40 HOW TO TREAT : MEDICALLY UNEXPLAINED SYMPTOMS
40 HOW TO TREAT : MEDICALLY UNEXPLAINED SYMPTOMS
8 DECEMBER 2023 ausdoc . com . au
Box 4 . Strategies when managing patients with chaotic illness
• Acknowledge that life is difficult , with multiple challenges .
• Acknowledge that , despite these difficulties , the patient has survived : — It is important to recognise and respect their strengths .
• With the patient ’ s permission , ask about experiences of trauma , safety and security .
• Ask about their social situation , including whether they are safe at home and work , and whether they find it difficult to cope financially : — Social interventions are important .
• Where relevant , explain how childhood trauma can ‘ upregulate ’ the nervous system and change the structure and function of the brain so that many physical symptoms , including pain , are worsened in adult life : — It is often important to acknowledge that these symptoms are not the patient ’ s fault .
• Be sure to clearly and explicitly state that the symptoms are in the body as well as the mind .
• Explain that you understand there are no simple solutions , but offer what is possible within your community .
• Document preventive care requirements so they are not forgotten .
• It may be helpful to address physical and psychological issues separately so that neither are likely to be overlooked : — Sometimes , splitting care with another GP can be helpful . — This is particularly the case if you are discussing sexual trauma and need to perform an intimate examination , like a cervical screening test .
• Be prepared to acknowledge when a consultation did not go well , and reiterate your commitment to continue to do the best you can .
• Protect your patient as much as you can from health professionals who are dismissive or judgemental : — Choose generalist specialists where possible to minimise the number of therapeutic relationships the patient needs to manage .
• Proactively manage the therapeutic relationship and your own feelings ( see box 1 ).
• Schedule regular appointments to minimise crisis consultations .
• Spread the load with a small team , including the practice nurse , peer workers ( where available ) and agencies that address social needs .
children with significant biopsychosocial needs that are expressed through medically unexplained symptoms . Of course , many children will present with more straightforward issues , like abdominal pain associated with home sickness or headache before school assessments , which are temporary and easily managed in the GP setting with reassurance and simple problem-solving strategies .
MANAGING MEDICALLY UNEXPLAINED SYMPTOMS
MANAGEMENT begins with taking a sensitive holistic history and establishing an empathic therapeutic relationship . Many patients have experienced considerable difficulty having their needs met ; they are frustrated and distressed that the medical system has not been able to provide the diagnosis they expect . Patients do not complain of not being cured ; they complain that they are not taken seriously . 90
One author who experiences medically unexplained symptoms describes that it feels as though her medical notes follow her around “ like a criminal record … I feel that I am made to feel bad when I have actually done nothing wrong ”. 91
In light of this common experience of dismissal or devaluation , validation of the patient is essential . All patients need to believe they have a right to care , and this care should not depend on our capacity to make a diagnosis . Many patients will disengage from care , ‘ quiet quitting ’, when they “ cannot face engaging in a process that invalidates their pain ”. 92
If patients can talk openly about psychosocial stress , the likelihood of somatic intervention decreases . So where possible , it is important to take a broad history . 93 , 94 Patients do provide emotional cues , but doctors may not respond , particularly if they are short on time . 90 , 95-98 If doctors do not respond to these emotional cues , patients may feel that their concern is unimportant or the doctor is not interested . 99-101
There is good evidence for the use of physical therapies and CBT , so encourage patients who can access multidisciplinary teams to do so . Further strategies are provided in box 6 .
MANAGING SYNDROMES
A SYNDROME is a recognisable group of symptoms and signs for which a direct cause is not necessarily understood . 107 Syndromes become diseases once it is possible to identify the pathological features of the disease , the prognosis and the response to specific treatment . There are several syndromes that are currently contested . Again , the issue is legitimacy . Patients with syndromes do not have the psychosocial benefits of a diagnosis and may therefore be restricted in their access to therapies and financial support .
Many patients with syndromes , such as chronic fatigue syndrome , describe experiencing stigma ( see figure 7 ) and invalidation from healthcare providers , social agencies and the broader community despite the severity of their symptoms . 108 This invalidation compounds suffering and impedes recovery . It also impacts future therapeutic relationships as patients may disengage from health services to avoid feeling minimised , invalidated or judged . 42-45
The most common syndromes captured within the medically unexplained symptoms category are irritable bowel syndrome , chronic fatigue syndrome , fibromyalgia and
Box 5 . An approach to children with medically unexplained illness and their family
• Introduction : — Introduce the team and the purpose of the family session to establish rapport . — Construct a medical family tree :
• Draw up a three-generation family tree to acquaint the team with the names of the family members , the family context and the family ’ s medical and psychiatric history .
• Beginning with the medical history indicates to the family that the team is taking physical issues seriously .
• History of the presenting symptoms : — Over time , when the family is confident , move on to the history of the presenting symptom — for example , pain ; motor weakness ; paralysis ; sensory loss ; non-epileptic seizures ; non-specific somatic symptoms , such as tingling , dizziness and fatigue . — The symptoms can indicate mental illness without asking about mental state directly . — Linking the symptoms to context . — The aim of this stage is as follows :
• Clarify what was happening in the family before the onset of the child ’ s illness .
• Obtain a detailed history of the medical symptoms , medical help-seeking , diagnoses and help-seeking experiences .
• Identify any life events that took place at any point in this history .
• Explore any connections between the symptom ’ s onset , frequency or intensity and family life events , including physical or emotional illness in the family , any traumatic events , family conflict , bullying or other difficulties at school and any adverse interactions with the medical system .
• Co-constructing a formulation : — Work with the family to create a formulation that takes into account the family ’ s understanding of the problem and includes physical and psychosocial elements .
• Planning treatments : — The physical therapy module :
• Physical rehabilitation to address physical impairment , to prevent physical complications related to immobility and to maximise the child ’ s general physical functioning and wellbeing .
• Include allied health input , such as physiotherapy and exercise physiology .
• Encourage self-care to improve the child ’ s physical independence .
• If the child is in hospital , nursing staff will take on the role of helping the child to complete their own self-care , and the family is encouraged to enable the child to take control of their own health .
— The medical module :
• Treat pain , comorbid anxiety and depression or other manageable symptoms .
• Organising for individual family members , especially parents , to have their own conditions adequately treated .
— The psychological module :
• Individual work with the child to give them the language and capacity to name their emotions .
• Encourage mind – body connections .
• Family therapy to address unhelpful relationships and illness-reinforcing behaviour that may be contributing to the child ’ s symptoms .
— The educational / social module :
• Encourage attendance at school and other social groups .
• Address educational issues or bullying .
Source : Kozlowska K et al 2006 39
Box 6 . Core strategies for managing patients with medically unexplained symptoms
• Validation : — Validate the patient ’ s experience by acknowledging the symptoms are real and distressing . — Validate the frustration and uncertainty experienced when there is no concrete diagnosis . — Maintain an empathic and helpful therapeutic relationship ( see box 1 ).
• Explanation : — Establish common ground by agreeing on the nature of the problem and the goals of treatment ; this includes finding an explanatory framework on which you can agree . — Ideally , this framework should include biopsychosocial explanations — for example , “ I think this is irritable bowel syndrome , and although we do not really know what is causing your symptoms , they seem to be affected by your diet , stress levels and maybe your depression .”
— Where possible , give the symptoms a name ; this may involve diagnostic terms , like functional neurological symptoms ; or explanatory metaphors , such as stress headaches .
• Harm minimisation : — Limit iatrogenic harm . — Establish clear boundaries by actively managing the frequency and length of each consultation .
• Biopsychosocial management : — Address the body by examining appropriately and using physical therapies — such as massage , hydrotherapy and exercise — as appropriate . — If necessary , provide symptomatic relief . — Optimise lifestyle factors , including stress management . — Offer psychological strategies , like CBT . — Assist in obtaining appropriate social services and supports . — Consider and address the needs of carers and children where appropriate .
• Relational care : — Address your own needs using opportunities to debrief and reflect on the therapeutic relationship ( see box 1 ).
Source : Steinmetz D et al 2001 49 , Epstein R et al 2006 102 , olde Hartman T et al 2009 103 , Mayou R 2002 104 , Rosendal M et al 2005 105 , Henningsen P et al 2007 106
functional neurological symptoms . All seem to be transitioning from syndromes to diseases , with increasing evidence around the pathogenesis — genetics , lifestyle , inflammatory processes , biochemical changes — and some evidence for specific therapies .
For instance , diet has a significant role in the management of irritable bowel syndrome , specific physiotherapy for the management of functional neurological syndromes and energy management for chronic fatigue syndrome . 109-111 All syndromes suggest in their recommendations non-specific lifestyle interventions to mitigate symptoms and include exercise , healthy diet , physical therapies and psychological support and / or CBT . These interventions , particularly CBT , need to be tailored to the