Medical Unexplained Symptoms (MUS)

Question 1

Define Medically Unexplained Symptoms.

Answer 1

Physical complaints without evidence of underlying organic cause.

• Think of as ‘Functional Symptoms’

Question 2

Define Dissociative/Conversion Disorder.

Answer 2

Partial or complete loss of the normal integration between memories of the past, awareness of identify and immediate sensations, and control of bodily movements

Question 3

What are some sub-types of Dissociative/Conversion Disorder?

Answer 3

• Dissociative Amnesia - loss of memory
• Dissociative Fugue - dissociative amnesia + purposeful travel beyond normal everyday range
• Dissociative Stupor - lack of voluntary movement/response to stimuli
• Trance and Possession Disorders - loss of personal identity and sense/awareness of surroundings
• Dissociative Motor Disorders - loss of ability to move whole/part of a limb(s)
• Dissociative Convulsions - mimic of epileptic seizures
• Dissociative Anaesthesia

Question 4

What are the risk factors for Dissociative/Conversion Disorder?

Answer 4

• Traumatic events
• Intolerable problems
• Disturbed relationships

Question 5

What are the signs and symptoms of Dissociative/Conversion Disorder?

Answer 5

• Onset = acute, specific, dramatic, following sudden stress or conflict
• Presentation:
  
  • Paralysis
  • Blindness
  • Aphonia (cannot speak)
  • Seizures
  • Psychogenic amnesia (loss of all memories, including own identity)
  • Multiple personalities
  • Fugue (loss of memory entirely and wander away from home)
  • Stupor
• May show a relative lack of concern despite showing worrying symptoms (i.e. seizures)

Question 6

What are the appropriate investigations for Dissociative/Conversion Disorder?

Answer 6

Exclude organic causes

Question 7

What is the management of Dissociative/Conversion Disorder?

Answer 7

• Self-limiting spontaneous recovery – 75% return to normal
• Identify and treat any co-morbid mental health conditions
• Supportive therapy:
  
  • Encourage return to normal activity
  • Avoid reinforcing behaviour (i.e. a wheelchair for dissociative stupor/motor disorders)
  • Address physical stressors rather than focus on physical manifestations

Question 8

Define Somatisation.

Answer 8

Multiple, recurrent and frequently changing physical symptoms of greater than 2 years duration.

• Many have a complicated history of contact with medical care with many negative investigations carried out
• 10:1 F:M ratio

Question 9

What are the different sub-types of Somatisation?

Answer 9

• Undifferentiated Somatoform Disorder
• Hypochondrial Disorder - often cancer and have a pre-occupation with a single problem
• Somatoform Autonomic Dysfunction - symptoms of a physical disorder of a system/organ largely/completely under the control of the autonomic nervous system
• Persistent Somatoform Pain Disorder - persistent, severe and distressing pain

Question 10

What are the appropriate investigations for Somatisation?

Answer 10

Exclude organic causes

Question 11

What is the management of Somatisation?

Answer 11

• Continuity of care (seen by the same doctor each time)
• Treat co-morbid conditions (i.e. depression)
• 1^st line: Explain and Reassure:
  
  • Broaden clinical agenda from physical cause to a physical and psychological cause
  • Be clear about negative clinical findings and link the symptoms to psychological causes:
    
    • Acknowledge psychosocial distress
    • Elicit childhood experience of illness
  • Explain you’ll not conduct further investigations (and state why you are stopping)
  • Emotional support
• 2^nd line: CBT