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iCAAD London 2019 - Dr James Stallard - THE REVOLVING DOOR - PSYCHIATRY IN THE EMERGENCY DEPARTMENT: FREQUENT ATTENDERS, MEDICALLY UNEXPLAINED SYMPTOMS, OVERDOSE, ADDICTION AND PERSONALITY DISORDERS.
- 1. Psychiatry in ED: Frequent Attenders with Medically Unexplained Symptoms Dr James Stallard May 2019
- 3. 1 1. Frequent Attenders at the Emergency Department 2. Medically Unexplained Symptoms 3. FAMUS project at Royal Bournemouth Hospital
- 4. 1 • We set up a group in 2014 to monitor FAs • ED doctors and nurses, Alcohol liaison, Liaison Psychiatry, Ambulance service • Monitoring over the previous 3 months • Literature often defines >12 times per year as frequent attendance • Found far higher numbers – top 20 patients attending between 8 and 20 times in 3 months Frequent Attenders at ED
- 5. 1 • No physical illness brings someone to ED 20 times in 3/12 • Even if they do have treatable physical conditions, all frequent attenders have unmet psychological needs Who were they?
- 8. 1 Physical symptoms No physical pathology Mental symptoms Psychiatric diagnosis Physical Symptoms Physical pathology The Health System and MUS
- 9. 1 • The NHS in England spends at least £3 billion each year attempting to diagnose and treat MUS (Bermingham et al 2010) • Over half new attendees at medical out-patients fulfil criteria for one ‘functional somatic syndrome’ (Nimnuan 2001) • Persistent MUS is the most common reason for frequent attendance at GP (Jyvarsi 1998) • Pts with PMUS seek help from GP but are unwilling to see mental health professionals (Kirmayer and Robins 1996) • GPs express lower satisfaction with care for PMUS than pt with psychological problems (Hartz 2000) A very big issue!
- 10. 1 Rene Descartes 1596 – 1650 • Res Cogitans vs Res Externa • ‘Cartesian Dualism’ • The mind/body split
- 11. 1 • Every specialty has them • eg Fibromyalgia, Chronic Fatigue Syndrome, IBS, Non-cardiac chest pain, tinnitus, • Acceptable to patients • Bring relief and validation (Woodward et al 1995) BUT • They medicalise! Medical terminology : Functional Syndromes
- 12. 1 • Many similarities between people with different syndromes • eg females over-represented, CSA, psychiatric comorbidity (Fiedler et al 1998) • Great deal of symptom overlap (Wesseley et al 1999) • Separation into different syndromes is an artefact of medical specialisation (Wesseley et al 1999) • Probably not discrete entities Medical terminology : Functional Syndromes
- 13. 1 Medical terminology : the Functional Syndromes
- 14. 1 • Somatoform disorders, somatization disorder • Of little use to patients • Puts conditions in realm of mental health services • Not well used • …….on their way out? Psychiatric classification: ICD10
- 15. 1 • ‘Number Needed to Offend’ (Stone et al BMJ 2002) • Looking at patients perceptions of terminology around functional neurological symptoms • Descending ‘offence score’: • Symptoms all in the mind • Hysterical weakness • Psychosomatic weakness • Medically unexplained weakness • Stress related weakness • Chronic fatigue • Functional weakness TERMINOLOGY
- 16. 1 • >6 months of somatic symptoms which • impair function or are distressing • with excessive and disproportionate thoughts, feelings and behaviours towards those symptoms. • Criticised as being too broad, bringing millions of people into a ‘mental disorder’ • Removes need for symptoms to be unexplained • ie could be disproportionate reaction to a medical condition DSM5: Somatic Symptom Disorder
- 17. 1 Functional neurological symptoms: no pathology – dissociative phenomenon COPD plus anxiety Back pain Physical pathology Psychosocial factors Functional Abdo pain
- 18. 1 • An individual with some level of • Physical vulnerability • Difficulty in identifying feelings, seeking attachment etc • A system which medicalises, sending strong messages • Investigations, treatments, labels… • and then attempts to discharge them • Repeated, emotionally charged, dissatisfying encounters Functional symptoms:a BIOPSYCHOSOCIAL phenomenon
- 19. 1 • ‘Predictive coding’ and ‘the Bayesian brain’ • Karl Friston: The Free Energy Principle: A Unified Brain Theory. Nature Reviews Neuroscience 2010 • Abnormal health beliefs, fearful appraisal of sensations, paying attention to symptoms, putting value on symptoms etc • Amplifies otherwise inocuous sensations A Neuropsychological Model for Functional Symptoms
- 20. 1 Role of functional pain in the opiate crisis • Opiates are excellent for acute pain • Ineffective for chronic pain (and harmful) • Chronic pain clearly has a powerful psychological component (which opiates may partially ameliorate) • In the absence of underlying peripheral pathology, can be thought of as a ‘functional syndrome’ • Chronic opiate prescriptions should be avoided in this group!!
- 21. 1 Frequent Attenders with Medically Unexplained Symptoms (FAMUS) project at RBH • A non-randomised controlled trial • 25 patients recruited via Frequent Attenders meeting (functional abdo pain, back pain, chest pain…) • 25 patients recruited for control group from Poole Hospital
- 22. 1 ASSESSMENT PHASE • Engagement is key • Patients invited to meet us in ED • Stated aim is to help to ‘cope with symptoms’ • Start with the physical symptoms. Go into detail. • ‘Bleed the symptoms dry’
- 23. 1 Childhood experience of physical illness /sick role Attachment disruptions Biopsychosocial factors for functional symptoms Relational factors Dominant partner, advocating strongly Overconcerned family A ‘turning point’ Mental disorder Depression Anxiety EUPD Dissociative disorders External Factors Compensation Sickness Benefits Props: wheelchairs etc Loss of Role: bankruptcy, redundancy, loss of carer role Medical Factors Repeated investigations (reinforces abnormal health beliefs) Opiates Conflict with doctors Psychological Factors Other functional syndromes
- 24. 1 CBT Phase • Patients offered 10 – 16 weekly sessions of CBT (with a mean attendance rate of 12 sessions). • The CBT provided was based on an adaptation of: • CBT for Somatisation protocol (Woolfolk and Allen, 2007) • CBT for Persistent Health Anxiety protocol (Salkovskis et al. 2003)
- 25. 1 PHQ9 16.08 8.12 -49.5% GAD 7 15.92 5.88 -63.1% WSAS 25.52 17.84 -30.1% Psychometric Questionnaire Outcomes Pre & Post Intervention
- 26. 1 Results: Pre- and post- intervention 0 100 200 300 400 500 600 ED attends Target Group Bed days used Target Group ED attends Control Group Bed days used Control Group Pre-intervention Post intervention
- 27. 1 CONCLUSIONS • People with MUS are amongst the most frequent attenders at ED • Their high use of resources, and mood and anxiety scores, can be improved significantly with a CBT intervention • A good theoretical understanding of MUS is vital • Engagement is key
Editor's Notes
- Before brexit came along liaison psychiatrists blamed everything wrong with the world on rene Descartes. He is accused of being the father of dualism- the mind body split whereby in the west particularly all things to do with the physical body are separated from that to do with mind. We see nit in our organisations and we see it in the buildings which house those organisations. In our system we are good at dealing with people with physical problems who have underlying physician pathology and we are good at dealing with people wiht psychoform sx, but we are bad at people with physical symptoms which are driven by central or psychological processes.
- Before brexit came along liaison psychiatrists blamed everything wrong with the world on rene Descartes. He is accused of being the father of dualism- the mind body split whereby in the west particularly all things to do with the physical body are separated from that to do with mind. We see nit in our organisations and we see it in the buildings which house those organisations. In our system we are good at dealing with people with physical problems who have underlying physician pathology and we are good at dealing with people wiht psychoform sx, but we are bad at people with physical symptoms which are driven by central or psychological processes.
- Before brexit came along liaison psychiatrists blamed everything wrong with the world on rene Descartes. He is accused of being the father of dualism- the mind body split whereby in the west particularly all things to do with the physical body are separated from that to do with mind. We see nit in our organisations and we see it in the buildings which house those organisations. In our system we are good at dealing with people with physical problems who have underlying physician pathology and we are good at dealing with people wiht psychoform sx, but we are bad at people with physical symptoms which are driven by central or psychological processes.
- Before brexit came along liaison psychiatrists blamed everything wrong with the world on rene Descartes. He is accused of being the father of dualism- the mind body split whereby in the west particularly all things to do with the physical body are separated from that to do with mind. We see nit in our organisations and we see it in the buildings which house those organisations. In our system we are good at dealing with people with physical problems who have underlying physician pathology and we are good at dealing with people wiht psychoform sx, but we are bad at people with physical symptoms which are driven by central or psychological processes.
- Another way of coming at it is thinking about how big the psychological contribution is likely to be The whole gamut of SsD can be seen as a Spectrum. Physical condition with psychological overlay down one end. For instance in her respiratory clinic Sam sees a lot of people with severe COPD who don't cope well with it, are anxious, and this contributes tsignificanlty o their problems. You might see them as having a lot of physical component with a bit of psychological on top, driven by anxiety. Down the other end you might put the functional neurological symptoms, things like functional paralysis or non epileptic seizures, where there might be no physical pathology and the symptoms are truly psychogenic, and we can conceptualise them as being driven by diccoiation, the ability to separate off and compartmentalise aspects of mental functioning. One of the points of seeing things in this way is that it makes the point that there is little point in talking about what is real or not. This is a mind body issue. The symptoms are real, we just need to work out what's causing them and try to meet the patients needs.
- Another way of coming at it is thinking about how big the psychological contribution is likely to be The whole gamut of SsD can be seen as a Spectrum. Physical condition with psychological overlay down one end. For instance in her respiratory clinic Sam sees a lot of people with severe COPD who don't cope well with it, are anxious, and this contributes tsignificanlty o their problems. You might see them as having a lot of physical component with a bit of psychological on top, driven by anxiety. Down the other end you might put the functional neurological symptoms, things like functional paralysis or non epileptic seizures, where there might be no physical pathology and the symptoms are truly psychogenic, and we can conceptualise them as being driven by diccoiation, the ability to separate off and compartmentalise aspects of mental functioning. One of the points of seeing things in this way is that it makes the point that there is little point in talking about what is real or not. This is a mind body issue. The symptoms are real, we just need to work out what's causing them and try to meet the patients needs.
- A word about the medical system. First of all, I am by no means criticising my medical and surgical colleagues. The hospital is full of doctors who are doing their jobs, fixing the the things that can be fixed within their specialty. And these are the people that MUS patients actually present to. But by and large they do not feel equipped to cope with the complex psychopathology they encounter. They focus on the symtpoms. They do whath is within their r power to do. That means they ive opiates for pain, they investigate. In this climate of defensiveness there is a paranoia about missing something. If they are a surgeon they have a powerful intervention at theior disposal. Operations are what surgeons do. Im not criticising. Our medical and surgical colleagues actually do much more for this patient group than we in mental health do. They are he ones actually dealing with them. But inevitably, most of their interventions makes things worse.