NHS IAPT Medically Unexplained Symptoms/Functional Symptoms Postive Practice Guide

[Firestormm]

Tweeted by with thanks to @dxrevisionwatch

NHS Improving Access to Psychological Therapies

July 2014

Medically Unexplained Symptoms/Functional Symptoms Positive Practice Guide

1.1 Medically unexplained symptoms or syndromes (MUS) is a term commonly used to describe physical symptoms which cannot be explained by disease specific, observable biomedical pathology. The symptoms can be long-lasting and can cause significant distress and impaired functioning.

1.2 These symptoms constitute a clinically, conceptually and emotionally difficult area to tackle, with clinical presentations varying greatly, from people who regularly attend GP surgeries with minor symptoms to people with recognised functional syndromes (see section 2) such as chronic fatigue syndrome who can have severe enough symptoms to be bed- bound.

1.3 MUS are common, accounting for as many as one in five new consultations in primary care1. The unexplained symptoms can cause significant distress to the patient and, in some circumstances, impair functioning.

1.4 Between 20% and 30% of consultations in primary care are with people who are experiencing MUS and have no clear medical diagnosis. It is estimated that this rises to an average of 52% in secondary care where a substantial proportion of secondary care resources are used by frequent attenders whose symptoms remain unexplained2. Most of these patients currently receive little or no effective treatment or explanation for their symptoms so continue to be high users of health care and remain both distressed and disabled by their symptoms.

1.5 A recent systematic review of the economics of MUS found two main results: first, medically unexplained symptoms cause direct excess treatment costs per patient (between 432 and 5,353 USD per annum); second, interventions targeting GP’s diagnostic and patient management skills as well as CBT for patients have the potential to improve patients’ health status and to reduce costs3.

1.6 Irritable bowel syndrome is a commonly occurring MUS. A recent Scandinavian study concluded that irritable bowel syndrome (IBS) alone, incurs substantial direct and indirect costs corresponding to a share of up to 5% of the national direct outpatient and medicine expenditures 4. A UK IBS study published over 10 years ago conservatively estimated that IBS costs the UK £200million per year but that the cost could be as high as £600 million5.

1.7 Although models exist proposing that MUS are somatised forms of depression, there is increasing evidence of distinct differences between patients with MUS and those with a primary anxiety and depressive disorders. Although it may be possible to treat anxiety and depression comorbid to MUS, treatment approaches that have shown most efficacy for people with MUS are especially formulated for these conditions (see section 4 on treatment). Treating the anxiety and depression will not necessarily treat the physical symptoms or associated disability.

1.8 Community mental health teams and primary care mental health services have not been successful in engaging with patients experiencing MUS, as patients often do not perceive their condition to be related to mental health problems, and attempting to engage them in traditional mental health approaches is often ineffective.

1.9 Commissioning treatment that focuses specifically on evidenced based treatments for MUS, offered by health professionals trained in these approaches, is likely to offer the best health and cost benefits.

1.10 Currently there are relatively few therapists skilled in this area and specific training and ongoing supervision in this area needs to be a priority so that the correct treatment is more readily available to patients who need it.

Read more: http://www.iapt.nhs.uk/silo/files/medically-unexplained-symptoms-postive-practice-guide-2014.pdf

 

[Sidereal]

Horrifying.

 

[SilverbladeTE]

BASTARDS!
after IBS has been PROVEN to be physical and if folk think that's "Oh noes supports the mad mental patient" crap, too damn bad

you can't change the minds of those who are perverting the entire system towards horror and already to abuse...No point trying to play them at their own game.

 

[Cheshire]

Understanding FS (Functional syndromes) from a Cognitive Behavioural Perspective

4.5
Functional syndromes (FS) are best explained in terms of a multifactorial biopsychosocial model

10. One biopsychosocial model commonly used to guide therapeutic approaches in this area is the cognitive behavioural (CB) model which incorporates predisposing, precipitating and perpetuating factors

11. This model comprises biological, affective, behavioural and cognitive elements of the illness. The fundamental assumption of a CB model is that the perpetuating domains interact to maintain symptoms, disability and distress, and that change in one domain will effect change in the others. What should perhaps be highlighted in the application of this
model to FS is that this constitutes a previously undescribed disease mechanism, one which produces and/or maintains physical symptoms in the absence of either overt physical pathology or psychopathology. The basic hypothesis at work here is that of a systemic dysregulation which becomes self perpetuating

12.
4.6
For example, evidence suggests that predisposed people may be highly achievement orientated, basing their self-esteem and the respect from others on their abilities to live up to certain high standards. When these people are faced with precipitating factors which affect their ability to perform, such as a combination of excessive stress and an acute illness or injury, their initial reaction is to press on and keep coping. This behaviour leads to the experience of ongoing symptoms which may be more closely related to pushing too hard than to the initial insult or injury. However, in making sense of the situation, patients attribute the ongoing symptoms to the original trigger.

The common response to an acute illness is to rest. However, reduced activity conflicts with achievement orientation and may result in bursts of activity in an attempt to meet expectations. These periodic bursts of activity inevitably exacerbate symptoms and result in failure, which further reinforces the belief that they have a serious illness. As time goes by, efforts to meet previous standards of achievement are abandoned. Patients become increasingly distressed by their symptoms and increasingly accommodate to their illness. This accommodation to the illness and distress reinforces the symptoms through physiological changes related to poor sleep-wake cycle, lack of a daily routine and autonomic arousal with consequent insomnia.

This results in chronic disability. Three prospective studies of the development of IBS, CFS and post-concussion syndrome after acute infection or injury, provide sound evidence for this model in three distinct functional syndromes
13

4.7
The CB model needs to engage the patients in the therapy process but also obtain the best outcome for patients. Although many patients presenting with MUS have high levels of distress, treatment which focuses on reducing the severity of the symptoms or the acceptance of symptoms, and reducing the disability afforded by the symptoms often results in concomitant reductions in distress. Evidenced based models used in CBT approaches for these patients have distinct differences to the protocols used for treating people with a primary anxiety or depressive disorder.

4.8
Another simpler approach is to encourage a gradual return to previous activities, to reverse the changes secondary to inactivity. Such graded activity approaches are effective in helping patients with various functional syndromes to recover their health.

How simplistic the BPS model is when compared to the complex biological discoveries recently found.

And the usual blame of the victim...

"The common response to an acute illness is to rest."
"Another simpler approach is to encourage a gradual return to previous activities, to reverse the changes secondary to inactivity. "
Whatever we do, it is wrong, when we try to be active it is too much, when we rest, inactivity perpetuates our symptoms...

And how hypocritical

Therefore the fact that psychological treatments works does not mean that the illness is psychological.

 

[Snowdrop]

:thumbdown:

I'm conflicted. Experiencing various emotional responses. Maybe I should just .
Of course, because medicine can't explain the reason for a symptom it makes perfect sense to 'talk the patient down'.

NOT.

I notice that they are listening though. They seem to more and more use language that we would use, only with an evil twist .
An example would be how we often talk here of how we have pushed through or continue to push through trying to function when experiencing this illness (although we know this is a bad thing)

'a combination of excessive stress and an acute illness or injury, their initial reaction is to press on and keep coping. This behaviour leads to the experience of ongoing symptoms which may be more closely related to pushing too hard than to the initial insult or injury. However, in making sense of the situation, patients attribute the ongoing symptoms to the original trigger.'

Always we are to blame. If but for our behaviour we wouldn't be sick. I would like to see ME advocacy organisations speak out against this abuse. Who will stand up for us when most of us can't stand.

 

[SilverbladeTE]

As I've said before, it's like the Witch hunts: you are damned if you do, damned if you don't

That a lot of this crap is down to psychologists/psychiatrists isn't mere coincidence, fact is they know how to manipulate how people think about things, how to write good PR....

 

[Snowdrop]

From the Guide:

2. Issues of terminology

2.1 Although the term MUS is commonly used in healthcare practice and academic articles it is unsatisfactory for a number of reasons. Foremost, it fails to engage patients in treatments as patients feel it invalidates their symptom experience and infers that their symptoms are 'all in the mind'6. In order to increase access to psychological therapies for this patient group it is crucial that our terminology is both accurate and acceptable to potential patients.

2.2 Other reasons cited for why we should not use the term MUS summarised in Creed et al.7 include:

2.2.1 It reinforces dualistic thinking and the idea that illness is either biological or psychological.

2.2.2 The term defines the illness by what it is not: i.e. it implies no organic cause which is not necessarily accurate and affords no treatment utility.

2.2.3 Research has shown that most patients want a positive description of symptoms i.e. an explanation of what it is rather than what is isn’t.

2.2.4 The term may appear dismissive and provides the message that nothing can be done. This is inaccurate as there are evidenced based approaches which show that methods such as CBT and graded exercise are effective treatments for these conditions.

2.2.5 Similar approaches also assist patients with well recognised medical conditions reduce the severity of symptoms and disability associated with the symptoms. Therefore the fact that psychological treatments works does not mean that the illness is psychological.

2.3 The IAPT MUS Task and Finish group strongly advises that when engaging or treating patients, the term MUS is not used. The experience of experts working in this field is that where possible patients should be given a specific diagnosis of a syndrome which describes their central symptom(s) without inferring that the aetiology is psychological. Common syndromes include:

- - -

Fibromyalgia
Irritable Bowel Syndrome
Chronic Fatigue Syndrome
Tempromandibular Joint (TMJ) dysfunction -
Atypical facial pain -
Non-Cardiac l chest pain -
Hyperventilation

Chronic Cough -
Loin Pain haematuria syndrome -
Functional Weakness / Movement Disorder -
Dissociative (Non-epileptic) Attacks -
Chronic pelvic pain/ Dysmenorrhoea

2.4 Many of these conditions have published diagnostic criteria which can be used in diagnosis.

2.5 Other terms in use which appear more acceptable to patients include persistent physical symptoms or functional syndromes/symptoms (FS)8. The term “functional” here is used because it is assumed that the disorder is one of function, which may be physical and/or psychosocial function, rather than anatomical structure. Sharpe likens this distinction to a car that needs tuning rather than a car which has mechanical damage. More recently, physiologically explained symptoms have also proposed as an alternative. For the rest of this paper we will refer to functional symptoms or syndromes (FS) rather than MUS.

This is not good. They have thrown people in the garbage by creating this. Dr's are/will be trained with only this in mind.

 

[Scarecrow]

Are we paying for the NHS to send these people on creative writing courses or is this something they do in their spare time?

 

[Scarecrow]

You know you're a high achiever when.........................

you have three or more of the following:

Fibromyalgia
Irritable Bowel Syndrome
Chronic Fatigue Syndrome
Tempromandibular Joint (TMJ) dysfunction -
Atypical facial pain -
Non-Cardiac l chest pain -
Hyperventilation
Chronic Cough -
Loin Pain haematuria syndrome -
Functional Weakness / Movement Disorder -
Dissociative (Non-epileptic) Attacks -
Chronic pelvic pain/ Dysmenorrhoea

Nice to see dysmenorrhea making another MUS appearance. But wait, don't period pains usually disappear around about the time that menses cease?

Medically unexplained? Really?

Sharp as dog biscuits, the lot of them.

 

[OverTheHills]

Are we paying for the NHS to send these people on creative writing courses or is this something they do in their spare time?

(your post) (their 'paper').

 

[Esther12]

Moss-Morris was the chair... oh-oh.

 

[Scarecrow]

Moss-Morris was the chair... oh-oh.

And the other usual suspects made an appearance.

 

[Leopardtail]

Tweeted by with thanks to @dxrevisionwatch

The title says it all. This is little more than gratuitous self promotion.

 

[Sean]

This is little more than gratuitous self promotion.

Indeed. Unfortunately it is from people who currently have the upper hand politically, and can do real damage in the meantime, until they are defanged.

 

[daisybell]

Members of the fibromyalgia association must be delighted that their Chair contributed to this .....

 

[zzz]

From the Guide:
2. Issues of terminology
2.1 Although the term MUS is commonly used in healthcare practice and academic articles it is unsatisfactory for a number of reasons. Foremost, it fails to engage patients in treatments as patients feel it invalidates their symptom experience and infers that their symptoms are 'all in the mind'6. In order to increase access to psychological therapies for this patient group it is crucial that our terminology is both accurate and acceptable to potential patients..

So in other words, it's fine for doctors to believe in this crap - they just shouldn't let their patients know.

This, unfortunately, is my doctor's philosophy.

It's a complete violation of the Autonomy section of medical ethics, which emphasizes the importance of keeping the patient honestly informed of their condition, as well as their doctor's evaluation of it. This is considered important so that patients can make informed decisions regarding their health.

I notice that they are listening though. They seem to more and more use language that we would use, only with an evil twist .

In other words, they're hijacking it. That way, if we use this language, they can claim that we're agreeing with them, and this confirms their diagnosis.

Nice to see dysmenorrhea making another MUS appearance. But wait, don't period pains usually disappear around about the time that menses cease?

Medically unexplained? Really?

Sharp as dog biscuits, the lot of them.

A swipe against women is mandatory in pseudo-psychiatry (hey, even Freud did it). Paying attention to the facts is not (again, see Freud).

This is just a slightly more refined version of Epidemic of apathetic and tired women.

 

[Sean]

Medically unexplained symptoms or syndromes (MUS) is a term commonly used to describe physical symptoms which cannot be explained by disease specific, observable biomedical pathology.

How much difference three sobering words could make:

Medically unexplained symptoms or syndromes (MUS) is a term commonly used to describe physical symptoms which cannot currently be adequately explained by known, disease specific, observable biomedical pathology.

But making it a conditional claim (as it should be) would expose their whole act. So it has to be made as an absolute claim ("…cannot be explained by…" ).

 

[heapsreal]

Medically unexplained because they don't allow the appropriate tests and if something is abnormal it's explained by saying it's nothing to worry about.

I'm starting to think there is a conspiracy on nk function testing. If gp's could test for this imagine how many they would find and this would help explain different infections and possibly then have to have better infection testing. But the health system don't want to pay for this or the antivirals some may need. It's cheaper to prescribe Zoloft and prozac.

how come other doctors and researchers can find and explain abnormalities in cfsme. It's not unexplained, it's just that they have no idea or the psychobabblers have a conflict of interest.

 

[Scarecrow]

4.6 For example, evidence suggests that predisposed people may be highly achievement orientated, basing their self-esteem and the respect from others on their abilities to live up to certain high standards.

When these people are faced with precipitating factors which affect their ability to perform, such as a combination of excessive stress and an acute illness or injury, their initial reaction is to press on and keep coping. This behaviour leads to the experience of ongoing symptoms which may be more closely related to pushing too hard than to the initial insult or injury. However, in making sense of the situation, patients attribute the ongoing symptoms to the original trigger.

The common response to an acute illness is to rest. However, reduced activity conflicts with achievement orientation and may result in bursts of activity in an attempt to meet expectations. These periodic bursts of activity inevitably exacerbate symptoms and result in failure, which further reinforces the belief that they have a serious illness.

As time goes by, efforts to meet previous standards of achievement are abandoned. Patients become increasingly distressed by their symptoms and increasingly accommodate to their illness. This accommodation to the illness and distress reinforces the symptoms through physiological changes related to poor sleepwake cycle, lack of a daily routine and autonomic arousal with consequent insomnia. This results in chronic disability.

Three prospective studies of the development of IBS, CFS and post-concussion syndrome after acute infection or injury, provide sound evidence for this model in three distinct functional syndromes13, 14, 15.

14 Moss-Morris, R., Spence, M., & Hou, R. The pathway between glandular fever and chronic fatigue syndrome. Can the cognitive behavioural model provide the map? Psychological Medicine, 2011, 41, (5), 1099-1108. (doi:10.1017/S003329171000139X)

Edited to add paragraph breaks

This reads like a Just So story to me, only not quite so diverting. It doesn't resonate with me at all because my own experience of falling ill and how I responded was so different. But I'm curious. Is there any pwMe or pwCFS out there who recognises this pattern in themselves?

 

[Leopardtail]

This reads like a Just So story to me, only not quite so diverting. It doesn't resonate with me at all because my own experience of falling ill and how I responded was so different. But I'm curious. Is there any pwMe or pwCFS out there who recognises this pattern in themselves?

I was and still am achievement oriented, and I have had to respect the illness and learn my new limits. The fact the few people with the illness surrender to it and many actively seek information on how to regain their health and get medical help partially fits their paradigm. What they forget is threefold:

1. people are less driven and have ME are more likely to recognise their capacity and avoid making themselves very ill. A driven personality plus ME is a very bad combination.
2. the people are who driven are more likely to be seen by medics, one has to fight hard to shake of the depression diagnosis and getting proper action.
3. people who have psychiatric mis-diagnoses or who are depressed due to their ME are more likely to accept psych referrals than those with dominantly physical symptoms.

I suspect they both forget what subset of ME patients they see due to the above, forget the impact personality on the ME (fighting against it) and focus on the symptoms they understand and know how to manage.