Medically unexplained symptoms: assessment and management (2021) Mujtaba Husain and Trudie Chalder

[Esther12]

ABSTRACT
Medically unexplained symptoms or persistent physical symptoms are common, real and are associated with significant distress, loss of functioning and high healthcare costs. History, examination and appropriate investigations are essential to make a diagnosis. Once the diagnosis has been made, exploring the impact of the symptoms helps us to tailor our advice to patients. This paper sets out a practical approach to taking a history, assessment and stepwise management principles.

https://www.rcpjournals.org/content/clinmedicine/21/1/13

This is barely worth posting, but I read it. It's so basic it felt like it was written for children - is that because it's in a journal for doctors rather than researchers? So many strong assertions ("The first and most important step is a positive diagnosis and explanation of what the diagnosis means") that were then so vague on implementation.

Table 3 is based on the PRINCE trial's approach to MUS and managing activity: https://www.rcpjournals.org/highwire/markup/11946/expansion?width=1000&height=500&iframe=true&postprocessors=highwire_tables,highwire_reclass,highwire_figures,highwire_math,highwire_inline_linked_media,highwire_embed

I remember @dave30th writing about some exaggerated claims on this, but I think that this figure is lower than the ones previously used: "PPS are also estimated to account for approximately 10% of total NHS expenditure for the working-age population in England.7"

 

[Hutan]

It's so basic it felt like it was written for children

I'm not surprised. The whole premise is at that level.

History, examination and appropriate investigations are essential to make a diagnosis.

Really, only three questions are required for diagnosis:
1. Do you have any symptoms? If yes, go to 2.
2. Have they been persistent? If yes, go to 3.
3. Can I explain all your persistent symptoms with my limited understanding of the current body of bio-medical knowledge (possibly made more limited by a lack of time or interest to take a proper history, and lack of authority or interest to order tests)? If no, inform the patient that they have PPS or MUS.

 

[dave30th]

I remember @dave30th writing about some exaggerated claims on this, but I think that this figure is lower than the ones previously used: "PPS are also estimated to account for approximately 10% of total NHS expenditure for the working-age population in England.

This paper is part of a whole special issue on functional disorders, I think. That figure is a slight misstatement of what the paper said. In the working age population, 11 % of total NHS expenditures is spent on those in that age group with PPS or MUS. That's not to say that all the expenditures were for MUS, although most probably were. The mistake was that Chalder & her colleagues kept writing that these costs accounted for 11% of the cost for the total NHS population, which was about three times as large as for the total costs just for the working-age population.

 

[Sean]

 

[Jonathan Edwards]

This is barely worth posting, but I read it. It's so basic it felt like it was written for children - is that because it's in a journal for doctors rather than researchers?

It is produced by the Royal College of Physicians and is clearly intended as curricular material for trainee physicians. Which makes it a catastrophe. Medicine based on the blind leading the blind.

 

[Joan Crawford]

("The first and most important step is a positive diagnosis and explanation of what the diagnosis means")

So, diagnosing a non-diagnosis (by definition) of MUS is the best and sparkliest thing for our trainee physicians. Pretty patronising to patients and the trainee physicians

 

[Jonathan Edwards]

("The first and most important step is a positive diagnosis and explanation of what the diagnosis means")

So, diagnosing a non-diagnosis (by definition) of MUS is the best and sparkliest thing for our trainee physicians. Pretty patronising to patients and the trainee physicians

Indeed: 'The first thing to learn in medicine is how to make things up without letting on - how to bullshit professionally.'

 

[Joan Crawford]

Indeed: 'The first thing to learn in medicine is how to make things up without letting on - how to bullshit professionally.'

Ha ha start them young

 

[Hoopoe]

Then there are maintaining factors which keep the symptoms going. These can be divided into four groups.

• Physiological: autonomic dysregulation, central sensitisation, hypothalamic–pituitary–adrenal (HPA) axis dysfunction and sleep disruption.
  
• Social: loss of role and medical uncertainty.
  
• Cognitive: catastrophic misappraisal of symptoms, symptom focusing and intolerance of uncertainty.
  
• Behavioural: avoidance behaviour, ‘all or nothing’ behaviours and poor sleep hygiene.

I'm sure this is all supported by good science and not a confusion of consequences of illness with cause of illness.

 

[Jonathan Edwards]

Looking at the blurb for the magazine is pretty dispiriting. It is indeed for children. The mission statement includes:

peer-reviewed journal of the Royal College of Physicians, Clinical Medicine (ClinMed) publishes advances in general and specialist medicine and authoritative reviews ... it particularly encourages submissions from trainees and early-career researchers who wish to build their publication portfolio.

I.e. it publishes authoritative reviews by trainees who know nothing much about their subject. Maybe that is who the first author is here. I have always been appalled by the tradition in medicine to get trainees to write review articles so that they can polish their CV (openly admitted as the aim here). Usually there is also a senior author who is happy to tag their name on to her enlarge their publication list to 900.

I see that the editor in chief is at UCH.I have met him. He seemed pleasant but I had a suspicion he was tied up with 'functional' diagnoses in a muddled sort of way.

 

[FMMM1]

Looking at the blurb for the magazine is pretty dispiriting. It is indeed for children. The mission statement includes:

peer-reviewed journal of the Royal College of Physicians, Clinical Medicine (ClinMed) publishes advances in general and specialist medicine and authoritative reviews ... it particularly encourages submissions from trainees and early-career researchers who wish to build their publication portfolio.

I.e. it publishes authoritative reviews by trainees who know nothing much about their subject. Maybe that is who the first author is here. I have always been appalled by the tradition in medicine to get trainees to write review articles so that they can polish their CV (openly admitted as the aim here). Usually there is also a senior author who is happy to tag their name on to her enlarge their publication list to 900.

I see that the editor in chief is at UCH.I have met him. He seemed pleasant but I had a suspicion he was tied up with 'functional' diagnoses in a muddled sort of way.

I assume I'm missing something here but wouldn't it be better to try to understand what the underlying problem is and treat it? E.g. if there's a shed load of money, to investigate an apparent case of MUS - say in the US or a wealthy country where money is no object - and it turns out that MUS was actually a biomedical problem "X", then find a biomarker for "X" and see how many MUS are actually explained by "X". OK it may not be that simple e.g. MUS may be many things (rare diseases) and understanding a particular case may be extremely difficult. A genome-wide association study (GWAS) might turn up something but if MUS is many things then I guess that is really difficult (finding suitable controls).

 

[Hutan]

Indeed: 'The first thing to learn in medicine is how to make things up without letting on - how to bullshit professionally.'

That worked really well when access to medical knowledge was tightly restricted.

I wonder how big an impact google, social media and patient forums are having on the ability of doctors, and especially GPs, to bullshit and not get caught out, and what that might eventually mean for MUS. The doctor might be right 99 times out of a hundred, but the one time they clearly make things up could not only severely erode the faith their patient has in them, but (after the bullshit has been tweeted about globally) cause a loss of prestige for the profession as a whole.

Arguably, that is what is happening for ME/CFS, with the result that guidelines are changing and new treatment trials of MUS participants don't include people with a 'primary' diagnosis of CFS

 

[Trish]

I.e. it publishes authoritative reviews by trainees who know nothing much about their subject. Maybe that is who the first author is here.

Just checked - the first author is a Consultant Liaison Psychiatrist at the South London and Maudsley NHS Trust which is where Chalder is also based as well as being a professor of CBT at Kings'.

I've just read it. The first part is surely at the level of introductory case history taking for medical students, not for qualified physicians, then there's all the usual unfounded claims about MUS having a large psychological component, and the latter part is the usual 'all roads lead to CBT'.

What a disaster.

 

[rvallee]

I'm not surprised. The whole premise is at that level.

I don't know. Children usually have mastered object permanence. This is more at the toddler level, "if you don't test for it, you have zero cases".

 

[MSEsperanza]

Just checked - the first author is a Consultant Liaison Psychiatrist at the South London and Maudsley NHS Trust which is where Chalder is also based as well as being a professor of CBT at Kings'.

He's also one of the persons who gave their expert testimony to the NICE committee.

https://www.nice.org.uk/guidance/GID-NG10091/documents/supporting-documentation-3

 

[Snowdrop]

I'm struck by the comment of 'broad eligibility criteria'

We have broad eligibility criteria to
ensure we do not exclude people from getting help.

It occurs to me that we hit a wall with this because it's backwards. It is explicit in stating that as many as possible be considered and implicitly it suggests that only we with ME would be included otherwise. Yet the evidence is the other way round. There is more evidence to exclude PwME than general fatigue. So one might more correctly say that the many with fatigue are the primary focus and that PwME are looking to be excluded form that -- not as is suggested in the way they put it -- that people with general fatigue should also be included.

If that makes sense.

 

[Simbindi]

I'm struck by the comment of 'broad eligibility criteria'

We have broad eligibility criteria to
ensure we do not exclude people from getting help.

It occurs to me that we hit a wall with this because it's backwards. It is explicit in stating that as many as possible be considered and implicitly it suggests that only we with ME would be included otherwise. Yet the evidence is the other way round. There is more evidence to exclude PwME than general fatigue. So one might more correctly say that the many with fatigue are the primary focus and that PwME are looking to be excluded form that -- not as is suggested in the way they put it -- that people with general fatigue should also be included.

If that makes sense.

This is an interesting find. Because this is why they are arguing against PEM/PESE being the core symptom in the new NICE guidelines. They want them to cover as many people as possible, including those who have general fatigue.

 

[Arnie Pye]

One thing that has never occurred to me until just now is :

Who makes the MUS diagnosis? Is it a GP? A doctor in secondary care? Can someone be seen by a GP, get given an FBC (Full Blood Count), and end up being sent straight to an MUS clinic without being seen by secondary care, do not pass Go and do not collect £200?

 

[Invisible Woman]

One thing that has never occurred to me until just now is :

Who makes the MUS diagnosis? Is it a GP? A doctor in secondary care? Can someone be seen by a GP, get given an FBC (Full Blood Count), and end up being sent straight to an MUS clinic without being seen by secondary care, do not pass Go and do not collect £200?

I reckon most of the time the GP will have formed an opinion based on presentation and who you are referred on to will reflect that i.e. whether it's rheumatology or neurology or straight to IAPT.

The snag is once referred to IAPT you may never climb back out of that particular waste basket whereas other specialist clinics will refer back to the GP if they feel they can't help & the patient needs a different speciality.

So if you get sent to IAPT I reckon it may be a GP diagnosis by default because I doubt they'll turn many away.