Medically unexplained symptoms

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Medically unexplained symptoms

• Dr. Simon Hatcher
• University of Auckland
• www.shatcher.co.nz

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Nomenclature

• Heartsink patients
• Fat folder patients
• Chronic complainers
• Somatisation disorder
• Chronic multiple functional symptoms
• Unexplained medical symptoms
• Frequent flyers

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Epidemiology

• Medically unexplained symptoms common
• One third of new neurological out patients
• Conversion disorders 5/100,000 (cf MS)
• Female gt male
• History of physical and sexual abuse
• Emotionally deprived childhoods

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Somatisation in DSM IV

• The presence of physical symptoms that suggest a
  medical conditionand are not fully explained by
  a general medical condition.
• The physical symptoms are not intentional i.e.
  under voluntary control (cf factitious disorders).

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Somatisation in DSM IV
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Somatisation disorder

• Recurring multiple clinically significant
  somatic complaints for which treatment is sought
• Begins before age 30
• Four pain symptoms
• Two gastrointestinal symptoms
• One sexual symptom
• One pseudoneurological condition

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Somatisation disorder

• Hysteria or Briquets syndrome
• 0.2 to 2 of women, 0.2 of men
• Chronic fluctuating disorder

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Somatoform disorder

• One or more physical complaints
• Medically unexplained
• Duration at least 6 months
• Each medical specialty has its own version

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Somatoform disorder

• Medically unexplained symptoms
• Residual category for those persistent somatoform
  presentations that dont meet criteria for
  somatisation disorder or another somatoform
  disorder
• Maybe single symptom or multiple

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Conversion disorder

• One or more symptoms or deficits affecting
  voluntary motor or sensory function
• Clear link with psychological factors

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Conversion disorders

• Common following extreme stress e.g. war
• Commoner in less knowledgeable individuals
• Symptoms more common on left (55-60)
• Onset 10 to 35 years old recurrence common (20
  at one year)

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Pain disorder

• Pain in one or more anatomical sites
• Psychological factors clearly involved
• Common (?10-15 of adults in US have work
  disability due to back pain)

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Hypochondriasis

• Preoccupation with fears of having a serious
  disease based on the persons misinterpretation
  of bodily symptoms
• Minimum 6 months duration
• Preoccupation persists despite appropriate
  medical evaluation and reassurance

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Body dysmorphic disorder

• Preoccupation with an imagined defect in
  appearance.

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Factitious disorders

• Intentional production or feigning of physical or
  psychological signs or symptoms
• Motivation to assume the sick role
• External incentives for the behaviour are absent

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Malingering, factitious and somatoform disorders
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An aetiological classification

• Somatisation secondary to depression or anxiety
• Somatisation secondary to physical disorder
• Somatisation secondary to emotional distress
  being converted to physical distress

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Somatisation secondary to depression/anxiety

• 20 of all GP consultations in UK (5 presented
  with psychological complaints)
• Somatic symptoms are a manifestation of
  depression or anxiety

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Somatisation and physical illness

• Slater 1965
• 10 year follow up of 85 hysterical patients.
• 33 patients no organic disease after 10 yrs.
• 4 suicides
• Slater revisited 1998
• 5-7 year follow-up of 64 patients
• 3 had organic disorders. 44 had a psychiatric
  diagnosis

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Somatisation and emotional distress

• Freud and Breur

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Somatisation and emotional distress
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Assessment 1 - generalist

• History of physical complaints symptoms are
  real, nothing is wrong unhelpful
• Life events and other perpetuating factors
• Experience of medical profession
• Illness history
• Early development
• Collaborative history including old notes
• Formulation

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Assessment 2 - specialist

• Ally
• Model
• Predicament
• Background of reverse parenting, emotional
  deprivation
• Cultural issues

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Management of unexplained medical symptoms for
non-psychiatrists -1

• Identify psychosocial cues
• Provide unambiguous information about what is
  normal and what is abnormal
• Time planning
• Setting the agenda develop a problem list
• Set limits for investigation
• Other specialist referrals starting and
  stopping
• Dont treat what the patient hasnt got
• Avoid a dualistic model i.e. physical or
  psychological

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Management of unexplained medical symptoms for
non-psychiatrists - 2

• Provide an explanatory model
• Decide who manages the psychosocial problems
• One doctor to integrate management
• Honesty is the best policy
• Do joint assessments
• Rebutting the rebuttals
• Be consistent
• Training and education
• Avoid spurious diagnosis

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Management issues 2 - specialist

• Engagement important
• Treat depression/anxiety where appropriate
  (reattribution techniques)
• Psychotherapeutic approaches
• CBT in CFS
• Psychodynamic therapy and IBS
• Treating the system (damage limitation)

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Brain function

• Increased activity in limbic regions
• Hypnosis reduces conflict in the anterior
  cingulate cortex (conflict monitoring)
• The parts of the brain involved in emotion
  inhibit normal brain functioning

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References

• Stone J, Carson A, Sharpe M. Functional symptoms
  and signs in neurology assessment and diagnosis
  J Neurol Neurosurg Psychiatry 200576 (Suppl
  I)i2-i12
• Stone J, Carson A, Sharpe M. Functional symptoms
  in neurology management J Neurol Neurosurg
  Psychiatry 200576 (Suppl I)i13-i21
• Bass C, May S. ABC of psychological medicine.
  Chronic multiple functional somatic symptoms BMJ
  2002325323-326