Medically unexplained symptoms

Presented by Dr. Ahmed Elabwabi Abdelwahab MD. Psychiatry SMSB

What is it??
symptoms which do not fit to any known medical diagnosis . psychiatrists help is requested when :
symptoms do not conform to any known medical disorder, when the pattern make it unlikely to be medically driven .. intensity is grossly out of proportion to physical findings, particularly in pain syndromes .

A. Sick Role
Have you ever played sick in order to get out of something? How did that work out (did you get what you wanted)? Sick attention (friends, family, medical) = secondary gains Likely link between secondary gains and somatoform disorders Some medical condition may actually exist

Somatisation
This is the experience of psychological distress as physical symptoms. symptom of various disorders :
As a normal accompaniment of physical illness As a common presentation of depressive illness As a core component of the illness (the somatic syndromes) Part of a longstanding pattern of behaviour

 Conversion: the process by which thoughts or memories unacceptable to the conscious mind are repressed from conscious expression and converted into physical symptoms, sometimes with symbolic meaning to the patient.

Diagnosis
A positive and confident diagnosis is crucial. Diagnosis may be organic and non-organic diagnosis (e.g. where there is undoubted organic disease but also significant MUS morbidity). Acknowledge the patient's distress and disability; a diagnosis of MUS should not mean to the patient that you believe that there is nothing wrong with them

Somatisation disorder
chronic disorder. multiple medically unexplained symptoms, affecting multiple organ systems . presenting before the age of 40. associated with
significant psychological distress, functional impairment, repeated presentations to medical services ( doctor consumers) Briquet's syndrome : (Full blown somatisation disorder ) .. represents the severe end of a continuum of abnormal illness behaviour ..

Term somatization disorder was first used in DSM-III (1980) Known as Hysteria, hypochondriasis, and melancholia until 1800s when mental disorders were differentiated

Somatisation disorder
Clinical features
long, complex medical histories (fat-file patients) .. 2 years at least .. may minimise all but the most recent symptomatology. any system .. The most frequent symptoms are nonspecific and atypical. Presentation:
4 pain symptoms 2 gastrointestinal symptoms 1sexual symptom 1 pseudoneurological symptom

There may be discrepancy between the subjective and objective findings : intractable pain <-> joking with relatives). From system to system..

 Life revolves around the illness as does family life. large numbers of diagnostic procedures and surgical or medical treatments. doctor-patient relationship Hostility and frustration. another psychiatric disorder -> Twothirds of pts
Depression and anxiety personality disorder and substance abuse.

 Aetiology :
childhood illnesses parental anxiety towards illness. somatisation disorder in first degree relatives. neuropsychiatric basis -> faulty assessment of normal somatic sensory input. Association with childhood sexual abuse.

 Epidemiology
Lifetime prevalence of -0.2%. > in particular populations. M: F = 1: 5

Differential diagnosis
Undiagnosed physical disorder: particularly those with variable, multisystem presentations (e.g.
SLE, AIDS, porphyria, tuberculosis, multiple sclerosis

Psychiatric disorder: major affective and psychotic illnesses

 Other somatoform disorders:

hypochondriasis (presence of firm belief in particular disorder), somatoform pain disorder (pain rather than other symptoms is prominent), conversion disorder (functional neurological loss without multisystem complaints).

On-going management
Regular review by single, named doctor. Reviews should be at planned and agreed frequency, avoiding emergency consultations. Symptoms should be examined and explored with a view to their emotional meaning. Avoid tests to rule out disease, investigate objective signs only. All secondary referrals made through one individual. Disseminate management plan. These patients can exhaust a doctor's resources plan to share the burden over time.

Prognosis
Poor in the full disorder; tendency is for chronic morbidity with periods of relative remission. Treatment of psychiatric comorbidity and reduction of iatrogenic harm will reduce overall morbidity.

Somatoform pain disorder

persistent severe and distressing pain which is not explained or not adequately explained by organic pathology . psychological factors. not better explained by somatisation disorder, another psychiatric diagnosis, or functional overlay of organic disease.

 factors inclue
the situation, the degree of arousal, the affective state, the beliefs about the source, and meaning of the pain.

modified by its chronicity and associations two-way relationship with affective state, with chronic pain predisposing to depressive illness,

 Management
recognise and treat occult comorbid depression. Opiates
not generally effective risk of dependence.

Psychological treatments: enabling the patient to manage and live with the pain, rather than aspiring to eliminate it completely
relaxation training biofeedback hypnosis group work CBT

Conversion (dissociative) disorders

A loss or disturbance of normal function which initially appears to have a physical cause but is attributed to a psychological cause . Hippocrates Believed disorder only occurred in women Attributed it to a wandering uterus Originally known as Hysteria - Greek word for uterus

 Freud
Coined term conversion Anxiety and conflict converted into physical symptomsSymptoms are not produced intentionally the presence of secondary gain is not part of the diagnosis

Clinical features
Paralysis:
One or more limbs or one side of the face or body . Flaccid paralysis may develop contractures. Often active movement of the limb is impossible during examination but synergistic movement is observed (e.g. Hoover's test: Other motor : Dysphasia . Ataxia . Vomiting . Mutism

Loss of speech (aphonia )There may be complete loss of speech, or loss of all but whispered speech.
comprehension and writing is unimpaired Laryngeal examination is normal

 Sensory loss The area of loss will cover the patient's beliefs about anatomical structure rather than reality Blindness . Deafness . Anosmia . Anesthesia . Diplopia . glove and stocking anesthesia disturbance of consciousness:

 Seizures
generalised shaking, rather than regular clonic contractions, no post-ictal confusion or prolactin rise. only in the presence of an audience, no injury on falling to the ground, tongue biting and incontinence are rare,

AMNESIA FUGE

Labelle indifference: i.e. in spite of the disability, the patient is mostly laughing or normal

 Diagnosis
non-anatomical or clinically inconsistent nature of the signs. No , or minor organic disease, psychological explanation .

 Treatment
Supportive psychotherapy, explanation that symptoms were initially organic but now problems are due to maladaptive response, perhaps with physiotherapy involvement. Treatment of psychiatric comorbidity.

Hypochondriasis
preoccupation with the fear of having a serious disease which persists despite negative investigations and causes distress and impaired function. patient may repeatedly ruminate on this possibility minor abnormalities, normal variants, normal functions, and minor ailments will be interpreted as signs of serious disease.

 unable to be reassured in a sustained fashion by negative investigations. over-valued idea Where the belief in illness is of delusional intensity, the patient should be treated as for delusional disorder

 Aetiology :
As in somatisation disorder . combination of anxiety symptoms -> medical advice. -> temporary relief of anxiety -> further medical attention seeking more likely.

Equal sex incidence. Comorbidity : major depressive illness, OCD, and panic disorder.

 Management
Psychotherpy and family education . Pharmacologically : antidepressant . E.g. fluoxetine 20mg, CBT (identify and challenge misinterpretations,

Dysmorphic disorder
preoccupation with the belief that some aspect of physical appearance is markedly abnormal, unattractive or pathological. over-valued, it is not amenable to reassurance. may develop delusional intensity. The bodily part is normal, or if abnormal is only trivially so may present requesting plastic surgery or mutilating surgical procedures, many similarities to OCD

 Any part of the body may be affected, most usually the face, head, and secondary sexual characteristics. Patients believe that the supposed deficit is noticeable to others and attempt to hide or minimise it. associated functional impairment, agoraphobia, and risk of suicide. Comorbidity : 60% risk of major depression.

 Treatment
Operative Plastic surgery not indicated, even successful surgery new preoccupation or a focus on surgical scarring. Pharmacological : SSRI, try fluoxetine 20mg or clomipramine

Psychological : CBT treatment focused on response prevention, challenging cognitive errors, and behavioural tasks.

Prognosis
Chronic course with fluctuating symptom severity. Partial rather than full remission.

Factitious disorder (Munchausen's Syndrome)

patients intentionally falsify their symptoms and past history and fabricate signs of physical or mental disorder with the primary aim of obtaining medical attention and treatment. Dx : the intentional and conscious production + lack of gain beyond medical attention and treatment.

 Three distinct sub-groups are seen.

Wandering
mostly males producing dramatic and fantastic stories. may be aggressive personality or dissocial PD and comorbid alcohol or drug problems.

Non-wandering mostly females

overlap with chronic somatisation disorder. Association with borderline PD.

By proxy
mostly female. Mothers, carers, or paramedical and nursing staff simulate or prolong illness in their..

 The behaviours can mimic any psychical and psychiatric illness. Behaviours include: self-induced infections, simulated illnesses, interference with existing lesions, selfmedication, altering records, reporting false physical or psychiatric symptomatology. Early diagnosis reduces iatrogenic morbidity

 Management
There are no validated treatments. Management in these cases is directed towards reducing iatrogenic harm Direct challenge Easier if there is direct evidence of feigned illness

Indirect challenge : face-saving .. way out . Systemic change

Unchangable patient changing the approach of the health care system to assessing them in order to minimise harm. dissemination of the patient's usual presentation and distinguishing marks to regional hospitals..

Chronic fatigue syndrome

central feature is severe fatigue, unrelated to exertion and unrelieved by rest. may date the symptoms very precisely to an episode of viral infection with sore throat, fever, and tender lymph nodes myalgic encephalomyelitis (ME) and post-viral fatigue syndrome Management Medication : antidepressant (SSRI ) Graded exercise : gradual negotiated increase over time.
The aim is to break the cycle of inactivity, brief excess activity, and consequent exhaustion.

Psychotherapy : CBT.

Malingering
Intentional production of false or grossly exaggerated physical or psychological symptoms Motivated by external incentives (avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs)

Malingering
Warning signs
Medicolegal context e.g. the person is referred by an attorney to the clinician for examination Marked discrepancy between the persons claimed stress or disability and the objective findings Lack of cooperation during the diagnostic evaluation and in complying with the prescribed treatment regimen The presence of Antisocial Personality Disorder

Factitious Disorder vs. Malingering

Motivation:
Factitious Disorder no external incentives are present, rather, the motivation is a desire to maintain the sick role Malingering external incentives are present

Dissociative disorders

Some General Considerations

The four diagnoses are hierarchical and only one can be used at any given time
Dissociative Identity Disorder Dissociative Fugue Dissociative Amnesia Depersonalization Disorder

Dissociative Identity Disorder

Dissociative Fugue

Dissociative Amnesia

Depersonalization Disorder

Depersonalization Disorder
Experience especially among younger males. Approximately 30% of individuals that had one or more episodes of depersonalization in their lifetimes. Episodes of depersonalization usually become less frequent or disappear as the individual gets older. The disorder is rarely diagnosed, however, because depersonalization is often considered either not pathological or part of another diagnosis.

Depersonalization Disorder
Persistent or recurrent experiences of feeling detached from, and as if one is an outside observer of, one's mental processes or body (e.g., feeling like one is in a dream). During the depersonalization experience, reality testing remains intact. The depersonalization causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

 The depersonalization experience does not occur exclusively during the course of another mental disorder, such as Schizophrenia, Panic Disorder, Acute Stress Disorder, or other Dissociative Disorder, and is not due to the direct physiologic effects of a substance or a general medical condition.

Depersonalization Disorder
Onset of this disorder usually occurs between the ages of 15 and 30 and has been noted in children as young as 10 years of age. The course of the disease is generally chronic and stable. Depersonalization Disorder is notoriously refractory to both psychotherapy and chemotherapy.

Dissociative Amnesia
This is perhaps the best known of these disorders due to recovered memories of childhood sexual abuse forming the basis for numerous prosecutions and law suits in recent years. There is serious debate about the validity of such recovered memories

Dissociative Amnesia
One or more episodes of inability to recall important personal information, of a term addict or stressful nature, that is too extensive to be explained by ordinary forgetfulness. Exclusde : Dissociative Identity Disorder, Dissociative Fugue, Post-Traumatic Stress Disorder, Acute Stress Disorder, or Somatization Disorder , substance and a neurological or other general medical condition. distress or impairment in social, occupational, or other important areas of functioning

Dissociative Amnesia
Individuals experiencing it seem remarkably undistressed by their inability to remember. In most cases memories returned, at first in fragmented form, over a relatively brief period of time.

Dissociative Fugue
Extremely rare . look at the possibility of delirium, dementia, or substance intoxication. in men who have been experiencing high levels of distress arising primarily from conflicts in personal and professional identity. also in natural disasters and military combat.

Dissociative Fugue
sudden, unexpected travel away from home or once customary place of work, with inability to recall one's past. Confusion about personal identity or assumption of a new identity. Exclue : Dissociative Identity Disorder , physiologic effects of a substance and general medical condition. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

Dissociative Identity Disorder

Formerly referred to as Multiple Personality Disorder. rare disorder individual appears to have more than one identity, or personality. Often the predominant personality is completely oblivious to alternate identities, while some alternate personalities or identities have access to the memories of the predominant identity.

Dissociative Identity Disorder

Presence of two or more distinct identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self). At least two of them currently take control of the person's behavior. Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness.

 Not due to the direct physiological effects of a substance or a general medical condition. Note: in children the symptoms are not attributable to an imaginary playmates or other fantasy play

Dissociative Identity Disorder

Generally individuals who have this disorder are identified initially because they complained of having lost periods of time during which they apparently were doing something but have no recollection of what. Long-term psychotherapy is the treatment of choice- uncover trauma.