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Psychiatry in ED:
Frequent Attenders
with
Medically Unexplained Symptoms
Dr James Stallard
May 2019
1
Liaison Psychiatry Department
1
1. Frequent Attenders at the Emergency Department
2. Medically Unexplained Symptoms
3. FAMUS project at Royal Bournemout...
1
• We set up a group in 2014 to monitor FAs
• ED doctors and nurses, Alcohol liaison, Liaison Psychiatry, Ambulance
servi...
1
• No physical illness brings someone to ED 20 times in
3/12
• Even if they do have treatable physical conditions,
all fr...
1
Contents
Alcohol Dependent
Medically
Unexplained
Symptoms
Emotionally
Unstable
Personality
Disorder
1
MEDICALLY UNEXPLAINED
or
‘FUNCTIONAL’ SYMPTOMS
1
Physical symptoms
No physical
pathology
Mental
symptoms
Psychiatric
diagnosis
Physical Symptoms
Physical pathology
The H...
1
• The NHS in England spends at least £3 billion each year attempting to
diagnose and treat MUS (Bermingham et al 2010)
•...
1
Rene Descartes
1596 – 1650
• Res Cogitans vs Res Externa
• ‘Cartesian Dualism’
• The mind/body split
1
• Every specialty has them
• eg Fibromyalgia, Chronic Fatigue Syndrome, IBS, Non-cardiac chest
pain, tinnitus,
• Accepta...
1
• Many similarities between people with different syndromes
• eg females over-represented, CSA, psychiatric comorbidity
...
1
Medical terminology : the Functional Syndromes
1
• Somatoform disorders, somatization disorder
• Of little use to patients
• Puts conditions in realm of mental health se...
1
• ‘Number Needed to Offend’ (Stone et al BMJ 2002)
• Looking at patients perceptions of terminology around functional
ne...
1
• >6 months of somatic symptoms which
• impair function or are distressing
• with excessive and disproportionate thought...
1
Functional neurological
symptoms: no pathology –
dissociative phenomenon
COPD plus anxiety
Back pain
Physical pathology
...
1
• An individual with some level of
• Physical vulnerability
• Difficulty in identifying feelings, seeking attachment etc...
1
• ‘Predictive coding’ and ‘the Bayesian brain’
• Karl Friston: The Free Energy Principle: A Unified Brain
Theory. Nature...
1
Role of functional pain in the opiate crisis
• Opiates are excellent for acute pain
• Ineffective for chronic pain (and ...
1
Frequent Attenders with Medically Unexplained Symptoms
(FAMUS) project at RBH
• A non-randomised controlled trial
• 25 p...
1
ASSESSMENT PHASE
• Engagement is key
• Patients invited to meet us in ED
• Stated aim is to help to ‘cope with symptoms’...
1
Childhood
experience
of physical
illness /sick
role
Attachment
disruptions
Biopsychosocial factors for functional sympto...
1
CBT Phase
• Patients offered 10 – 16 weekly sessions of CBT (with
a mean attendance rate of 12 sessions).
• The CBT prov...
1
PHQ9 16.08 8.12 -49.5%
GAD 7 15.92 5.88 -63.1%
WSAS 25.52 17.84 -30.1%
Psychometric Questionnaire Outcomes Pre & Post In...
1
Results: Pre- and post- intervention
0
100
200
300
400
500
600
ED attends Target Group Bed days used Target
Group
ED att...
1
CONCLUSIONS
• People with MUS are amongst the most frequent attenders
at ED
• Their high use of resources, and mood and ...
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iCAAD London 2019 - Dr James Stallard - THE REVOLVING DOOR - PSYCHIATRY IN THE EMERGENCY DEPARTMENT: FREQUENT ATTENDERS, MEDICALLY UNEXPLAINED SYMPTOMS, OVERDOSE, ADDICTION AND PERSONALITY DISORDERS.

Functional, or medically unexplained, symptoms are some of the most complex and controversial problems presenting to clinicians. Overuse of opiates for pains which never get better, demands for operations which aren't necessary and long stays in hospital. How does a psychiatrist working on the frontline of the NHS steer treating teams and patients towards better outcomes?

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iCAAD London 2019 - Dr James Stallard - THE REVOLVING DOOR - PSYCHIATRY IN THE EMERGENCY DEPARTMENT: FREQUENT ATTENDERS, MEDICALLY UNEXPLAINED SYMPTOMS, OVERDOSE, ADDICTION AND PERSONALITY DISORDERS.

  1. 1. Psychiatry in ED: Frequent Attenders with Medically Unexplained Symptoms Dr James Stallard May 2019
  2. 2. 1 Liaison Psychiatry Department
  3. 3. 1 1. Frequent Attenders at the Emergency Department 2. Medically Unexplained Symptoms 3. FAMUS project at Royal Bournemouth Hospital
  4. 4. 1 • We set up a group in 2014 to monitor FAs • ED doctors and nurses, Alcohol liaison, Liaison Psychiatry, Ambulance service • Monitoring over the previous 3 months • Literature often defines >12 times per year as frequent attendance • Found far higher numbers – top 20 patients attending between 8 and 20 times in 3 months Frequent Attenders at ED
  5. 5. 1 • No physical illness brings someone to ED 20 times in 3/12 • Even if they do have treatable physical conditions, all frequent attenders have unmet psychological needs Who were they?
  6. 6. 1 Contents Alcohol Dependent Medically Unexplained Symptoms Emotionally Unstable Personality Disorder
  7. 7. 1 MEDICALLY UNEXPLAINED or ‘FUNCTIONAL’ SYMPTOMS
  8. 8. 1 Physical symptoms No physical pathology Mental symptoms Psychiatric diagnosis Physical Symptoms Physical pathology The Health System and MUS
  9. 9. 1 • The NHS in England spends at least £3 billion each year attempting to diagnose and treat MUS (Bermingham et al 2010) • Over half new attendees at medical out-patients fulfil criteria for one ‘functional somatic syndrome’ (Nimnuan 2001) • Persistent MUS is the most common reason for frequent attendance at GP (Jyvarsi 1998) • Pts with PMUS seek help from GP but are unwilling to see mental health professionals (Kirmayer and Robins 1996) • GPs express lower satisfaction with care for PMUS than pt with psychological problems (Hartz 2000) A very big issue!
  10. 10. 1 Rene Descartes 1596 – 1650 • Res Cogitans vs Res Externa • ‘Cartesian Dualism’ • The mind/body split
  11. 11. 1 • Every specialty has them • eg Fibromyalgia, Chronic Fatigue Syndrome, IBS, Non-cardiac chest pain, tinnitus, • Acceptable to patients • Bring relief and validation (Woodward et al 1995) BUT • They medicalise! Medical terminology : Functional Syndromes
  12. 12. 1 • Many similarities between people with different syndromes • eg females over-represented, CSA, psychiatric comorbidity (Fiedler et al 1998) • Great deal of symptom overlap (Wesseley et al 1999) • Separation into different syndromes is an artefact of medical specialisation (Wesseley et al 1999) • Probably not discrete entities Medical terminology : Functional Syndromes
  13. 13. 1 Medical terminology : the Functional Syndromes
  14. 14. 1 • Somatoform disorders, somatization disorder • Of little use to patients • Puts conditions in realm of mental health services • Not well used • …….on their way out? Psychiatric classification: ICD10
  15. 15. 1 • ‘Number Needed to Offend’ (Stone et al BMJ 2002) • Looking at patients perceptions of terminology around functional neurological symptoms • Descending ‘offence score’: • Symptoms all in the mind • Hysterical weakness • Psychosomatic weakness • Medically unexplained weakness • Stress related weakness • Chronic fatigue • Functional weakness TERMINOLOGY
  16. 16. 1 • >6 months of somatic symptoms which • impair function or are distressing • with excessive and disproportionate thoughts, feelings and behaviours towards those symptoms. • Criticised as being too broad, bringing millions of people into a ‘mental disorder’ • Removes need for symptoms to be unexplained • ie could be disproportionate reaction to a medical condition DSM5: Somatic Symptom Disorder
  17. 17. 1 Functional neurological symptoms: no pathology – dissociative phenomenon COPD plus anxiety Back pain Physical pathology Psychosocial factors Functional Abdo pain
  18. 18. 1 • An individual with some level of • Physical vulnerability • Difficulty in identifying feelings, seeking attachment etc • A system which medicalises, sending strong messages • Investigations, treatments, labels… • and then attempts to discharge them • Repeated, emotionally charged, dissatisfying encounters Functional symptoms:a BIOPSYCHOSOCIAL phenomenon
  19. 19. 1 • ‘Predictive coding’ and ‘the Bayesian brain’ • Karl Friston: The Free Energy Principle: A Unified Brain Theory. Nature Reviews Neuroscience 2010 • Abnormal health beliefs, fearful appraisal of sensations, paying attention to symptoms, putting value on symptoms etc • Amplifies otherwise inocuous sensations A Neuropsychological Model for Functional Symptoms
  20. 20. 1 Role of functional pain in the opiate crisis • Opiates are excellent for acute pain • Ineffective for chronic pain (and harmful) • Chronic pain clearly has a powerful psychological component (which opiates may partially ameliorate) • In the absence of underlying peripheral pathology, can be thought of as a ‘functional syndrome’ • Chronic opiate prescriptions should be avoided in this group!!
  21. 21. 1 Frequent Attenders with Medically Unexplained Symptoms (FAMUS) project at RBH • A non-randomised controlled trial • 25 patients recruited via Frequent Attenders meeting (functional abdo pain, back pain, chest pain…) • 25 patients recruited for control group from Poole Hospital
  22. 22. 1 ASSESSMENT PHASE • Engagement is key • Patients invited to meet us in ED • Stated aim is to help to ‘cope with symptoms’ • Start with the physical symptoms. Go into detail. • ‘Bleed the symptoms dry’
  23. 23. 1 Childhood experience of physical illness /sick role Attachment disruptions Biopsychosocial factors for functional symptoms Relational factors Dominant partner, advocating strongly Overconcerned family A ‘turning point’ Mental disorder Depression Anxiety EUPD Dissociative disorders External Factors Compensation Sickness Benefits Props: wheelchairs etc Loss of Role: bankruptcy, redundancy, loss of carer role Medical Factors Repeated investigations (reinforces abnormal health beliefs) Opiates Conflict with doctors Psychological Factors Other functional syndromes
  24. 24. 1 CBT Phase • Patients offered 10 – 16 weekly sessions of CBT (with a mean attendance rate of 12 sessions). • The CBT provided was based on an adaptation of: • CBT for Somatisation protocol (Woolfolk and Allen, 2007) • CBT for Persistent Health Anxiety protocol (Salkovskis et al. 2003)
  25. 25. 1 PHQ9 16.08 8.12 -49.5% GAD 7 15.92 5.88 -63.1% WSAS 25.52 17.84 -30.1% Psychometric Questionnaire Outcomes Pre & Post Intervention
  26. 26. 1 Results: Pre- and post- intervention 0 100 200 300 400 500 600 ED attends Target Group Bed days used Target Group ED attends Control Group Bed days used Control Group Pre-intervention Post intervention
  27. 27. 1 CONCLUSIONS • People with MUS are amongst the most frequent attenders at ED • Their high use of resources, and mood and anxiety scores, can be improved significantly with a CBT intervention • A good theoretical understanding of MUS is vital • Engagement is key

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Functional, or medically unexplained, symptoms are some of the most complex and controversial problems presenting to clinicians. Overuse of opiates for pains which never get better, demands for operations which aren't necessary and long stays in hospital. How does a psychiatrist working on the frontline of the NHS steer treating teams and patients towards better outcomes?

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