Medically unexplained symptoms
News and presentations from today’s conference researched and produced in partnership with The Tavistock and Portman NHS Foundation Trust looking at how to better understand and meet the needs of people with medically unexplained symptoms/somatic symptom disorder.
Improving management and treatment of ‘medically unexplained symptoms’: A partnership approach
Dr Mark Griffiths, Consultant Lead Clinical Psychologist & Professional Lead for Psychology/Clinical Lead/Head of Services, Aintree University Hospital NHS Foundation Trust
In his presentation Dr Griffiths commented; "MUS is currently a huge political factor due to the high cost involved"
"MUS accounts for 4-6% of GP consultations and 25% of hospital/A&E attendances"
"MUS is a long term condition in itself"
"There is no one way of managing patients with MUS"
"Need to support improved identification of stress factors on medical status and on the experience of persistent physical symptoms"
"Need to improve emergency care management of complex and persistent medical presentations"
"Must reduce the number of recurrent AED attendances of patients presenting with persistent medical conditions"
"Biopsychosocial Management - 6 months after medical psychology input into care, re-attendance rates reduced by 41%"
An increasing volume of NHS policy, clinical evidence and guidance emphasises the strong and integral overlap and dynamic relationships between mental and physical health status.
Mental health factors now being increasingly acknowledged and understood as commonly affecting physical health symptomology; with an equally pertinent inverse relationship existing, particularly relevant when people are faced with living with chronic physical conditions or illness. These dynamic relationships driving a huge volume of healthcare need, frequently mismanaged by traditional healthcare pathways, that often then fail to identify the relevance of psychological or psychosocial factors on medical status, thereby perpetuating unhelpful patient journeys and iatrogenic factor influence. These complexities of relationship drive a high volume of healthcare attendances across primary and secondary care, accounting for around 15% of GP consultations and 25% of hospital outpatient attendances. Within this context, persistent physical or medically unexplained symptoms pose a huge burden on our healthcare system, leading to a UK healthcare cost now exceeding £3.1 billion (RCPsych, 2011), with total societal costs of around £18 billion (Bermingham et al, 2010)
This presentation discusses two separate clinical service models, both seeking to support improved identification of stress factors on medical status and on the experience of persistent physical symptoms; with the aim of supporting improved primary and acute emergency care management of complex and persistent medical presentations (where psychological factors play a key detrimental role in maintaining persistent symptom patterns).
The primary care GP support service discussed, explains a practice-based GP training and support programme developed and outcomes achieved to date.
Discussion then moves to the Aintree AED Medical Psychology service; a specialist clinical psychology service set up within the AED medical pathway, aimed at supporting an enhanced model of care for patients presenting with persistent physical symptom/ physical long term condition complaints affected by psychological/ stress factors (where the likelihood of these relationships is determined by AED medical assessment). The aim of this service model being to reduce the number of recurrent AED attendances of patients presenting with persistent medical complaints. Outcomes so far are discussed, highlighting maintained re-attendance reduction rates of 41%, 6 months after medical psychology input into care. Further indicating cost-avoidance of £4.29 for every £1 spent on supporting this service, relative to the urgent healthcare costs averted through this model, for patients seen.
Creating an Integrated System of Care for PPS/MUS
Tim Kent, Service Lead Primary Care, Consultant Psychotherapist & Social Worker, The Tavistock & Portman NHS Foundation Trust
Ahmet Caglar, Clinical Practitioner Psychotherapist & Turkish Speaking Community Project Group Therapist, The Tavistock & Portman NHS Foundation Trust
This presentation will be an overview of an ongoing horticultural psychotherapy project in City & Hackney Psychotherapy Consultation Service/ Tavistock & Portman NHS Trust. Participants are Turkish speaking patients who have been experiencing MUS, psychosomatic presentations with long term depression and anxiety. The language of the project is Turkish. This is an attempt to explore some of the root causes of the issues participants have been facing and to suggest some useful tools to participants to self-manage them with long lasting changes by using, group therapy, psychoeducation, gardening, cooking and more.
Dr Ellie Cavallie, Team Around the Practice Clinical Lead for the Community Photography Group, The Tavistock & Portman NHS Foundation Trust
This presentation describes a community photography group project which has run within the Tavistock and Portman primary care services since 2014. An overview of the project is given and the benefits of photography as a therapeutic tool are described, particularly for individuals with medically unexplained symptoms. Some photos are presented with some reflections from the group members who took them. The presentation concludes with some comments from the group evaluation and an overview of an exhibition of the project.
Dr Ellie Cavallie PowerPoint Presentation
A novel primary care package for management and treatment of ‘medically unexplained symptoms’
Prof Frank Röhricht, Associate Medical Director, East London NHS Foundation Trust
In his presentation Prof Rohricht said; "The NHS in England estimates to spend at least £3 billion each year trying to diagnose and treat MUS."
"MUS is costly to patients, providers and society"
"GPs play an important role in assessment, engagement and sign-posting for treatment"
"Innovative intervention strategies are necessary to achieve better health and economic outcomes"
Patients with Medically Unexplained Symptoms (MUS, also referred to Bodily Distress Syndrome in newer classification systems) complain of physical symptoms that cannot be explained adequately or sufficiently by organic pathology, causing distress and functional impairment. Persistent MUS (more than 3 months) is highly prevalent and costly to patients, providers and society; patients with MUS often have unmet health needs as a result of their own health beliefs, incorrect diagnosis and consequently ineffective treatment despite frequent presentation at primary and secondary care services. GPs play an important role in assessment, engagement and sign-posting for treatment. Take-up amongst MUS sufferers through traditional referral systems and response rates for talking therapies are known to be low. New and innovative intervention strategies are necessary to achieve better health and corresponding economic outcomes.
Based upon experiences gathered in the context of a specialist somatoform disorder clinic and taking into account findings from a pilot trial and the wider evidence base regarding the efficacy of body oriented psychological therapy for MUS sufferers, we developed and evaluated a primary care intervention package.
The paper will summarise data from previous trials and present findings from a prospective cohort intervention study involving a cluster of GP surgeries providing a “One-Stop-Shop” primary care treatment service. This includes discussing the feasibility of implementing the pragmatic care package (recruitment, retention and acceptability) as well as the potential impact on clinical outcomes and service utilisation.
The care package included: Identification, Assessment, Engagement, Psychoeducation and a choice of Group Interventions (Mindfulness Based Stress Reduction/MBSR and Body Oriented Psychological Therapy/BOPT). Baseline and follow-up data on somatic symptom levels (PHQ-15), health-related quality of life (SF-36, EQ-5D) and service utilisation was analysed.
145 patients were referred and assessed for eligibility, 93 included in the study. Participants engaged well with different components of the care package and gained significant improvements in somatic symptom levels with corresponding increases of quality of life ratings and a reduction in health care utilisation (GP contacts and referrals to specialist services) as well as associated health care costs.
It will be argued that the primary care treatment package can be successfully implemented in primary care at a relatively low cost and easily adopted into routine care. The body-oriented approach is well accepted by clinicians and patients. Controlled trials should be conducted to test the efficacy of the treatment package as compared with treatment as usual.
For further information please visit the project website: www.mus.elft.nhs.uk or download open access paper: http://bjgpopen.org/content/early/2017/10/04/bjgpopen17X101121/tab-article-info
Prof Frank Röhricht PowerPoint Presentation
Medically Unexplained Symptoms and Trauma
Dr Tony Downes, General Medical Practitioner, North Wales, Honorary Research Fellow, Cardiff University
The effects of traumatic stress were formally recognised by the American Psychiatric Association’s Diagnostic Statistical Manual in 1980 (DSM III) as Post- Traumatic Stress Disorder (PTSD) and later by the WHO in the International Classification of Diseases (ICD).
PTSD has been described throughout history under numerous names such as Shell Shock in the First World War. The description of PTSD has evolved since 1980 and ‘Complex PTSD’ has been proposed for ICD-11 due 2018.
The traditional separation of health into either mental or physical problems, which is attributed the 17th Century philosopher Rene Descartes as ‘Cartesian Dualism’, has led to two types of classification for the bodily unexplained symptoms; one for psychiatrists and one for physicians namely ‘Somatisation’ and ‘Medically Unexplained Physical symptoms’ amongst several others. As with PTSD, bodily expression of psychological trauma has been described throughout history under numerous names such as ‘Soldiers Heart’ and ‘Railway Spine’. Although earlier descriptions of ‘PTSD’ alluded to the inter-connection between the physical and mental presentations of traumatic stress, both remain separated in clinical practice. This is leading to suboptimal care for many people who fall between services, a problem compounded by specialisation. The cost of MUPS has been estimated as 7% of the NHS budget akin to diabetes and Adverse Childhood Events (ACE’s) studies, have provided evidence on the link between social trauma in childhood with adult ill health and benefits to services and patients by a trauma focussed approach.
Developments in PTSD research, including the neurosciences and epigenetics, are revealing connections between the mental and physical experiences of traumatic stress that inform effective care pathway development and evidence based interventions. The NHS is under pressure to find new ways of working and In Wales, there is the potential to better manage MUPS through a trauma informed, socially inclusive approach to healthcare, which is based on the founding principles of the NHS.
1 Trauma and MUPS symptoms are linked and often explainable
2 The mind –body split, ‘Cartesian Dualism’, negatively impacts on care for people with Trauma and MUPS including the development of effective care pathways.
3 Specialisation in clinical care can have a negative impact on the patient journey.
4 A trauma informed approach to the care of people with MUPS can benefit the patient and health services.
5 Risk management is a significant issue as people can have both diseases and MUPS. People with PTSD are at more risk of accidents, suicide and cancer.
References and further reading
Available on request
Also of interest:
IAPT: Improving Psychological Therapies for Older People
New Savoy Conferences presents Disrupting IAPT: can digital pathways 'change the game'?
Improving Psychological Therapies For Mental Health Trauma National Summit 2017
30 October 2017