Medically Unexplained Symptoms (MUS) and Somatoform disorders

Question 1

What are Somatisation disorders?

Answer 1

characterised by physical symptoms that cannot be accounted for by a physical disorder or other psychiatric disorder, but that are thought to result from psychological factors

Question 2

what are the key feature of somatisation disorders?

Answer 2

 The concerns/symptoms must be:
o unexplained, or disproportionate to any organic disease
o severe enough to cause distress
o persistent >6 months
o not a result of another clear psychiatric disorder (e.g. depression, or delusional somatic hallucinations in psychosis)
o not deliberately manufactured
 see factitious disorder and malingering
o not predominantly a loss of a specific function
 see dissociative and conversion disorder

Question 3

What often occurs alongside somatisation disorders?

Answer 3

• Depressive/anxiety symptoms
  but must be insufficient to reach a primary diagnosis of depression or anxiety

 Depression/anxiety may often present with somatic symptoms (somatised depression/anxiety)
o e.g. GI complaints, weakness, loss of appetite
o particularly common in children, elderly and certain immigrant populations

Question 4

What are some causative factors in somatisation disorder?

Answer 4

• Patient psychological factors (e.g. health beliefs, affective state, personality), childhood deprivation and abuse, childhood illness, parental illness, effects of disturbed sleep, effects of prolonged inactivity

Question 5

What is important in somatisation disorder?

Answer 5

• Proper diagnosis is important in order to see improvement

 Also inappropriate medical investigations/treatment should be avoided as may induce harm (radiation, surgery - adhesions, painkillers - opiate dependency etc)
o May also encourage unhealthy behaviour

Question 6

What is a good explanation of somatisation disorder?

Answer 6

Symptoms are real and not imagined. However there seems to not be any specific or structural cause for your symptoms that we can pinpoint and ‘fix’. This is very common and we see it in a lot of patients and we can help train the body to function normally again

Question 7

What are the different types of somatisation disorders?

Answer 7

Somatic symptom disorder
Somatisation disorder (Briquet’s syndrome)
Persistent somatic pain disorder
Hypochondriacal disorder
Dysmorphophobia or body dismorphic
disorder
Factitious disorder and malingering
Dissociative (conversion) disorders

Question 8

What is somatic symptom disorder?

Answer 8

somatisation of specific symptoms

Question 9

what are the key features of Somatisation disorder (Briquet’s syndrome)?

Answer 9

• Multiple, different MUSs
• Occurred over many years
• Complicated history of contact with many different medical professionals
• High risk of iatrogenic harm and/or substance dependence
• Mostly women
• First presentation below 40
• Adopted “illness as a way of life”
• 2/3 have depressive/anxiety symptoms
• (often deny or attribute them to physical Sx – “only depressed cos of pain”)
• frequently seek medical attention but find it unreassuring
• some regard condition as personality disorder

Question 10

What are the key features of Persistent somatic pain disorder?

Answer 10

• Severe and distressing pain
• Remember all pain is subjective!
• Common in other somatoform disorders and depression
• Recognise and treat comorbid depression
• Anti-depressants (particularly tricyclics) may be useful (for pain also)
• CBT/psychological therapy focused on managing/living with pain
• Pain clinics (usually anaesthetist-led)
• Also TENS, anti-convulsants, nerve blocks

Question 11

What are the key features of Hypochondriacal disorder?

Answer 11

• Preoccupied with the idea they have a specific disease which they do not
• Over-valued idea
• Links to OCD – has been considered an anxiety disorder
• Not reassured by negative investigations
• Anti-depressants and CBT may be helpful
• Allow patients to vent their health anxieties
• Clarify that symptoms with no structural cause are real and severe
• Transient in med students
• POSSIBILITY of early/insidious form of disease in question should always be considered!

Question 12

What are the key features of Dysmorphophobia or body dismorphic disorder?

Answer 12

• Preoccupation with a subjectively abnormal appearance
• Abnormal, unattractive or pathological
• Where there is no objective deformity
• Patients may attempt to hide deformity
• Can develop delusional intensity  skin picking etc
• Can have severe functional impairment, may seek plastic surgery
• 60% risk major depression

TREATMENT – plastic surgery generally not indicated (will develop new obsession)
SSRIs, CBT

Question 13

What are the key features of Factitious disorder and malingering?

Answer 13

• patients who consciously elaborate or invent symptoms
• ? level of awareness of their actions

Factitious disorder = when aim is to maintain ‘sick role’
Severe = Munchausen’s (can be by proxy – role of carer)
Wandering (male, hospital to hospital) vs non-wandering (female)

Malingering = when aim is for other benefit e.g. attainment of opiates, avoid legal
proceedings or military conscription

Directly or indirectly challenge pt (e.g. if this doesn’t work then it is factitious”)

Question 14

What are the key features of Dissociative (conversion) disorders?

Answer 14

• loss of function, not medically explained
• presentations include:
• loss of memory (psychogenic amnesia), wandering
  in a trance (fugue), loss of function (paralysis, pseudo-seizures, inability to walk), loss of sensory function (glove and stocking anaesthesia)
  o anaesthetic areas of skin often have boundaries which make it clear that they are associated more with the patient’s ideas about bodily functions than with medical knowledge/dermatomal distribution
  o Although dissociative disorders lack an organic cause, they are no less real than organic symptoms, and are not simply ‘put on’ by the patient
  o Different from disorders involving pain and other complex physical sensations mediated by the autonomic nervous system, which are classified under somatisation disorder

Question 15

What is Ganser’s syndrome?

Answer 15

A very rare syndrome characterised by absurd statements, confusions, hallucinations and psychogenic physical symptoms. There is a giving of approximate answers to questions (e.g. ‘2 plus 2 equals 5’ when not associated with dissociative amnesia or dissociative fugue.

Question 16

How can you differentiate between real and pseudo seizures?

Answer 16

serum prolactin usually raised 10-20 mins after legit seizure (not pseudo)

Question 17

What investigations should you do in somatisation disorders?

Answer 17

• Prior to the consultation, obtain the full hospital case records for all specialties. Discuss the case with the GP and obtain copies of GP records if available. Clarify whether the patient is seen in other hospitals or health care services and aim to obtain these records. Establish whether there are any pending investigations and what the patient has been told about their presumed diagnosis.
• At the interview: establish full details of current symptoms; circumstances of symptom onset; and ‘life context’ of symptom development.
• Explore their illness beliefs: specific worries about cause and possible prognosis; ask the patient to describe their understanding of their symptoms and what they feel they may represent.
• Full details of past medical history (may be reticent—‘no problems before current symptoms’ or overly dramatic); what were they told at the time by the doctors treating them?
• Remember to explore possible psychiatric differential diagnoses— full mental state as normal, even if no symptoms spontaneously mentioned.
• Observe patient in waiting room/onward/entering and leaving room—be alert to inconsistencies in symptoms.

Question 18

What is the management of somatisation disorders?

Answer 18

(1) thorough assessment but not when no clinical indication
(2) confident diagnosis
(3) clear explanation
(4) minimization of iatrogenic harm
(5) empirical use of potentially beneficial treatments - CBT, antidepressants and treatment of comorbid psychiatric disorders may be helpful
(6) consideration of involvement in treatment trials.
(7) Appropriately investigate genuinely new symptoms.

Question 19

What is chronic fatigue syndrome?

Answer 19

Clinical syndrome with key features of severe fatigue, unrelated to exertion (or only minor exertion), and not relieved by rest

Question 20

What do patients with chronic fatigue complain of?

Answer 20

subjective lethargy, ‘increased effort to do anything’, aching muscles/joints, headaches, difficulty concentrating, sleep disturbance

Question 21

What is the cause of chronic fatigue?

Answer 21

o Patients may pinpoint onset of symptoms to episode of viral illness (sore throat, fever, swollen lymph nodes)
o Patients with documented EBV can develop a fatigue syndrome but role of viruses is controversial
o True aetiology unknown
 Combination of causes likely
 May be described as:
• Spectrum of illness triggered by acute stress reaction
• Minor illness in a vulnerable individual
o = those with abnormal symptom attribution, increased awareness of normal bodily processes, cognitive errors & perfectionist personality types
o Post-viral syndrome also referred to as myalgic encephalomyelitis (ME)

Question 22

What is the epidemiology of chronic fatigue?

Answer 22

o Overlap with depression, somatisation disorder and hypochondriasis
o 4x F:M
o most common in 40s-50s, occasionally adolescence
o often comorbid depression (treatment of which can improve CFS)

Question 23

What is the management for Chronic fatigue?

Answer 23

o Graded Exercise Therapy (GET)
 Use diary to establish current daily activity level
 Encourage them to reach their maximum tolerable level every day
 Then gradually negotiate increases
 Aim to break cycle of inactivity, brief excess activity and resultant exhaustion
o CBT
o Psychotropic medication
 Consider SSRIs even when no evidence of affective Sx
o Symptomatic medication
 Pts may experience more intolerance & greater S/Es from drugs
 If appropriate, drugs for Sx control should be low-dose

Question 24

What is hypochondriasis?

Answer 24

preoccupation with the fear of having a serious disease which persists despite negative medical investigations and appropriate reassurance with subsequent distress and impaired function.

Question 25

What are the features of hypochondriasis?

Answer 25

 The central and diagnostic clinical feature is the preoccupation with the idea of having a serious medical condition, usually one which would lead to death or serious disability.
 The patient repeatedly ruminates on this possibility and insignificant bodily abnormalities, normal variants, normal functions, and minor ailments will be interpreted as signs of serious disease.
 The patient consequently seeks medical advice and investigation but is unable to be reassured in a sustained fashion by negative investigations.

• The form of the belief is that of an over-valued idea; the patient may be able to accept that their worries are groundless but nonetheless be unable to stop dwelling and acting on them. Where the belief in illness is of delusional intensity, the patient should be treated as for delusional disorder.

Question 26

What comorbidities are common in hypochondriasis?

Answer 26

• High (>50%) incidence of generalized anxiety disorder.
• Hypochondriasis may also coexist with major depressive illness, OCD, and panic disorder.
• Examination of the time course of symptom development and most prominent clinical features helps to distinguish primary hypochondriasis from a secondary clinical feature of these disorders.

Question 27

What are the differentials in hypochondriasis?

Answer 27

• The main differentiation is from the feared physical disease.
• In most cases this is straightforward, but the possibility of an early, insidious disease with vague physical signs and normal baseline investigations should be considered.

Question 28

What is your initial management of hypochondriasis?

Answer 28

 Allow patient time to ventilate their illness anxieties.
 Clarify that symptoms with no structural basis are real and severe.
 Aim to plan continuing relationship and review, not contingent upon new symptoms. Explain negative tests and resist the temptation to be drawn into further exploration.
 Patients will in the early stages often change or expand symptomatology.
 Emphasize aim to improve function.
 Break cycle of reassurance and repeat presentation—family education may help in this

Question 29

What is your pharmacological management of hypochondriasis?

Answer 29

 Uncontrolled trials demonstrate antidepressant benefit, even in the absence of depressive symptoms.
 Try fluoxetine 20mg, increasing to 60mg, or imipramine up to 150mg.

Question 30

What psychological therapies can you use in hypochondriasis?

Answer 30

 Behavioural therapy (response prevention and exposure to illness cues)
 CBT (identify and challenge misinterpretations, substitution of realistic interpretation, graded exposure to illness-related situations, and modification of core illnessbeliefs), 75% symptom reduction in one controlled trial.