Sridevi Sira Mahalingappa Consultant Psychiatrist, Royal Derby Hospital
Outline Definition Differential diagnosis Assessment Management
Definition Persistent & distressing somatic symptoms for which adequate somatic explanation dose not reveal sufficient explanatory organic pathology Shaefert et al 2013 Many of these terms are used interchangeably MUS Somatisation Functional symptoms Others Hysteria Psychosomatic
Case vignettes 42 year lady, frequent non specific pain in upper abdomen for 2 years, had routine bloods & U/N normal, seen surgeon - has sphincter of oddi dysfunction, cholecystectomy, symptoms persists, discharged back to GP 48 year old lady, EUPD, non engagement, long standing back pain, on opoids, Amitriptyline, wants increase in Diazepam dose 22 year old lady, multiple stress, has epilepsy, admitted with episode of shaking, thought seizures, CBZ dose increased, episodes witnessed by nurses appears non epileptic in nature, EEG normal.
Common functional somatic syndromes in medicines Irritable bowel syndrome Functional dyspepsia Atypical chest pain Hyperventilation Irritable bladder Fibromyalgia Repetitive strain injury Chronic back pain Chronic pelvic pain Multiple chemical sensitivity syndrome Atypical facial pain * cultural influence
MUS Hypochondriasis Medical Illness Somatoform Disorders Depression and Anxiety Functional Somatic Syndromes
Somatization disorder >2 year duration Multiple and variable physical symptoms Multiple presentations to doctors Despite investigations patient is not accepting of reassurance (or not sustained) Causes impairment of functioning/distressing Thoughts/feelings/behaviours are disproportionate
Hypochondriacal disorder Persistent preoccupation with the possibility of having one or more serious physical illness There is a named illness Repeated presentations despite investigations and reassurance
Factitious disorder Commonly known as Munchausen s Patient feigns symptoms for no obvious reason Patient may even inflict self-harm in order to produce symptoms or signs Internal motivation with aim of adopting the sick role Malingering Deliberately,Conscious falsifying the symptoms for a secondary gain e.g. benefits, housing
Conversion disorder Show psychological stress in physical ways Weakness or paralysis Abnormal movement, such as tremors or difficulty walking Loss of balance Difficulty swallowing or "a lump in the throat" Seizures or convulsions Episode of unresponsiveness
Impact Very common Significant distress to patients Impact on health service
What causes MUS Predisposing factors Biological mechanisms Perpetuating factors
How commonly does MUS turn out to be organic disease?
How commonly does MUS turn out to be organic disease? Few studies UK study in Primary care 10% of symptoms that have been present for several months. Depression, Anxiety, substance misuse history often missed
What is not helpful Its all in your mind There is nothing wrong with you There is nothing that you can do to help them Prescribe more medications which can be addicting for eg opoids Adding multiple antidepressant medications
What is helpful?
Type of explanation Rejecting The doctor denies the reality of the patients symptoms. The doctor implies that the problem is imaginary or related to a psychological problem, which the patient perceives as stigmatising Colluding The doctor acquiesces to the explanation offered by the patient Empowering The doctor provides a physical mechanism of causation The doctor removes any sense of blame from the patient. The doctor strengthens the relationship with the patient, enabling them to resolve the problem together Source: Salmon et al(1999)
Explanation & reassurance Develop deep listening skills - Use of what does it feel like Make patient feel understood & engaged in treatment Reassure - no serious organic pathology Empathetic acknowledge that pain is real for them Reassure - we might not be able to pin point exact cause but we can help train body to function normally again and help you cope better. Involve carer Use of analogy Use Metaphors hardware software or Piano out of tune
Management Communication between professions Regular scheduled appointments ideally by one doctor Performing brief physical examination at each visit look for signs of disease Avoid unnecessary investigations & Rx it may help to negotiate a final test Stop unnecessary medications Treat associated psychiatric disorders eg antidepressants Offer specific psychological therapy, CBT Graded exercise
Feel exhausted with resources support colleagues in sharing the care plan Balint groups?
How to discuss making a referral to a mental health services?
Prognosis Few studies Overall prognosis for majority of patients good. Majority - remit spontaneously Others find ways to cope 1/3 of patients unexplained symptoms persist after 12 months
The Future Psychiatry referrals unlikely to work Primary care Liaison Psychiatry? Specialist nurses but supported/supervised++ CBT model
Summary MUS are common All symptoms should be treated seriously Explanation, empowerment, is the key Associated organic pathology are rarely missed Psychiatric diagnosis are common & often missed Offer psychotherapy / antidepressants Support to professionals
Useful resources Self help books Rcpsych website Neurosymptoms.org. Non epileptic attack. info Mobile applications HEADSPACE, CALM Online resources ABC of MUS BMA Maudsley prescribing guidelines