Doctor’s view on Medically Unexplained Symptoms

Discussion in 'Homesteading Questions' started by Jenn, May 17, 2006.

  1. Jenn

    Jenn Well-Known Member Supporter

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    Traditional (allopathic) doctor’s view on Illnesses without a medical explanation

    COI: I am not quite a traditional Dr: I am a near organic, near homesteader, crunchy granola sometimes hairy-legged woman type even to most Drs. I have Ulcerative Colitis (starting in past year) and have had depression and am dealing with my own issues of illness and disease.

    Doctors want to fix things, and get gratitude for having done so. Bladder infection, time and antibiotics, better, you’re welcome Mrs Jones. Repeat appointments, I’m not better yet, that didn’t work, maybe you (Dr) don’t even believe I’m actually sick or know what the devil you're doing…. Doctors have a term for these patients- in the UK it's "heartsink" as in the Dr's heart sinks when he sees the patient on the list or as she (usually) walks into the room. Medically unexplained symptoms is the term used in a few papers lately. ME FM MCS are the sorts of things Drs have in mind when we use that term.

    Lot of resentment/anger at these patients from some Drs. Guess they don't fit our model of we fix you, you thank us. Further they don't fit the scientific model of we can measure what's wrong objectively not with you telling me it happens but noone else was affected that way and it isn't even 100% for you. N=1 sample size and no big research explaining the reason for your illness.

    In my training I saw a lot of disdain for patients who “weren’t really sick”. My insight that they were afraid- that without my knowledge I too would be afraid if I were them- has led to my slightly better tolerance of such pts. Furthermore medical science advances in my career lifetime show us that today’s unexplained symptoms may be tomorrow’s well delineated and treatable disease. Fibromyalgia is actually a described and pretty much accepted disease amongst docs now where it was at ME’s stage- “they say they’re sick not depressed but if they try antidepressants half of them get better”.

    This all leads to resentment between drs and pts, drs not able to make pts happy and pts feeling maybe drs are part of a conspiracy to ignore their illness. (See ME and its handlng by the Wessely School school- google them- for a case history of a psychiatrist, Dr Wessely, with clear issues with a disease, ME) Sure some drs vote Republican, own bigpharm stock, some even sadly get gifts from bigpharma. But if we had a magic cure we’d give/sell/offer it to you.
     
  2. Jenn

    Jenn Well-Known Member Supporter

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    Drs don’t have absolute cures for a lot of these things. We don’t believe in the cures offered by complementary medicine which haven’t been tested in a double blind placebo controlled research project. But some things seem to help by those standards and I support their use, ie for everyone with these illnesses to give them an honest try.

    These are 1. antidepressants or other psychiatric meds: why? Because your illness can cause a depression. Or because maybe your illness is a somatisization disorder (presenting physical aches etc because of a mental illness) which often gets better when treated with antidepressants or other psychiatric meds. Who cares which came first or second- let’s do a research experiment on you N=1 and see if you get better! Can’t take one drug? Try another. And another. Along with other efforts to get better/ find a cause and then a treatment.

    And 2. graded exercise and rehabilitation to return those who have lost ability toward fuller ability and functioning. I see arguments that this is a bad thing for some ME sufferers. It is however certainly good for all of MY ME type symptoms [although I do not claim to suffer from ME (but I certainly might if I felt it helpful to me to use the term)] and I expect it will benefit some patients with it. I am also quite certain it benefits most other people who might otherwise decrease activity and suffer thereby- those depressed, injured especially at work, injured with hopes of a legal claim whch is strengthened by their continued disability, those with advancing old age related or immunologic arthritides or arthropathies and sometimes myopathies.
     

  3. Jenn

    Jenn Well-Known Member Supporter

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    Walker EA, Unützer J, and Katon WJ. Understanding and Caring for the Distressed Patient With Multiple Medically Unexplained Symptoms. J Am Board Fam Pract 11(5):347-356, 1998.

    http://www.medscape.com/viewarticle/417808 but have to sign in to see all, here's excerpts

    Abstract
    Background: Although physicians commonly encounter patients with complicated medical problems, some have a mix of unexplained medical symptoms and distress that can seem overwhelming to patient and physician alike.
    Methods: We describe a model for thinking about and helping these complex patients. The model was developed from our personal clinical experience as primary care psychiatric consultants, as well as from a review of the literature using such key words as "difficult," "frustrating," and "somatization."
    Results: The model involves understanding predisposing factors that render the patient vulnerable to the development of a disabling condition, precipitating factors that initiate an episode of illness, and perpetuating factors that maintain maladaptive illness behaviors with time.
    Conclusions: Awareness of these factors allows the clinician not only to tolerate and gradually unravel the complicated interactions that create and sustain distress in patients with multiple medically unexplained symptoms, but also devise practical and effective management strategies for these complex patients.


    Traditional biomedical training has emphasized detecting physical disease in a manner similar to puzzling out a murder mystery. Clinicians often derive intellectual satisfaction from the diagnosis of occult diseases. Yet for some patients no cause is found for their symptoms, and the clinician, gradually fatigued and defeated, can lose interest in the patient's condition.

    Recent studies have shown that no organic cause can be found for more than three quarters of such physical complaints as fatigue, chest pain, or dizziness.[11] In the search to rule out physical disease, many patients receive extensive workups for their illness complaints, while psychosocial evaluations are frequently deferred or incompletely accomplished. When psychosocial evaluations are accomplished, the most common findings include complicated mixes of current stressful life events, chronic social stressors, psychiatric disorders, childhood and adult sexual and physical victimization, chronic somatization, high health care utilization, and comorbid medical disease.[12,13] These studies have also shown that patients and physicians differ markedly in their perception of how medically ill and disabled the patient is. Patients not only are likely to perceive themselves as considerably more ill and disabled than their physicians do, but they often perceive a lack of empathy and understanding on the part of their physicians.

    ....


    Understanding Illness and Disease
    One of the most helpful starting points is the ability to differentiate between illness and disease. Although these terms are frequently used interchangeably, medical sociologists have made useful distinctions between the two concepts.[14] Disease describes the objective, physiologic changes that are associated with organic abnormalities and physical signs. Thus, high blood pressure, heart murmurs, and abnormal laboratory and physical examination findings are characteristic signs of disease. Illness, on the other hand, refers to subjective physical or psychologic symptoms that are perceived by the patient and can be associated with decrements in emotional, role, social, and occupational functioning.

    Patients can have relatively severe diseases, such as myocardial infarctions, yet adapt well and refuse to give up their work or social roles; thus, they have disease with little illness. Often these patients are admired for being brave and stoical, for getting on with their lives despite their disease. When hospitalized, these patients can minimize or deny they have a serious disorder and might attempt to leave against medical advice. Alternatively, physicians also encounter patients who appear to be highly disabled physically, emotionally, or occupationally out of proportion to the degree of suffering or despite the absence of any discoverable disease. These patients are often perceived as whiners and crocks, and when hospitalized, might attempt to stay against medical advice.

    Thus, although many patients have disease and illness episodes simultaneously, some might have disease without illness, and others might have illness without disease. In our culture we have far more difficulty dealing with the latter; it can provoke strong negative feelings in health care providers, which, in turn, can cause patients to persist in demanding that they get their medical needs met.

    A Model of Illness and Disease Interaction
    To deal with the many biologic, psychologic, and social factors that can affect clinical outcomes in patients, it is sometimes useful to use a three-stage model in which factors are grouped according to their role in the development and maintenance of a set of symptoms.[15] In this model particular events that occur during a patient's life can lay the groundwork for, initiate, or maintain the process of illness. The three stages of the model are (1) predisposing factors, (2) precipitating factors, and (3) perpetuating factors (the P-P-P model).

    Predisposing factors are patient characteristics that provide a basis for developing a disabling condition. Certain patient attributes contribute to the potential for a symptom to develop, like fuel waiting to be ignited. They can include such factors as biologic diatheses (eg, increased intestinal motility in patients with irritable bowel syndrome or autonomic nervous system instability in patients with panic disorder), chronic childhood medical illnesses, childhood maltreatment, low resilience, poor coping ability, low social support, chronic social stress, comorbid medical disease, and low psychologic mindedness.

    Precipitating factors are those elements of the patient's life that precipitate an illness event. They can include medical disease; a psychiatric disorder; social, fiscal, or occupational stress; a car accident; changes in social support; reexperienced trauma; or something as simple as change in routine or diet. These factors ignite the potential energy of the predisposing factors and precipitate a crisis that pushes the patient into a distress state and increases the use of health care.

    Finally, perpetuating factors are features of the patient's life that maintain the illness process and are akin to additional fuel for the fire. These features can include financial reinforcers of disability for a patient who dislikes his job, decreased self-confidence, decreased activation and weight gain, social isolation, and personal gain from the symptoms. Perpetuating factors often involve coping skills learned by the patient that at one time might have been adaptive solutions but have now become maladaptive and counterproductive.
    .....
     
  4. Jenn

    Jenn Well-Known Member Supporter

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    MCS doesn't quite fit into the above except that it's not yet well defined (and therefore accepted/believed in) by allopathic medicine and it has a lot in common with somatisization and other disorders; where one the pay off for having the illness may influence the recovery from the illness and two drs can't offer much satisfying treatment.

    So anyway I suggest if you have or might have MCS don't expect your Dr to have an easy way to fix it, approach him/her matter of factly when telling them you (may) have it (s/he may not believe in the condition) and plan on explaining it if they ask you to, and realise they'll be hesitant to write you a note saying you should go on disablity because you're allergic to work.

    And whatever MCS is, the mindbody process of emotions affecting the body and vice-versa- as in someone blows smoke in your face or sprays perfume into your office making you mad at them and terrified you might end up in hospital or sick all week- and that you collapsing or wheezing will help prove that you really are sick- may overlay biologic processes and affect how you let your illness play out and how much stress life hands you (you perceive) and how that stress affects your health.
     
  5. Jenn

    Jenn Well-Known Member Supporter

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    ...Reduce Functional Disability
    Many patients with chronic symptoms expect to become completely symptom-free. Because symptoms can accomplish something positive for a patient (ie, a woman with abdominal pain might [unconsciously] find her husband less physically abusive when she is ill), it is unlikely that such a patient would be willing to give up the positive benefits of such a symptom. By understanding the importance of the symptom to the patient, it is possible to find alternative ways to provide the desired outcome independent of the symptom (eg, suggesting marital therapy). Patients need to see their symptoms as annoyances to be overcome, not as deterministic limits on their lives. The main goal is improving functioning as much as possible.

    Let patients know that their symptoms might be long-lasting and that learning to live with the symptoms will help them regardless of whether the symptoms completely resolve. Emphasize that you can collaborate with the patient to help reduce distress from symptoms, but you might not be able to eliminate the symptoms entirely. Because physical deconditioning is common in patients with benign, nonmalignant pain, gradual, stepwise increments in physical exercise are usually necessary to build physical tolerance. For example, a patient with chronic low-back pain might be directed to a physical therapy program designed to increase mobility and conditioning and to prepare the patient to return to work, and the workplace might be modified to decrease the opportunities for back strain. You might not be able to cure the symptom completely, but you might be able to reduce its impact on the patient's daily functioning.

    ...
    Work on Changing Illness Beliefs
    Whereas some patients feel well most of the time and occasionally get sick, somatizing patients can feel as though they are ill most of the time and only occasionally experience good health. Reversing this distorted perception might require regular medical visits to reduce the patient's need to develop new complaints to gain access to and the attention of physicians.[20-24] Determine how many times the patient has appeared for treatment in the last 2 months, and schedule regular appointments accordingly. Regularly scheduled appointments decrease the patient's need for a physical complaint to obtain an appointment. Somatic fixation will often abate as patients realize the physician will see them regardless of whether they have a symptom. Replace the attention and caregiving that accompany symptomatic visits with reinforcement of patient's attempts at increasing positive activities and social contacts.
    Restoring a sense of control over symptoms and learning how stress and symptoms interact can benefit patients. Patients sometimes have the attitude of "your job is to fix me." A successful physician-patient collaboration requires that the clinician and patient both view healing as a cooperative venture and recognize that not every aspect is within the control of either the physician or the patient. A useful strategy is to explain that there might be no cure for the chronic symptoms, but that you and the patient can work together to improve functioning to the highest degree possible.
     
  6. mpillow

    mpillow Well-Known Member Supporter

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    My MIL claims to have fibromyalgia among other things...she falls and hurts herself alot because she drinks too much scotch.
    She has a stockpile of narcs and uses them regularly for other than prescribed uses/doses.....I called her doctor on it after finding her unconscious and had her admitted to the hospital. I told the doc that she was a drunk etc...but he was a friend of MIL's late husband (also a doc) and continues to give MIL every pill she asks for and passing it off as Fibromyalgia.....well you know what?
    When you drink too much and pass out in an awkward position of course you are going to have neck and shoulder pain :shrug: :grump: MIL=drunk and prescription drug addict....who needs the "betty ford" clinic and a doctor that will tell her to get over her whining and unhealthy lifestyle :hobbyhors

    Doctoring is an inexact science.....and quite limited by what the patient tells and what the doc asks...
     
  7. hedgeapple

    hedgeapple Well-Known Member

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    hey jenn, thanks so much for taking the time for such an in depth reply. it will be tonight before i can really sink my teeth into it but i look forward to it.
     
  8. hedgeapple

    hedgeapple Well-Known Member

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    well, it is not tonight yet, but i just had to read your posts one more time before doing afternoon work. again, thanks for taking the time to discuss this. i certainly, certainly understand and feel sorry for doctors who have to deal with certain patients - my mother is one of them (difficult patients, that is). even taking the time to give you a brief history of her and her actions would leave me depressed for the rest of the day - in my opinion and i have known her for almost fifty years, she is self-centered and manipulative among other things and uses alleged and/or real health complaints as part of her manipulative bid for attention. on the other hand, it seems like almost everyone i know over thirty says they just do not feel all that well, etc. some attribute it to age, some to personal and/or modern living stresses, etc. since i know i have had objective, verifiable physical reactions to some products, i am increasingly wondering if my not feeling good and other symptoms are less objective, less verifiable physical reactions to a variety of environmental factors, as i said on my post on mcs, i am thinking of secluding myself for at least a week away from modern world and its products to the extent i can and see if i can tell any difference. i think i can arrange to do this week after next. i think it is going to be hard, but i think it should yield me some personal info on whether mcs may be my problem. again , thanks, and i intend to do some more research on your posts.
     
  9. hedgeapple

    hedgeapple Well-Known Member

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    to wind in her hair, - just thought i would let you know that jenn just started a new thread to answer a question i asked her on another thread about chemical sensitivity. when i saw she was a doctor, i wanted her take on multiple chemical sensitivy from a doctor's viewpoint.
     
  10. susieM

    susieM Well-Known Member

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    Years ago, I was feeling quite sick, so my doctor stuck me into the hospital, and ran all sorts of tests...including ultrascan and IVP Dye...after a few days, he let me out, and gave me a bible, with the advice that it was all in my head, and I should perhaps take to reading the bible, for a cure.

    I took my Mom's advice, and went for a pregnancy test, instead....turns out THAT was the problem!
     
  11. nodak3

    nodak3 Well-Known Member Supporter

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    Yeah--had drs tell me I have ms, that I am depressed, that I have bad discs, have arthritis, etc. Took a nurse to question if I could be b12 low. One blood test later, we had an answer. Cheap, effective, therapy.
     
  12. ThreeJane

    ThreeJane Me Love Your Face

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    ..waiting...waiting for BobK to come trampling in...
     
  13. Jenn

    Jenn Well-Known Member Supporter

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    unkind response deleted- forgive me it's been a bad month.
     
  14. dixiedoodle

    dixiedoodle Well-Known Member

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    Guess ya just sh** out of luck! Mine has also been dragging his but!!!!!!!!!!!!!!!!!!!!!!!!!! :shrug:
     
  15. gypsymama

    gypsymama Well-Known Member

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    After reading the threads about Multiple Chemical Sensitivity and then Jenn's reply, it really struck a raw nerve with me.

    I've been battling illness (and therefore my sanity) since '96. Looking back it probably started way before that. I have been to multiple specialists and switched internists three times. For the last couple of years, I've pretty much given up hope.

    I know that at a certain level, I need to ask questions, be informed and stand up for myself. But unless I'm the one suggesting tests, coming up with theories and basically spoon feeding the doctors, they could care less about follow up let alone searching for an answer.

    I realize there are those doctors out there who do care and put out the effort, I just haven't found them.

    Thanks for listening....just had to get that off my chest!
     
  16. Jenn

    Jenn Well-Known Member Supporter

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    gm- yes, sorry I can't say that drs are a (big) source of assistance on these issues! Can only explain why maybe they can't/won't be!

    My concern though is that the folks willing to assist are more likely to be charlatans and less likely to follow any rigorous scientific method that would prove that their methods are effective.

    We (pts) can only be our own advocate, and be careful of any promises of miracle cures- that's a time to hold carefully onto your purse!
     
  17. Quint

    Quint Well-Known Member

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    /Quint screams like 6 year old girl

    TMI
    TMI
    TMI
    TMI