MUPS (Medically Unexplained Physical Symptoms)

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MUPS (Medically Unexplained Physical Symptoms)
Dr Mike Ewart Smith, psychiatrist
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Matters for discussion

• The label MUPS has become non-PC
• DSM-5 imminent
• Changes may affect insurance medicine
• Risk of overdiagnosis of mental disorder
• MUPS, Conversion Disorder Pain Disorder
  patients will not disappear
• No obvious treatment breakthroughs?

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MUPS

• Symptoms unexplained after appropriate medical
  assessment
• Very Common, persistent and stressful
• Common comorbidity !! anxiety depression !!
• Higher prevalence in women
• Severe functional impairments
• Possibly more MUPS off work, in wheelchairs, than
  patients with chronic illness
• Enormous costs ..NB Disability Benefits

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All Specialties See MUPS

• Rheumatologist (ME, fibromyalgia)
• Cardiologist (non-cardiac chest pain)
• Neurologist (headache,dizziness)
• Gynaecologist (multiple)
• Orthopaedic (chronic back pain)
• Gastroenterologist (IBS, NUDS, spastic colon)
• Paediatrician (proxy)
• Psychiatrist (somatisation)

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MUPS Patients

• High level of health related anxiety
• Cant accept absence of medical explanation
• Doctor shopping
• Know about their condition, internet printouts,
  support groups, newsletters
• Poor response to treatment..side effects
• The Sick Role,The Disability Syndrome
• FAT FILE PATIENTS

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Psychiatric Terminology

• DSM-IV (Somatoform Disorders)

• DSM 5 (Somatic Symptoms and Related Disorders)

• Somatisation Disorder
• Conversion Disorder
• Hypochondriasis
• Body Dysmorphic Disorder
• Pain Disorder
• Undifferentiated Somatoform Disorder
• Somatoform Disorder NOS

• New Diagnosis Somatic Symptom Disorder
• No medically unexplained
• Focus excessive responses to distressing,
  chronic, somatic symptoms
• Plus dysfunctional thoughts, feelings or
  behaviours

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Changes

• Somatisation Disorder DSM-IV

• Somatic Symptom Disorder
• DSM-5

• MUPS symptoms before age 30 yrs
• Leading to treatment or psychological impairment
• At least 8 MUPS from 4 symptom groups
• At least 4 pain and 2 GIT symptoms

• Just 1 bodily symptom
• For 6/12, one of
• disproportionate thoughts about the
  seriousness
• High levels of anxiety about health
• Excessive preoccupation with symptoms health or
  concerns

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The new diagnosis SSD

• The medically unexplained criterion has been
  obliterated
• Just 1 symptom/concern qualifies
• Likely to be diagnosed in
• (a) patients with established illness eg
  diabetes, coronary disease, cancer)
• (b) unexplained medical symptoms

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The new diagnosis SSD

• Mislabelling normal reactions as mental disorder
• Iatrogenic disease
• Inappropriate medication
• Increase in OWCs and Disability Claims on
  psychiatric grounds

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Conditions vulnerable to misdiagnosis as DSM-5
mental disorder

• Chronic Fatigue Syndrome
• Fibromyalgia
• Irritable Bowel Syndrome
• Chronic backache
• Gynaecological mysteries

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Anecdotal experience of somatisation illnesses

• I have seldom, if ever, seen one of these women,
  referred for total permanent disability, who has
  ever been counselled appropriately, about the
  cause of her somatic complaints
• M Ewart Smith (repeatedly)

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Rx of MUPS etc

• Acknowledge reality of problem/therapeutic
  alliance
• Identify secondary gain
• Identify perpetuating factors
• Attributions, coping styles, stressors
• CBT A/Ds both effective (Multidisciplinary
  management)
• Encourage activity

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Other nightmares for the Ombudsman

• Conversion Disorder
• Pain Disorder
• Change in DSM Axes System

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Conversion Disorder Functional
Neurological Disorder

• One or more neurological symptoms
• Unexplained or inconsistent with recognised
  disorder
• Clinically significant distress or impaired
  functioning
• Relevant psychological stressor not a requirement
• Not required to prove absence of feigning
  symptoms

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PAIN DISORDER

• Patient is preoccupied with continuous pain
• Emotional distress, functional impairment
• No pathophysiological explanation for presence or
  intensity of the pain
• Psychological factors play a primary role in
  onset, severity, exacerbation or maintaining the
  pain
• Not intentionally produced

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No Multiaxial Diagnoses

• Axis I, II, and III combined into one list
• all mental disorders
• personality disorders
• intellectual disability
• general medical conditions
• Part 2
• psychosocial and environmental factors
• other reasons for visit
• GAF Score replaced by combined assessment of
  symptom severity, suicide risk, social functioning