BMJ article: How should we manage adults with persistent unexplained physical symptoms? - looks bad.

[trishrhymes]

Can anyone access the full article. The abstract looks bad. Classifies ME as psychological.

How should we manage adults with persistent unexplained physical symptoms?

Persistent physical symptoms are common and include those symptoms that last at least three months and are insufficiently explained by a medical condition after adequate examination and investigation.12 Examples include unexplained abdominal pain, musculoskeletal pains, fatigue, headache and dizziness. These symptoms are often associated with functional impairment and psychological distress among patients, and increase healthcare costs.2345 Observational studies in primary care report that women, especially those aged 35-45 years, more commonly present with these symptoms.25

Defining and categorising an unexplained symptom is tricky and disputed (see box 1).910 Sometimes symptoms fit criteria for somatoform or psychiatric disorders set out in the Diagnostic and Statistical Manual of Mental Disorders IV (DSM IV)6 or functional somatic syndromes such as irritable bowel syndrome. In other cases there is no label to offer the patient.

Box 1: Terminology used in this article

• 
  
  • Persistent unexplained physical symptoms—Physical symptoms existing for ≥3 months not sufficiently explained by an underlying medical condition after adequate examination and investigation2
  • Somatoform disorders—Psychiatric disorders (DSM-IV, ICD-10) with persistent unexplained physical symptoms as key factor6
  • Undifferentiated somatoform disorder—One or more physical symptoms without medical explanation with clinically significant suffering or functional impairment, existing for ≥6 months6
  • Functional somatic syndrome—A combination of unexplained physical symptoms occurring together (such as irritable bowel syndrome or chronic fatigue syndrome)7

http://www.bmj.com/content/356/bmj.j268

 

[Cheesus]

Defining and categorising an unexplained symptom is tricky and disputed (see box 1).910 Sometimes symptoms fit criteria for somatoform or psychiatric disorders set out in the Diagnostic and Statistical Manual of Mental Disorders IV (DSM IV)6 or functional somatic syndromes such as irritable bowel syndrome. In other cases there is no label to offer the patient.

I'd rather have no label than a fake label.

 

[slysaint]

"If you consider symptoms to be unexplained, explore all symptom dimensions (somatic, cognitive, emotional, behavioural, and social) and perform a focused but thorough physical examination".

Puts the BPS criteria at the top of the list to consider.................then what is the 'focused but thorough physical examination"?.........no specific tests, no list of conditions to rule out. And having already 'decided' its BPS why bother looking for any other cause? We've all been there.

ETA: just read the two current threads on Lyme diagnosis (or lack of). Appropriate here too.

 

[hixxy]

http://sci-hub.cc/10.1136/bmj.j268

 

[chipmunk1]

Can anyone access the full article. The abstract looks bad. Classifies ME as psychological.

How should we manage adults with persistent unexplained physical symptoms?

Persistent physical symptoms are common and include those symptoms that last at least three months and are insufficiently explained by a medical condition after adequate examination and investigation.12 Examples include unexplained abdominal pain, musculoskeletal pains, fatigue, headache and dizziness. These symptoms are often associated with functional impairment and psychological distress among patients, and increase healthcare costs.2345 Observational studies in primary care report that women, especially those aged 35-45 years, more commonly present with these symptoms.25

We consider cognitive behavioural therapy worth offering but do not advise pharmacological therapy.

translation:

we do not know what to do with these cases. We do not want to see them anymore. Let's give them a fake label and send them home.

How patients were involved in the creation of this article

Two patients with persistent unexplained physical symptoms were asked if this article covers issues that matter to them and what information might help doctors to better manage their symptoms. They suggested to provide explanations of some definitions and to encourage doctors to talk openly with their patient about the condition and treatment options. These suggestions were incorporated in the paper.

 

[Valentijn]

A Cochrane review examined different forms of psychological therapy (21 randomised controlled trials (RCTs), 2658 participants) including cognitive behavioural therapy, behaviour therapies, third-wave cognitive behavioural therapy (mindfulness), psychodynamic therapy, and integrative therapy in patients with somatoform disorders or persistent physical symptoms.12 Taken altogether, psychological therapies were effective in reducing symptom severity compared with usual care or waiting list....

Sounds like a pretty shitty review, if such different therapies were combined. Mindfulness is pretty much the polar opposite of the psychosomatic CBT aimed at ignoring/denying symptoms, for example. Since they had to combine those to get an effect, there probably is no effect.

... but effect sizes were small and psychological therapies had higher dropout rates than usual care. No harms or side effects were reported. The overall quality of evidence is low due to a high risk of bias with lack of blinding of the participants, therapists, and outcome assessors.

So a lot of useless "evidence", even without taking into account the lack of objective outcome measurements.

Despite zero evidence of psychosomatic causation, tell the patient what you want them to hear, to try to get them to do what you think they should, even if you have no support for it:

Share your findings based on the examination and investigations with the patient and explain that no underlying medical condition has been identified and is unlikely to exist. Where possible, provide an explanation for the persistence of symptoms—for example, by using the vicious circle theory, where pain can lead to less exercise and less exercise can lead to more pain.

The PhD student seems well on track to become another abusive quack.

 

[A.B.]

The CBT and mindfulness literature is typically conducted with methodology that is virtually guaranteed to produce false positives. Studies with poor methodology need to be rejected, not accepted as "low grade evidence". Conducting many such studies does nothing to correct the underlying flaw. It is exactly like throwing a loaded dice over and over again and concluding that the power of the mind can make it roll sixes most of the time.

Unfortunately the authors working in this field seem to have little interest in producing trustworthy knowledge, so it will probably fall on patients to demand higher standards.

 

[chipmunk1]

These symptoms are often associated with functional impairment and psychological distress among patients, and increase healthcare costs.2345 Observational studies in primary care report that women, especially those aged 35-45 years, more commonly present with these symptoms.25

Middle aged,hysterical and probably unmarried attention-seeking females bankrupting the healthcare system.

 

[trishrhymes]

It is deeply worrying that the BMJ has published such a poorly researched article.

The authors, presumably primarily the PhD student, seem only to have done their literature research using the trigger words 'somatoform disorders'.

They seem blithely unaware that to include CFS, IB and FM in these so called unexplained disorders is controversial, let alone that it is just plain wrong.

If they had widened the search to include these specific disorders, they should have found loads of biomedical research and even PACE and FINE, which are not mentioned!

How can anyone be awarded a PhD on the basis of such abysmally narrow 'research'?

The only good thing I can see coming out of this is that, at least they conclude that the research evidence for treatments, both antidepressant and CBT and other psychological therapies is so poor as to be almost non-existent.

Maybe this can be used as ammunition in the fight against the rolling out of psychobabble therapies for MUS / PPS in the UK.

On the other hand, the advice to GP's that the best way forward is to explain to patients that they have wrong illness beliefs and the 'vicious circle theory', and that there is very unlikely to be a physical cause of their symptoms is imho criminally irresponsible.

 

[A.B.]

Why not ask the affected patients how these cases should be managed? A poll that doesn't go through a biased intermediary would be good.

 

[RogerBlack]

Clicking through to 'responses' at least finds some rays of hope.

My experience (as a GP with special interest in integrative medicine) is that in many patients who are labelled as having ‘persistent unexplained symptoms’ (after routine investigations come back as ‘normal’), it is simply that the relevant investigations have not been ordered to actually diagnose the underlying cause! For example, often there are nutritional deficiencies (e.g. vitamin D, magnesium or iodine deficiency), which have not been tested for, as a cause of fatigue; vitamin D deficiency is often misdiagnosed as ‘fibromyalgia’; a significant percentage of patients that I see who have been labelled as having ‘irritable bowel syndrome’ have gastro-intestinal parasites (and their ‘IBS’ gets better after appropriate anti-parasitic treatment!).

As a psychotherapist – and widow of a GP who took his own life whilst diagnosed with ‘depression’, ‘health anxiety’ and ‘somatisation’ (having lived with ‘treated’ Addison’s disease for 26 years) – I have become deeply alarmed to learn about more and more people who are suffering apparent psychiatrically labelled ‘medically unexplained symptoms’ and ‘somatic disorders’ and who are indeed very unwell. They are unable to function and have become disabled or worse.

 

[lilpink]

QED wrote a reply to Petra's review (review 8/2/17) on Amazon review page for Suzanne O'Sullivan's 'It's All in Your Head' .

https://www.amazon.co.uk/review/R7D...wContentID=Mx3J9JQ3H9IQ4QS&store=digital-text


They discuss a new sexist paper in BMJ (see final paragraph) -" How should we manage adults with persistent unexplained physical symptoms?"

http://www.bmj.com/content/356/bmj.j268


Well worth a read, especially if you think that there isn't a sexism issue at play with ME or MUS!

 

[Cinders66]

We should in uk have activism to get the IOM report and it's message clear over here. Ironically the BMJ actually have quite a good ME/CFS resource except the end where it still advocates CBT & GET as effective treatment

Disdain from some for the SEID name meant 2015 we missed that window of opportunity to turn things around in uk as same old was preferred over new and imperfect. I personally detest same old and think we need a proper UK advocacy movement (beyond a one day awareness event) to mobilise all the suffering and disgruntled patients here with no effective outlet for their discontent. We just need people well enough to lead it and who don't allow dilution of it by the status quo defending charities.

 

[Mohawk1995]

I am quite familiar with the Cochrane Review process. Problem is I have only found them to be helpful with diseases that are clearly defined and to which many research studies have been performed. Lumping everyone in a category may be helpful for them to feel they have accomplished something, but it does little to advance effective treatments.

The reference to "Share your findings based on the examination and investigations with the patient and explain that no underlying medical condition has been identified and is unlikely to exist." is horrifically bad advise. Not opposed to telling someone that with tests we have at our disposal we have been unable to identify a cause, but the tests we have at our disposal do not test everything. Acknowledging that the tests to determine how the body is functioning at a cellular, biochemical, hormonal and neurophysiological level are just not that sophisticated.

I recently heard a man speak who was functioning at a high level (leading a large church and running ultramarathons) who within the course of 2 weeks was in the ICU on a ventilator and has now taken over 3 years to recover to the point in which he can return to work. All that could be determined is that he had a muscle disorder killing his muscle tissue. He was never given a diagnosis despite the fact that his tissue samples were distributed throughout the world only to return negative.

To tell a person that there is no underlying medical condition and is unlikely to exist is just as bad as using sham treatment measures to make money off those who suffer! Both may be driven by the same motive. Worse yet is the practitioner who really is trying to help people, but reads this and sees this a "Best Practice" or "Evidenced Based".

 

[user9876]

I am quite familiar with the Cochrane Review process. Problem is I have only found them to be helpful with diseases that are clearly defined and to which many research studies have been performed. Lumping everyone in a category may be helpful for them to feel they have accomplished something, but it does little to advance effective treatments.

I think Cochrane have quality control issues with their ME reviews (or they just mindlessly trust the authors). They claimed that PACE was high quality and said that outcome switching was fine but then again they also switched the outcomes published in their review from their analysis plan. There are technical issues with their analysis where they use mean differences for non-linear scales as well - but if they defend PACE and switch their own outcomes then I wouldn't expect them to understand fine technical details.

Ultimately I suspect that Cochrane's support for PACE will do a huge amount of damage to their reputation.

 

[user9876]

There are 2 worries with these articles the first is the harm patients with ME because GPs tell them to ignore symptoms often leading to a relapse. The second is it encourages GPs to dismiss patients symptoms without doing tests and they end up delaying treatments till it is too late. There is a reason why early cancer diagnosis is poor in the UK. The BMJ and those peddling the myths of psychosomatic illness have a lot to answer for.

 

[Mohawk1995]

"If you consider symptoms to be unexplained, explore all symptom dimensions (somatic, cognitive, emotional, behavioural, and social) and perform a focused but thorough physical examination".

Puts the BPS criteria at the top of the list to consider.................then what is the 'focused but thorough physical examination"?.........no specific tests, no list of conditions to rule out. And having already 'decided' its BPS why bother looking for any other cause? We've all been there.

Two issues I have with the statement: 1) That exploring all symptom dimensions lists 4 cognitive dimensions and only 1 "non-cognitive" (somatic although there is a lot of word association by the same thinking that puts that into the psycho-somatic category). There are far more symptom dimensions in the non-conscious systems of our body than the conscious ones. Really how many people can consciously and willfully make pain appear in their body! Symptom dimensions including both input and outflow, nociception, tactile, reflexive and yes even the dreaded Central Sensitization are NOT cognitive! And as a general from what I have seen and heard the cognitive is a far weaker influence on symptoms.

The other issue is that many physicians lack the skills to perform a thorough physical examination (I am not saying all do). Their reliance on diagnostic tests, their lack of time to truly perform one and the practice of "legally defensible" medicine especially in the US would likely prevent it even if they are capable. So you get a focus on the wrong symptom dimension (cognitive) and ill prepared or incomplete examination and yet get either a big ZERO or worse yet you tell the patient their condition is not medical and likely never will be.

I grew up in my career admiring and following what I considered the British School of Clinical Reasoning in Physical Therapy. Names you may not know like James Cyriax (ENG), Robin McKenzie (NZ) and Geoff Maitland (Australia) who were excellent clinicians with superb examination skills. Fortunately in at least many circles of PT their practices carry on. Doesn't sound like so in most of England's Medical Community.

 

[TigerLilea]

Middle aged,hysterical and probably unmarried attention-seeking females bankrupting the healthcare system.

No, it's the middle aged, married women whose children didn't turn out as she had hoped, and doesn't feel fulfilled by her marriage. I heard a British psychiatrist say this once in an interview.

 

[TiredSam]

Where possible, provide an explanation for the persistence of symptoms—for example, by using the vicious circle theory

A more likely explanation for the persistence or worsening of symptoms is the vicious psychoquackbabbler theory.

 

[JaimeS]

Mindfulness is pretty much the polar opposite of the psychosomatic CBT aimed at ignoring/denying symptoms, for example.

Good call. Quite literally taking the opposite tack.

Middle aged,hysterical and probably unmarried attention-seeking females bankrupting the healthcare system.

We have to get our male attention from someplace, and it is a well-established fact that many physicians are men, @chipmunk.

It is deeply worrying that the BMJ has published such a poorly researched article.

Unsurprising. Not just in ME research -- the BMJ publishes anything these days, it seems. BMJ publishes a great deal that's still sensible, but their wild speculation: decent science ratio is worryingly low. I wonder how long it takes before their reputation really suffers? I'm going to say a long, long time. People are used to thinking of the BMJ as a well-respected journal.