Medically Unexplained Physical Symptoms

Question 1

SOMATOFORM DISORDERS:

1. Somatization disorder(Briquet’s syndrome)
2. Hypochondriacal disorder
3. Body dysmorphic disorder
4. Somatoform autonomic dysfunction
5. Persistent somatoform pain disorder

Answer 1

• Symptoms take up the form of a physical illness.
• No detectable structural/neurophysiological abnormalities
• Not under voluntary control

1. ICD-10 says all of these have to be present:
   - ≥2y of symptoms with no physical explanation found
   - Persistent refusal to accept reassurance from several doctors that there is no physical cause for the symptoms.
   - Some degree of functional impairment due to symptoms and resulting behaviour.

• Patients must have numerous symptoms from various systemic groups ie GI, Sexual, Urinary and neurological
• Can result in iatrogenic diseases/symptoms
• Often dependent on analgesics and sedatives.

2. • Misinterpretation of normal bodily sensations leading to believe that there is a serious progressive physical DISEASE.
     - Patients refuse to accept reassurance of numerous doctors that they do not have a serious physical illness, in contrast to somatization disorder where patients tend to seek relief for symptoms.

3, - Considered a subtype of Hypochondriacal disorder(under ICD-10)

• Preoccupation with an imagined minor defect in physical appearence
• Causes significant distress and impairs functioning

4. • Symptoms concerning the autonomic nervous system. Objective evidence: sweating, palpitations, tremor etc. Subjective; pain, burning, heaviness, tightness, feeling bloated etc.
     - Attributes cause to particular organ/system in contrast to somatisation disorder where numerous symptoms not attributed to only one organ.
     - eg: Da Costa’s syndrome(Cardiovascular), psychogenic hyperventilation, IBS.
5. • Severe and persistent pain that cannot be fully explained by physical illness.
     - Differs from somatization disorder which reports numerous symptoms from multiple system where pain is not the overwhelmingly dominant symptom.

Question 2

FACTITIOUS DISORDER(MUNCHAUSEN’S SYNDROME)

Answer 2

• Intentional feigning of physical/psychological symptoms
• Primary gain: assuming the sick role
• Munchausen’s syndrome by proxy:
• carer seeks help for fabricated/induced symptoms in dependant(usually a child)
• remove dependant from direct influence of carer and inform relevant authorities.

Question 3

MALINGERING

Answer 3

• Intentional feigning of physical/psychological symptoms
• Focuses on secondary(external) gain of secondary consequence from diagnosis
• eg: avoiding military service,
  evading criminal prosecution, obtaining illicit drugs, obtaining benefits/compensation.

Question 4

DDX:

Answer 4

1. Psychotic Disorders(eg: Schizophrenia)
   - somatic delusions/visceral somatic hallucinations
   - explanation of symptoms often odd and other psychotic symptoms usually accompany physical complaints
2. Mood Disorders
   - Episodic
   - Resolves with treatment of mood disorder ie depression
3. Anxiety disorders
   - Multiple somatic symptoms during panic attack but resolve when panic attack subsides.
   - Anxiety not limited to physical symptoms in GAD
4. Conversion/Dissociative Disorders
   - Can present with neurological symptoms wtihout evidence of organic causes.
   - Symptoms usually clearly defined and isolated as opposed to somatization disorder.
5. Insidious multi-system disease/physical illness
   - More likely if older age

*≥1/2 of patients with somatization disorder have coexisting mental illness.

Question 5

EPIDEMIOLOGY(SOMATOFORM DISORDERS):

1. Somatization disorder
2. Hypochondriacal disorder

Answer 5

1. Somatization disorder
   - Lifetime prevalence: 0.2-2%
   - Onset usually <25y
   - Female 10:1
2. Hypochondriacal disorder
   - Lifetime prevalence: 1-5%
   - Onset usually early adulthood
   - Men and women 1:1

Question 6

AETIOLOGY(SOMATOFORM DISORDERS)

Answer 6

1. Genetic
2. Environmental:
   - Childhood sexual abuse
   - Environment that more readily acknowledge physical distress compared to psychological distress.

Question 7

COURSE AND PROGNOSIS:

Answer 7

1. Usually chronic episode course
   - waxing/waning symptoms
   - exacerbated by stress
2. Good prognostic features: acute onset, brief duration, mild hypochondriacal symptoms, presence of genuine physical comorbidity and absence of comorbid psychiatric disorder

Question 8

MANAGEMENT AS GP:

Answer 8

1. Arrange to see patients at regular, fixed intervals rather than at patient’s request
2. Limit contact to 1-2 doctors to avoid iatrogenic harm.
3. High threshold for referral, take physical symptoms seriously
4. Support during times of stress
5. Help patients to think in terms of coping with problem rather than curing it
6. Treat coexisting mental disorders