Medically Unexplained Symptoms Flashcards
ICD-11 Classification of medically unexplained symptoms
People with medically unexplained symptoms are distressed and preoccupied with symptoms not fully explained by an organic cause and will typically repeatedly seek medical attention for these symptoms. MUS can also be described as a disorder of bodily distress
How common are MUS, who is predisposed to MUS
- Extremely common: around 20-25% of people attending their GP report MUS
- F>M
- Associated with shorter duration of formal education, childhood experiences and genetics. Often MUS present alongside an organic condition.
What models exist to explain the development of MUS
- Psychodynamic models: suggest that unconscious ‘conflict’ is converted into physical symptoms which provide primary gain (reduction in anxiety) and secondary gain (care and attention from others). Often this focuses on early childhood experiences. Physical symptoms can be easier to manage than facing any underlying distress. Additionally family attitudes to the disease can play a role
- Cognitive models: Interpretation of a persons normal physiology can create anxiety and perpetuate MUS e.g someone concerned about palpitations can misinterpret normal symptoms such as an elevated heart rate as palpitations> leads to acute awareness
- Biological models: Abnormalities in autonomic function, proprioception and the cortisol response have all been suggested as relevant- may be genetic
Differentials for MUS
- Organic: rule out any possible physical cause. When symptoms are variable look at multisystem organ pathology e.g sarcoidosis, malignancy
- Psychiatric conditions: anxiety and depression can cause and exacerbate physical symptoms, PD may be comorbid (clusters B and C), Psychosis can present with some somatic hallucinations and hypochondrial delusions.
What is dissociative/ conversion disorder, how does it present?
Considered a subset of MUS. The patient develops specific neurological symptoms that are not consistent with a recognized neurological disease. The presentation is often acute and dramatic and may follow a conflict or stressor. ‘Conversion’ comes from the idea that internal conflict is converted into physical symptoms
- Involves partial or complete loss of the normal integration between memories, awareness of identity, and immediate sensations and control of bodily movements
- e.g amnesia, fugue, trance, paralysis, sensory loss, seizures or non-epileptic seizure, stupor, dissociative identity (‘multiple personality’ disorder)
- Recognised neurological signs may be present, but these generally wont necessarily follow established patterns e.g bilateral focal seizure
- These symptoms are generally not generated consciously but there may be unconscious primary or secondary gain e.g sick role.
La Belle Indifference
a relative lack of concern over objectively worrying symptoms, often present in conversion disorder (debated)
In what populations are conversion disorder more common
- F>M, often occurs in younger patients
- Commonly occurs in epilepsy, MS, after head injury
- More common in those with childhood trauma
Management of conversion disorder
Symptoms usually terminate abruptly and recovery is generally complete with few recurrences
Presentation of bodily distress disorder (somatisation)
Multiple, recurrent, and frequent changing physical symptoms, which can affect any body system. These symptoms are generally difficult to treat and evolve over time, resulting in distress.
- usually present for (at least) two years.
- Has a high co-morbidity with a range of psychiatric diagnoses e.g anxiety/depression/PD.
- Often chronic, with a presentation at least once a year, generally following some form of disruption in social/ family relationships, work, or daily activities.
- Lifetime prevalence: 0.1 - 0.2 % , F:M ratio = 5-20:1
- Age of onset: before 30 years old (usually in the teens
- Symptoms may cluster:
- Rheumatology- fibromyalgia (wisdespread pain, touch sensitivity, fatigue, headache), chronic fatigue syndrome (may follow viral infection e.g glandular fever, but also arises spontaneously, some evidence for graded exercise and CBT)
- Gastroenterology- IBS, Non-ulcer dyspepsia
- Cardiology- Non-cardiac chest pain, palpitations
- Pain clinics- back pain, pelvic pain
Presentation of hypochondrial disorders
(worried about diagnosis)
An extreme form of health anxiety. Rather than being distressed by the experience of multiple unexplained symptoms, the person fears that they are suffering a specific serious illness. Preoccupation with the possibility of having one or more serious and progressive physical disorders, and even a disfigurement. E.g ‘Palpitations means I am having a heart attack’
- Insight may be good, poor or absent
- Up to 80% may have co-existing anxiety or depressive illness
- Prevalence: 5%, F=M, typical onset in 20’s
Presentation of factitious disorder (and difference between munchausens and malingering)
In contrast to other medical conditions causing MUS, these patients deliberately produce or exaggerate physical symptoms to receive medical treatment. The motive is generally psychological: to obtain sympathy or attention and re-enact a child-parent relationship through a doctor. Severe form of this disorder is Munchausen syndrome and when imposed on another Munchausen-by-proxy. Malingering is a similar disorder but the motivation is for external reward (e.g drugs, avoidance)
Management of MUS
- Therapeutic Assessment
- Full history and physical examination but DO NOT OVER INVESTIGATE- specific referrals and physical medications can reinforce beliefs and increase anxiety.
- Explain and Reassure:
- Many patients will benefit from being reassured that their symptoms are not serious and are common and familiar
- Reattribution Modelà Ensure they feel understood and broaden the agenda from a physical and psychological cause. Then make a link between symptoms and psychological factors
- Emotional Support> Encourage patients to discuss emotional difficulties and support them in dealing with stress
- Encourage Normal Function: Patients may avoid normal activities because they think it will exacerbate problems
- Treat Comorbid Illness: Particularly anxiety or depression
- CBT- there is a strong evidence base for CBT in CSF and conversion disorder
- Graded Exercise: Helpful in CFS (chronic fatigue syndrome) and fibromyalgia
What factors might improved prognosis in MUS
- Shorter duration of MUS and milder symptoms have a better prognosis.
- Over 25% of people with MUS attending primary care and 2/3rds with functional neurological symptoms remain symptomatic after 1 year.
