Medically unexplained symptoms (somatisation, hypochondriasis, conversion disorder)

Question 1

Define functional symptoms.

Answer 1

Complex problems in the body with no detectable structural or physiological cause

Question 2

What % of consultations in GP are due to MUS?

Answer 2

Up to 20%

Question 3

Why is MUS important?

Answer 3

Associated with unnecessary costs and hospitalisations

Affects all ages

Investigation can cause harm

UK cost of MUS exceeds £3.1 billion each year

Question 4

Define MUS.

Answer 4

Persistent bodily complaints for which adequate examination doesn’t reveal sufficient explanatory structural or other specific pathology

Question 5

What are the main three categories of MUS symptoms?

Answer 5

• Pain in different locations
• Functional disturbance of organ systems
• Complaints of fatigue and exhaustion

Question 6

What is the general criteria for diagnosing MUS?

Answer 6

• Physical symptoms
• For 3 months
• Affecting functioning
• Cannot be readily explained

Psychological and physical factors are often key, not just psychological.

Question 7

Rather than mind and body, what is a more useful classification of MUS?

Answer 7

Functional vs structural

Whereby functional is MUS. Medically unexplained can seem like a psychiatric issue (i.e. it’s all in the person’s head) and like not enough investigations can be done, when actually we know a lot about MUS/functional symptoms

Cartesian mind-body dualism is not useful

Question 8

Which MUS is CBT useful in?

Answer 8

• Chronic fatigue syndrome
• Irritable bowel syndrome
• Chronic pain
• Multiple somatisation disorder

Question 9

What are the risk factors for MUS?

Answer 9

• Long term conditions associated with anxiety/depression
• Childhood adversity/abuse
• More common in women
• In severe cases overlap with personality disorder
• Recent infection, current physical illness, severe illness or death of close relative

Question 10

What % of patients with MUS go on to have an organic explanation for their presentation?

Answer 10

4-10%

75% remain unexplained at 1 year

Question 11

What % of patients with MUS have a coexistent psychiatric disorder?

Answer 11

30% (but could be 10-80%)

Question 12

How do patients and doctors with MUS often feel?

Answer 12

Patients:

1. Very strong feelings
2. Disbelieved and accused of fabricating symptoms

Doctors:

1. Doctors feel challenged about competence
2. They get called different negative terms - “frequent fliers”, “heart sink”

Physical disorders are seen as real and patients as victims, psychiatric disorders as ‘not real’ and patients responsible for symptoms

Question 13

What do patients say is the most useful and important factors in their recovery?

Answer 13

Whether the diagnosis and explanation they were given made sense to them – perhaps not immediately, but eventually.

Question 14

What are the key parts of the explanation of MUS?

Answer 14

1. You have something common – you are not weird
2. You do have something genuine – you are not imagining it
3. You have symptoms that are potentially reversible
4. It’s not your fault that you have these symptoms
5. But you will need to put some effort into getting better

Question 15

Compare and contrast the somatoform disorders.

Answer 15

Somatization Disorder – patients believe they have been sickly most of their lives, complain of multitude of symptoms referred to numerous organ systems. Great concern about symptoms.

Conversion Disorder (now seen as dissociative symptoms) – loss of function, characterized by signs or symptoms inconsistent with what is known about anatomy and pathophysiology. Patients usually only have one symptom almost always neurological. They sometimes appear surprisingly unconcerned about their condition

Hypochondriasis – patient will believe, or strongly suspect, that they are ill with a very serious disease. Minor symptoms or anomalies support or augment their concern. The concern persists despite reassurance by doctors. Not so much concerned with the symptoms but the implied terrible and undiagnosed disease.

Question 16

What is somatisation disorder AKA?

Answer 16

Briquet’s Syndrome

Question 17

How common is somatisation disorder? Who is it more common in?

Answer 17

Lifetime prevalence is 0.1-0.2%

F:M 5-20-:1

Usually onset in teens (<30yrs)

Question 18

What are some theories for the aetiology of somatisation?

Answer 18

Biological: there is some evidence for faulty processing of sensory inputs in patients with this disorder. Genetics: 10 – 20 % 1st degree relatives

Psychosocial: a form of communication or as substitutions for repressed instinctual urges.

• The Sick Role (Parsons)
• Illness Behaviour (Mechanic/Pilowsky)
• Alexithymia – no words for moods
• Culture / Family experience – early learning/attentional gain
• Environment – secondary gain

Question 19

What do you call the lack of concern about the patients’ condition in conversion disorder?

Answer 19

La Belle indifference - a casual disregard for normally alarming symptoms

Question 20

Describe the usual onset of somatisation disorder.

Answer 20

• Gradually fall in in teenage years (onset past 30 years is rare)
• Common initial complaints are headache, dysmenorrhoea, abdominal pain

Question 21

What are the features of symptoms of somatisation disorder? What parts of the body are usually affected?

Answer 21

Multiple, recurrent and frequent changing

• Patients are vague or dramatic, giving vague accounts and moving from one organ system to another
• Have seen many doctors and hospitalized many times
• Patients often fatigued, weak all over, plagued with headaches, dizzy spells and pain in the chest, heart beats wildly and dyspnea can occur
• Pains in arms and legs, the back and many joints
• Vague and poorly localized abdominal pain, nausea and bloating, constipation, irregular painful or heavy menstruation

Question 22

How do you manage somatisation disorder in a GP setting?

Answer 22

1. Establish long-term relationship with one clinician
2. Schedule regular follow ups e.g. every month
3. Consider psychiatric consultation, group therapy or CBT
4. +/- antidepressants for those with depressive symptoms
5. Gradual and managed increase in exertion

Question 23

What is the prognosis of somatisation disorder?

Answer 23

Often chronic, presents at least once a year and a new symptom occurring when stressed

Question 24

What is the management of chronic fatigue syndrome?

Answer 24

1. Combination of psychological and antidepressant treatment
2. Gradual and managed increase in exertion

Question 25

What can sometimes affect the type of symptoms which occur in conversion disorder?

Answer 25

Generally a reflection of symptoms the patient has seen in another or has personally experienced The symptom is like a 'sign language' saying what the patient cannot put into words

Question 26

When does conversion disorder usually occur?

Answer 26

Any time of life but usually adolescence and early adult life Usually following a stressful life event

Question 27

What criteria must be fulfilled to diagnose conversion disorder?

Answer 27

* Demonstrate with certainty that the symptoms clearly violate laws of anatomy and pathophysiology * No other explanation can be found * If in doubt, defer diagnosis and observe the patient over a period of time until clinical picture crystalises

Question 28

What are the differentials for conversion disorder?

Answer 28

* MS * SLE * Polyarteretis nodosa * Sarcoidosis These can all present in subtle and deceptive ways.

Question 29

What are the clinical features of conversion anaesthesia?

Answer 29

_Conversion anaesthesia:_ * **Anaesthesia** of extremities (glove and stocking) with recise sharp boundaries often located at a joint * If asked yes/no to touch with eyes closed says no each time anaesthetic area is touched (i.e. they shouldn't be saying anything)​ * **Hemianaesthesia** bisecting the body * **Lack of feelings** in legs yet able to walk normally * Reflexes show no hyporeflexia

Question 30

What are the clinical features of conversion paralysis?

Answer 30

_Conversion paralysis:_ * Weakness with precise boundaries * Hemiplegia in arm will cause it to hang lumply in side for a long time rather than be in typical flexion posture * Wrong way tongue sign * Weakened leg is dragged instead of circumducted * Hoover's sign * Absent Babinski's sign and no reflexes

Question 31

What is wrong way tongue sign?

Answer 31

Protruded tongue instead of deviating towards the hemiplegic side deviates instead to the normal side

Question 32

What is Hoover's sign?

Answer 32

Hip flexure on normal side against resistance produces downward pressure in affected leg

Question 33

What are the clinical features of conversion seizures?

Answer 33

_Conversion seizures_ * Grand mal seizures most common * Onset gradual rather than sudden * If patient cries out at onset it is usually **intelligible screaming** rather than an inarticulate cry * Movements during seizure **appear purposeful** (thrash around, strike at walls, break one piece of furniture) in contrast to the rhythmic tonic-clonic activity seen in grand mal seizures. - *when you say their name they will look away purposefully rather than ignoring* * Most **don’t bite their tongue** and only those with considerable medical sophistication **may pass urine.** * End **gradually** rather than abruptly and after patients are neither confused nor sleepy * If eyes open tend to **look away from the observer**

Question 34

What investigations can you do to confirm conversion seizures?

Answer 34

* Post ictal **Babinski’s sign** * Post ictal **prolactin** elevation (take blood 15-30 minutes after seizure) ## Footnote *Many patients with epilepsy also have non-epileptic seizures, conversely patients who display non-epileptic seizures may also have epilepsy*

Question 35

Give a feature of these other conversion disorders. 1. Conversion deafness 2. Conversion blindness + unilateral blindness 3. Conversion aphonia 4. Conversion syncope 5. Conversion coma

Answer 35

* **Conversion deafness -** the blink reflex to loud and unexpected sound is present * **Conversion blindness** - the pupillary reflex is present * **Unilateral blindness** - demonstrate that the peripheral fields are full in the unaffected eye and that the pupillary response is present in both eyes. * **In conversion aphonia** – ask patient to cough during examination of lungs. Cough is full and loud. * **Conversion syncope** - faint has a swooning character * **Conversion coma** – fluttering of eyelids when eyelashes lightly stroked, resistance to eyelid opening & abrupt closure when eyelids released & normal pupillary responses. Surprise touch to the face of an ice cube

Question 36

What is the prognosis with conversion disorder?

Answer 36

May be episodic or chronic course Can remit spontaneously within weeks/months

Question 37

What is the management of conversion disorder?

Answer 37

**1. Inform the patient**- *"I have good news: the examination and the tests have revealed no damage to the brain and nerves. Although we don’t always know the cause of symptoms it is known that patients recover usually within weeks."* **Never say “there is nothing wrong with you” as this will ruin the doctor-patient relationship.** **2. Physiotherapy** helps the patient providing an honourable way out of the symptoms.

Question 38

What are the clinical features of hypochondriasis? When does it usually begin?

Answer 38

*Can begin from teenage to older years* * Patients believe that they are **sick with perhaps a life threatening illness** * Patients may be willing to undergo dangerous tests e.g cardiac catheterization. * **Symptoms change** with time * They **may bring photocopies** of all their records with them * **Reassurance does not work** and leads to a fragile alliance which rarely lasts * Includes **non-delusional dysmorphophobia** - a preoccupation with an imagined bodily defect ***Be alert to the possibility that minor symptoms do in fact indicate a serious disease***

Question 39

What is a useful method for explaining somatisation/conversion to patients?

Answer 39

Drawing a timeline Helps patients visualise

Question 40

What can be a trigger for hypochondriasis? What are some other aetiologies?

Answer 40

Witnessing or experiencing an illness can be a trigger – the post MI patient who becomes a “cardiac cripple”. * Faulty cognitive scheme of focusing on bodily sensations and misinterpreting them as serious * Entering the sick role as a "way out" of insurmountable problems * Variant in the presentation of anxiety/mood disorder * Displacement of aggressive and hostile wishes towards others, or expression of guilt or low self esteem

Question 41

How common is hypochondriasis?

Answer 41

* Prevalence: 5% * F=M * Typically onset in 20’s

Question 42

What is the prognosis with hypochondriasis?

Answer 42

Tends to be chronic and lifelong Doctors may cause iatrogenic harm 30-50% improve significantly

Question 43

What is the management of hypochondriasis?

Answer 43

**CBT/ psychodynamic/ group therapy**- patient untlikely to accept, although it may have some positive benefit **Consistency: offer patient regularly scheduled appointments,** with the same therapist/doctor **Medication: some evidence that Fluoxetine 60-80 mg** reduces concerns ***Need to exclude depression** especially in elderly where hypochondraical symptoms may predominate. Hypochondraical delusions will not respond to reassurance whereas they will briefly in hypochondriasis.*

Question 44

Key point: Associated pathology is rare and rarely missed, whereas psychiatric diagnoses are common and often missed Agree levels of activity and tell them not to do more than agreed Management...

Answer 44

1. Regular scheduled appointments 2. Perform a **brief physical examination at each visit** 3. Look for **signs of disease rather than relying on symptoms** 4. Avoid investigations and hospital admissions, unless clearly indicated, m**ay decrease physical functioning** 5. Antidepressants can help (NNT 4), low dose may be helpful 6. **Advise activity rather than rest for back pain, fatigue & fibromyalgia (activity to be agreed, not to do more than agreed, and gradually increased)**

Question 45

What is the NNT for antidepressants in MUS?

Answer 45

Only 4 so they are actually very effective