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更新时间:2014-3-18 12:59:53 来源:华尔街日报中文网 作者:佚名

Mystery Medical Symptoms Hit a Surprising Number of Patients

It's a common scenario: You have an odd pain for weeks or are feeling too tired lately. So you head to a doctor, who may run a test or two. But no clear cause for the symptom shows up.

Despite a dizzying array of high-tech medical tests, the reality is that many symptoms, such as fatigue or headaches, are never explained. In most cases, when doctors rule out serious disease, patients are reassured. But some patients remain bothered by the mystery symptoms, returning to the doctor again and again worrying that they are missing some dire illness.

Now, some family doctors and internists are treating patients disturbed by medically unexplained symptoms with techniques to prompt patients to think differently about their symptoms, including cognitive behavioral therapy and relaxation strategies.

This reflects the reality that paying excess attention to symptoms can often make them feel worse. The goal is to teach patients to live with their symptoms, to see them as benign and even ignore them. Recent research shows the techniques can ease symptoms and, perhaps just as important, the distress they can cause.

Mystery symptoms can be frustrating for doctors and patients alike. Patients can feel like their concern is being dismissed as all in their heads. Doctors may feel there is little they can do -- and may resent the time these patients take.

'Most people don't want to hear 'I don't really know,' but the truth is often we don't really know,' says Susan H. McDaniel, associate chair of the department of family medicine at the University of Rochester Medical Center in New York.

'What we consider a good outcome is not necessarily that the symptoms disappear but that they are no longer bothersome or disturbing,' says Arthur Barsky, professor of psychiatry at Harvard Medical School.

Medically unexplained symptoms are strikingly common. One 2011 study of 620 German primary-care patients published in the journal Psychosomatics found that medically unexplained symptoms made up two-thirds of all reported symptoms. Other studies estimate that anywhere from 10% to 20% of U.S. primary-care patients have medically unexplained symptoms that impair them in some way. About 5% to 7% of the population has a more serious psychiatric illness, somatic symptom disorder, where symptoms (either explained or unexplained) persist more than six months and are accompanied by a high level of anxiety.

(This is different from what was known as hypochondriasis, an illness where physical symptoms may be mild or nonexistent but where patients are fearful of having a serious disease. Hypochondriasis no longer exists as a diagnostic term: The latest edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM, uses the term 'illness anxiety disorder' instead.)

Almost anything can be a mystery symptom. The most common medically unexplained ones are fatigue, back pain, headache and abdominal pain, doctors say. Dizziness, vertigo and numbness also sometimes have no identifiable medical cause.

Hannah Letterman was a 17-year-old high school senior when she suddenly was struck with nausea, headaches and vertigo. 'I would feel I was being dragged in circles by my feet,' says the now 19-year-old college freshman in Rochester, N.Y. 'I couldn't read. I couldn't do homework. I couldn't have conversations for more than a few minutes.'

The feeling lasted for months. She saw multiple doctors who ran many tests. Then, at the University of Rochester's epilepsy center, she was finally referred to William Watson, a psychologist there. Dr. Watson had her keep a symptom diary: She wrote down what activities, thoughts and feelings seemed to make the symptoms better or worse. In weekly therapy sessions, she worked to 'really accept my emotions for what they are,' she says. The approach worked. Ms. Letterman says she still has some residual symptoms, but is 'fully functional.' She initially thought it ridiculous that her symptoms could be psychologically generated, but has come around to that view.

Some patients with medically unexplained symptoms who return almost monthly to the doctor may have an underlying psychological issue fueling the symptoms and the 'health-seeking' behavior, says Robert C. Smith, professor of medicine and psychiatry at the Michigan State University College of Human Medicine. 'It is a red flag that there is an underlying psychiatric disorder,' such as depression or anxiety, he says.

Dr. Smith and colleagues have developed a treatment for primary-care providers to deliver. It combines antidepressant medication and the elimination of narcotic pain drugs, which can make depression worse, with relaxation techniques, exercise and other strategies.

A study published in the Journal of General Internal Medicine in 2006 examined 206 patients who averaged more than 13 visits to their doctor in the year before the study. About 60% of the patients were found to have major depression. Those who received the treatment -- provided by four nurse practitioners in 12 visits over one year -- saw decreased psychological distress and better coping skills compared with a control group.

In a study published in 2013 of 89 patients who visited their primary-care doctors frequently for medically unexplained symptoms and had a lot of anxiety about their heath, Dr. Barsky and colleagues found that both a cognitive behavioral therapy program and a relaxation training program eased symptoms, improved mental health and reduced impairment. In the year after the study, patients also visited their doctors less: About 8.8 times, compared with 10.3 times in the year before the study.

The cognitive behavioral treatment was delivered in four to eight sessions by nurse practitioners or physicians' assistants who had undergone several training seminars. In the treatment, patients are first taught to alter their 'dysfunctional beliefs' about health and symptoms, such as the misconception that 'good health is symptom-free,' Dr. Barsky says. Then patients are guided to eliminate 'maladaptive illness behavior' such as excessively researching their symptoms online or going to many doctors in search of a diagnosis.

Patients also are taught to distract themselves from their symptoms. They are asked to come up with a range of enjoyable activities to switch to as soon as they find themselves ruminating about their symptoms. The CBT patients also learn relaxation techniques like meditation.

Wanda Filer, a family physician in York, Pa., says she is wary of sending patients with medically unexplained symptoms on a 'therapeutic misadventure' by shuttling them to multiple specialists or ordering many tests. The possibility for false positives increases. You could 'find a little cyst that is probably totally fine and then they get totally obsessed with it.'

Molly Cooke says some of her patients are 'really good noticers,' especially of chronic abdominal pain. Dr. Cooke, president of the American College of Physicians and a practicing internist in San Francisco, tells patients, 'You are a super good noticer of what your body is doing. The GI tract is very active and a lot of people don't really notice that.'

In these kinds of patients with vague symptoms, she'll agree on a time frame with them for further exploration. If the symptoms are still bothersome in a few months or weeks, depending on the situation, she'll pursue more testing. 'I'm hoping this will go away or be replaced by another set of symptoms,' she says. 'A lot of people don't feel good about coming to the doctor if they don't have some symptoms.'





纽约罗切斯特大学(University of Rochester)医学中心家庭医学部副主任苏珊·H.麦克丹尼尔(Susan H. McDaniel)说:“大多数人并不想听到‘实际上我也不清楚’之类的话,但事实常常是,我们的确不清楚。”

哈佛医学院(Harvard Medical School)精神病学教授阿瑟·巴斯基(Arthur Barsky)称:“我们认为好的结果并不一定是症状消失,而是它们不再给人带来困扰或忧虑。”

(这和疑病症不同,疑病症指的是病人没有任何身体症状或者症状轻微,却疑心自己患上了严重的疾病。疑病症已经不再是一个诊断术语,最新版的《精神疾病诊断与统计手册》(Diagnostic and Statistical Manual of Mental Disorders)中,疑病症已被“疾病焦虑障碍”一词替代。)


汉娜·莱特曼(Hannah Letterman)在17岁读高中时突然觉得恶心、头疼、头晕。她说:“当时,我可以感觉到我被自己的双脚困在原地兜圈子。我没法阅读,没法做功课,和人说话都只能持续几分钟。”莱特曼现年19岁,正在纽约州罗切斯特读大一。

这种感觉持续了几个月。她去看了好几名医生,做了许多检测。最终,在罗切斯特大学癫痫中心,她转诊到了心理学家威廉·沃森(William Watson)处就医。沃森博士让她写症状日记:记下那些似乎导致症状减轻或加剧的行为、思想和感觉。莱特曼说,在每周一次的心理治疗期间,她试着努力“真正接受自己的情绪,不管它们是什么”。这种方法见效了。莱特曼说,现在她还依然有些剩余的症状,但身体功能“已经完全恢复了”。她最初觉得,将自己的症状归结为心理原因愚蠢可笑,但现在她慢慢接受了这一观点。

密歇根州立大学人类医学院(Michigan State University College of Human Medicine)医学和精神病学教授罗伯特·C.史密斯(Robert C. Smith)说,一些带有医学上无法解释的症状、几乎每月去看一次医生的患者,可能有着潜在的心理问题,这些问题引发了这些症状以及“求医”行为。他说,“这些症状是患有潜在精神疾病的危险信号”,如抑郁或焦虑。


《普通内科医学》(Journal of General Internal Medicine)期刊2006年发表了一项针对206名病人的研究的论文,这些病人在该项研究前平均每年看医生的次数超过13次,检查发现其中约60%的患者有严重的抑郁症。相较于控制组,那些接受了治疗(四名执业护士一年内探访患者12次并对其进行治疗)的人心理困扰减轻,并且能更好地应对病症。




宾夕法尼亚州约克市(York)的家庭医生万达·法勒(Wanda Filer)说,她不会轻易将那些有着医学上无法解释的症状的患者推给一堆专科医生或是让他们做许多检测,她觉得这是一种“治疗灾难”。误诊的可能性会加大。你有可能“发现一个小囊肿,原本可能并无大碍,但却导致病人因此困扰不已”。

美国内科医师学会(American College of Physicians)主席、旧金山执业内科医生莫莉·库克(Molly Cooke)说,她的一些病人“非常善于观察”,特别是患有长期腹痛的人。库克博士对病人说:“对于自己的身体状况,你是一个超级好的观察者。胃肠道的活动其实是很积极的,但很多人并没有觉察到这一点。”