CT 10 - The Patient With Inter-relating Conditions Of Mind And Body Flashcards
The sick role:
The special role in society occupied by a person who has declared himself as ill, and whose illness has been legitimised or ‘sanctioned’ by a doctor (or cultural equivalent), or by relatives or friends.
Obligations:
* The person must want to get well as soon as possible.
* They should seek professional medical advice and cooperate with the doctor.
Privileges:
* The person is allowed (and perhaps expected) to shed some normal responsibilities and activities.
* They are regarded as being in need of care and unable to get better by his/her own will.
what are examples of abnormal illness behaviours
1) illness denial Behaviours to avoid the ‘stigma’ + Inability to accept the physical/mental disease)
2) illness affirmation
Behaviours which inappropriately affirm illness behaviours
Invalidism
Disproportionate disability compared to symptoms/signs
illness affirmation may lead to two disorders…
1) somatisation which can be acute or chronic
2) simulation which if conscious leads to factitious disorder or malingering
if unconscious leads to dissociation
what are MUS
Physical symptoms not explained by organic disease and for which there is positive evidence or a strong assumption that the symptoms are linked to psychological factors
why is MUS a big problem
20% of GP new episodes
53% in gastroenterology
42% in neurology
£3 billion of NHS costs
types of MUS symptoms
Psychosomatic = A disorder having physical symptoms but originating from mental or emotional causes. Often used in mainstream media to describe MUS
Somatoform = repeated presentation of physical symptoms, with persistent requests or medical investigations, in spite of repeated negative findings and reassurances by doctors that the symptoms have no physical basis
Dissociative/conversion disorders = simulated conditions related to acute trauma. Present acutely, often dramatically, with the patient’s idea of a devastating condition e.g. leg weakness with normal reflexes
what is somatisation
a process where patients present with physical symptoms as a manifestation of psychological distress.
is an unconscious process
is different to somatisation disorder
what are the pre-disposing factors in somatisation
History of early (chronic) physical illness:
family or patient
Somatic vocabulary
alexithymia / LD / difficulties establishing mental representations of emotion
Childhood neglect / abuse
Early regime: attention for physical illness but not for emotional distress
“conditional caretaking” (Violon 1985)
Central pain mechanisms
growing evidence that psychosocial factors can affect pain perception more than peripheral signals. Association between abuse and central mechanisms of pain modulation and amplification
“Emotional avoidance culture” in severe somatoform disorders
absent, insufficient or dismissive communication with significant adults…
difficulty communicating about problems, concerns and emotions re: stress
what are perpetuating factors in somatisation
Dilemma / conflict resolution
Role changes / reduced social responsibility and expectation
Changing dynamics of relationships
Physical consequences of illness behaviour
Iatrogenic harm
Compensation?
public recognition of suffering
MUS is related to which MH conditions
Depression
Anxiety
Panic disorder
Obsessive Compulsive Disorder
Post-traumatic stress disorder
Post-natal depression
what is dissociation and conversion
Dissociation is an unconscious separation from a difficult, usually traumatic stimulus
Conversion is an unconscious ‘converting’ of a psychological stressor into a physical illness
They are distinct from somatisation (which is an unconscious expression of psychological difficulties through physical symptoms)
These are simulated conditions- a deflection or distancing from the psychological stressor through the presentation of an abnormal state.
Dissociation can present through a highly abnormal mental state e.g. amnesia, dissociative fugue (where the person flees the stressor but without any memory of doing so)
The primary gain is relief of primary stressor
Mechanism for coping with an intolerable situation
The physical or mental complaints often symbolic
what is conversion disorder
A deflection or distancing from the psychological stressor through the presentation of physical illness. The basis for this is nearly always trauma
Presents differently from somatisation-based illness
Acute, dramatic onset of a serious physical condition e.g. blindness, paralysis
Often simulates patient’s ideas about neurological disease e.g. paraesthesia that does not follow dermatomes
Majority are acute (can become chronic)
Function is intact eg leg ‘paralysis’, but normal tone and reflexes. No disuse atrophy if chronic
Often gets labelled as a ‘functional’ condition by neurologists/acute medics which can delay appropriate treatment
Addressing the trauma is key
what is malingering
presenting with made-up symptoms of an illness for secondary material gain e.g. money, housing, benefits, drugs
what is factitious disorder
more complicated = conscious production of symptoms but the main gain is attention and intervention from healthcare professional
Also diversion from psychosocial stressors
Not as straight forward as for malingering
what is munchausen syndrome
Where a caregiver feigns symptoms in a dependent (most often parent and child)
50% have a somatoform disorder and/or factitious disorder and >75% a co-existing personality disorder.
This is child abuse and must be reported to safeguarding
