li></ul></ul><ul><li>i.e. more likely if GP values patient, values somatic interventions, devalues own psychological skills. </li></ul><ul><ul><ul><ul><li>Salmon et al, Gen Hosp Psych 2008 </li></ul></ul></ul></ul>
    11. 11. How can doctors help? <ul><li>Reattribution </li></ul><ul><li>Focus on symptoms </li></ul><ul><li>Expanding explanations </li></ul><ul><li>Focus on function </li></ul>
    12. 12. Reattribution <ul><li>Three RCTs </li></ul><ul><ul><li>Effects small, limited to physical symptoms </li></ul></ul><ul><ul><ul><li>Larisch et al, J Psychosom Res 2004 </li></ul></ul></ul><ul><ul><li>Improved doctor-patient communication, but not patient outcomes </li></ul></ul><ul><ul><ul><li>Rosendal et al, Fam Pract 2005 </li></ul></ul></ul><ul><ul><ul><li>Morriss et al Br J Psych 2007 </li></ul></ul></ul>
    13. 13. Reattribution <ul><li>Why limited effects? </li></ul><ul><ul><li>Patients fear doctors will ignore their symptoms </li></ul></ul><ul><ul><ul><ul><li>Peters et al, JGIM 2009 </li></ul></ul></ul></ul><ul><ul><li>Sympathetic GPs see many barriers to implementation </li></ul></ul><ul><ul><ul><ul><li>Dowrick et al, BMC Fam Pract 2008 </li></ul></ul></ul></ul>
    14. 14. How can doctors help? <ul><li>Reattribution </li></ul><ul><li>Focus on symptoms </li></ul><ul><li>Expanding explanations </li></ul><ul><li>Focus on function </li></ul>
    15. 15. Focus on symptoms <ul><li>Diagnostic </li></ul><ul><ul><li>ICPC-2 </li></ul></ul><ul><ul><li>Code by symptoms </li></ul></ul><ul><ul><ul><li>as reasons for encounter </li></ul></ul></ul><ul><ul><ul><li>no aetiological attribution </li></ul></ul></ul><ul><li>Management </li></ul><ul><ul><li>Symptom as primary focus </li></ul></ul><ul><ul><ul><li>Sharp M, Clin Med 2002 </li></ul></ul></ul><ul><ul><li>Stepped care </li></ul></ul><ul><ul><ul><li>Kroenke K, Int J Methods Psychiatry Res 2003 </li></ul></ul></ul>
    16. 16. Stepped Care 1 <ul><li>Focused examination </li></ul><ul><li>Address patient expectations </li></ul><ul><li>Symptom-specific treatments </li></ul><ul><ul><ul><li>analgesics, GI meds etc </li></ul></ul></ul><ul><li>Watchful waiting </li></ul>
    17. 17. Stepped Care 2 <ul><li>Psychological screening </li></ul><ul><li>Selected diagnostic tests </li></ul><ul><li>Treatments: </li></ul><ul><ul><li>medication </li></ul></ul><ul><ul><ul><ul><li>Kroenke et al, JAMA 2001 </li></ul></ul></ul></ul><ul><ul><li>psychosocial </li></ul></ul><ul><ul><ul><li>CBT in primary care? </li></ul></ul></ul><ul><ul><ul><ul><li>Escobar et al, Ann Fam Med 2007 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Arnold et al, Psychosomatics 2008 </li></ul></ul></ul></ul>
    18. 18. Stepped Care 3 <ul><li>Symptom care manager </li></ul><ul><li>Referral to appropriate specialist </li></ul><ul><ul><ul><li>with interest in symptoms </li></ul></ul></ul><ul><ul><ul><ul><li>Burton et al [in process] </li></ul></ul></ul></ul>
    19. 19. How can doctors help? <ul><li>Reattribution </li></ul><ul><li>Focus on symptoms </li></ul><ul><li>Expanding explanations </li></ul><ul><li>Focus on function </li></ul>
    20. 20. Expanding explanations <ul><li>Patients’ complex networks of meaning </li></ul><ul><ul><ul><li>Explanations valid within patients’ conceptual world </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Dowrick et al, Br J Gen Pract 2004 </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Need validation of bodily nature of suffering and culturally based explanations </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Kirmayer et al, Can J Psychiatry 2004 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Miresco et al, Am J Psychiatry 2006 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Dowrick, Beyond Depression 2009 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Kovandzic et al, (submitted) </li></ul></ul></ul></ul></ul>
    21. 21. How can doctors help? <ul><li>Reattribution </li></ul><ul><li>Focus on symptoms </li></ul><ul><li>Expanding explanations </li></ul><ul><li>Focus on function </li></ul>
    22. 22. Focus on function <ul><li>[Not function of symptoms] </li></ul><ul><li>Impairment or disability as a result of symptoms </li></ul><ul><ul><li>‘ What does [x] stop you doing?’ </li></ul></ul><ul><ul><li>‘ What can we do to overcome this?’ </li></ul></ul><ul><ul><li>NB Functional Wellbeing Model </li></ul></ul>
    23. 23. Frank <ul><li>What do these symptoms stop you doing? </li></ul><ul><ul><li>‘ taking my grandson to school’ </li></ul></ul><ul><ul><li>‘ painting’ </li></ul></ul>
    24. 24. Frank (the artist)
    25. 25. Final thought <ul><li>Just be there… </li></ul>
    26. 26. Just be there… <ul><li>Somatic outcomes less likely if GPs’ facilitate patients’ psychosocial talk </li></ul><ul><ul><ul><li>P=0.001 </li></ul></ul></ul><ul><ul><li>not if GPs offer psychosocial explanations </li></ul></ul><ul><ul><ul><li>P=0.926 </li></ul></ul></ul><ul><ul><li>‘ simpler than we think, or fear’ </li></ul></ul><ul><ul><ul><ul><ul><li>Salmon et al, Psychosom Med 2007 </li></ul></ul></ul></ul></ul>
    27. 27. Christopher Dowrick <ul><li>Professor of Primary Medical Care </li></ul><ul><li>University of Liverpool </li></ul><ul><li>[email_address] </li></ul>