MEDICALLY UNEXPLAINED SYMPTOMS

BYKHALID GAMAL,MD

Psychosomatic medicine

“I have a headache…I must have a brain tumor!”

Psychosomatic medicine  It is an interdisciplinary medical field

exploring the relationships among social, psychological, and behavioral factors on bodily processes and quality of life

Consists of distressing somatic symptoms with abnormal thoughts, feelings and behaviours in response to those symptoms

The myth

A substantial proportion of patients resenting to primary care, or to any individual hospital specialty, will have symptoms for which, after adequate investigation, no cause can be found.

Non-specific symptoms without underlying organic pathology are very common and usually transient.

Where they become prolonged enough to merit medical attention they may present to any specialty, with presentations such as pain, loss/disturbance of function, and altered sensation.

Kroenke et al Am J Med 1989

Symptom ‘meaning’

Doctor VS patient

Patients present to doctors with illness (symptoms and behaviours)

doctors diagnose and treat disease (pathology and other recognized syndromes)

The ‘problem’ of MUS arises, in part, from the different meanings symptoms hold for patient and doctor

If there is no recognized diagnosis available the doctor may respond with ‘there’s nothing wrong’, expecting to be met with pleasure!!!!!

What doctors usually do!

continue to investigate

therapeutic trial

refer to another specialty

Or just dismiss!

Why this mismatch?

Examining the role of doctors

GP somatic interventions related tonegative view of selfpositive view of others

i.e. more likely if GP values patient, values somatic interventions, devalues own psychological skills.

Salmon et al, Gen Hosp Psych 2008

Psychiatric role Ability to assess and treat the frequently

comorbid depressive/anxiety symptoms A tolerance for diagnostic uncertainty Ability to take a long-term view of

improvements.

Misdiagnosis A long-held belief was that, despite

repeated negative findings, all such patients (or a majority) would eventually be found to suffer from an organic disease

This concern was largely based on older, poorly conducted studies with significant methodological flaws.

Iatrogenic harmexcess negative

investigations

Irradiation

operative procedures

Those disorders associated with chronic pain carry the

risk of iatrogenic opiate dependency.

Causative mechanismspatient psychological factors

patient’s health beliefs

affective state

underlying personality

degree of autonomic arousal

increased muscle tension

effects of hyperventilation

effects of disturbed sleep

DIFFERENTIAL DIAGNOSIS

Symptoms directly related to psychiatric disorders, such as depression, anxiety disorders, or psychosis.

Functional somatic illness(atypical chest pain, CFS, IBS, fibromyalgia, hyperventilation syndrome, tension headache).

Conversion and dissociative disorders (functional neurological disorder)

Pain disorders. Somatization disorder (somatic symptom disorder). Factitious disorder. Malingering. Uncommon medical syndromes which have not yet been

diagnosed.

Somatic Symptom Disorder• Combination of somatization, pain disorder and hypochondriasis

• Presence of Symptom, medically explained or not

• Health Concern is a central role in their life.

Illness Anxiety Disorder Formerly Hypochondriasis

Excessive worry or reaction on physical symptoms

Not normal health concerns

Conversion Disorder

Functional neurological symptoms disorder

Freud’s Conversion hysteria

Dramatic loss of function resembling a serious neurological disorder.

Factitious Disorder a form of mental illness where

an individual will deliberately produce, or exaggerate symptoms in order to gain sympathy and attention. 

Divided into:

Imposed on selfImposed on another

(Previously by proxy)

To be continued…