Elizabeth Marks

Medically Unexplained Symptoms: an acceptable term?

Background: The term ‘Medically Unexplained Symptoms’ (MUS) is used by health professionals and researchers to refer to persistent bodily complaints, including pain and discomfort. Aims: This study explores the views held by a lay sample on the clinical terminology used to describe ‘MUS’, to ascertain reasons for particular preferences and whether preferences differ between individuals who experience more somatic symptoms. Design and methods: A sample (n = 844) of healthy adults completed an online survey, which included a questionnaire measuring somatic symptoms (Patient Health Questionnaire-15 (PHQ-15)) and a question about their preferences for terminology used to describe MUS. Results: Of 844 participants, 698 offered their preferences for terminology. The most popular terms were ‘Persistent Physical Symptoms’ (20%) and ‘Functional Symptoms’ (17%). ‘MUS’ (15%), ‘Body Distress Disorder’ (13%) and ‘Complex Physical Symptoms’ (5%) were less popular. And 24% indicated no preference, but high PHQ-15 scorers were more likely to express preferences than low scorers. Conclusion: Persistent Physical Symptoms and Functional Symptoms are more acceptable to this sample of healthy adults than the more commonly used term ‘MUS’.

Non-cardiac chest pain: time to extend the rapid access chest pain clinic?

Non‐cardiac chest pain is common. It has a low risk of coronary events, but causes considerable physical and social disability and inappropriate health‐care usage. It is a heterogeneous condition, which may be caused by or associated with gastro‐oesophageal, musculoskeletal or psychiatric abnormalities and sustained by psychological factors including catastrophisation, avoidance behaviour and abnormal help‐seeking. These may coexist and their relative contributions may vary in different patients or at different times in an individual patient. The absence of a unitary cause probably explains why treatment studies show only moderate success. An individualised biopsychosocial approach takes account of all causative and sustaining processes and has been shown to work in pain syndromes at other sites. We suggest that this approach should be tried for chest pain using a multidisciplinary clinic model including cardiologists, psychologists and nurses linked with a Rapid Access Chest Pain Clinic.

The head says yes but the heart says no: what is non-cardiac chest pain and how is it managed?

### Learning objectives Chest pain is common and usually non-cardiac in origin. The lifetime population prevalence of non-cardiac chest pain (NCCP) is approximately 20–33%1–7 compared with approximately 6–7% for angina.3 ,8 The incidence of NCCP depends on the clinical setting. It is 70–80% for patients presenting to a general practitioner or a rapid access chest pain clinic9–11 and around 50% attending emergency departments.12 ,13 Normal coronary anatomy is found in 40% having diagnostic coronary angiography.14 Despite this, the focus of clinical care is on excluding coronary disease rather than on the positive management of NCCP. As a result, patients with NCCP are often left with chronic symptoms, high levels of psychological distress,15 ,16 high unemployment and heavy use of healthcare resources.17–19 The causation may be complex with an interaction of organic and psychological processes. However, treatment can be effectively delivered at low cost.20 ,21 This article describes the causes, natural history and management of NCCP with an emphasis on the psychological processes which inform our approach to care. Chest pain may be obviously benign, for example after straining a muscle or being hit in the chest by a football. It only becomes of medical concern when the person seeks advice for one or more reasons: severe or recurrent pain; a family history of coronary disease; health anxiety as a result of personality or induced by societal concerns, for example, healthcare advertisements. The general practitioner may be confident to reassure the person without tests. However, someone referred to a cardiac outpatient or …

Shared decision-making in tinnitus care: an exploration of clinical encounters

Objectives This study examined clinical encounters between clinicians and patients to determine current practice for the diagnosis and treatment of tinnitus. The objective was to develop an understanding of the ideal clinical encounter that would facilitate genuine shared decision‐making. Design Video ethnography was used to examine clinical encounters for the diagnosis and treatment of tinnitus. Methods Clinical encounters were video‐recorded. Patients were interviewed individually following their clinic appointment. Data were analysed using constant comparison techniques from Grounded Theory. Initial inductive analyses were then considered against theoretical conceptualizations of the clinician–patient relationship and of the clinical encounter. Results Alignment between clinician and patient was found to be essential to a collaborative consultation and to shared decision‐making. Clinician groups demonstrated variation in behaviour in the encounter; some asked closed questions and directed the majority of the consultation; others asked open questions and allowed patients to lead the consultation. Conclusions A shift away from aetiology and physiological tests is needed so that tinnitus is managed as a persistent unexplained set of symptoms. This uncertainty is challenging for the medical professionals; lessons could be learned from the use of therapeutic skills. Further research is required to test techniques, such as the use of decision aids, to determine how we might create the ideal clinical encounter. Statement of contribution What is already known on this subject? Tinnitus is a condition in which sound is heard in the absence of an external source. Current approaches to managing tinnitus vary depending on clinical site (Hoare & Hall, 2011). In most instances, tinnitus does not have a straightforward medical cause. Tinnitus care is challenging to traditional biomedical encounters because the process of diagnosis may not lead to a defined treatment. Clinicians are required to consider not only what the tinnitus sounds like but more importantly, what it means for the affected individual. This requires a careful and skilled approach to eliciting a patients current behaviour, coping, and preferences for both outcomes and treatment approaches. What does this study add? We provide the first in‐depth description of decision‐making in clinical services for tinnitus. Findings suggest a shift in focus is required to move away from the current prioritization of the biomedical treatment of tinnitus. There is variation to the extent different clinicians were able to deal with the uncertainty presented by the symptoms of tinnitus.

A novel biopsychosocial, cognitive behavioural, stepped care intervention for patients with noncardiac chest pain

ABSTRACT Background: Non-cardiac chest pain (NCCP) is associated with psychological distress, work absenteeism, impaired functioning and reduced quality of life. This study explores how a novel biopsychosocial, stepped-care treatment for NCCP works, and explores outcomes at each step and process variables. Methods: Patients with persistent NCCP were referred to a new biopsychosocial, multidisciplinary clinic for chest pain (CP). There were three possible ‘steps’ of treatment: (1) biopsychosocial assessment (BA) only, (2) BA plus low-intensity cognitive behaviour therapy (CBT) and (3) BA plus high-intensity CBT. Outcome measures assessed chest pain (frequency and interference), anxiety (GAD7), depression (Patient Health Questionnaire-9 (PHQ-9)), somatic symptoms (PHQ-15) and illness perceptions (Brief Illness Perception Questionnaire) at baseline, 3 and 6 months post-assessment. Participants gave feedback about treatment once completed, which was analysed using content analysis. Results: Significant improvements were found on all outcome measures at 3 months and 6 months compared to baseline. Benefits were found in all treatment steps and occurred regardless of baseline distress, chest pain or demographic characteristics. The strongest predictor of improvement in chest pain at 6 months was a positive change in illness perceptions at 3 months. Patients reported how treatment helped by increasing their understanding of chest pain, reducing concern and improving their sense of control. Conclusions: A biopsychosocial, stepped-care intervention appears to be effective, efficient and acceptable for a variety of patients with NCCP. Changes in beliefs about chest pain were the main predictors of improvement (reduced chest pain interference and frequency) at 6 months follow up.

The development of a decision aid for tinnitus

Abstract Objective: To develop a decision aid for tinnitus care that would meet international consensus for decision aid quality. Design: A mixed methods design that included qualitative in-depth interviews, literature review, focus groups, user testing and readability checking. Study sample: Patients and clinicians who have clinical experience of tinnitus. Results: A decision aid for tinnitus care was developed. This incorporates key evidence of efficacy for the most frequently used tinnitus care options, together with information derived from patient priorities when deciding which choice to make. Conclusion: The decision aid has potential to enable shared decision making between clinicians and patients in audiology. The decision aid meets consensus standards.

Mindfulness based cognitive therapy for chronic tinnitus: evaluation of benefits in a large sample of patients attending a tinnitus clinic

Objectives: Mindfulness-based approaches may benefit patients with chronic tinnitus, but most evidence is from small studies of nonstandardized interventions, and there is little exploration of the processes of change. This study describes the impact of mindfulness-based cognitive therapy (MBCT) in a “real world” tinnitus clinic, using standardized MBCT on the largest sample of patients with chronic tinnitus to date while exploring predictors of change. Design: Participants were 182 adults with chronic and distressing tinnitus who completed an 8-week MBCT group. Measures of tinnitus-related distress, psychological distress, tinnitus acceptance, and mindfulness were taken preintervention, postintervention, and at 6-week follow-up. Results: MBCT was associated with significant improvements on all outcome measures. Postintervention, reliable improvements were detected in tinnitus-related distress in 50% and in psychological distress in 41.2% of patients. Changes in mindfulness and tinnitus acceptance explained unique variance in tinnitus-related and psychological distress postintervention. Conclusions: MBCT was associated with significant and reliable improvements in patients with chronic, distressing tinnitus. Changes were associated with increases in tinnitus acceptance and dispositional mindfulness. This study doubles the combined sample size of all previously published studies. Randomized controlled trials of standardized MBCT protocols are now required to test whether MBCT might offer a new and effective treatment for chronic tinnitus.

Non-cardiac chest pain: time to extend the rapid access chest pain clinic?: Non-cardiac chest pain

Non‐cardiac chest pain is common. It has a low risk of coronary events, but causes considerable physical and social disability and inappropriate health‐care usage. It is a heterogeneous condition, which may be caused by or associated with gastro‐oesophageal, musculoskeletal or psychiatric abnormalities and sustained by psychological factors including catastrophisation, avoidance behaviour and abnormal help‐seeking. These may coexist and their relative contributions may vary in different patients or at different times in an individual patient. The absence of a unitary cause probably explains why treatment studies show only moderate success. An individualised biopsychosocial approach takes account of all causative and sustaining processes and has been shown to work in pain syndromes at other sites. We suggest that this approach should be tried for chest pain using a multidisciplinary clinic model including cardiologists, psychologists and nurses linked with a Rapid Access Chest Pain Clinic.

Non-cardiac chest pain

Non‐cardiac chest pain is common. It has a low risk of coronary events, but causes considerable physical and social disability and inappropriate health‐care usage. It is a heterogeneous condition, which may be caused by or associated with gastro‐oesophageal, musculoskeletal or psychiatric abnormalities and sustained by psychological factors including catastrophisation, avoidance behaviour and abnormal help‐seeking. These may coexist and their relative contributions may vary in different patients or at different times in an individual patient. The absence of a unitary cause probably explains why treatment studies show only moderate success. An individualised biopsychosocial approach takes account of all causative and sustaining processes and has been shown to work in pain syndromes at other sites. We suggest that this approach should be tried for chest pain using a multidisciplinary clinic model including cardiologists, psychologists and nurses linked with a Rapid Access Chest Pain Clinic.