Medically Unexplained Symptoms

Question 1

Medically Unexplained Symptoms

Answer 1

Concern about physical symptoms is a common
reason to seek medical help; some remain unexplained by identifiable disease despite
extensive medical assessment

Question 2

How common are medically unexplained symptoms

Answer 2

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

Question 3

Psychological factors

Answer 3

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

Question 4

Functional Symptoms

Answer 4

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)

Question 5

Somatoform Autonomic Dysfunction

Answer 5

one or more unexplained symptoms under Autonomic

control

Question 6

Somatisation Disorder

Answer 6

Multiple, Recurrent and Changing unexplained physical symptoms with multiple presentations to medical care

Question 7

Hypochondriasis

Answer 7

Severe persistent anxiety about ill health and disease

Question 8

Persistent Somatoform Pain Disorder

Answer 8

Pain intensity and duration not accounted for by

primary physical or mental disorders

Question 9

Dissociative/Conversion Disorder

Answer 9

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

Question 10

Aetiology of Functional Symptoms

Answer 10

• 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)

Question 11

Attribution

Answer 11

• 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)

Question 12

Symptom Alleviation

Answer 12

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

Question 13

Assessment of Functional Symptoms: Explanation

Answer 13

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

Question 14

Assessment of Functional Symptoms: Assessment

Answer 14

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

Question 15

Treatment of Functional Symptoms: Assessment as treatment

Answer 15

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

Question 16

Treatment of Functional Symptoms: Positive Explanation

Answer 16

Positive Explanation of Symptoms – Outlines Behavioural, Psychological and Emotional Factors that might exacerbate Physiological Based Symptoms

Question 17

Treatment of Functional Symptoms: Self Help

Answer 17

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

Question 18

Treatment of Functional Symptoms: Return to Activity

Answer 18

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)

Question 19

Treatment of Functional Symptoms: Specialist Psychiatric Care

Answer 19

Advice on Complex Antidepressant Regimens, Anxiety Management, Cognitive/Behavioural/CBT, Graded Activity, Management of Complex Social
and Psychological Issues

Question 20

Irritable Bowel Syndrome

Answer 20

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

Question 21

MSK and Chronic Pain

Answer 21

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

Question 22

Chronic Fatigue Syndrome

Answer 22

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)

Question 23

Somatisation Disorder

Answer 23

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

Question 24

Dissociative and Conversion Disorders

Answer 24

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

Question 25

Factitious Disorder

Answer 25

– 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

Question 26

Munchausen’s

Answer 26

Extreme and Uncommon; Multiple attendances and often swapping
between identities;

Question 27

Munchausen’s By Proxy

Answer 27

Child Abuse; Giving false account of Symptoms in the child, and may fake physical signs

Question 28

Malingering

Answer 28

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