This document outlines a psychoeducational group for patients with medically unexplained physical symptoms (MUPS). It includes an initial assessment, follow up letters, and an 8-week program outline. The program aims to educate patients on MUPS and teach coping strategies. Sessions cover topics like the impact of stress, illness beliefs, pain management, and putting learning into practice. The goal is for patients to better understand and manage their symptoms.

1. Dr Adrian Hemmings
hemfipsych.com
Working with Medically Unexplained
Physical Symptoms (MUPS)

2. During this presentation we will
examine:
 The outline of a psychoeducuative group
 Different classifications of MUPS
 An overview of theories of aetiology
 What do Neuro-imaging studies have to offer?
 An overall theory of MUPs
 So what ? How might this be relevant to 10 minute
consultation?
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3. Initial letter to patient from GP
I am writing to let you know about a new course that we are
about to start that will be held here at the surgery. It is
called ‘Coping with Health Problems’. I know that you
have had a series of health problems and I thought that
this programme might be helpful to you
It will be run by … who has a special interest in working
with people with health problems in order to help them
cope with their illness.
The course consists of an initial assessment when a
comprehensive history will be taken along with few simple
and harmless tests. You will be told more about the
course and, if you both agree that it might be useful, you
will be invited to eight one-and-a-half-hour weekly group
meetings.
If you would like to attend simply contact….
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4. Assessment
 Client’s attitude to the referral and the problem
 Details of the illness
 Present symptoms: Type of pain, Occurrence
 What makes it worse and what makes it better
 Thoughts accompanying pain
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5. Assessment
 Coping Strategies
 Consequences on life
 Others response
 History including previous treatments
 General beliefs about the nature and meaning
of the symptoms
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6. Assessment
 Biofeedback:EMG,GSR,Peripheral Temp
 Medication Other treatments
 Goals of treatment What would you like to
change?
 Rationale for psychological treatment
(contribution of stress as a cause or effect.
Test out hypothesis of psychological element)
 Description of course:
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7. Follow-up letter from group leader to
patient
Following our meeting on ….. concerning the effects of your
(symptom description), enclosed is the course outline that I
promised. The course will start on (date) at the … (directions) .
It will start at ... in … room. Each meeting will last for one and
a half hours.
As I explained when we met the course is a mixture of education
and self help. This means that in between each meeting an
exercise will be set which will help you to monitor your progress.
Before we meet I'd be grateful if you would have a think about what
you would like to gain from the course - try imagining yourself in
eight weeks time and think of what you would like to have
changed by then. You'll be able to discuss this in more detail at
our first meeting.
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8. Programme Outline
Week 1: General introduction , goal setting
and models of health
 Introduction to the notion of coping
 Hot cross bun
 Goals on a flip chart
 Introduction to self monitoring
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9. Programme Outline
Week 2: What happens when we are stressed
by health problems
 Self monitoring review
 Stress what is it?
 Individual stress reactions to symptoms
 Early experiences of illness
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10. Programme Outline
Week 3: Physical reactions to stress
 Self monitoring review
 Cave person exercise
 Active progressive relaxation
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11. Programme Outline
Week 4: How do individual views of illness
effect health?
 Review of self monitoring
 How thinking and beliefs effect feelings
 NATS and BATS
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12. Programme Outline
 Week 5 : How does behaviour affect health: in
introduction to TA
 Self monitoring review
 How behaviour can maintain behaviour
 How we interact with other people
 TA overview – Ego states, transactions and
games
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13. Programme Outline
 Week 6: Pain and Pain management
 Review of self monitoring exercises
 The relative nature of pain – the gateway
theory
 Autogenic training
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14. Programme Outline
 Week 7: Putting together the pieces
 Open ended group for participants to bring own
agenda
 So what?
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15. Programme outline
Week 8: Evaluation of goals and the future
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16. Exercise
 Thinking of your childhood how was illness
managed in your family?
 How did your parents respond to you/your
siblings when you were ill?
 How did you respond to your parents/siblings?
 How has this effected your current relationship
with illness?
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17. The Organic Genesis of Patient
Presentations (Kroenke and Manglesdorf 1993)
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18. Types of MUPS
Functional
Symptoms
Somatic
presentation
among patients
with depression
or anxiety and
somatisation
Hypochondriacal
Worry/ Health Anxiety

19. Functional somatic syndromes
Gastroenterology Irritable Bowel Syndrome,
Functional dyspepsia
Cardiology Atypical chest pain
Neurology Common Headache, CFS
Rheumatology Fibromyalgia
Complex regional pain syndromes
Gynaecology Chronic pelvic pain
Allergology Multiple chemical sensitivity
Orthopaedics Chronic back pain
Dentistry Temporomandibular joint dysfunction

20. Somatisation
 A transient or persistent tendency to
experience and communicate psychological
distress in the form of somatic symptoms and
to seek medical help for them. It occupies a
continuum from a simple misinterpretation of a
subjective bodily sensation to an unwavering
belief that a physical disease is present
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21. Health Anxiety
 Health anxiety OCD spectrum of ‘disorders’.
 Obsessional preoccupation with the idea or the
thought of currently (or will be) experiencing a
physical illness.
 Common health anxieties tend to centre on
conditions such as cancer, HIV, AIDs etc,
 May fixate on any type of illness.
 Also called illness phobia/ illness anxiety or
hypochondriasis.
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22. The Spectrum of MUPS
Duration: transient persistent
No. of Sx: one multiple
Insight: good none
Disability: none severe

23. Theories of Aetiology
 Psychobiological
 High levels of physiological arousal
 Alexithymia
 Cognitive/Behavioural
 Somatisation is rewarded
 Secondary gains reinforce symptoms
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24. Theories of Aetiology
 Psychoanalytical
 Real conflicts denied, suppressed or repressed
 Anxiety displaced into physical symptoms
 Sociocultural
 Emotions expressed through physical
symptoms
 Specific “culture bound” syndromes (Koro,
taijin kyofusho)
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25. • EP posits a theoretical framework to understand false
illness signaling
• An EP approach to somatisation asks whether false
illness signaling represents an innate psychological
mechanism triggered by situational exigencies
• Somatisation may represent a behavioural strategy
that bestows survival value
Theories of Aetiology
Evolutionary psychology (EP)

26. Theories of Aetiology
Early Trauma
 High correlation with early trauma and MUPs
(Roelofs and Spinhoven 2006) (Salmon et al 2003)
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27. Theories of Aetiology
Attachment styles
 Secure – reliable care giving as children, positive view
of self and comfortable depending on others
 Dismissing – unresponsive caregiving, self reliant
others not to be relied on
 Preoccupied – inconsistent caregiving, negative view of
self seen as unlovable and expecting others to view
negatively preoccupied vigilant
 Fearful – needs not met when young negative view of
self and others approach and avoidant
 High correlation with MUPS and preoccupied and
fearful AS hemfipsych.com

28. Continuum of Attachment
B
Secure
A
Avoidant
C
Resistant/Ambivalent
Up regulateDown regulate Flexible

29. Theories of Aetiology
Dissociation
 Higher levels of dissociative amnesia in
somatising patients (Brown et al 2005)
 Linked to pseudo-seizures (Prueter et al 2002)
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30. Theories of Aetiology
Immune system
 Activation of the immune system seems to
induce behaviour patterns that are similar to
the illness behaviour seen in depression and
somatisation (Rief and Barsky 2005).
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31. Neuro-imaging studies: Irritable
Bowel Syndrome
 Anterior Cingulate Cortex (ACC) as having a
role in the regulation of pain in IBS (Ringel et al
1999)
 Uprated in chronic and downrated in acute
(Peyron et al 2000)
 Association with CSA and dissociation (Salmon
et al 2003)

32. Neuro-imaging studies: Chronic
Fatigue Syndrome
 Significant positive relationships were found for
cerebellar, temporal, cingulate and frontal regions and a
significant negative relationship was found for the left
posterior parietal cortex in CFS patients v controls (Cook
et al. 2007).
 Increased activation in the occipito-parietal cortex,
posterior cingulate gyrus and parahippocampal gyrus,
and decreased activation in dorsolateral and
dorsomedial prefrontal cortices (Caseras et al. 2008).
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33. Neuro-imaging studies:
Fybromyalgia
 Low stimulus pressure associated with 13
regions of brain activated compared with only
one in controls. (Gracely et al. 2002).
 Greater activation in contralateral insular cortex
in both non painful warm and pain stimulus
(Cook et al. 2004).

34. Neuro-imaging studies: Expectation
(Nocebo effect)
(Rief & Broadbent 2007)
 Expectation of symptoms leads to the
activation of brain areas corresponding to
symptom perception
 Distraction from symptoms reduces brain
activity in perception areas
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35. The perception-filter model of
somatisation
(modified from Rief and Barsky 2005 in Rief and Broadbent 2007)
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36. The Triune Brain
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37. The role of emotion
 Emotion associated with profound physiological
changes
 Often unconscious as bypasses frontal cortex
 Often clients have limited language for emotions
 Affect avoidance (having feelings, expressing
feelings and confusion about feelings)
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38. Common Safety Behaviours
 Checking pulse
 Hypervigilence of ‘symptoms’
 Reducing activity
 Symptom browsing on internet
 Seeking reassurance from GP
 Palpating parts of the body
 Reducing food intake
 Slowing down/speeding up
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39. Potential interventions: Behavioural
 Reducing “boom and bust” mode
 Reducing symptom-focusing behaviours
 Anxiety management skills
 Re-education re somatising precipitators and
perpetuators and treatment programme
 Graded exposure (using exposure hierachy)
 Identifying and reducing safety behaviours
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40. Potential interventions:
physiological
 Relaxation exercises (diaphragmatic breathing,
APR autogenics)
 Graded exercise
 Moving specific symptom focused parts of
body
 Diet
 Substance use
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41. Potential interventions: Emotional
 Identifying feelings
 Developing language for feeling
 Reducing feeling avoidance
 Having conversation with symptom
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42. Development of ‘illness behaviour’
 Often related to attachment styles
 When GP and patient are together – two
attachment styles and illness behaviours are
interacting
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43. Attunement enables
affect-regulation
Like the securely attached mother, the
empathic psychobiologically attuned clinician’s
regulation of the patient’s affective-arousal
states is critical to transforming the patient’s
insecure nonconscious internal working model
that encodes strategies of affect regulation
Schore 2007 12

44. • B.. Background -What is happening in your
life at the moment?
• A.. Affect- How do you feel about that?
• T.. Trouble -What is the most troubling part
of..
• H..Handling - How are you managing
to deal with that?
• E..Empathy - That must be difficult for you.
The BATHE technique
(Stuart and Leiberman 2002)

45. Dos and Don’ts:
DO
 Talk about coping
 Use one designated GP
 Schedule frequent, brief, regular visits not
contingent on new complaints.
 Allow "sick role;" focus on function rather than
symptoms.
 Explore psychosocial issues.
 Prescribe benign treatments and enjoyment
time. hemfipsych.com

46. Dos and Don’ts:
DON’T
 Suggest "It's all in your head.“
 Pursue invasive diagnostic tests, medications
or surgical interventions without good
indications.
 Refer excessively to specialists.
 Focus on the symptoms themselves
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47. MUPS Further Reading
Bass, C Ed (1990). Somatisation: physical symptoms and psychological illness.
Blackwell Oxford.
Donohugue, P. & Seigel ,M. (1997). Sick and Tired of Feeling Sick and Tired,
Living with invisible chronic illness and Sage
Mayou, R., Bass,C. & Sharpe, M. (1995). Treatment of functional somatic
symptoms. Oxford University Press. Oxford.
Gill, D. (2007). Hughes’ Outline of Modern Psychiatry. Wiley & Sons (see
Chapter 9 on Physical Symptoms and Psychiatric Disorders)
Sanders, D., (1996) ofor Psychosomatic Problems. London: Sage Publicationst
Woolfolk, R. & Allen, L. (2007).Treating Somatization. A Cognitive Behavioral
Approach Guildford Press
Johnson,S. (2008). Medically Unexplained Illness. Gender and Biopsychosocial
Implications. APA
Journals: Journal of Psychosomatic Research, Psychosomatics
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