Medically Unexplained Physical Symptoms

1
Medically Unexplained Physical Symptoms
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• MUPS are defines as complaints of physical
  symptoms or signs for which there is no adequate
  objective pathophysiologic evidence to explain
  the distress. The diversity of conditions that
  fall under this classification remains a source
  of controversy and paradox.

3

• MUPS are encountered principally in medical
  settings, where patients and clinicians often are
  unfamiliar with psychological explanations.

4

• MUPS implies the presence of symptoms that do not
  conform to known disease processes. MUPS defines
  a predicament rather than a disorder, a way of
  drawing attention to a societal situation in
  which the meaning of distress is contested. It
  is critical to accept that unexplained does not
  necessarily imply purely psychological origins,
  as the history of psychiatry is replete with
  examples of disorders once considered
  functional, that were subsequently proven to
  result from organic processes.

5

• Some patients may have vague symptoms initially
  that appear to be unexplained, only to manifest
  clearer evidence of underlying disease later in
  the course of illness (i.e. multiple sclerosis or
  myasthenia gravis).

6

• Is it normal for patients to occasionally seek
  reassurance for transient physical symptoms? What
  is the threshold for distinguishing MUPS from
  worried-wellness, and should it depend on
  symptoms, severity, chronicity, or functional
  impairment? Is the degree of conscious awareness
  versus volitional control of reliable factor in
  distinguishing MUPS disorders?

7

• Sharpe and Mayou questioned the validity of MUPS
  as a defining feature of somatoform disorders and
  challenged the assumption of psychogenesis in
  many of these disorders. Ballas and Staab also
  questioned contemporary criteria and suggested
  classifying MUPS based on organ systems.

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EPIDEMIOLOGY
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• The direct and indirect economic costs
  attributable to MUPS are staggering. Patients
  with MUPS have increased healthcare utilization
  rates, including frequent visits, demands for
  tests, unnecessary surgery, numerous
  consultations, and hospitalizations.

10

• The current financial cost of MUPS in the United
  States exceeds 100 billion annually. This does
  not include substantial indirect costs of lost
  workplace productivity and disability payments.
  Another burden and hidden cost to society stems
  from prescription and over-the-counter drug sales
  targeting common minor ailments and fueled by
  direct-to-consumer advertising.

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SPECIFIC SOMATOFORM DISORDERS
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Secondary MUPS Syndromes

• Secondary MUPS syndromes encompass patients with
  primary psychiatric disorders. A variety of
  nonspecific physical complaints often are
  associated. Up to 76 of patients hospitalized
  for depression report multiple pain symptoms.
  Vegetative symptoms form an integral part of
  diagnostic criteria for depression, ruminate
  about fatigue, weight loss, pain, somatic
  depression or masked depression, these
  physical ailments occur frequently in depression,
  especially among the elderly.

13

• MUPS are common among patients with anxiety
  disorders and compromise a significant component
  of diagnostic criteria through activation of the
  autonomic nervous system and comes to clinical
  attention because of palpitations, chest pain,
  dizziness, abdominal discomfort, and other
  symptoms.

14

• Patients with psychotic disorders
  schizophrenia, mood disorders, substance induced
  psychosis, delusional disorder, delirium, or
  dementia also may present with MUPS.

15

• Delusional Disorder Somatic Type
• Somatization Disorder
• Conversion Disorder
• Hypochondriasis
• Body Dysmorphic Disorder
• Pain Disorder
• Factitious Disorders
• Malingering

16

• Early psychodynamic hypotheses were based on
  studies of hysteria. Central to this line of
  reasoning is the notion of conversion as
  reflecting defense mechanisms that symbolically
  transform unconscious emotional trauma and
  conflict into physical symptoms.

17

• More recent work in mental cognitive
  neuropsychology extends and clarifies
  psychodynamic mechanisms underlying MUPS. New
  ideas concern the development of emotional
  processing from nonverbal, subsymbolic expression
  in childhood to more mature, adaptive and verbal
  abilities that allow for translation of emotional
  states into identifiable feelings on an abstract,
  logical and reality-based level.

18

• MUPS are the result of activation of or
  regression to subsymbolic somatic symptoms
  disassociated from verbal, symbolic
  representations of feelings and objects. Patients
  therefore experience somatic signs only, detached
  from psychological meaning or in other words,
  they exhibit alexithymia.

19

• MUPS are associated somatoform disorders remain
  an enormous problem in terms of prevalence,
  personal suffering and disability, and costs to
  society.

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• In the culture of the modern era, characterized
  by increasing social, political, and economic
  pressures to label syndromes with or without
  scientific support, to promote quick and
  profitable remedies, and to control costs all at
  the same time, the need for better understanding
  of MUPS has never been more compelling.