Who said: don't bother testing patients?

I have read it in several places but my memory is so bad.

I had thought it was in the Adults Improving Access to Psychological Therapies programme ( see https://www.england.nhs.uk/mental-health/adults/iapt/ ), but in a quick glance through the links I did not find it stated clearly.

It is implicit in Christopher Burton book "ABC of Medically Unexplained Symptoms" (see http://book.masaratcom.com/library/20130929101455_masarat_library_-1119967252Unexplained.pdf ) in a couple of places, but I am struggling to read it all tonight (too frustrating).

There was also information put out by ... ... was it a North West Health Authority covering Cumbria,
I think discussed here ... ... but I have also read info out by the Health Authority covering Devon and Cornwall on developing MUS services, but I am struggling to remember details and may be mixing the two sets of paper work.
 
Here is a clear statement in the 'Guidance for health professionals on medically unexplained symptoms (MUS)' Royal College of Psychiatrists, which states "Investigation causes significant iatrogenic harm" see https://www.rcpsych.ac.uk/pdf/CHECKED MUS Guidance_A4_4pp_6.pdf

It has a reference list and cites two seen as supporting this statement.

[Added - these references are
  1. Kouyanou K, Pither CE, Wessely S. Iatrogenic factors and pain. Psychosomat Med 1997; 59:597-604.

  2. Fink P. The use of hospitalizations by persistent somatizing patients. Psychol Med 1992; 22:173-80. ]
 
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JaimeS said:
not to run blood tests
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Several of the references suggest basic blood tests be used so that these can be used by the doctor in explaining that there are no underlying medical conditions (see Burton 'ABC of medically unexplained symptoms') but the implicit suggestion seems to be that further tests and referral to non psychiatric consultants then reinforces the false beliefs.

The implicit gist of the Royal College Psychiatrists' guidance seems to be that diverting people to CBT or giving them antidepressants saves money by bypassing more testing or other consultants
 
Here is yet another one: "the more investigations and referrals they receive, the more difficult it becomes to help them"

from Implementing a psychotherapy service for MUS in a primary care setting
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5742798/

which cites Barsky A.J. Hypochondriasis. Psychosomatics. 1996;37:48–56. doi: 10.1016/S0033-3182(96)71598-0. as justification

[added - This 'Implementing a psychotherapy service ... ...' has some interesting comments, my favourite so far is a suggestion that treating people with MUS can be so stressful for clinicians that they may end up somatising their own distress and themselves present with MUS. So not content with adding large swaths of patients to their psychiatric client list they also want to add the clinicians treating them to their patient list as well. Yet more empire building.]
 
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Here is another quote from 'Implementing a psychotherapy service':

Another important issue to address is the commonly held belief that MUS should only be diagnosed by exclusion, i.e., that these processes can only be diagnosed after all other tests have been ruled out. This does not have to be the case. The central philosophy implemented at the outset of the MUS service is that emotional factors are not assumed to be present, but they are also not assumed to be absent either. Instead, the ISTDP assessment process involves a direct ‘psychodiagnostic’ evaluation in order to ‘rule in or out’ somatic processes by detecting emotional aspects of physical symptoms. In brief, this involves facilitating emotional mobilization and then observing the body’s physiological response to this ‘emotional palpation’ (e.g., presentations such as IBS which are mediated by the sympathetic nervous system). This sort of palpation is analogous to other forms of physical examinations.

This focus on testing and observing bodily processes is fundamental to the ISTDP assessment process. There are a number of potential outcomes based on patients’ response to this ‘emotional palpation’.
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What a nightmare, no wonder the clinicians this group work with find themselves getting distressed and stressed.
 
A 1991 editorial by SW contains the following:
However, the simple combination of history, examination and basic tests will establish those who require further investigation. 49 In the majority this simple screen will be normal, and over investigation should be avoided. Not only is it a waste of resources, it may not be in the patients' interest, and may reinforce maladaptive behaviour in a variety of ways. "As patients undergo more tests, they will focus on a laboratory abnormality and subsequently find researchers interested in studying these abnormalities". 50 This may help the researchers, but not the patient.

49 Valdini A, Steinhardt S, Feldman E. Usefulness of a standard battery of laboratory tests in investigating chronic fatigue in adults. Family Practice 1989;6:286-91.
50 Armon C, Kurland L. Chronic fatigue syndrome: issues in the diagnosis and estimation of incidence. Review of Infectious Diseases 1991;13(Suppl 13):68-72.

https://jnnp.bmj.com/content/jnnp/54/8/669.full.pdf
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As seems par for the course, his 2½ page editorial contains 51 references.

I found this among a compendium of similar SW quotes gathered by @Valentijn at PR.
https://forums.phoenixrising.me/index.php?threads/simon-wessely-quotes.21025/
 
Re the quote from 'Implementing a psychotherapy service':

Peter Trewhitt said:
Instead, the ISTDP assessment process involves a direct ‘psychodiagnostic’ evaluation in order to ‘rule in or out’ somatic processes by detecting emotional aspects of physical symptoms. In brief, this involves facilitating emotional mobilization and then observing the body’s physiological response to this ‘emotional palpation’ (e.g., presentations such as IBS which are mediated by the sympathetic nervous system). This sort of palpation is analogous to other forms of physical examinations.
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Ugh, emotional palpation. What a term.

An ugly term based on a stupid idea. Any number of conditions get worse when someone is emotionally stressed. It doesn't mean there isn't an underlying biomedical problem.
 
Henningsen, Fink et al. "Medically Unexplained Symptoms, Somatisation and Bodily Distress: Developing better clinical Services", Cambridge Medicine, Ch. 2, p. 63:

"If the doctors do not consider the possibility that the symptoms are stress reactions or otherwise based on altered perceptions, they may inflict iatrogenic harm to the patients by unnecessary examinations, tests and treatment attempts that will be fruitless, but not always harmless. It is still not well enough known that for enduring and disabling bodily symptoms a purely biomedical explanation of the extent of the symptoms is hardly ever appropriate."

Henningsen, Martin, „Das Chronische Erschöpfungssyndrom“, 2012, doi: 10.1055/s-0032-1327258:
"Es besteht ein iatrogenes Chronifizierungs- und Fixierungsrisiko darin, zu lange immer neue organische Differenzialdiagnostik auch exotischerer Art durchzuführen, ohne die Möglichkeit eines CFS zu bedenken und Anamnese und Therapie in diese Richtung zu lenken."
[There is an iatrogenic risk of chronification and fixation if organic differential diagnistic is performed too long and repeatedly, inclzding exotic tests, without considering the possibility of CFS, and to steer anamnesis* and therapy** in that direction.]

*For Henningsen, that's psychiatric assessment, like childhood, childhood trauma, lifestyle, work, stress, personality.
** CBT, GET

The same can be found in the S3 guideline „Nicht-spezifische, funktionelle, somatoforme Körperbeschwerden“ [Non-specific functional somatoform bodily symptoms].

Henningsen, et al. "Management of functional somatic symptoms", 2007,
DOI:10.1016/S0140-6736(07)60159-7
"For example, qualitative research in primary care showed that patients with so-called unexplained symptoms often voice psychosocial clues that are not taken up by their doctors; instead, doctors and not patients themselves somatise—ie, commonly initiate
further diagnostic testing despite the assumption that the complaint is not explained by structural disease."
There is more...

See also Henningsen et al. "Management of Functional Somatic Syndromes and Bodily Distress", 2018, DOI: 10.1159/000484413.

Edit: basic diagnostic tests that can be done by a GP are recommended though. But it is also recommended to consider a psychosomatic disorder from the beginning.
 
Inara said:
"If the doctors do not consider the possibility that the symptoms are stress reactions or otherwise based on altered perceptions, they may inflict iatrogenic harm to the patients by unnecessary examinations, tests and treatment attempts that will be fruitless, but not always harmless. It is still not well enough known that for enduring and disabling bodily symptoms a purely biomedical explanation of the extent of the symptoms is hardly ever appropriate."
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This is the one i was trying to remember :emoji_face_palm:
@JaimeS is this the one you were looking for?
 
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What is most disturbing about this is that it is clearly taking shape in the GP surgery. Not just in our own experiences, but i recently watched a couple of episodes of GPs Behind Closed Doors. I'm often not well enough for tv & this wouldn't be my top choice for viewing, but recently for various reasons i have ended up watching a few episodes. When comparing to a few of episodes i saw some yrs ago - maybe 3-5yrs ago, the difference is stark. I dont know whether its an editorial decision or what, but every other consult was a GP patronisingly asking about 'mood' in presenting issues that were utterly unrelated. And EVERY consult about pain, unless the signs were obvious - like massive swelling - the person was asked about their mood.

They are all very nice & smiley & if i didn't know what i know about the MUS agenda i probably wouldn't have noticed, but it's getting really obvious.
 
JemPD said:
They are all very nice & smiley & if i didn't know what i know about the MUS agenda i probably wouldn't have noticed, but it's getting really obvious.
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The references relating to GP training and to service delivery, as well as encouraging GPs to think of psychiatric diagnoses as a first not a last resort, repeatedly stress approaches designed to keep the patient on board through feeling valued and understood, but are intended to placate and mislead the patient that their symptoms are being taken seriously when in fact they are being medically ignored.

I know someone with a diagnosis of functional neurological symptoms who understands this to mean she has something similar to ME or ME itself. She has mild to moderate symptoms and does not seem to have taken on board the implication of her diagnosis that she has a psychiatric condition. [She appears to be happy that her doctor is listening to her and implicitly trust what her doctor says. The tendency of the Biopsychosocial advocates to emphasise anything that blurs the lines between the psychological and the biomedical produces a dangerously plausible pseudoscience that uninformed patients may be happy to accept.]
 
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. . . such 'inappropriate' referrals to physicians can lead to extensive physical investigation that may perpetuate the symptom patterns of physical attributions.
Powell R, Dolan R, Wessely S. Attributions and self esteem in depression and the chronic fatigue syndrome. J Psychosomatic Res 1990; 34: 665-673.

However, the simple combination of history, examination and basic tests will establish those who require further investigation. In the majority this simple screen will be normal, and over investigation should be avoided. Not only is it a waste of resources, it may not be in the patients' interest, and may reinforce maladaptive behaviour in a variety of ways.
Wessely S. Chronic Fatigue Syndrome. J Neurol Neurosurg Psychiatry 1991;54; 669-671.

Further investigation of chronic fatigue in primary care shows that history taking and physical examination are more useful than laboratory tests in the assessment of chronic fatigue, and the doctor is most likely to presume a psychosocial cause.
Lewis G, Wessely S. The Epidemiology of Fatigue: More Questions than Answers. J Epidem Comm Health 1992; 46; 92-97.

from Valentijns thread
eta: https://www.s4me.info/threads/simon-wessely-research-related-quotes.1304/
 
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This from Manu's chapter in Ciba Foundation Symposium 173 (1992):
Conclusions
Most patients with a chief complaint of chronic fatigue suffer from clinical depression, panic disorder, and/or somatization disorder. Therefore, laboratory investigations should be pursued with restraint, and a formal psychiatric evaluation must be performed in all patients with chronic fatigue, regardless of the style of presentation.

As currently defined for research and clinical applications, CFS is usually diagnosed in middle-aged white individuals (mostly women) with a high lifetime prevalence of major depression and somatization disorder and a strong belief in the physical nature of their illness. These findings, and the lack of specific physical and laboratory abnormalities, support a pathogenetic hypothesis that regards CFS as endogenous depression occurring in individuals with a tendency to amplify somatic complaints and explanations. The clarification of the aetiology of CFS will require multidisciplinary research within the framework of long-term studies of carefully stratified cohorts of chronic fatigue patients, and meticulous comparisons with control groups of patients with clearly defined psychiatric conditions.
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I'll add more to this post as I find them...

ETA: In David Mechanic's chapter, he talks about the futility of laboratory testing, because "CFS is a diagnosis made by exclusion. The exclusionary possibilities are abundant, offering opportunities to use expensive and invasive laboratory tests to examine varying hypotheses," which he goes on to warn against.

Later, he adds,
As noted earlier, even the restrictive case definition is sufficiently confounded with psychosocial and psychiatric factors to require careful exploration of these dimensions. The restrictive definition is arbitrary and there is no evidence that cases identified in this way are in a separate category from fatigue cases of shorter duration. While it is useful for scientists to proceed selectively, practising physicians must treat a variety of patients with chronic fatigue in a way that conveys concern, is helpful, and avoids reinforcing dysfunctional illness behaviour and associated disability.
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ETA 2: The overwhelming consensus from the symposium (looking at the other chapters) is that extensive testing is unwarranted and unnecessary because it never seems to yield anything. They conclude that if there is undiscovered occult pathology (ie, indicative of something else), it will become apparent with time anyway.
 
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Third, the use of extensive laboratory investigation has been found to be unrewarding and may be psychologically harmful to the patient by reinforcing their beliefs or concerns about serious physical disease.

@p995

Many patients with CFS are assessed solely by their general practitioner. If further investigation is required the patient may be referred to a physician. However, excessive investigation should be avoided.

@p1000

Michael Sharpe. Psychiatric management of PVFS. British Medical Bulletin (1991) vol 47 pp989-1005
 
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