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Medically Unexplained Symptoms (somatisation)

Medically Unexplained Symptoms (somatisation). Dr Anna Fryer ST6 Liaison Psychiatry, Manchester Royal Infirmary. Learning objectives. Understand what somatisation is and when it is diagnosed Knowledge of the epidemiology, diagnosis, treatment and management of these disorders

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Medically Unexplained Symptoms (somatisation)

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  1. Medically Unexplained Symptoms (somatisation) Dr Anna Fryer ST6 Liaison Psychiatry, Manchester Royal Infirmary

  2. Learning objectives • Understand what somatisation is and when it is diagnosed • Knowledge of the epidemiology, diagnosis, treatment and management of these disorders • Broad understanding of the six DSM-IV categories of somatisation disorder

  3. Medically Unexplained Symptoms • Physical symptoms suggesting physical disorder for which there are no demonstrable organic findings or known physiological mechanism, and for which there is positive evidence, or a strong assumption, that the symptoms are linked to psychological factors

  4. Somatisation and emotional distress • Freud and Breur

  5. MUS: other terms or related terms • Somatisation-physical expression of emotional distress • functional somatic symptoms -symptom clusters • abnormal illness behaviour • hysteria • Hypochondriasis- worry about illness • Somatoform disorders – psychiatric disorder

  6. Why are they important? • Accounts for up to 20% of GP consultations • Similar picture in Secondary care • Common, and cause similar level of disability as those caused by disease • Annual healthcare cost >3.1billion in the UK • Total cost estimated at 18 billion • Investigation can cause significant iatrogenic harm

  7. Classification • A large and heterogeneous group • Classified in ICD-10 through neurotic, stress related and somatoform disorders • Classified in DSM-V under 6 categories

  8. Somatisation in DSM IV

  9. Functional Somatic syndromes • Most specialists have somatic syndromes associated with them • Examples include: • Cardiology: Non Cardiac Chest pain • Gastroenterology: Irritable bowel disease, Functional bowel disease • Rheumatology: Fibromyalgia • Gynaecology: Chronic pelvic pain

  10. Epidemiology: Prevalence • In community subjects 11.6% prevalence of ‘somatization syndrome’(lifetime history of at least 6 unexplained somatic symptoms) • Chronic pain syndrome 7.3-12.9% of adult population • Fibromyalgia: 0.5-5% • IBS: 3-20% depending on criteria • Somatisation disorder- 0.2% to 2% females, 0.2% of men

  11. Who gets FSS? • Females> Males • Some inheritability likely from twin studies: MZ vs DZ (38% VS 11%) • Childhood experiences; childhood abuse, more likely to have experience their own or parents illnesses • Stress of some kind at time of illness or months preceding (Chronic fatigue, IBS and fibromyalgia) • More likely to have a psychiatric disorder- usually anxiety and depression • Recent infection • Illness or death of relative

  12. Prevalence of psychiatric disorder in somatization/MUS • Community Gp clinic Treatment resistant 10% 20-30% 40% 50-60%

  13. Prognosis • 4%-10% go onto have an organic explanation for their presentation • 75% remain unexplained at 12 months • 30% (10% – 80%) have an associated psychiatric disorder (usually depression, anxiety) depending on how many unexplained symptoms are present • 25% persists for over 12 months (in primary care)

  14. Management • Engage the patient • Reduce unnecessary medications • Concentrate on helping to manage symptoms and improve functionality • Screen for depression and anxiety and treat appropriately • Physiotherapy and Exercise Therapy help • Consider a shared plan set out for other professionals and discussed with the patent

  15. Management • reduce expectation of cure • don’t expect rapid changes • share knowledge and plan with other partners

  16. Management • Psychological (Cognitive Behavioural Therapy) • Pharmacological ( treat existing anxiety and depression with antidepressants) • Treatment packages • Maintain therapeutic relationship with short regular appointments to minimise unnecessary investigations • Graded Physical Exercise

  17. Psychotherapy • Cognitive behavioural therapy • Behavioural goals • Short term dynamic psychotherapy • Psychodynamic interpersonal therapies • May require referral to Psychiatry services

  18. Pharmacological therapy • Evidence of efficacy in IBS, CFS & chronic facial pain • TCAs and SSRIs • Definitely use if evidence of depression • high rate of side effects and discontinuance of treatment

  19. Predictors of poor outcome • Ongoing litigation • No life events before onset of symptoms • Constant pain • Marked pain behaviour • Dysfunctional illness beliefs

  20. Somatisation disorder • Recurrent multiple physical complaints that have no physical basis • First noted by Pierre Briquet in 1859 • Lifetime prevalence of <0.5% • Females> males • Typical onset in early adulthood • 4 pain symptoms • 2 GI symptoms • 1 sexual symptom • 1 pseudo neurological symptom

  21. Somatisation disorder • Cannot be fully explained by a medical condition, or the action of a substance • Not intentionally feigned or produced

  22. Conversion disorder • One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition. • Psychological factors are associated • Cannot be explained by a medical condition • Significant distress or impairment in functioning • Not better accounted for by any other mental disorder

  23. Conversion disorder • Following extreme stress • Symptoms more common on left (55-60%) • Commoner in less knowledgeable individuals • Onset 10-35 years • Recurrence common (20% at 1 year)

  24. Pain Disorder • Pain in one or more sites of severity to warrant medical attention • Causes significant distress and impairment in functioning • Psychological factors have a role in course and onset • Not explained by a medical condition • Not better explained by another mental disorder • Common (e.g. chronic back pain)

  25. Hypochondriasis • Preoccupied with the fear or belief that one has a serious disease • Persists despite evaluation and reassurance • Causes significant distress and impairment in functioning • Duration of at least 6 months • Not explained by other mental disorder

  26. Body Dysmorphic Disorder • Marked by a preoccupation with an imagined or trivial defect in appearance • causes clinically significant distress or impairment in functioning • The individual's symptoms must not be better accounted for by another disorder • 1-2% of population fulfil criteria • Higher completed suicide rate

  27. Factitious disorder • Intentional production or feigning of physical or psychological signs or symptoms • Motivation to assume the sick role • External incentives for the behaviour are absent • Can be by proxy (to those people care for)

  28. Malingering, somatoform and factitious disorders

  29. Case presentation • 47 year old male • 2 year history of increasing attendance at A and E • Coincided with severe stressor of loss of wife • Several acute presentations with chest pain • No medical cause found • anxiety

  30. Assessment • Both physical and psychological • Needs investigations for IHD • BP, cholesterol 24 hour ECG • Psychiatric assessment and Mental State

  31. Case • No evidence of IHD • Lifestyle advice • Panic disorder • Generalized Anxiety disorder

  32. Treatment • Antidepressant treatment- SSRI (citalopram 20mg PO od) • Graded exercise programme • Psychological treatment • CBT • Interpersonal psychodynamic

  33. Summary • Important and common • 20% of GP consultations • 40% of outpatients referrals to medical clinics have MUS • Current challenge is to recognise in Primary and Secondary care and integrate psychological and physical management

  34. Questions?

  35. Further reading • Handbook of Liaison Psychiatry. E.Guthrie and Geoffrey Lloyd, Cambridge (available on NHS Evidence) • Oxford Handbook of Psychiatry • Somatisation and Conversion disorders, Best Practice Guidelines, BMJ publishing • International Classification of Diseases and Related Health Problems (10th edition), World Health Organisation • Diagnostic and Statistical Manual of Mental Disorders 4th edition, American Psychological Association

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