Medically unexplained sx Flashcards
epidemiology of medically unexplained sx?
f>m
sx for more than 6 months
25% of gp patients!
aetiology of MUS?
Genetics
Theories;
1. Somatization - unconscious expression of
psychological distress through physical symptoms
- Psychiatric illness can present with
physical symptoms i.e anxiety - 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.
how does MUS present?
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.
what is teh aetiology of chronic fatigue syndrome?
how does it present?
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.
how is chronic fatigue syndrome managed?
• 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.
list some Differential diagnoses for MUS?
1.organic
- 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.
- 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.
ivx for MUS?
HADs - hospital anxiety and depression scale
Treatment for MUS?
- Antidepressants may be useful
e.g. tension headache, irritable bowel syndrome,
fibromyalgia, and ‘idiopathic pain’ (Stahl 2003). - Treat comorbid illness
- CBT Discussion - decrease avoidance and reassurance-seeking
- Graded exercise is very helpful in some disorders,
e. g. CFS and fibromyalgia.
Others:
-> may play greater role in conditions ie somatisation
- Therapeutic assessment
- 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
- Avoid over-investigation, unnecessary specialist
referrals or physical medication. Do a brief a focussed physical exam. - Emotional support
- Encourage normal function/activities
prognosis of MUS?
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
how do Conversion (dissociative) disorders present?
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.
how are conversion disorders managed?
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.
prognosis of conversion disorders?
weeks - years/decades
often no cure
patients may go into remission they can relapse at any point
how does icd-10 and dsm5 characterise conversion disorder?
ICD-10 classifies conversion disorder as a dissociative disorder
while DSM-IV classifies it as a somatoform disorder.
aetiology of conversion/dissociative disorder?
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
define somatisation?
This is the unconscious expression of
psychological distress through physical symptoms,
e.g. rather than anger, a patient experiences abdominal
pain.
define factitious disorder?
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.
define malingering?
feigning symptoms to obtain
external reward, e.g. escape military service, gain
money or drugs.
how to manage a patient with somatisation?
- 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. - Avoid over-investigation, unnecessary specialist
referrals or physical medication - Emotional support
- Encourage normal function/activities
- they usually stop doing these things and working
because of sx
- > Phsyiotherapy!! for functional motor symptoms
Lecture:
- Family CBT/Psycodynamic/Group therapy
- Medication pain/mood
- Consistency: same doctors, regular appointments
when do MUS become a disorder?
when they believe the sx are due to something detrimental i.e tumour
what are functional symptoms?
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 -
what is the Hoover’s sign?
Hoover’s Sign is an orthopedic test used to determine if someon is malingering or is suffering from neuromuscular weakness.
which factors suggest better outcome?
younger
less disability
accept that psych factors may be involved.
what are types of dissociative disorders?
FINISH
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
rx for conversion/ dissociative disorders?
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
what is primary and secodary gain in conversion disorders?
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.
what are the risk factors for conversion disorders?
- F>M
- Younger
- Epilepsy, MS, Head injury
aetiology of somatisation?
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)
patients with somatisation tend to have comorbid _____ ?
anxiety, depression, substance abuse, histrionic pd
what is non-delusional dysmorphophobia and what condition do we see it?
it is a preoccupation with an imagined bodily defect.
in hypochondriasis
how do we manage Separation anxiety ?
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