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Rapid Responses: Rapid Responses published:
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Explaining the unexplained
- Jecko Thachil (16 May 2008)
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Explaining the explanation
- Douglas T Fraser (16 May 2008)
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Role of radiology in the Assessment and management of medically unexplained symptoms
- Dhakshina M Ganeshan (17 May 2008)
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Treating clinical presentations rather than psychiatric syndromes or diseases in primary care
- Sherab Tsheringla, K S Jacob (17 May 2008)
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Experience in management of medically unexplained symptoms
- jyotirmoy ghosh (19 May 2008)
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A judicious Evaluation of unexplained symptoms
- Shirwan A Mirza, MD, FACP, FACE (19 May 2008)
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The unexplained is merely the unknown
- Annette l. Barclay (19 May 2008)
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Homesick
- Hugh Mann (20 May 2008)
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The need for a multidisciplinary approach
- Jon Jureidini, Philip Calvert (22 May 2008)
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Is avoidance now the best option?
- Ian T McLachlan (22 May 2008)
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Acupuncture for people with Medically Unexplained Symptoms
- Charlotte Paterson, On behalf of the CACTUS Study Research Team (22 May 2008)
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Uncovering Explanations
- Randy S Baker MD (23 May 2008)
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Re: The need for a multidisciplinary approach
- Raymond G Holder (23 May 2008)
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The undiagnosable
- Kenneth A Hoekstra (24 May 2008)
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Medically unexplained symptoms and impaired capillary blood flow.
- Les O. Simpson (25 May 2008)
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Re: A judicious Evaluation of unexplained symptoms
- John P Cosgrove (25 May 2008)
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Medically unexplained symptoms
- Daniel S. Elman (5 July 2008)
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Jecko Thachil, Research Fellow University of Liverpool, Liverpool, L7 8XP
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Hatcher and Arroll give a very practical approach to a very common and interesting problem of medically unexplained symptoms [1]. They stress the disadvantages of over investigation and overtreatment leading to increased "illness behaviour". At the same time, it is important to have ruled out any associated pathology, with a good history and appropriate investigations by an experienced clinician, especially when these symptoms are persistent. Two of the rare conditions which can present with these unexplained symptoms and are often missed, are acute porphyria and chronic lead intoxication. Acute porphyria is a metabolic disorder which has been described as the “great masquerador” and can present with non specific symptoms including diffuse abdominal pain, muscle weakness, psychiatric disturbances and neurological symptoms. The acute porphyrias are often misdiagnosed according to a review by Thadani et al in the journal [2]. A recent expert panel recommendation on the management of acute porphyria urged to consider this condition in “all adults with unexplained symptoms” with certain clinical features being very suggestive including women of reproductive age, abdominal pain, muscle weakness, hyponatremia and dark or reddish urine [3]. It is however illogical to think of any patient who present with abdominal pain or psychiatric disturbances to have porphyria. Some helpful clues which suggest the possibility of porphyria include new- onset hypertension; hyponatremia; proximal muscle weakness; pain associated with the luteal phase of the menstrual cycle; recent use of medications known to exacerbate porphyria; or low calorie, low- carbohydrate diets [2,3]. The diagnosis of acute porphyria is made by measuring the levels of porphyrins in blood, or urine[4]. Chronic lead toxicity is another condition which presents with non specific symptoms and is becoming an increasing concern not just in developing countries. Lead paint is the primary source of lead exposure and the major source of lead toxicity in children [5]. As lead paint deteriorates and airborne lead settles, it contaminates dust and soil and can become significantly hazardous for children. Other causes of toxicity include lead pipes, lead-glazed ceramic plates, vinyl lunchboxes and herbal remedies [5]. Chronic exposure to lead through these mechanisms can cause serious neurological deficits but is also known to cause non specific symptoms initially which can manifest as generalised fatigue, headache, insomnia, irritability, weight loss and personality changes [6]. Gastrointestinal manifestations of lead poisoning include chronic or recurrent abdominal pain, nausea, vomiting, constipation, bloating, anorexia and weight loss, all of which can be mistaken for irritable bowel syndrome or a functional bowel disorder [7]. The characteristic red blood cell changes which have been thought to be useful in the diagnosis of lead poisoning may only occur with very high blood levels and cannot be relied upon in all situations [8]. A high index of suspicion should therefore be maintained and blood checks for the levels of the heavy metal should be initiated. Thus, though it is important to entertain psychiatric diagnoses in patients with unexplained symptoms, it is important not to miss some rare conditions which can be easily diagnosed and managed. This would have helped to cure King George’s madness (due to porphyria) and Beethoven’s strange illness (due to lead toxicity) if it was thought of, in time. References 1. Hatcher S, Arroll B. Assessment and management of medically unexplained symptoms. BMJ 2008;336:1124-1128. 2. Anderson KE, Bloomer JR, Bonkovsky HL, Kushner JP, Pierach CA, Pimstone NR, Desnick RJ. Recommendations for the diagnosis and treatment of the acute porphyrias. Ann Intern Med. 2005; 142: 439-50. 3. Kauppinen R. Porphyrias. Lancet. 2005; 365: 241-52. 4. Thadani H, Deacon A, Peters T. Diagnosis and management of porphyria. BMJ. 2000 ; 320: 1647-51. 5. Patrick L. Lead toxicity, a review of the literature. Part 1: Exposure, evaluation, and treatment. Altern Med Rev 2006; 11: 2-22. 6. Needleman H. Lead poisoning. Annu Rev Med2004;55:209-222. 7. Begovic V, Nozic D, Kupresanin S, Tarabar D.Extreme gastric dilation caused by chronic lead poisoning: A case report.World J Gastroenterol. 2008; 14: 2599-601. 8. Paglia DE, Valentine WN, Fink K.Lead poisoning. Further observations on erythrocyte pyrimidine-nucleotidase deficiency and intracellular accumulation of pyrimidine nucleotides. J Clin Invest. 1977; 60:1362-6. Competing interests: None declared |
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Douglas T Fraser, musician W6
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Hatcher and Arroll explain that many people consult their doctors about symptoms for which their doctors are unable to provide an explanation. As a result of their inability to provide an explanation, there cannot be any disease. Hence people must be suffering from a fancy mental aberration that can presumably be accurately diagnosed, and elaborated until the cows come home. It is this alleged "disorder" rather than the actual disease yet to be researched and explained that must be treated "properly" - in order to save money ! The article reminded me of a comment by Paul Ewald in a recent interview: "Human beings didn’t evolve to be scientists. Instead they evolved to be competitive – to grab and hold onto what is theirs. Hence the name calling often observed among the medical community and the resistance among scientists to fund or support ideas other then their own, ideas that question the validity of current dogma." Interview with evolutionary biologist Paul Ewald http://bacteriality.com/2008/02/11/ewald/ Competing interests: None declared |
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Dhakshina M Ganeshan, Specialist Registrar in Radiology Whiston Hospital, L35 5DR
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Dear Sir/ Madam The clinical review article ''Assessment and management of medically unexplained symptoms'' by Simon Hatcher and Bruce Arroll is certainly interesting and very well laid out. As a radiology trainee, I was particularly interested in the portion where they talk about the evidence of using diagnostic tests for reassurance. The randomised control trial by Howard L et al they have quoted had used non-contrast MRI for the study. It was interesting to note that this study found no significant difference in the level of symptoms and health concerns at one year between those patients with chronic daily headache (and psychiatric distress) who had MRI scan compared to those who did not. However they do mention that those patients who had scans had lower service costs. My concern is that this study may be misconstrued and people may start promoting routine scanning in patients with chronic headache, citing lower service costs. It is important to note that the randomised control trial by Howard et al have admirably used MRI and not CT scan for the study. They have rightly mentioned that the reason for that is to avoid the radiation dose associated with CT scan. However most of the other hospitals in NHS may not have the luxury of using MRI, which is already oversubscribed, has a much higher waiting list and is also associated with greater costs. This would lead to resorting to CT scans for this purpose. The result of such a practice has many repercussions. Firstly, as mentioned before, it results in a significant radiation dose. Then the issue of sensitivity arises. Multi-slice scanners such as 64 slice scanners have a greater sensitivity than the single slice scanners. Also, it is well known that contrast enhanced CT scans have greater sensitivity than non-contrast scans but this would mean further increase in cost and more importantly the associated risk of contrast toxicity, which is quite significant. Further, it is also known that MRI has a much higher sensitivity and specificity compared to CT. So, when the patients ask the clinicians if a normal CT scan completely rules out all pathologies, the honest answer would have to be no. If that is the case, where does one stop? Also to consider is the issue of incidental findings on these scans. Often, certain findings are seen on the CT or MRI scan whose significance may be unclear. This leads to a battery of further tests and worsens patients’ anxiety tremendously such that they were worse off than before. One solution to these problems would be to have local guidelines in place after a clear understanding between the clinicians and the radiologists. Clearly, patients with more worrying symptoms should have the most sensitive study. Good communication between the patients, clinicians and radiologists is the key to achieving success. There is another solution and interestingly this has been described well by the randomised control trial by Petrie KJ et al, which has been mentioned by the authors. Asking the patients what they understood by a normal scan and the level of re-assurance they would have from that can help to decide the impact that the scan may produce on these patients. Competing interests: None declared |
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Sherab Tsheringla, Post Graduate Registrar in Psychiatry Christian Medical College, Vellore, Tamil Nadu, India - 632002, K S Jacob
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Hatcher and Arroll discuss the management of medically unexplained symptoms from a Primary Care Psychiatry perspective. [1] Psychiatry views mental disorders, using the medical lens and model, as diseases and supposes central nervous system etiology and pathogenesis, documents signs and symptoms, offers differential diagnosis, recommends somatic therapies and prognosticates about course and outcome. Nevertheless, psychiatric treatments are essentially symptomatic with specific classes of medication or psychotherapy being used in a variety of disorders (e.g. SSRIs or CBT are used to treat depression, anxiety, phobia, panic, stress disorders, etc). On the other hand, the perspectives held by general practitioners’ differ from those espoused by psychiatry. [2] Patients visit GPs when they are disturbed or distressed, when they are in pain or are worried about the implication of their symptoms.[3] Bereavement, marital discord, inability to cope at work and financial problems can also lead people to seek help. The difficulty in separating distress from depression becomes a major issue. While psychiatrists suggest that brief screening instruments can easily identify people with depression, most GPs would argue that many of those identified are distressed.[4] The depression GPs encounter is often viewed as a result of personal and social stress, life style choices or as a product of habitual maladaptive patterns of behavior. The reality of primary care with it’s milder, less distinct, subsyndromal and mixed presentations, the difficulty in distinguishing disease from distress, problems with labeling, the high rates of placebo response and spontaneous remissions and the association with stress, coping and lifestyle issues and the Cartesian dichotomy make the use of psychiatric syndromes difficult in clinical practice. [5,6] The context of primary care argues for a radically different approach aimed at managing the clinical presentation (without a formal psychiatric diagnosis) and using a general protocol (rather than distinct and individual psychiatric guidelines). [5,6] The steps in management recommended for people who present with medically unexplained symptoms include: (i) Acknowledging distress, (ii) Eliciting patient’s perspective on symptoms, (iii) Focused history, physical examination and laboratory investigations, (iv) Reassuring patients about the absence of serious disease, (v) Providing alternative explanation for symptoms, (vi) Prescribing medication, if necessary (vii) Suggesting general stress reduction strategies, (viii) Exploring possible stress and specific measures to reduce tensions, (ix) Transferring responsibility for improvement, (x) Giving a specific appointment for review. Eclectic models which take into consideration both medical and psychosocial issues allow the physician an opportunity for explanation and holistic care rather than avoidance of or discomfort in using psychiatric models. The current psychiatric treatment strategies, despite their elaborate specifications are essentially symptomatic. Simplifying protocols will ensure their use in routine clinical practice. Recent concepts and interventions, based on specialist perspectives, have not only complicated the issues but have disempowered general practitioners with psychiatric jargon and techniques which are impractical and counterproductive in primary care settings. The reality of primary care, its problems and opportunities demand unique solutions. Sherab Tsheringla K.S. Jacob Department of Psychiatry, Christian Medical College, Vellore 632002 India. Correspondence: sherabla@gmail.com References 1. Hatcher S, Arroll B. Assessment and management of medically unexplained symptoms. BMJ 2008;336:1124-1128 2. Jacob KS. The cultures of depression. Natl Med J India 2006; 19: 218- 220. 3. Heath I. Commentary: There must be limits to the medicalisation of human distress. BMJ 1999; 318: 439-440. 4. Kessler D, Lloyd K, Lewis G, Gray DP, Heath I. Cross sectional study of symptom attribution and recognition of depression and anxiety in primary care. BMJ, 1999; 318: 436 - 440. 5. Jacob KS. The diagnosis and management of depression and anxiety in primary care: The need for a different framework. Postgraduate Med J 2006; 82: 836-9. 6. Jacob KS. A simple protocol to manage unexplained somatic symptoms in medical practice. Natl Med J India, 2004; 17: 326-328. Competing interests: None declared |
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jyotirmoy ghosh, Private practice Durgapur (w.bengal), India
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Ref. (Clinical review)- Assessment and management of medically unexplained symptoms, I would like to append my comments to this extremely important topic for clinicians in practice in outpatients in general and specialist clinics along with my experience published elsewhere (1) 65% of patients in my clinical practice in primary care in Indian scenario (2) present with complaints of what they ubiquitously term as “Gas”, “Acidity”, “Dysentery”. 85% in one group and 73% in another with these presenting symptoms had wide spectrum of physical symptoms- correlates when elucidated by detailed history taking. These physical symptoms comprised 53% predominant gastro-intestinal symptoms, 25% neurological & 20% chest & cardiovascular symptoms. However, 73% of these cases had anxiety & depression when specifically elicited. All these symptoms were overlapping in overwhelming majority of patients. Interestingly, the symptom- correlates apparently were typical of non ulcer dyspepsia, many had symptoms of irritable bowel syndrome, others seemed to satisfy criteria of migrain/tension headache and non- articular rheumatism. Physical examination, relevant investigations and follow-up failed to substantiate organic basis of these physical symptom correlates and hence these were termed as so-called unexplained somatic symptoms (USSs’(1)). Studies in this clinic practice setting which is mainly devoted to diagnosis, treatment and follow-up of systemic diseases showed that mental diseases as co-morbidity were very common viz. 40.7% to 52.2%. In addition, cases of anxiety and depression without systemic diseases accounted for 19% to 33 %. In view of predominant anxiety and depression, long term low dose tricyclics & SSRI e.g. sertraline are routinely given in my clinic to these patients with unexplained somatic symptoms with or without systemic diseases. Result of treatment of such patients with their own assessments are given below:- Amitryptiline(83 pts)*,Dothiepen(52 pts)**,Sertraline(20 pts)*** Good - 38(45.9%)*,29(57%)**, 6(30%)*** Satisfactory - 32(38.5%)*,16(31%)**, 12(60%)*** No response - 13(15.7%)*,4(8%)**,2(10%)*** Relapses - 48(57.8%)*,27(53%)**,8(40%)*** Relapses were due to interruption of treatment. Therefore, in my view patients presenting with medically unexplained symptoms should have low dose anti-depressants instead of frequently used symptomatic therapies such as proton pump inhibitors, anti-cholinergic drugs etc. which at best give short term placebo effect. Ref.: 1. Ghosh J.M. –Unexplained somatic symptoms – diagnostic window for mental disorders. Journal of Indian Medical Association - vol 104, no. 05, May 2006, pp 255- 260 2. NAMBI S.K., PRASAD J., SINGH D., ABRAHAM V., KURUVILLA A., JACOB K S. - Explanatory Models and Common Mental Disorders among Patients with Unexplained Somatic Symptoms attending a Primary Care Facility in Tamil Nadu. National Medical Journal of India 2002; 15:331-5. Competing interests: None declared |
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Shirwan A Mirza, MD, FACP, FACE, Clinical Assistant Professor Private Practice, New York, USA
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Our patients owe us at least a thorough listening (without interruption) and a complete clinical evaluation to put their complaints into context. Simon Hatcher et al, psychiatrists by training, bring their bias to their article. Why do we always have to rush to judgment whenever we fail to make a diagnosis? One reason, in my view, is the pressure physicians feel to give a diagnosis right away. How about if you just gather clinical information, glean clues, and solidify those with a judicious laboratory (or sometimes imaging) investigation. Then you see the patient again in a second visit and try to put all these objective information together, and add to that a screening for psychiatric disorders such as depression and anxiety, keeping in mind many patients are depressed as a reaction to their symptoms being dismissed, and not necessarily the depression itself causing the symptoms. My colleagues above bring up the possibility of porphyria and chronic lead poisoning in people with vague abdominal pains associated with depression; I find these as valid points. I do add to these 2 points the following: I thoroughly evaluate nutritional status of patients especially when it comes to the levels of: iron, vitamin B12, and 25 hydroxy vitamin D. In the right clinical context, I also screen for celiac disease, subtle thyroid disease by measuring both TSH and free T4 (free T4 is essential in this population to rule out central hypothyroidism). I also include morning cortisol and ACTH (to rule out central hypoadrenalism). In women with estrogen therapy I check copper level since copper overload in this population causes severe fatigue. If these tests are done in the right clinical context, they bring a lot to the table in terms of clarifying mysterious symptoms. Of course every patient with unexplained symptoms should have a baseline CBC, to rule out anemia, or cytopenias, comprehensive metabolic panel and magnesium levels, to rule out renal, hepatic, and electrolyte derangements. Finally, attention to sleep hygiene, and optimal blood pressure and lipid profiles, is important. I have seen many patients who present with fatigue or unexplained cognitive function because of uncontrolled hypertension, or severe hypertriglyceridemia. I usually tailor these tests to specific patients rather than doing them all in every patient. If we are too lazy to do the right evaluation, more of our patients come to us with "unexplained symptoms" and it would be convenient to label them with depression, chronic fatigue syndrome, and similar "empty" diagnoses. Competing interests: None declared |
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Annette l. Barclay, On sofa watching the cricket (too ill to go to Lords) w9 1dt
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When a patient presents with physical symptoms to a GP, they want an explanation for their symptoms and if possible a cure. When a GP cannot provide the former the symptoms are labelled as "unexplained". Further investigations may reveal a cause, or the patient may face inappropriate tests that only cover a range of currently well understood diseases. The GP may not be able to provide any appropriate tests or treatments. What may be considered routine in one country may be offered in another. Therefore the range of "medically unexplained symptoms" varies from country to country. The patient may need to go abroad for treatment or to pay for private tests. The USA based physician into chronic fatigue syndrome, Dr Byron Hyde said **Initially in 1985 to 1990, I was able to unravel the causative disease or illness in the ME/CFS group in no more than 10% to 20% of the patients I examined. By 2000, I was able to discover the major elements of the underlying disease pathophysiology in 70% to 80% of the patients I examined. Each year, my success ratio has improved. Because of this, I believe that the 20% to 30% failure rate in defining the pathophysiology of this group is due to my own deficiencies as a physician and/or the deficiencies of the available technologies. One should not blame patients for their illness or jump too casually to a psychiatric or sociological diagnosis.** Having been seen by doctors in both NZ and the UK, I can vouch that "medically unexplained symptoms" does vary depending on the knowledge of the physician and the quality of the tests and interpretation. Competing interests: Person with a diagnosis of ME (or Tapanui Flu) |
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Hugh Mann, Physician Eagle Rock, MO 65641 USA
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As a baby, I wanted Competing interests: None declared |
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Jon Jureidini, Head, Department of Psychological Medicine Women's and Children's Hospital, Adelaide, 5006, Philip Calvert
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We are concerned that this otherwise excellent paper does not pay sufficient attention to multidisciplinary coordinated treatment approaches. Although we lack systematic evidence (because such approaches are very difficult to research quantitatively), it is clear that management of medically unexplained symptoms is most likely to be successful when all professionals involved in the patients care speak the same language and pursue the same goals. Our experience has been that a coordinated approach from medicine, psychological medicine, physiotherapy, and school staff is the ideal. (Calvert and Jureidini, 2003) We favour management in general medical or surgical settings, rather than in psychiatric settings. Second, the role of physiotherapy in the rehabilitation of medically unexplained symptoms was insufficiently acknowledged. Physiotherapists have a clear leadership role in activity modification and strictly controlled goal orientated physical rehabilitation. Furthermore the prevalence of medically unexplained symptoms is likely to be under reported if patients are excluded who consult directly with physiotherapists rather than seeking a medical opinion. Calvert P and Jureidini J (2003): Restrained rehabilitation: An approach to children and adolescents with unexplained signs and symptoms. Archives of Disease in Childhood 88: 399-402 For correspondence please contact: Associate Professor Jon Jureidini: jon.jureidini@cywhs.sa.gov.au Competing interests: None declared |
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Ian T McLachlan, Unemployed because of illness B45 9UN
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Hatcher and Arroll’s article is, from a patient perspective very sad. Certainly sufferers of Myalgic Encephalomyelitis (who are only too aware the no government money is being made available to fund biomedical research into their illness) would see it as having all the predictable components that they now expect to be written by psychiatrists, i.e. medically unexplained, symptoms not caused by disease, waste of resources, etc. Having fallen ill with ME after a bout of Glandular Fever aged only a twenty-three, I sought an explanation for my symptoms as long ago as 1988 and never got one. Now aged forty-three I no longer have any faith that I will. Despite the severity of my condition I now do not seek one, or hope for treatment and therefore do not use precious resources. Is complete avoidance of the medical profession becoming the best way forward for people whose experiences of illness is genuine but not taken seriously? Competing interests: None declared |
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Charlotte Paterson, Senior Research Fellow Institute of Health Services Research, Peninsula Medical School, University of Exeter. EX1 2LU, On behalf of the CACTUS Study Research Team
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Hatcher and Arroll state that attempts to help people with Medically Unexplained Symptoms (MUS) are ‘hindered by a dualism that divides causes into physical or psychological and by simplistic aetiological models that rely on a single explanatory factor’(1). However, their paper illustrates how difficult this is to achieve for doctors with a biomedical, or ‘conventional medicine’ perspective. For example, although only 60% of people with MUS in primary care have psychiatric co-morbidity (2), Hatcher & Arroll’s review focuses on the use of anti-depressants, cognitive behavioural therapy, and referral to psychiatrists. Whilst cognitive and behavioural interventions show some promise for people who are caught in the process of somatisation, it is clear that additional therapeutic options are urgently required. In an attempt to use a model that integrates mind and body in a more fundamental way, our research group is investigating the effectiveness of offering classical five-element acupuncture to these patients. The CACTUS Study – Classical Acupuncture for Treating Medically Unexplained Symptoms – is a randomised controlled trial with a nested qualitative study which will evaluate the effect of adding acupuncture to usual care, in terms of changes in health status and general practitioner consultation rate. Funded by the King’s Fund, the study is based in four general practices in London (www.cactus-study.co.uk). Ineffective medical treatment is a common reason for consulting complementary and alternative practitioners (3;4). Although we could locate no randomised trials of complementary therapies for people with MUS, there is increasing evidence of the effectiveness of acupuncture in a number of related conditions including chronic back pain (5), headache (6) and fibromyalgia (7). In our study, practitioners will be using classical five element acupuncture, which is based on the theories of Chinese medicine and is a degree level qualification in the UK. At the heart of five element acupuncture, is the conviction that many of today’s physical ailments result from emotional distress, as much as any physical cause. The practitioner assesses and treats each individual as a whole and the treatment aims to help people discover a greater sense of self, to find lifetime tools to make changes, and to live life as fully as possible. This orientation makes it potentially appropriate as a treatment for people with MUS. We have taken up the challenge of evaluating this intervention using standard trial methodology and qualitative interviews and look forward to being able to publish our findings in 2009. 1. Hatcher S,.Arroll B. Assessment and management of medically unexplained symptoms. BMJ 2008;336:1124-8. 2. Smith RC, Lyles JS, Gardiner JC, Sirbu C, Hodges A, Collins C et al. Primary Care Clinicians Treat Patients with Medically Unexplained Symptoms: A Randomized Controlled Trial. Journal of General Internal Medicine 2006;21:671-7. 3. Vincent C,.Furnham A. Why do patients turn to complementary medicine? An empirical study. British Journal of Clinical Psychology 1996;35:37-48. 4. Paterson C,.Britten N. Doctors can't help much: the search for an alternative. Br J Gen Pract 1999;49:626-9. 5. Manheimer E, White A, Berman BM, Forys K, Ernst E. Meta-analysis: acupuncture for low back pain. Annals of Internal Medicine 2005;142:651- 63. 6. Vickers AJ, Rees RW, Zollman CE, McCarney R, Smith C, Ellis N et al. Acupuncture for chronic headache in primary care: large, pragmatic, randomised trial. BMJ 2004;328:744-47. 7. Holdcraft LC, Assefi N, Buchwald D. Complementary and alternative medicine in fibromyalgia and related syndromes. Best Practice and Research in Clinical Rheumatology 2003;17:667-83. Competing interests: None declared |
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Randy S Baker MD, Family physician in private practice Soquel, CA 95073
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Uncovering Explanations As a holistic family physician, I see many people who suffer from a myriad of common symptoms and who saw other physicians who performed a standard work-up, found nothing to explain their symptoms and were essentially told it was all in their heads. When I do thorough evaluation on such patients, I almost always uncover significant physiologic problems that can explain these symptoms. Many of these have already been discussed above. While I agree with Jecko Thachil that acute porphyria is relatively rare, chronic lead intoxication is far from rare. Clair Patterson repeatedly found evidence that the average person alive in western society today has approximately 1000-fold the body buden of lead as people who lived 700-1000 years ago in pre-industrial society [1]. Besides the omnipresence of lead toxicity, many people suffer from toxicity secondary to mercury, cadmium and other heavy metals, as well as PCB’s, dioxins and other common pollutants. Even newborn babies have measurable levels of an average of 200 industrial toxins and pollutants [2]. Besides ill-effects from metals and industrial toxins, many people suffer from significant symptoms due to exposure to toxins from mold in their homes and workplaces [3]. Shirwan Mirza MD correctly points out the need for thorough testing for thyroid dysfunction, adrenal insuffiency and nutritional deficiencies. I would encourage practioners to test for free T3, an even more useful measure than free T4, and to realize that someone can be clinically hypothyroid despite a “normal” TSH [4]. Thyroiditis is surprisingly common, yet seldom tested for. A 2001 study by B. Wikland published in the Lancet found that forty percent of 219 patients with chronic fatigue had chronic thryoiditis found on fine-needle biopsy. Of interest, only half of these had elevated thryroid antibodies in their serum. Treatment with levothyroxine resulted in clinical improvement, even though many of these patients had “normal” TSH levels [5,6]. Just as 25 years ago it was not known that ulcers were caused by infections, evidence is accumulating that conditions like irritable bowel syndrome, often dismissed as psychosomatic, are often caused by microbes, such as small bowel bacterial overgrowth. On careful examination, many patients with chronic GI distress as well as chronic pain and fatigue have increased intestinal permeability caused by imbalances of intestinal flora, parasites and fungal overgrowth [7,8,9]. These conditions often result in food sensitivities, which can contribute to a wide variety of symptoms, from joint pains to headaches to anxiety and depression [10,11,12,13]. Many chronically-ill patients suffer from chronic low-grade infections, such as undiagosed Lyme disease and other insect- borne infections such as Babesiosis, Ehlrichiosis and Bartonella, as well as chronic mycoplasma infections and a myriad of chronic viral infections. These infections are more likely to occur in people with impaired immunity, which can be secondary to heavy metal toxicity, nutritional deficiencies and psychological stress. I do not deny that emotional factors play a very significant role in health. Many people with chronic illness came from dysfunctional families and have a history of physical and/or emotional abuse and/or lack of nurturing. Unresolved emotional conflicts can affect autonomic nervous system regulation of organs interfering with the ability to detoxify, leading to accumulation of heavy metals which make organs more prone to dyfunction and infection. I know of no illness that is not made worse by stress. But it does a huge disservice to such patients to ignore the physiological factors contributing to their health problems and essentially attribute their problems to a deficiency of psychotropic pharmaceuticals. [1] Sci Total Environ. 1991 Sep;107:205-36. Natural skeletal levels of lead in Homo sapiens sapiens uncontaminated by technological lead. Patterson C, Ericson J, Manea-Krichten M, Shirahata H. [2] Hudnell, H. K. AND R. C. Shoemaker. SICK BUILDING SYNDROME: POSSIBLE ASSOCIATIONS WITH EXPOSURE TO MYCOTOXINS FROM INDOOR AIR FUNGI. Presented at 8th International Symposium on Neurobehavioral methods and effects in occupational and environmental Health, Brescia, Italy, 6/23/ 2002 http://oaspub.epa.gov/eims/eimsapi.dispdetail?deid=76755 [3] http://archive.ewg.org/reports/bodyburden2/execsumm.php [4]David Derry M.D.,Ph.D. Re: TSH Tests http://thyroid.about.com/od/thyroiddrugstreatments/l/blderryb.htm [5]Wikland B, et al. Fine-needle aspiration cytology of the thyroid in chronic fatigue. Lancet. 2001;357:956-957. [6]Wikland B, et al. Subchemical hypothyroidism. Lancet. 2003;361:1305. [7] Laitinen K, Isolauri E. Management of food allergy: vitamins, fatty acids or probiotics? Eur J Gastroenterol Hepatol. 2005 Dec;17(12):1305-11. [8] Fasano A, Shea-Donohue T. Mechanisms of disease: the role of intestinal barrier function in the pathogenesis of gastrointestinal autoimmune diseases. Nat Clin Pract Gastroenterol Hepatol. 2005 Sep;2(9):416-22. [9] DeWitt RC, Kudsk KA. The gut's role in metabolism, mucosal barrier function, and gut immunology. Infect Dis Clin North Am. 1999 Jun;13(2):465-81. [10] Duggan, JM: Coeliac Disease: the great imitator MJA 2004;180(10): 524-526 [11] Potocki P, Hozyasz K.: Psychiatric symptoms and coeliac disease. Psychiatr Pol. 2002 Jul-Aug;36(4):567-78. [12] Lunardi C, Bambara LM, Biasi D, Venturini G, Nicholis F, Pachor ML, DeSandre G: Food allergy and rheumatoid arthritis. Clin Exp Rheumatol 1988;6:423-26. [13] R Goldstein, D Braverman, H Stankiewicz.: Carbohydrate malabsorption and the effect of dietary restriction on symptoms of irritable bowel syndrome and functional bowel complaints. Israel Medical Association Journal, 2000, Vol 2, Iss 8, pp 583-587 Competing interests: None declared |
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Raymond G Holder, Retired engineer Home BH9 3NF
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I am well acquainted with three problems whose treatments are unknown or unrecognised by official medicine, They are Statin damage, Post Polio syndrome, and ME/CFS (suffered by a family member) I believe that the major problem is compartmentalisation of specialisms, certain problems thought to be in the territory of a particular one, eg Post Polio the possession of neurologists, but it is no longer neurological but often a problem of deficiency of carnitine, a metabolic one. Similarly, the NICE work on ME/CFS was predominated by Psychiatry, very wide of the mark, and a rapid response by a John Tovey on this subject last October gave a much more likely cause of the illness by reference to his success in treating Chlamydia pneumoniae aggressively with various anti-biotics, the organism taking refuge inside cells, and taking energy away from them directly from their mitochondria. I saw no response to this line of approach, it didn't fit into any specialism normally involved with ME/CFS, but it explains the symptoms experienced much better, and exercise is definitely not a good option at some stages. Then to come to statin damage, this is firmly in the hands of cardiology and vascular medicine, but their major interest is in the body's "plumbing", the damage being done to the energy production, as ATP, not solely in any one organ, but in microscopic mitochondria distributed throughout the whole body, is someone else's territory, and for them to deal with. An instance of this effect was posted on a website recently where the patient was having muscle problems from statins, and had been referred by the cardiologist to a rheumatologist,(not in this country), and he remarked "I have told the cardiologist not to send me any more of his statin damaged patients, I can do nothing for them" I believe that NICE, by asking for candidates for its committees, gets just those who believe the problem to be their prerogative. A far better way would be to have a multi disciplinary group to decide what is the composition best suited to examine the problem from all angles. without bias from commercial interests and responsive to worldwide kmnowledge on the subject. I can sympathise with the ME/CFS sufferer writing on the same subject, we have been there too. Competing interests: Statin damaged and Post Polio patient |
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Kenneth A Hoekstra, Public Health Vancouver, BC
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This article highlights the assessment and management of medically unexplained symptoms and emphasizes the misdiagnosis of psychiatric disorders (1). Along similar lines, the National Institute of Health (NIH) will launch a program for undiagnosed diseases (2) that will begin accepting patients in July 2008. As mentioned in earlier comments, there is a greater need for a multidisciplinary approach to all aspects of medicine. Perhaps this will help. 1. Hatcher S., Arroll B. Assessment and management of medically unexplained symptoms. BMJ 2008; 336: 1124-1128 2. http://rarediseases.info.nih.gov/Resources.aspx?PageID=31 Competing interests: None declared |
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Les O. Simpson, retirred medical research worker Dunedin, New Zealand, 9077
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A feature of this lengthy correspondence is the apparent lack of recognition of the fact that any event which alters the internal environment (stress, chemicals, etc) stimulates changes in the morphology of red cells. Such changes are accompanied by a reduction in red cell deformability with an impairment of capillary blood flow. It is not surprising that three of the contributors raised the topic of ME, as in 1986 we reported that the blood of ME people filtered poorly and in 1989 showed that in ME people, the shape populations of red cells were changed. It is very relevant that in chronic disorders shown to have changed red cell shape populations, SPECT scans show reduced regional cerebral blood flow. For example, in major depression there are several reports of reduced regional cerebral blood flow, with one study reporting that in a region with reduced blood flow during depression, normal blood flow was noted after the resolution of the depression. Because tissue dysfunction will result from inadequate rates of delivery of oxygen and nutrient substrates, the resulting dysfunction will be apparent first in those tissues which are are sensitive to oxygen deprivation, such as muscles and nervous tissue. Unfortunately, studies in this field fall within the ambit of blood rheology, which is not taught at medical school. But given the breadth of reported information, it would seem that a SPECT scan should be one of the early tests when assessing a medically unexplained condition. Competing interests: None declared |
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John P Cosgrove, GP Faringdon, Oxfordshire SN7 7YU
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Hatcher and Arroll imply that guidance on investigation of fatigue is secure.[1] Blood tests recommended by the cited guideline include full blood count, erythrocyte sedimentation rate and/or C-reactive protein, "basic biochemistry tests", thyroid function, creatine kinase, immunoglobulin, autoantibody screen and consideration of cortisol and viral serology.[2] Mirza adds to this list iron, B12, vitamin D, coeliac serology and copper.[3] Presumably the population this evaluation should be conducted on are the 10% of general practice attenders with fatigue.[4] Can such an evaluation accurately be described as judicious? Even if such a degree of investigation caused no iatrogenic damage[1], what are the health economic implications of such a population-wide screening test? Which of these tests meet the criteria for a screening test?[5] Authoritative guidance in this area would eliminate risk and the need for clinical intuition[6], but at what cost? Let us hope a general practitioner's ability to absorb risk and uncertainty[7] is more secure. References 1. Hatcher S, Arroll B. Assessment and management of medically unexplained symptoms. BMJ 2008;336:1124-1128 2. Viner R, Christie D. Fatigue and somatic symptoms. BMJ 2005;330:1012-5 3. Mirza SA. A judicious evaluation of unexplained symptoms. BMJ Rapid responses 2008;http://www.bmj.com/cgi/eletters/336/7653/1124#195696 4. David A, Pelosi A, McDonald E, Stephens D, Ledger D, Rathbone R, Mann A. Tired, weak, or in need of rest: fatigue among general practice attenders. BMJ. 1990;301:1199-202 5. Wilson JMG, Jungner G. Principles and Practice of Screening for Disease. WHO 1966 6. Barraclough A. Medical intuition. BMJ 2006;332:497 7. Haslam D et al. The future of general practice. RCGP 2004 Competing interests: None declared |
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Daniel S. Elman, Tutor Doctoring/Clinical Skills David Geffin School of Medicine UCLA
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Remember when peptic ulcer disease was thought to be psychological? We fed them cream, antacids and acid blockers and sent them to psychiatrists to take away their psychological "proplems" or to surgeons to perform vagotomies and gastric resections. Then H. Pylori was found to be the cause. The medically unexplained syndromes are just diseases with undiscovered medical causes and when causation is discovered, we will be able to properly treat them. Useless blame of a psychological etiology causes distress for our patients and is not in their or our best interests. Accepting our lack of knowledge of the causation of these syndromes and dislaying compassion for the patient will be most beneficial for our patients and ourselves until someone discovers the causation. Dumping patients on our psychologists and psychiatrists or doing numerous lab and radiological testing will run up costs and cause patient anxiety with no or minimal benefits. Competing interests: None declared |
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