INTER-RELATING CONDITIONS OF MIND AND BODY

Question 1

What is illness behaviour?

Answer 1

refers to any actions or reactions of an individual who feels unwell for the purpose of defining their state of health and obtaining physical or emotional relief from perceived or actual illness. These behaviors include how individuals monitor and interpret bodily sensations, utilize healthcare resources, discuss illness or symptoms with providers, and adhere to prescribed medical regimens.

Question 2

What is the sick role?

Answer 2

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.

Question 3

What are the obligations for the sick role?

Answer 3

The person is not responsible for assuming the sick role.
The sick person is exempted from carrying out some or all of normal social duties (e.g. work, family).
The sick person must try and get well – the sick role is only a temporary phase.
In order to get well, the sick person needs to seek and submit to appropriate medical care.

Question 4

What are the privileges of the sick role?

Answer 4

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.

Question 5

What are abnormal illness behaviours?

Answer 5

Inappropriately perceiving, evaluating or acting in relation to one’s health

Question 6

What are examples of abnormal illness behaviours?

Answer 6

Illness denial
Hypochondriasis

Question 7

What is illness denial?

Answer 7

Inability to accept the physical or mental disease
Behaviours are carried out to avoid the stigma

Question 8

What are medically unexplained symptoms?

Answer 8

Physical symptoms not explained by organic disease for which there is positive evidence or a strong assumption that the symptoms are linked to a psychological factor

Question 9

What are the criteria for MUS

Answer 9

Not a diagnosis of exclusion
Requires positive psychological factors to be elicited
The sympotms are Not deliberately produced
Transient sympotms

Question 10

Outline the burden of MUS?

Answer 10

20% of new GP episodes
53% in gastroenterology
42% in neurology
Account for £3 billion of direct NHS costs per annum

Question 11

Whats the issues with MUS?

Answer 11

Pts may undergo inappropriate or hazardous investigations and treatment
Over-investigation and overtreatment are common

Question 12

What are some types of MUS?

Answer 12

Psychologically-based physical symptoms
Malingering
Factitious

Question 13

Whats the difference between Psychologically-based physical symptoms and Malingering/factitious symptoms?

Answer 13

Psychologically-based are unconscious
Malingering and factitious symptoms are concious

Question 14

What are psychosomatic disorders?

Answer 14

Disorders with physical sympotms that originate from mental or emotional causes

Question 15

What are somatoform disorders?

Answer 15

Repeated presentations of physical symptoms with persistent requests or medical investigations in spite of repeated negative finings and reassurances by doctors that symptoms have no physical basis

Question 16

What are the somatoform disorders?

Answer 16

Somatisation disorder
Undifferentiated somatoform disorder

Question 17

What are some examples of functional symptoms?

Answer 17

IBS
Chronic pelvic pain
Chronic fatigue syndrome
Non-epileptic attack disorder
Functional neurological disorder
Tension headaches
Hyperventilation syndrome
Chronic idiopathic back pain
Fibromyalgia

Question 18

What is somatization disorder?

Answer 18

The main features are multiple, recurrent and frequently changing physical symptoms of at least two years duration. Most patients have a long and complicated history of contact with both primary and specialist medical care services, during which many negative investigations or fruitless exploratory operations may have been carried out.
The course of the disorder is chronic and fluctuating, and is often associated with disruption of social, interpersonal, and family behaviour.

Question 19

What is undifferentiated somatoform disorder?

Answer 19

When somatoform complaints are multiple, varying and persistent, but the complete and typical clinical picture of somatization disorder is not fulfilled, the diagnosis of undifferentiated somatoform disorder should be considered.
I.e. less than 2 years or less striking symptom patterns

Question 20

What proportional of somatisation disorders are associated with a psychiatric disorder?

Answer 20

50%

Question 21

What are some indications that someone has somatisation disorder?

Answer 21

Many unexplained symptoms (often pain)
Frequent consultations in primary and secondary care
Multiple investigations
Excessively disabled
Polypharmacy
Thick case notes
Dissatisfied with care
Odd beliefs
Unrealistic expectations of cure
Denial or minimisation of life problems

Question 22

What are some predisposing factors for somatisation disorder?

Answer 22

History of early physical illness
Somatic vocabulary i.e. difficulty expressing emotions
Childhood neglect or abuse
Early regime e,g, attention for physical illness but not for emotional distress “conditional caretaking’
Emotional avoidance culture

Question 23

What is Briquets syndrome?

Answer 23

Aka somatisation disorder

Question 24

What are non-epileptic attack disorders?

Answer 24

episodes of uncontrolled movements, sensations or behaviour. But unlike epileptic seizures, dissociative seizures are not caused by abnormal electrical activity in the brain.

Instead, it’s thought they are a physical reaction to distressing triggers such as sensations, thoughts, emotions and difficult situations. E.g. common with dissociative disorders and PTSD

Question 25

What is dissociation?

Answer 25

An unconscious separation from a. Difficulty, usually traumatic stimulus

Question 26

What is conversion?

Answer 26

Unconscious converting of psychological stressors into physical illness
Mechanism for coping with intolerable situations. The primary gain is relief of primary stressor

Question 27

What are conversion disorder?

Answer 27

A deflection or distancing from psychological stressor through the presentation of physical illness.
Involuntary Neurological symptoms
Often a presence of a stressor e.g. big sports game coming up

Question 28

Whats the difference between somatisation and conversion disorders?

Answer 28

Conversion disorder occurs when the somatic presentation involves any aspect of the central nervous system over which voluntary control is exercised. Conversion reactions represent fixed ideas about neurologic malfunction that are consciously enacted, resulting in psychogenic neurologic deficits
Acute dramatic onset of a serious physical condition e.g. paralysis
Often simulates pt ideas about neurological disease e.g. paraesthesia that doesnt follow dermatomes

conversion disorder is associated with neurological symptoms rather than physical pain or irritation (which is more in line with somatic symptom disorder)

Question 29

What is malingering?

Answer 29

Presenting with made-up symptoms of an illness for secondary material gain e.g. money, benefits, drugs

Question 30

What is factitious disorder?

Answer 30

Conscious production of symptoms but the main gain is attention and intervention from the healthcare professional i.e. wants the ‘sick role’

Question 31

Outline the prevalence of factitious disorder?

Answer 31

1% of all outpatients in general hopsital
High proportion are healthcare workers

Question 32

How should you deal with factitious disorder?

Answer 32

Collect evidence from multiple sources
Supportive confrontation with a colleague and offer of psychological support
Discuss with your indemnity provider and their registration body (if a health care worker)

Question 33

What is Münchausen syndrome?

Answer 33

Aka factitious disorder

Question 34

What is factitious disorder imposed on another?

Answer 34

When a caregiver feigns symptoms in a dependant when someone falsely claims that another person has physical or psychological signs or symptoms of illness, or causes injury or disease in another person with the intention of deceiving others.
This is child abuse and should be reported to safegaurding

Question 35

What are the ICD10 criteria for diagnosing somatisation disorder?

Answer 35

At least 2 years of symptoms with no adequate physical explanation found
Persistent refusal by the pt to accept reassurance from several doctors that there is no physical cause for the symptoms
Some degree of functional impairment due to the symptoms and resulting behaviours

Question 36

What is hypochondriacal disorder?

Answer 36

The essential feature is a persistent preoccupation with the possibility of having one or more serious and progressive physical disorders.
Patients manifest persistent somatic complaints or a persistent preoccupation with their physical appearance e.g. body dysmorphic disorder.
Normal or commonplace sensations and appearances are often interpreted by patients as abnormal and distressing, and attention is usually focused upon only one or two organs or systems of the body.
Marked depression and anxiety are often present, and may justify additional diagnoses.

Question 37

Whats the difference between hypochondriacal and somatisation disorder?

Answer 37

because pt misinterpret normal bodily sensations which lead them to believe they have serious and progressive physical disease and they will ask for investigations to definitively diagnose their underlying disease.

Question 38

What is somatoform autonomic dysfunction?

Answer 38

Symptoms are presented by the patient as if they were due to a physical disorder of a system or organ that is largely or completely under autonomic innervation and control, i.e. the cardiovascular, gastrointestinal, respiratory and urogenital systems.
The symptoms are usually of two types, neither of which indicates a physical disorder of the organ or system concerned. First, there are complaints based upon objective signs of autonomic arousal, such as palpitations, sweating, flushing, tremor, and expression of fear and distress about the possibility of a physical disorder.
Second, there are subjective complaints of a nonspecific or changing nature such as fleeting aches and pains, sensations of burning, heaviness, tightness, and feelings of being bloated or distended, which are referred by the patient to a specific organ or system.

Question 39

What are examples of somatoform autonomic dysfunction?

Answer 39

Cardiac neurosis / Da costa’s syndrome
Psychogenic hyperventilation and cough
Gastric neurosis or psychogenic flatulence
Psychogenic dysuria and urinary frequency

Question 40

What are persistent somatoform pain disorders?

Answer 40

The predominant complaint is of persistent, severe, and distressing pain, which cannot be explained fully by a physiological process or a physical disorder, and which occurs in association with emotional conflict or psychosocial problems that are sufficient to allow the conclusion that they are the main causative influences.
The result is usually a marked increase in support and attention, either personal or medical.

Question 41

Whats the aetiology of MUS?

Answer 41

May be in part due to genetic factors - 1/5th of sufferers have a first degree female relative who also have the condition
Biological - theories that physical symptoms could result from a failure to regulate cytokines
Psychological models - symptoms unconsciously produced as a substitute form of communication

Question 42

Whats the course of MUS?

Answer 42

Tend to have a chronically episodic course with waxing and waning symptoms often exacerbated by stress

Question 43

What are good prognostic factors for MUS?

Answer 43

acute onset
brief duration
mild hypochondriacal symptoms
the presence of genuine physical comorbidity
the absence of a comorbid psychiatric disorder

Question 44

Whats the role of the GP in MUS?

Answer 44

Arrange to see pt at regular fixed intervals rather than reacting to the pts frequent requests to be seen
Increase support during times of stress for the pt
Take symptoms seriously but also encourage pt to talk about emotional problems
Limit the use of unnecessary medication
Treat coexisting mental disorders
Limit special investigations to those absolutely necessary
Have a high threshold of referral to specialists
If possible, arrange for the pt to only see 1-2 doctors in the practice to help with containment and reduced potential iatrogenic harm
Help to cope with the problem not sure it
Involve family members or carers in the management plan
Consider referring to a psychiatrist or psychotherapist

Question 45

Whats the outcome for MUS?

Answer 45

66% report some improvements in 12 months
Conversion disorders - majority recover or improve quickly

Question 46

How should you treat MUS?

Answer 46

Elicit symptms
Find the meaning of them to the pt
Carry out a physical examination and any appropriate investigations
Give a clear diagnostic statement
Explain pathophysiology of symptoms
State and discuss the need for treatment
Refer on to psychological medicine if necessary
Set up brief regulat meetings every 6-8 weeks to review
Symptoms management
Pain service referral
Promote self efficacy

Question 47

When should you refer MUS to mental health services?

Answer 47

Frequent attendances in primary/secondary care
Diagnostic dilemmas
Very distressed or very disabled
Longer history >12 months
Conversion Disorders the exception- should be referred sooner rather than
later if problems haven’t resolved within a few weeks