Medically Unexplained Symptoms Flashcards
Medically Unexplained Symptoms
Concern about physical symptoms is a common
reason to seek medical help; some remain unexplained by identifiable disease despite
extensive medical assessment
How common are medically unexplained symptoms
Common – 20% of population; Most transient and not brought to medical attention
o Sizeable minority persistent, often disabling; Up to half remain disabled by
symptoms at 12 months
o May occur with serious physical illness
Psychological factors
Psychological factors (and sometimes Psychiatric disorders) are important to aetiology; Psychological and Behavioural interventions have important role • Different from deliberate manufacture, or exaggeration of symptoms/signs
Functional Symptoms
can be explained either as
Syndromes of Descriptive Pain, where Psychiatric Conditions are the Primary cause of Functional Symptoms, and Psychiatric Syndromes of Health Concern and Functional
Symptoms (=Somatoform Disorders)
Somatoform Autonomic Dysfunction
one or more unexplained symptoms under Autonomic
control
Somatisation Disorder
Multiple, Recurrent and Changing unexplained physical symptoms with multiple presentations to medical care
Hypochondriasis
Severe persistent anxiety about ill health and disease
Persistent Somatoform Pain Disorder
Pain intensity and duration not accounted for by
primary physical or mental disorders
Dissociative/Conversion Disorder
Partial/Complete loss of Normal Integration between
Memories of the past, Awareness of Identity and Immediate Sensations, and Control of
Movements in absence of a medical explanation
o Common symptoms include Amnesia, Aphonia, Paralysis and Anaesthesia
Aetiology of Functional Symptoms
• Integrated model of Physical, Psychological and Social factors; Suggests that functional symptoms arise form Minor Physiological/Pathological bodily sensations trigged by multitude of usually benign causes (e.g. Anxiety, Insomnia)
Attribution
• Attribution – Normalising, Psychologising or Somatising; Individuals attribute based on several
factors (e.g. Personality, Personal Situation, Family History, Past Medical History, Medical Knowledge from multiple sources, Family/Friends/Medical Professionals response to their physical sensation)
Symptom Alleviation
Attempts to alleviate symptoms might paradoxically exacerbate (Physical Deconditioning,
Increased Focus on Symptoms and Disability) and symptoms might become part of patient
identity; Disability Benefits, Ongoing Litigation might lead to focus onto disability instead; Persistent medicalisation by professionals can also maintain symptoms
Assessment of Functional Symptoms: Explanation
Explanation that physical symptoms are often only fully explained by considering physical,
psychological and social factors relating to individual’s health
o Allows psychological treatment as part of usual medical care rather than alternative
that patient does not feel like physical symptoms are taken seriously
Assessment of Functional Symptoms: Assessment
Need to exclude organic causes and emphasis that you are taking patient
concerns seriously; Thorough History, Focussed Examination and Medically-indicated Investigations; Identify Concerns and Beliefs, reviewing previous history of unexplained
symptoms, and investigation how patient reacts and copes
o Screen for Depressive, Anxiety and Substance Abuse Disorders
Treatment of Functional Symptoms: Assessment as treatment
Assessment as treatment – With Careful Explanation and Reassurance
o Most reassured that symptoms are common; Rarely associated with serious disease
o That symptoms are real and familiar to the medical team
o That symptoms often settle in time and need not be an impediment to active living
o For review again for symptoms persist
Treatment of Functional Symptoms: Positive Explanation
Positive Explanation of Symptoms – Outlines Behavioural, Psychological and Emotional Factors that might exacerbate Physiological Based Symptoms
Treatment of Functional Symptoms: Self Help
Simple Advice on Self-Help Techniques – Control of Negative Thoughts, Relaxation Techniques, Increasing Activity Levels; CBT-based approach
o Reassurance should target patient’s specific concerns
o Discuss and Agree on Treatment Plan, Follow up, Decision-making, Primary Care and
Good Medical Record-keeping and Communication
Treatment of Functional Symptoms: Return to Activity
Encourage Graded Return to Activity, Treat Underlying Psychiatric Disorders, Review
Medicines and Reconciliation, Referral only if appropriate and with clear indications and goals
o Social Factors E.g. Relationship Conflict, Financial Problems, Unemployment
o Consider Prescribing Antidepressants – Concurrent Depressive Disorder, and
Neuromodulation (Reducing Physiological Disturbance due to Psychological factors)
Treatment of Functional Symptoms: Specialist Psychiatric Care
Advice on Complex Antidepressant Regimens, Anxiety Management, Cognitive/Behavioural/CBT, Graded Activity, Management of Complex Social
and Psychological Issues
Irritable Bowel Syndrome
Almost half of Gastroenterology; Most relatively mild and
managed in primary care through Self Help regarding Diet, Activity and Symptom Relief
Medications; 1/3 referred to specialists
o Antidepressants – TCA at low dose, SSRI as Neuromodulators
o CBT, Hypnotherapy; Management of Underlying Psychiatric Disorders
MSK and Chronic Pain
Reassurance, Helping Regain Function, Progressive Mobilisation and Graded Return to Activity, Regular Analgesia (vs PRN use), Realistic Goals and Rewards
o Analgesic Approaches – Distraction and reduction of Reinforcing Behaviour, Cognitive Approaches, Antidepressant Medication, Intensive MDT Pain Management
Chronic Fatigue Syndrome
Persistent Fatigue, Aches and Pains in the absence of Physical or
Mental Disorder; Mild Exertion often followed by Increased Fatigue and Pain
o Many are convinced it is due to chronic infection or other undetected medical
condition; More likely mixture between Psychological and Physiological factors
o Common Triad of Viral Illness (Physical), at the time of Personal Stress (Social) in an
individual with driven personality (Psychological)
o Might co-occur with Depressive Disorder requiring Antidepressant treatment
o Reassurance that it is common, real and familiar, and has no specific medical
treatment but there are ways to improve outcome (Graded Programme, Progressive
Return, CBT and Exercise Therapy)
Somatisation Disorder
Multiple Functional Symptoms over long periods
o Management often focussed on coping (limiting distress and unnecessary
investigation); Negotiate and Limit number of Healthcare staff, Primary Care and use
of Medications and Investigations
o Proactive (Brief, Regular Appointments) rather than Reactive during crises
o Avoid Repeated Reassurance, Focussing on Coping with Disability and Psychosocial
problems; Encouraging Graded Return to normal and being Realistic about outcomes
Dissociative and Conversion Disorders
Unexplained Sensory and Motor Symptoms, Amnesia,
Fugue (Amnesic Wandering), Stupor or Identity Disorder
o Occasionally, Organic Disease might be present but not detected at presentation
o Shaped by patient’s concept of illness, although not deliberately manufactured
o Discrepancies between symptoms and organic pathophysiology e.g. Does not conform to known innervation, varying intensity and responsiveness to suggestion
o Dissociation Symptoms – Amnesia, Fugue, Stupor
o Attention over time should be directed to problems that caused disorder;
Sympathetic Concern but with Self-Help and avoid reinforcing Disability
Factitious Disorder
– Intentional Production of Physical Pathology or Feigning Illness
o C/f Malingering, where there is external reward e.g. Avoidance in Military, Financial
o Sometimes involves worsening current medical problems, or Self-inflicted injuries
Munchausen’s
Extreme and Uncommon; Multiple attendances and often swapping
between identities;
Munchausen’s By Proxy
Child Abuse; Giving false account of Symptoms in the child, and may fake physical signs
Malingering
Fraudulent Simulation or Exaggeration to gain rewards (Obvious external gain)
o Patient should be informed tactfully of this conclusion, and encouraged to deal more appropriately with problems that contributed to this behaviour
