Medically Unexplained Symptoms Flashcards
Define medically unexplained symptom
• Physical complaints without evidence of an underlying organic cause
Aka functional, psychosomatic, somatised and somatoform
Give 3 different theories for MUS
Somatisation
o Unconscious expression of psychological distress through physical symptoms
o E.g. anger as abdominal pain
Psychiatric Illness
o Depression and anxiety symptoms can be psychological (e.g. sadness/fear) and physical (e.g. muscle aches, constipation, palpitations)
Cognitive Models
o An individual’s interpretation of normal physiology can create anxiety and perpetuate MUS (e.g. someone concerned about palpitations may misinterpret normal physiological experiences (e.g. rapid heart rate whilst anxious) as a feature of a heart attack)
Explain the aetiology of somatisation using a bio-psycho-social model
Biological
- Predisposing: Genetics
Psychological
- Predisposing: Short duration of formal education
- Precipitating: Cultural/family attitudes
- Perpetuating: Unhelpful cognitive styles
Social:
- Predisposing: Childhood experiences e.g parental illness
- Precipitating: Stressful life events
Outline the symptoms in presentation of MUS in the following systems: rheumatology, gastroenterology, otolaryngology, cardiology, generalised pain
- Rheumatology - fibromyalgia
- Gastroenterology - IBS, non-ulcer dyspepsia
- Otolaryngology - dizziness, tinnitus
- Cardiology - non-cardiac chest pain, palpitations
- Pain clinics - headache, pelvic pain, lower back pain
There may be very clear psychological stressors
Give some differentials for MUS
Organic: rule out any physical cause
Psychiatric Illness
• Anxiety and Depression: can cause and exacerbate symptoms (e.g. depression lowers pain threshold)
• Hypochondriasis: extreme form of health anxiety where patients believe they have a specific illness (e.g. cancer) rather than presenting with inexplicable symptoms
• Schizophrenia, persistent delusional disorder: hypochondriacal delusions and somatic hallucinations may occur
Deliberate Production of Symptoms (RARE)
Give examples of deliberate production of symptoms
Factitious Disorder: deliberate production of symptoms to receive medical treatment (e.g. PUO, haematuria, skin lesions)
Malingering: feigning symptoms to obtain external reward (e.g. escape military service, get money or drugs)
Outline the management for MUS
Therapeutic Assessment
o Full history and physical examination
Explain and Reassure:
Reattribution Model
• Ensure they feel understood
• Broaden the agenda from a physical AND psychological cause
• Make a link between symptoms and psychological factors
Emotional Support
• Encourage patients to discuss emotional difficulties
• Support them in dealing with stress
Encourage Normal Function
Antidepressants
Treat Comorbid Illness
CBT
Graded Exercise
• Helpful in CFS (chronic fatigue syndrome) and fibromyalgia
Outline the main features of chronic fatigue syndrome (CFS)
Aka myalgic encephalomyelitis
• May follow viral infection (e.g. glandular fever)
• Can arise spontaneously
• Extreme fatigue is the main complaint
• Patients will become exhausted by mild exertion
• Aches and pains
Outline the main features of somatisation disorder
Rare, disabling and chronic, 10 x more common in women
• Multiple medically unexplained symptoms affecting any system in the body
• Symptoms are difficult to treat
Identify the possible complications of somatisation and its management
- Depression
- Anxiety
- Suicidal ideation
- Substance use/abuse
Define conversion (dissociative) disorders and outline its main clinical features
- An internal conflict is unconsciously converted into neurological symptoms
- Presentations are acute, specific and often DRAMATIC following sudden stress or conflict
o Paralysis
o Blindness
o Aphonia (inability to produce speech)
o Seizures
o Psychogenic amnesia (loss of ALL somatic memories including own identity)
o Multiple personality disorder (rare and controversial)
o Fugue (patients lose their memory entirely and wander away from home)
o Stupor
Outline the management approach for conversion disorders
- Encourage a return to normal activities
- Avoid reinforcing symptoms of disability (e.g. providing a wheelchair)
- Patients should be supported to address triggering stressors rather than focusing on physical manifestations
