Medically Unexplained Symptoms (somatisation)

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