Medically unexplained sx

Question 1

epidemiology of medically unexplained sx?

Answer 1

f>m

sx for more than 6 months

25% of gp patients!

Question 2

aetiology of MUS?

Answer 2

Genetics

Theories;
1. Somatization - unconscious expression of
psychological distress through physical symptoms

2. Psychiatric illness can present with
   physical symptoms i.e anxiety
3. Cognitive models misinterpretation of normal physiology can create anxiety and perpetuate
   MUS.

Behaviours such as repeated checking (e.g.
of pulse rate) or constantly seeking reassurance would
maintain anxiety long term; reassurance reinforces
the importance of these behaviours whilst preventing
patients from realizing that symptoms are benign.

Question 3

how does MUS present?

Answer 3

in every specialty with gyane being most common:

• rheumatology—fibromyalgia
• gastroenterology—irritable bowel syndrome, non-ulcer
dyspepsia
• otolaryngology—dizziness, tinnitis.

• cardiology—non-cardiac chest pain, palpitations
• military medicine—Gulf War syndrome
• pain clinics—headache, pelvic pain, lower back pain.

Question 4

what is teh aetiology of chronic fatigue syndrome?

how does it present?

Answer 4

Also known as myalgic encephalomyelitis (ME).
• It may follow viral infection (e.g. glandular fever), but can
also arise spontaneously.
• Extreme fatigue is the main complaint; patients are typically
exhausted by mild exertion. This produces either an
alternating pattern of activity and debilitating fatigue or
complete exercise avoidance.
• Other symptoms are common, e.g. aches and pains.

Question 5

how is chronic fatigue syndrome managed?

Answer 5

• There is strong evidence for graded exercise; this is scheduled and gradually increasing activity (rather than rest).

• Pacing of activity is important: patients need realistic goals
and should not do more activity than planned, even if they
feel like it; otherwise they tend to exacerbate problems.

• Cognitive behavioural therapy (CBT) improves fatigue and
physical functioning.

Question 6

list some Differential diagnoses for MUS?

Answer 6

1.organic

2. psychiatric illness
   - depression and gad
   - Hypochondriasis: an extreme form of health
   anxiety where patients believe that they have a
   specific illness (e.g. cancer) rather than presenting
   with inexplicable symptoms.

• Schizophrenia, persistent delusional disorder,
  or affective psychosis should be considered, since
  hypochondriacal delusions and somatic hallucinations
  may occur.

3. Deliberate production of symptoms (rarely)
   • Factitious disorder: the deliberate production
   of symptoms to receive medical treatment. Extreme cases are termed Munchausen’s syndrome.
   • Malingering: feigning symptoms to obtain
   external reward, e.g. escape military service, gain
   money or drugs.

Question 7

ivx for MUS?

Answer 7

HADs - hospital anxiety and depression scale

Question 8

Treatment for MUS?

Answer 8

6. Antidepressants may be useful
   e.g. tension headache, irritable bowel syndrome,
   fibromyalgia, and ‘idiopathic pain’ (Stahl 2003).
7. Treat comorbid illness
8. CBT Discussion - decrease avoidance and reassurance-seeking
9. Graded exercise is very helpful in some disorders,
   e. g. CFS and fibromyalgia.

Others:
-> may play greater role in conditions ie somatisation

1. Therapeutic assessment
2. Explain and reassure
   Use the Reattribution Model:

• Ensure they feel understood.
• Broaden the agenda from a physical cause to a
physical and psychological explanation.
• Make the link between symptoms and psychological
factors.
- emphasize that it is a common condition

3. Avoid over-investigation, unnecessary specialist
   referrals or physical medication. Do a brief a focussed physical exam.
4. Emotional support
5. Encourage normal function/activities

Question 9

prognosis of MUS?

Answer 9

may receive a diagnosis of organic condition

stress makes it worse

25% remain symptomatic after a year

better prognosis if shorter duratoin and milder sx

Question 10

how do Conversion (dissociative) disorders present?

Answer 10

Internal conflict is unconsciously ‘converted’ into neurological symptoms.

Presentations are acute, specific, and often dramatic,
following sudden stress or conflict.

For example:
• paralysis
• blindness
• aphonia (inability to produce speech)
• seizures
• psychogenic amnesia (this is loss of all semantic
memories including own identity)
• multiple personality disorder (rare and controversial)
• fugue (patients lose their memory entirely and wander
away from home)
• stupor.

Question 11

how are conversion disorders managed?

Answer 11

Encourage a return to normal activities and avoid reinforcing the symptoms or disability (e.g. by providing a
wheelchair).

Patients should be supported to address
triggering stressors rather than focus on physical manifestations.

The outcome tends to be better than for
other MUS.

Question 12

prognosis of conversion disorders?

Answer 12

weeks - years/decades

often no cure

patients may go into remission they can relapse at any point

Question 13

how does icd-10 and dsm5 characterise conversion disorder?

Answer 13

ICD-10 classifies conversion disorder as a dissociative disorder

while DSM-IV classifies it as a somatoform disorder.

Question 14

aetiology of conversion/dissociative disorder?

Answer 14

possibly due to ongoing mental health issue eg depression

Psychodynamic: amnesia is seen as a defence mechanism used alongside repression and denial as a way of dealing with an emotional conflict or an external stressor

Freud: hysteria was due to emotionally-charged ideas which had become lodged in the unconscious of the patient at some previous time, and which were excluded from consciousness by repression

Question 15

define somatisation?

Answer 15

This is the unconscious expression of
psychological distress through physical symptoms,
e.g. rather than anger, a patient experiences abdominal
pain.

Question 16

define factitious disorder?

Answer 16

the deliberate production
of symptoms to receive medical treatment. Presentations
include pyrexia of unknown origin,
haematuria, and skin lesions. Extreme cases are
termed Munchausen’s syndrome.

Question 17

define malingering?

Answer 17

feigning symptoms to obtain
external reward, e.g. escape military service, gain
money or drugs.

Question 18

how to manage a patient with somatisation?

Answer 18

2. Explain and reassure
   Use the Reattribution Model:
   • Ensure they feel understood.
   • Broaden the agenda from a physical cause to a
   physical and psychological explanation.
   • Make the link between symptoms and psychological
   factors.
3. Avoid over-investigation, unnecessary specialist
   referrals or physical medication
4. Emotional support
5. Encourage normal function/activities
   - they usually stop doing these things and working
   because of sx

• > Phsyiotherapy!! for functional motor symptoms

Lecture:

1. Family CBT/Psycodynamic/Group therapy
2. Medication pain/mood
3. Consistency: same doctors, regular appointments

Question 19

when do MUS become a disorder?

Answer 19

when they believe the sx are due to something detrimental i.e tumour

Question 20

what are functional symptoms?

Answer 20

Functional sx is a medical symptom with no known physical cause.

Illness behaviour - unconsciously comes up
Motive - unconsciously comes up

examples;
irritable bowel syndrome - gastro
chronic fatigue syndrome - endo, rheum
chronic pelvic pain - gynae
fibromyalgia - resp
temporomandibular joint disorder -

Question 21

what is the Hoover’s sign?

Answer 21

Hoover’s Sign is an orthopedic test used to determine if someon is malingering or is suffering from neuromuscular weakness.

Question 22

which factors suggest better outcome?

Answer 22

younger
less disability
accept that psych factors may be involved.

Question 23

what are types of dissociative disorders?

FINISH

Answer 23

dissociative amnesia - memory loss, self neglect, wandering. this is loss of all semantic memories including own identity

dissociative fugue - amnesia + make long purposeful journey; often dont remember why they do it.
occasional new identity. self care maintained.
patients lose their memory entirely and wander
away from home.

stupor

trance

movement/sensation

Question 24

rx for conversion/ dissociative disorders?

Answer 24

self limiting - Symptoms usually terminate abruptly and recovery is generally complete with few recurrences

Attempts to try and restore the patient’s lost memories by:
• initial interview
• informant history
• ‘abreaction’ via medication or hypnosis

Question 25

what is primary and secodary gain in conversion disorders?

Answer 25

Primary gain - the exclusion from consciousness of anxiety due to psychological conflict.
• Secondary gain - the disorder confers some advantage to the patient, e.g. excused from normal responsibilities, largely socially determined.

Question 26

what are the risk factors for conversion disorders?

Answer 26

• F>M
• Younger
• Epilepsy, MS, Head injury

Question 27

aetiology of somatisation?

Answer 27

Biological: there is some evidence for faulty processing of sensory inputs in patients with this disorder.

Genetics: 10 – 20 % 1st degree relatives

Psychosocial: a form of communication or as substitutions for repressed instinctual urges.
• The Sick Role (Parsons)
• Illness Behaviour (Mechanic/Pilowsky)
• Alexithymia – no words for moods
• Culture / Family experience – early learning/attentional gain
• Environment – secondary gain (DBS)

Question 28

patients with somatisation tend to have comorbid _____ ?

Answer 28

anxiety, depression, substance abuse, histrionic pd

Question 29

what is non-delusional dysmorphophobia and what condition do we see it?

Answer 29

it is a preoccupation with an imagined bodily defect.

in hypochondriasis

Question 30

how do we manage Separation anxiety ?

Answer 30

Practise short separations from your baby to begin with + reunion
- Eventually getting longer
Talk about what you’ll do together later

Leave something comforting with your baby