25 Sep Update – managing patients with medically unexplained symptoms
Since writing my ‘Outsider’s Observation’ piece about Medically Unexplained Symptoms in General Practice for GP View at the end of 2016, there seems to have been a remarkable proliferation of articles, and medical CPD events, around the issues of managing patients with medically unexplained symptoms. Of course these will all have been in the pipeline for many months or longer.
The most notable of the articles has been:
- BMJ article How should we manage adults with persistent unexplained physical symptoms February 2017
- BMC Family Practice Medically unexplained symptoms and symptom disorders in primary care: prognosis-based recognition and classification February 2017
- BJGP March 2017 article Medically unexplained symptoms: continuing challenges for primary care
These have made for illuminating and alarming reading. I and some courageous patients have contributed rapid responses and e-letters (where it has been possible for non-doctors to do so) and several of these contributions have been published. It has been very noticeable that there has been almost no reaction, response, acknowledgement, challenge or whatever to what we have written.
I was especially alarmed by the BMC Family Practice article (above no.2), which describes Bodily Distress Syndrome (BDS) – more severe MUS – thus:
Recent studies on BDS suggest that central sensitisation not only results in multiple symptoms; it may also prompt several specific symptom patterns described by arousal and/or exhaustion symptoms. These symptoms cluster in four groups: 1) cardiopulmonary/autonomic arousal symptoms (palpitations/heart pounding, precordial discomfort, breathlessness without exertion, hyperventilation, hot or cold sweats, dry mouth), 2) gastrointestinal arousal symptoms (abdominal pains, frequent loose bowel movements, feeling bloated/full of gas/distended, regurgitations, diarrhoea, nausea, burning sensation in chest or epigastrium), 3) musculoskeletal tension symptoms (pains in arms or legs, muscular aches or pains, pains in the joints, feelings of paresis or localized weakness, backache, pain moving from one place to another, unpleasant numbness or tingling sensations), and 4) general symptoms (concentration difficulties, impairment of memory, excessive fatigue, headache, dizziness).
The same article goes on to recommend that:
Taking a prognostic approach, while remaining agnostic about aetiology, is likely to be acceptable for both doctors and patients.
This is frankly astonishing. I very much doubt whether remaining ‘agnostic about aetiology’ of such extreme bodily distress is indeed acceptable to GPs or patients?
The pertinent and very informative blog What’s the harm in taking an antidepressant by Kelly Brogan MD, summarising very clearly for GPs the research about antidepressants by Carvalho et al published in 2016 , points to a clear overlap with many of the BDS symptoms described above. I know of many people who have direct experience of this terrible suffering – due directly to effects of antidepressants and/or benzodiazepines and other psychiatric medicines which have been taken as prescribed by their doctors.
Surely the medical establishment cannot continue to turn a blind eye to what seems to be happening all around us?
In March we (I, on behalf of a patient self-help group Recovery and Renewal) launched a public petition to the Scottish Parliament Petitions Committee, PE01651 ‘Prescribed drug dependence and withdrawal’. This is currently making its way through the Scottish Parliament Petitions process and gathering formal written statements as these become published online. A Scottish GP has written BJGP Bad Medicine: The medical untouchables supporting our petition. Now a similar public petition has also been launched with the Welsh Assembly Petitions Committee .
In Scotland our Chief Medical Officer, Catherine Calderwood, is promoting the impressive ‘Realistic Medicine’ initiative which was begun in 2016 and has now developed into ‘Realising Realistic Medicine’. I attended the Realistic Medicine conference in Edinburgh on 24 August, where some 70% of attendees were doctors. The conference was themed around improving communication between all parties and ‘listening to patients’. The speakers championed honesty around adverse events and the principles of the Duty of Candour. There was a relevant workshop about SIGN (Scottish Intercollegiate Guideline Network) guidelines and mention of ‘patient-centred outcome measures’ and patient surveys and aiming to ‘reduce harm and waste’. There was also a lot of discussion on the problems of ‘long-term conditions’, dementia and work with Alliance Scotland (such as ‘House of Care’) as well as end-of-life care difficulties and dilemmas. As our petition shows, many cases of long-term conditions may indeed be caused or exacerbated by over-use of prescribed antidepressants and benzodiazepines. We are calling on the Scottish Government to put their stated Realistic Medicine commitments into practice.
There are serious ethical issues that need to be taken into consideration, by all of us, which are set out starkly in the 2016 paper by Peter Breggin in his ‘Rational Principles of Psychopharmacology’ where he says:
“Psychologists, counselors, and social workers have been trained that it is their duty to refer their more distressed clients for psychiatric drugs. A growing, well-documented literature continues to describe the tragic results of this. Therapists and healthcare providers have an ethical duty to provide scientific information about the real effects of psychiatric drugs.”
“Psychologists, therapists and other healthcare providers who read this article will have a more accurate understanding of drug effects than the vast majority of prescribers.”
Peter Breggin’s paper makes for sobering reading.
Author: Marion Brown