Medically unexplained symptoms and other disorders Flashcards
What are medically unexplained symptoms + other names for them
Physical complaints without evidence of an underlying organic cause
Group of disorders that fit definition of physical Sx, that mimic physical disease or injury, but there is no identifiable physical cause
Diagnosis of exclusion!
AKA functional, psychosomatic, somatised or somatoform disorders
Theories of MUS
Contributing factors e.g. childhood experiences and cultural/family attitudes
Sx precipitated by stressful life events and maintained by unhelpful cognitive styles
Somatisation: unconscious expression of psychological distress through physical Sx. e.g. anger as abdo pain
Psych illness: depression/anxiety Sx can be psychological (sadness/fear) and physical (muscle aches, constipation, palpitations)
Cognitive models: individuals interpretation of normal physiology can create anxiety and perpetuate MUS (interpreting palpitations from anxiety as heart attack); selective attention -> acute awareness; behaviours like repeated checking/seeking reassurance; reassurance maintains long term anxiety and reinforces behaviours
Somatisation disorder
Multiple physical symptoms present for at least 2 years
Rare, disabling and chronic
10x more common in women
Pts refuse to accept reassurance or negative tests
Sx difficult to treat
Hypochondrial disorder
Persistent belief in the presence of an underlying serious disease e.g. cancer
Pt refused to accept reassurance or negative test results
Conversion disorder: what is + presentation/onset + Sx examples + management
Typically involves loss of motor or sensory function (neurological Sx)( without evidence of an underlying cause
Internal conflict is unconsciously converted into neurological Sx
Presentations are acute, specific and often dramatic, following sudden stress or conflict
Paralysis, blindness, aphonia (can’t produce speech), seizures, psychogenic amnesia (loss of all somatic memories incl. own identity), multiple personality, fugue (lose memory and wander away from home), stupor
Management:
- Exclude organic causes
- Encourage return to activities/avoid reinforcing Sx of disability
- Support to address triggering stressors over focusing on phys manifestations
Pt does not consciously feign the symptoms or seek material gain
La belle indifference - Patients may be indifferent to their apparent disorder/relative lack of concern despite worrying Sx
Symptoms resolve in 75% pts
Dissociative disorder
Dissociation: a process of separating off certain memories from normal consciousness
In contrast to conversion disorder, involves psychiatric Sx e.g. amnesia, fugue, stupor
Dissociative identity disorder: new term for multiple personality disorder; most severe form of dissociative disorder
Factitious disorder
AKA Munchausen’s syndrome
Internal deliberate production of physical or psychological symptoms
Not somatoform as there is a conscious process occurring
Malingering
Fraudulent stimulation or exaggeration of Sx with the intention of financial or other gain
Not somatoform as there is a conscious process occurring
Common clinical features of MUS
Diverse
Rheumatology - fibromyalgia
Gastroenterology - IBS, non-ulcer dyspepsia
Otolaryngology - dizziness, tinnitus
Cardiology - non-cardiac chest pain, palpitation
Military medicine - Gulf War syndrome
Pain clinics - headache, pelvic pain, lower back pain
May be clear psychological stressors
Differentials of MUS
Organic cause: rule out physical cause
Psych illness:
- Anxiety/depression - can cause and exacerbate Sx
- Hypochondriasis - extreme form of health anxiety where pts believe they have a specific illness (e.g. cancer) rather than presenting with symptoms
- Schizophrenia, persistent delusion disorder - hypochondriacal delusions and somatic hallucinations may occur
Deliberate production of symptoms (rare)
- Factitious disorder - deliberate production of symptoms to receive medical treatment
- Malingering - feigning Sx to obtain external reward (escape military service, get money, get drugs)
Management in MUS
Therapeutic assessment - full Hx and phys exam
Explain and reassure
Reattribution model - ensure they feel understood; widen to attribute Sx to phys and psychological causes; link between Sx and psych factors
Avoid over investigating/unnecessary referrals/meds - reinforces beliefs, increases anxiety
Emotional support - encourages pts to discuss emotional difficulties; support in dealing with stress
Encourage normal function - so pts don’t avoid normal activities because they think it will worsen problems
Antidepressants - may be useful even without depression
Treat comorbids
CBT
Graded exercise/physiotherapy
Chronic fatigue syndrome
AKA myalgic encephalomyelitis
May follow viral infection e.g. glandular fever
Can arise spontaneously
Extreme fatigue is the main complaint
Pts will become exhausted by mild exertion
Other Sx includes aches and pains
Strong evidence for graded exercises (scheduled; gradually increase
Pts need realistic goals and shouldn’t exceed plan
CBT improves fatigue and physical functioning
Grief reaction
Normal grief into 5 stages: denial (may incl. numbness, auditory/visual pseudohallucinations of deceased), anger, bargaining, depression, acceptance
RFs for atypical greif: Female Death sudden and unexpected Problematic relationship before death Poor social support
Atypical grief reactions:
Delayed grief - occur >2weeks pass before grieving begins
Prolonged grief - difficult to define
Sleep paralysis
Transient paralysis of skeletal muscles when occurs when awakening from sleep or less often while falling asleep
Thought to be related to paralysis that occurs as a natural part of REM sleep
Features: paralysis, hallucinations (images or speaking that appear during the paralysis)
Management: if troublesome, clonazepam may be used
Emotional incontinence/psuedobulbar affect:
Uncomfortable episodes of crying and/or laughing occurring secondary to a neurologic disorder or brain injury e.g. post-stroke
