Psychiatric Disorder Presenting with Physical Symptoms

Question 1

Somatisation Disorder

Answer 1

Repeated presentation of physical symptoms with persistent request for medical investigations, hx of physical complaints begins before 30yrs and can involve any body system

• Repeated investigations risk iatrogenic harm
• The patient has repeated presentation with various clinical complaints are there is somatisation of an underlying psychological disorder that manifests as varied physical symptoms

Question 2

Managing Somatisation Disorder

Answer 2

The first step in management is to diagnose the disorder, and following this the aim should be to limit additional harm through inappropriate investigations/treatment

• Physiological treatment can include psychotherapy
• There should be pharmacotherapy where there is a secondary disorder of affect or anxiety

Question 3

Functional Somatic Syndromes

Answer 3

These conditions can be seen as somatisation disorder that only presents with one physical complaint.
Examples include chronic fatigue and IBS
Somatoform pain disorder is similar to this, and is characterised by persistent severe pain that cannot be explained by a physiological process or physical disorder
- The pain has gradual onset and is described in indefinite terms (it is categorised by the region affected e.g. pelvic pain)
- The pain is in association with emotional conflict or psychosocial problems. It may be relieved by alcohol, psychotropic medication, or psychological therapies
The use of antidepressants can help in functional somatic syndromes, even in the absence of depression.

Question 4

Hypochondriacal Disorder

Answer 4

Hypochondriacal disorder is characterised by persistent preoccupation with the possibility of having one or more serious physical disorder(s). As such, normal or commonplace sensations and appearances are often interpreted by patients as abnormal and distressing
- Marked depression and anxiety are often present
- This condition is a neurosis, rather than a delusion
It is important to firstly rule out a physical cause of symptoms, and following this there can be psychological treatment e.g. CBT. Excluding the disorder that is the source of worry will help the patient to improve e.g. blood test and rule out HIV etc.

Question 5

Body Dysmorphic Disorder

Answer 5

Body dysmorphic disorder is characterised by persistent preoccupation with the appearance of the body, this leads to distress and often patients will seek plastic surgery
- Surgery can sometimes be useful to reduce the degree of distress; however it should be avoided in patients that have unrealistic expectations of surgery
Distress can be reduced by supportive therapy

Question 6

Conversion Disorder

Answer 6

Conversion disorder is a subconscious phenomenon in which there are one or more symptoms/ deficits affecting voluntary motor or sensory function. These symptoms are not intentional or feigned, and cause distress
- Conversion disorder is symbolic of unconscious conflict
- Treatment aims at regaining insight about the conflict, which will make the conversion disorder worse before it improves
Examples include anaesthesias, paralysis, and blindness. PET scanning will show the brain activating to move the affected limb, and EMG will show intact pathways, however the conversion disorder means that the patient will still be unable to move it.

Question 7

Dissociative Disorder

Answer 7

Dissociative disorders lead to a loss of integration between memories of the past, awareness of identity, sensations, and control of bodily movement. These can be seen as conversion disorders affecting the mind rather than the body and commonly follow an acute stressful event

• Dissociative amnesia is an inability to recall certain life events/personal information but all other aspects of memory are otherwise intact. This is often sudden and may relate to a traumatic event
• Dissociative fugue is sudden unexpected travel away from home with inability to recall one’s past
• Dissociative identity disorder is the presence of 2 or more distinctive identities/personalities that take control of the person’s behaviour. A sudden change from one identity to another is generally associated with a traumatic event

Question 8

Factitious Disorder

Answer 8

Factitious disorder is intentionally feigning physical or psychological symptoms with the aim of attaining the ‘sick role’. The patient does not have any external gain for carrying out these behaviours, and therefore their motivation is unclear
- Commonly, these patients will present with skin lesions, diarrhoea of unknown origin, pyrexia of unknown origin, and brittle diabetes
Factitious disorder is a maladaptive stress behaviour, similar to self-harm
It is important to observe carefully for discrepancies among the clinical findings before making the diagnosis. In some cases, patients will admit their behaviour but many others will deny it.

Question 9

Malingering

Answer 9

Malingering is the deliberate, conscious production of symptoms for external incentives e.g. avoiding prosecution, financial gain, obtaining illicit drugs
- This is not a psychiatric condition