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如何应对医学无法解释的症状

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
如何应对医学无法解释的症状

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.'

许多人都遇到过这样的情况:连续数周都感到身体某部分有莫名其妙的疼痛,或者觉得最近特别累。于是你去看医生,医生也许会给你做一两项检查,但却找不出导致这些症状的原因。

尽管做了一连串让人眼花缭乱的高科技医学检测,但现实是许多症状,如疲惫、头疼,都无从解释。大部分情况下,在医生排除了重大疾病的可能后,病人就放心了。但还有一些病人依然被神秘的症状所困扰,一次又一次地回去看医生,担心自己可能得了什么医生没有发现的恶疾。

现在,对那些被医学上无法解释的症状所困扰的病人,一些家庭医生和内科医生正采用认知行为疗法和放松疗法等治疗方式,帮助他们从不同的角度来看待这些症状。

这反映出,对此类症状给予过多关注通常会使病人感觉更糟。这类治疗方式的目标是教会病人和他们的症状和平共处,并将其视作无害的,甚至对其视而不见。最近的研究表明,这类治疗方式能够减轻症状,并缓解这些症状带来的忧虑(这一点也许同样重要)。

无法解释的症状令医生和病人同样沮丧。病人可能会感觉他们的担忧没有得到认真对待,似乎一切都是他们臆想出来的。医生则可能会觉得无能为力──还可能因为被这些病人占用了时间感到不满。
 
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。”
 
医学上无法解释的症状极其普遍。2011年一项针对620名德国初诊患者的研究发现,医学上无法解释的症状占了所有已报告症状的三分之二。这项研究发表在《心身医学》(Psychosomatics)杂志上。其它研究估计,美国10%至20%的初诊病人都有医学上无法解释的症状,而且这些症状在某种程度上损害了病人的健康。约5%至7%的人有着更为严重的精神疾病──躯体化障碍,这些病人的症状(既有医学上可解释的,也有不可解释的)持续超过半年,并伴随着严重的焦虑。

(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。)

任何症状都有可能是医学上无法解释的。最常见的有疲劳、背部疼痛、头疼和腹痛,医生说。头晕、眩晕和麻木有时候也无法找到确切的医学原因。

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。

史密斯博士和同事研究出了一种针对初诊患者的疗法。它包括了抗抑郁药,并去掉了会导致抑郁加重的麻醉止痛药,再辅以放松疗法、锻炼和其它方法。

《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。

2013年发表了论文的一项研究针对89名病人进行了调查。这89名病人因医学上无法解释的症状频繁地去看初诊医生,并对自己的健康状况非常担忧。巴斯基博士和他同事在该项研究中发现,认知行为疗法和放松训练都会缓解症状,并改善精神状况,减轻症状带来的损害。研究结束后的一年内,这些患者看医生的次数减少至平均大约8.8次,而研究开始前是10.3次。

认知行为疗法分为四至八个阶段,由执业护士或接受过多次研习班培训的内科医生助理来实施。巴斯基博士说,治疗时,护士或医生助理会首先教患者改变他们对于健康和病症的“不良理念”,如认为“健康就是没有任何病症”的错误观念。然后引导他们戒除“不良的疾病行为”,如过度在网上搜索关于自身病症的信息或是不停看医生以寻求一个诊断。

患者还被要求学着将注意力从症状上移开。一旦他们发现自己在想着这些症状,就马上转而去做一系列令人愉快的事情。接受认知行为治疗的病人还学会了冥想之类的放松技巧。

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。”

对这一类症状模糊不清的病人,她会同他们商定一个时间期限继续进行探查。如果在接下来的几个月或几周内病症依然困扰着他们,根据情况,她会对患者进行更多的检测。她说:“我希望,这类模糊症状会消失或是被其它一系列症状所取代。许多人觉得,没什么症状就去看医生不是太好。”

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