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Did I really say that about Wessely ? And then I remember how dreadful I was feeling at the time.
I hate to say this, since I support some form of nationalized health care in the US. But even though (I'm sure) there are many kind and qualified doctors in the British NHS, the organization seems to represent a necessary, but disliked bureaucracy to many Brits.
Professor Wessely: We should have my wife here. She is the chairman of the College of GPs. When she starts talking-
Professor Wessely: Please God, we are not advocating greater regulation. In the talking therapies market it is like trying to regulate water. It cannot be done. Information can be regulated, however. People need to know, when they are using treatments, that there is long-term evidence of effectiveness, good governance, good outcomes, good audit and good clinical practice. They need to know that, and they need to know where there isn’t that.
This paper proposes that well-intentioned actions by
medical practitioners can exacerbate or maintain medically
unexplained symptoms (MUS)—i.e. physical symptoms
that are disproportionate to identifiable physical disease.
The term is now used in preference to ‘somatization’.1
Patients with the highest number of MUS are likely to fulfil
the psychiatric criteria for somatization disorder—at least 2
years of multiple and various MUS, with persistent refusal
to accept advice and reassurance from doctors; functioning
impaired.
The medical
specialties employ shorthand descriptions for particular
clusters of MUS including irritable bowel syndrome, noncardiac
chest pain, fibromyalgia, chronic fatigue syndrome
and repetitive strain injury.
Although research has gone some way to explain the
predisposing and precipitating causes of MUS, there is little
information on the factors that maintain such symptoms and
resulting behaviour.
Factors predisposing to MUS are female gender,6
childhood experience of parental ill-health (particularly
paternal),7 childhood abdominal pain8 and lack of care in
childhood.9 High rates of ‘life events’ occur in the period
predating the onset of MUS in a pattern similar to that seen
before the onset of depressive illness.10 In those with
somatization disorder there are high rates of personality
disorder.11
Childhood pain was only very weakly associated with abdominal pain and headache at 36 years but was associated with increasing numbers of physical symptoms at this age. Because there is a strong association between psychiatric disorder and physical symptoms, psychiatric disorder was added to the model, and this led to the association between persistent abdominal pain and physical symptoms in adulthood failing to reach significance.
There was a modest association between traits such as day dreaming in class and having low levels of energy and persistent abdominal pain.
It is difficult to show a consistent relationship with the teachers' ratings of behaviour in the children. There were no associations between low energy, day-dreaming or disobedience, and unexplained hospital admissions.
What are the factors that lead to persistence of MUS in
some individuals? Examples of possible precipitating events
include chest pain induced by hyperventilation12 and muscle
ache after unaccustomed exercise.13 Some of these
mechanisms may become chronic. Additional psychosocial
factors may be ‘secondary gain’10 (for example, when
chronic pain spares a parent the burden of caring for a
difficult child) or maladaptive psychological coping
strategies.14 In this paper, we focus on the adverse effects
of medical interventions at various stages of the doctor–
patient encounter.
An earlier cross-sectional study by the same group had
aimed to identify possible iatrogenic factors in the
persistence of pain.20 47% of the chronic-pain patients
had received more than five types of treatment for their
pain (regarded as overtreatment) and 39% had been given at
least one inappropriate explanation. Qualitative evidence
shows that patients with MUS can experience medical
assessment as hostile and adversarial.21
The implication
is that a poor doctor–patient interaction in IBS and kindred
illnesses may lead to repeat consulting.
When asked
about past advice from doctors, the group with medically
unexplained symptoms were significantly more likely to
recall being told their pain was all in the mind.
Occasionally the GP or specialist will decide to refer the
patient to a psychiatrist. This is neither simple nor
straightforward. As one expert notes, ‘It is a commonplace
clinical observation that somatising patients—more than
any other group—resent psychiatric referral or at least are
very sceptical of its purpose’.16
Reassurance
Reassurance is particularly important with patients who are
hypochondriacal or have MUS. Some qualitative work has
looked at the experience of patients with MUS.34 Patients’
accounts of their doctor’s explanations were categorized
into three types—rejecting, colluding and empowering.
The authors suggest that empowering explanations—i.e.
explanations that make patients feel they have some
influence over their symptoms—are most beneficial
individually and to the health service.
The adoption of a label such as IBS, fibromyalgia, CFS or
repetitive strain injury affords the sufferer legitimacy,
avoids the stigma of a psychiatric illness and ensures that
dysfunction is not seen by others as imaginary—in other
words, it allows entry into the ‘sick role’.37
This point prompted this letter:In two studies, membership of a patient
organization was associated with poor prognosis.52,53 Even 225
if this does not prove cause and effect (since membership of
a self-help group is not randomly allocated) the finding can
still raise the possibility that aspects of group culture are
maladaptive—perhaps promoting emotional support and
legitimacy at the expense of continued disability.
The comment by Dr Page and Professor Wessely (May 2003 JRSM1) that 'the views propagated by [support groups] can encourage inappropriate illness behaviour' needs challenging. Certainly, membership of patient organizations may well be associated with a poor prognosis, since it is commonly when the outlook is poor that one needs the support of a group. Other reasons may include the lack of social and family support. But in my experience of cancer support organizations for the past 16 years, the aim is normally rehabilitation, not 'continued disability'. Unfortunately, some conditions, such as radiotherapy damage, are progressive and untreatable, and only other people in the same boat can understand. Another problem that perpetuates the 'sick role' for cancer survivors is the insistence by oncologists on regular check-ups even after the five-year mark is reached.
The reason many people continue to be members of support groups after they themselves have been successfully treated is that they wish to give voluntary help to others in their turn, after appropriate training. This is hardly maladaptive behaviour.
Unfortunately the important paper by Dr Page and Professor Wessely (May 2003 JRSM1) has served to widen the gulf between UK and USA physicians. Just as we have struggled to acquaint our non-psychiatric colleagues on the spectrum of conversion, hypochondriasis, somatization and factitious disorders as described in the DSM IV we are now presented with a new acronym MUS [medically unexplained symptoms]. US psychiatrists and medical colleagues would not know a MUS from a mouse so I would respectfully urge we stick to the terminology we all understand.
It's now really late.... but I wanted to get this done before crashing. I'm planning to read through and edit tomorrow.A new name may convey new understanding or mask questions that are unresolved. I am not sure where medically unexplained symptoms (MUS), proposed by Dr Page and Professor Wessely (May 2003 JRSM1), fits into those roles.
MUS surely depends upon who is providing the explanation? If I were to go with my somewhat foggy gastroenterological knowledge, based on my Membership examination, and do a busy GI clinic I imagine that I would reach fewer diagnoses than a general physician with an interest in gastroenterology. In turn the generalist might do less well than a specialist gastroenterologist, who might do less well than an upper GI superspecialist, and so on, if one looked at the subset of patients proven to have upper GI problems as the outcome.
As a neurologist interested in headache I see patients labelled with various terms, usually as functional, who have a clearly definable headache syndrome. It is rare in my experience to encounter undiagnosable headache, yet this is often a symptom quoted in such research.2 The unexplained portion seems to have been inadequately explored in the sense that those providing the data were not sufficiently expert to explain it. This brings a question of what is sufficient. We do not accept blood pressure information from faulty devices, so how can such research accept potentially flawed diagnoses?
To assure doctors that 30% of patients are medically unexplained is not very helpful as it implies that there is no diagnosis. To say that a patient has an unexplained problem would require that it has been adequately investigated, or at least a complete history taken by someone sufficiently trained to do so. Research in this area surely requires some standard of measurement of the accuracy of the explanation, or lack of it. Perhaps funds directed to MUS might be directed to better training of doctors in some common clinical problems that are misdiagnosed rather than unexplained.
To assure doctors that 30% of patients are medically unexplained is not very helpful as it implies that there is no diagnosis. To say that a patient has an unexplained problem would require that it has been adequately investigated, or at least a complete history taken by someone sufficiently trained to do so. Research in this area surely requires some standard of measurement of the accuracy of the explanation, or lack of it. Perhaps funds directed to MUS might be directed to better training of doctors in some common clinical problems that are misdiagnosed rather than unexplained.
Factors predisposing to MUS are female gender,6
childhood experience of parental ill-health (particularly
paternal),7 childhood abdominal pain8 and lack of care in
childhood.9 High rates of ‘life events’ occur in the period
predating the onset of MUS in a pattern similar to that seen
before the onset of depressive illness.10 In those with
somatization disorder there are high rates of personality
disorder.11
A quote from esther's post:
I think this is an interesting one. The implication seems to be that MUS must be psychriatric due to these causes. However look at the "childhood experiance of parental ill-health". I guess you could claim an explanation that this traumatises a child. But there are other explanations the main one I would have thought was that what ever the cause it is genetic or that there is a set of diseases that are more likely given a genetic explanation.
Can't help commenting on "high rates of personality disorder" classification used so freely by the psyches - one wonders if they themselves might have it (whatever it is in their book).
I am one of those ex-psychi nurses who doesn't believe in personality disorder. It sprang up out of nowhere to explain patients who did nasty things and expanded to cover patients who "seek attention" which covered just about anyone with serious illness requiring more than a 5 min GP appointment. It's a load of crap. Frankly, I think there is more evidence that fish can ride bicycles than that there personality disorders.
The adoption of a label such as IBS, fibromyalgia, CFS or
repetitive strain injury affords the sufferer legitimacy,
avoids the stigma of a psychiatric illness and ensures that
dysfunction is not seen by others as imaginary—in other
words, it allows entry into the ‘sick role’.37
‘We need to work to reverse the perception that psychiatry is isolated from the rest of medicine, and at the same time address common misunderstandings – such as that psychiatry is not sufficiently scientific, that our patients don’t get better and our treatments don’t work. None of these are true. But what is true is that psychiatry has a bright future, and psychiatrists are happier and more satisfied in their work than colleagues in other areas of medicine. Unless we get the message across what an exciting specialism psychiatry is and make these changes to training and capacity, it will have negative repercussions for the future of mental health research, and in turn impact on the profession, and finally those unlucky enough to suffer from mental disorders.’