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Medically unexplained symptoms

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... are not intentional i.e. under voluntary control (cf factitious disorders) ... Factitious ... Factitious. Malingering. Conscious reason for symptoms. Symptoms ... – PowerPoint PPT presentation

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Title: Medically unexplained symptoms


1
Medically unexplained symptoms
  • Dr. Simon Hatcher
  • University of Auckland
  • www.shatcher.co.nz

2
Nomenclature
  • Heartsink patients
  • Fat folder patients
  • Chronic complainers
  • Somatisation disorder
  • Chronic multiple functional symptoms
  • Unexplained medical symptoms
  • Frequent flyers

3
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

4
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).

5
Somatisation in DSM IV
6
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

7
Somatisation disorder
  • Hysteria or Briquets syndrome
  • 0.2 to 2 of women, 0.2 of men
  • Chronic fluctuating disorder

8
Somatoform disorder
  • One or more physical complaints
  • Medically unexplained
  • Duration at least 6 months
  • Each medical specialty has its own version

9
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

10
Conversion disorder
  • One or more symptoms or deficits affecting
    voluntary motor or sensory function
  • Clear link with psychological factors

11
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)

12
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)

13
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

14
Body dysmorphic disorder
  • Preoccupation with an imagined defect in
    appearance.

15
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

16
Malingering, factitious and somatoform disorders
17
An aetiological classification
  • Somatisation secondary to depression or anxiety
  • Somatisation secondary to physical disorder
  • Somatisation secondary to emotional distress
    being converted to physical distress

18
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

19
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

20
Somatisation and emotional distress
  • Freud and Breur

21
Somatisation and emotional distress
22
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

23
Assessment 2 - specialist
  • Ally
  • Model
  • Predicament
  • Background of reverse parenting, emotional
    deprivation
  • Cultural issues

24
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

25
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

26
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)

27
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

28
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
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