Medically Unexplained Symptoms

Question 1

What are somatoform disorders?

Answer 1

Somatoform disorders are a group of disorders whose symptoms are suggestive of, or take the form of, a physical disorder but in the absence of a physiological illness, leading to the presumption that they are caused by psychological factors. Sufferers repeatedly seek medical attention even when it has consistently failed to benefit them.

Question 2

What are dissociative (conversion) disorders?

Answer 2

Dissociative (conversion) disorders are characterized by symptoms which cannot be explained by a medical disorder and where there are convincing associations in time between symptoms and stressful events , problems or needs. The unpleasant stressful events or problems are ‘converted’ into the symptoms.

Question 3

Briefly describe the pathophysiology and aetiology of somatoform disorders

Answer 3

The cause of somatoform disorders is multifactorial. Patients adopt the sick role, which provides relief from stressful or unachievable interpersonal expectations (primary gain). This offers attention, care from others and sometimes even financial rewards (secondary gain) in many societies.

Biological

• Possible implication of neuroendocrine genes
• Studies indicate a genetic component

Psychological

• A high proportion of those with PTSD suffer from somatoform disorders
• Association between somatization and physical or sexual abuse

Social

• Adopting of the ‘sick role’ in order to gain relief from stress

Question 4

Briefly describe the pathophysiology and aetiology of dissociative (conversion) disorders

Answer 4

Dissociative disorders must be causally linked in time with stressful life events, problems or needs. As the name suggests, dissociative (conversion) disorders require two processes to occur:

1. Dissociation: a process of ‘separating off’ certain memories from normal consciousness. This is a psychological defence mechanism that is used to cope with emotional conflict that is so distressing for the patient, that it is prevented from entering their conscious mind.
2. Conversion: distressing events are transformed into physical symptoms. This, like somatoform disorders, can lead to primary and secondary gain

Question 5

Briefly describe the sequence of events in dissociative (conversion) disorders

Answer 5

Question 6

What are the risk factors for somatoform and dissociative disorders?

Note: CRAMPS

Answer 6

• Childhood abuse
• Reinforcement of illness behaviours
• Anxiety disorders
• Mood disorders
• Personality disorders
• Social stressors

Question 7

How common is somatoform and dissociative disorders?

Answer 7

The prevalence of somatoform disorders in the UK is 0.1– 2%.

Prevalence of dissociative disorder in clinical settings in Western societies is between 2 and 6 per 100 for ♀.

Question 8

Who is commonly affected by somatoform and dissociative disorders?

Answer 8

They are more common in ♀ than in ♂ and are likely to begin before the age of 30.

Question 9

Why are dissociative (conversion) disorders named so?

Answer 9

Dissociative (conversion) disorder is named on the premise that painful or stressful thoughts are subconsciously ‘converted’ into more bearable physical symptoms by the patient.

Question 10

Give examples of various dissociative (conversion) disorders

Answer 10

• Dissociative amnesia
• Dissociative fugae
• Dissociative stupor
• Trance and possessive disorders
• Dissociative motor disorders
• Dissociative convulsions
• Dissociative anaesthesia and sensory loss

Question 11

What is dissociative amnesia?

Answer 11

Amnesia, either partial or complete for recent events or problems that were traumatic or stressful. Too extensive and persistent to be explained by ordinary forgetfulness.

Question 12

What is dissociative fugae?

Answer 12

An unexpected physical journey away from usual surroundings followed by amnesia for the journey. Self-care is maintained.

Question 13

What is dissociative stupor?

Answer 13

Profound reduction in, or absence of, voluntary movements, speech and normal responses to stimuli. Normal muscle.

Question 14

What is trance and possessions disorder?

Answer 14

Trance: temporary alteration in state of consciousness.

Possession: absolute conviction by the patient that they have been taken over by a spirit, power or person.

Question 15

What is dissociative motor disorders?

Answer 15

Loss of the ability to perform movements that are under voluntary control (including speech) or ataxia.

Question 16

What is dissociative convulsions?

Answer 16

Sudden, unexpected spasmodic movements that resemble epilepsy but without loss of consciousness.

Question 17

What is aissociative anaesthesia and sensory loss?

Answer 17

Partial or complete loss of cutaneous sensation, vision, hearing or smell.

Question 18

Briefly describe the ICD-10 categories of somatoform disorders

Note: PUSHy SOMATOFORM patients

Answer 18

• Persistent somatoform pain disorder
• Undifferentiated somatoform disorder
• Somatization disorder
• Hypochondriacal disorder (including body dysmorphic disorder)
• SOMATOFORM autonomic dysfunction

Question 19

Briefly describe the ICD-10 Criteria for diagnosing somatisation disorder

Answer 19

Somatization disorder requires all four to be present:

A. At least 2 years’ duration of physical symptoms that cannot be explained by any detectable physical disorder

B. Preoccupation with symptoms causes physical distress which leads to them seeking repeated medical consultations and requesting investigations

C. Continuous refusal by patients to accept reassurance from doctors that there is no physical cause for their symptoms

D. A total of six or more symptoms

Question 20

Briefly describe somatisation disorder

Answer 20

Also known as Briquet’s syndrome.

Multiple, recurrent and frequently changing physical symptoms not explained by a physical illness.

More common in ♀ ( ♀ : ♂ ratio is 10:1 ).

Long history of contact with medical services.

Often dependent on analgesics with a degree of functional impairment.

Question 21

How may symptoms present in somatisation disorder?

Note: GI, cardiovascular, genitourinary and others

Answer 21

Question 22

What is hypochondriacal disorder?

Answer 22

Patient misinterprets normal bodily sensations, which leads them to the non-delusional preoccupation that they have a serious physical disease , e.g. cancer.

They refuse to accept reassurances from doctors.

Question 23

What is dysmorphophobia?

Answer 23

Dysmorphophobia (body dysmorphic disorder) is a variant of hypochondriacal disorder where there is an excessive preoccupation with barely noticeable or imagined defects in their physical appearance (e.g. the size and shape of their nose). The preoccupation causes significant distress.

Question 24

What is somatoform autonomic dysfunction?

Answer 24

Symptoms are related to the autonomic nervous system.

Symptoms of autonomic arousal are attributed by patients to a physical disorder of one or more of the cardiovascular, respiratory, upper GI, lower GI or genitourinary systems.

Multiple autonomic symptoms must be present such as palpitations, tremor, sweating, dry mouth, flushing and hyperventilation. Symptoms may be objective (sweating, tremor) or subjective (pain, paraesthesia).

Patients attribute symptoms to a specific system under autonomic control. For instance respiratory (psychogenic hyperventilation), gastrointestinal (irritable bowel syndrome) or cardiovascular (Da Costa’s syndrome).

Question 25

What is persistent somatoform pain disorder?

Answer 25

Persistent (of at least 6 months’ duration) and severe pain that cannot be fully explained by a physical disorder.

Pain usually occurs as a result of psychosocial stressors and emotional difficulties.

Differs from somatisation disorder in that pain is the primary feature and multiple symptoms from different systems are not present.

Question 26

Briefly describe the MSE of somatoform and dissociative (conversion) disorders

Answer 26

MSE findings in the areas of appearance, behaviour and mood may reflect underlying mood or anxiety disorders. Thoughts will show preoccupation with physical symptoms and overvalued ideas of having a serious medical condition. Insight into having a psychiatric illness will likely be clouded.

Question 27

Somatoform disorders are often a diagnosis of exclusion. What features point to a diagnosis of a somatoform disorder?

Answer 27

Somatoform disorders are often a diagnosis of exclusion. However, certain features point in the direction of a somatoform disorder. These include:

1. Multiple symptoms, often occurring in different organ systems;
2. Vague symptoms that exceed objective findings;
3. Chronic course;
4. Presence of a mental health disorder;
5. History of extensive diagnostic testing;
6. Rejection of previous physicians.

Question 28

What investigations should be ordered for a somatoform and dissociative (conversion) disorder?

Answer 28

A thorough physical examination and investigations are performed to rule out an organic cause depending on the symptoms present.

Blood tests:

• FBC (anaemia, infection)
• U&Es (electrolyte disturbance)
• LFTs (liver or biliary pathology)
• CRP (infection, inflammation)
• TFTs (thyroid dysfunction)

Further investigations:

• Gastrointestinal symptoms: AXR, stool culture, OGD, colonoscopy and diagnostic laparoscopy
• Cardiovascular symptoms: ECG, 24 hr tape, ECHO and angiogram
• Genitourinary symptoms: urine dipstick, MSU and cystoscopy

Question 29

What is malingering and factitious disorder?

Answer 29

In both malingering and factitious disorder (also known as Munchausen’s syndrome) physical or psychological symptoms are intentionally produced, i.e. faked. The difference between the two is the patient’s motive behind mimicking the symptoms.

Malingering

Patient seeks advantageous consequences of being diagnosed with a medical condition. For instance, evading criminal prosecution or receiving government benefits (i.e. secondary gain).

Factitious disorder (Munchausen’s syndrome)

The individual wishes to adopt the ‘sick role’ in order to receive the care of a patient, for internal emotional gain (i.e. primary gain).

Question 30

Briefly differentiate between factitious disorder, malingering, somatoform disorders and dissociative disorder

Answer 30

Question 31

Briefly describe the bio-psychosocial model of managing somatoform and dissociative (conversion) disorder

Answer 31

Biological

• Antidepressants
• Physical exercise

Psychological

• CBT
• Coping strategies

Social

• Encourage pleasurable private time
• Involve family where appropriate

Question 32

Briefly describe the biological therapies used for treating somatoform and dissociative (conversion) disorders

Answer 32

For somatoform and dissociative disorders include antidepressants (primarily SSRIs) for any underlying mood disorder. Physical exercise enhances self-esteem and can be particularly helpful in dysmorphophobia.

Question 33

Briefly describe the psychological therapies used for treating somatoform and dissociative (conversion) disorders

Answer 33

The mainstay of management is cognitive behavioural therapy usually in short courses. Developing certain coping strategies can also be very useful.

Question 34

Briefly describe the social therapies used for treating somatoform and dissociative (conversion) disorders

Answer 34

From a social perspective, stress-relieving activities such as meditation and long walks can prove effective, as well as interventions reducing specific causes of stress (e.g. marriage counselling). It may be appropriate to interview/ involve family members who serve to reinforce the sick role.

Question 35

Briefly discuss the how to explain the diagnosis to a patient with a somatoform disorder

Answer 35

A major obstacle in the management of patients with somatoform disorder or indeed any functional symptoms is that they often feel that doctors don’t believe them and they feel that this brings into question their integrity. Therefore, good communication is of the utmost importance.

• Discuss investigations → ‘The results of my examination and of the tests we conducted show that you do not have a life-threatening illness. However, what you are describing is something that I see often, but it is not completely understood.’
• Brief explanation → ‘Many people like yourself have physical symptoms that we cannot find a reason for. We usually call these ‘medically unexplained symptoms’ or ‘functional illness’.
• Placing a positive spin → ‘I would like to reassure you however, that there are still ways we can help you. We can help train your body to work normally again but may be unable to pinpoint the exact cause.’
• Relate to a disorder they are more familiar with → ‘We know that most physical illnesses get worse if the patient feels tense or down, for example stress makes asthma worse, and therefore I feel that if we manage other problems in your life you will automatically feel better within yourself. How do you feel about this?’

Question 36

What differentials should be considered for somatoform and dissociative disorders?

Answer 36

• Somatoform disorders
  
  • Somatisation disorder
  • Hypochondriacal disorder
  • Somatoform autonomic dysfunction
  • Persistent somatoform pain disorder
  • Undifferentiated somatoform disorder (less severe variation on somatisation disorder with a duration of at least 6 months – commonest somatoform disorder)
• Dissociative (conversion) disorder
• Factitious disorder
• Malingering
• Other psychiatric disorders
  
  • Mood disorder
  • Psychotic disorder
  • Anxiety disorder
  • PD
• Multi-systemic disease e.g. connective tissue disorders and inflammatory bowel disease