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Circuit Board Color - 50704

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Transcript of Circuit Board Color - 50704

The
Issue

What are
MUS?

History of
Concepts

Current
Nosology

Prevalence
Common
Impact
Financial
20% of
new GP
consultations
£3bn/year
to NHS
Frequent
attenders
Often
chronic
On the
patient
Disability
Iatrogenic
harm
Case
example
52% in
secondary
care
Distress
Excess
morbidity and
mortality
Broad
definitions
Physical symptoms which cannot be explained by disease specific, observable biomedical pathology
Persistent bodily complaints for which adequate examination does not reveal sufficient explanatory structural or other specific pathology
Physical symptoms that mask emotional
distress
General
Approach &
Management

'Functional overlay'
'Behavioural'
'Non-organic'
Physical symptoms
Recurrent & persistent
No causative pathology found
Differentials
1. A component of a physical illness
2. An uncommon or not yet diagnosed
medical syndrome
3. A functional somatic syndrome
4. Symptoms related to another
psychiatric disorder (e.g. depression)
5. A core component of a psychiatric
disorder
6. Feigned symptoms for
external gain
MUS: the possibilities....
Context
Nonspecific, unexplained symptoms are frequent
Sometimes a modest intervention or pharmacological prescription is offered
A small portion are persistent and disabling
portion of these are seen by psychiatrists and psychologists
Most are transient
he physician's interest, thorough history, physical examination and reassurance is usually enough
T
A
S
ome are disabling & associated with frequent consultation
On the
doctor
Can test the credibility of both the doctor and the patient
Concepts
ymptoms vs signs
S
I
llness vs disease vs sickness
A subjective experience or change in function, regarded as indicating disease
M
edical model
History, examination, investigations, interpretation and...
DIAGNOSIS
Sets problem under jurisdiction of medicine
Affirmation & sense of order
Legitamises & normalises
Provides prognosis & trajectory
Access to the sick role - rights & obligations
A diagnosis has power...
C
an stigmatise
A
ffects outcomes
Illness
behaviour
Ways in which people
Monitor their bodies and respond to bodily indications
Interpret, appraise and define their symptoms
Express distress
Behave to relieve or clarify the experience; help seeking
E.g. medicalising, self help, denial
Depends on many factors;
Meaning of symptoms
Psychological, social and cultural factors
E.g. women and higher social classes quicker to seek help
Will impact on extent to which symptoms interfere with life & the patient's cooperation with treatment
PNES
Tension headache
Functional weakness
TMJ dysfunction
Atypical facial pain
IBS
Functional dyspepsia
Chronic pelvic pain
Chronic fatigue syndrome
Globus syndrome
Hyperventilation syndrome
Chronic cough
Non-cardiac chest pain
Unexplained abdominal pain
Fibromyalgia
Substantial overlap
Strong emotional attachments to the label
Links to depression & anxiety
Multiple chemical sensitivity
1. A component of a physical illness
2. An uncommon or not yet diagnosed
medical syndrome
3. A functional somatic syndrome
4. Symptoms related to another
psychiatric disorder (e.g. depression)
5. A core component of a psychiatric
disorder
6. Feigned symptoms for
external gain
MUS: the possibilities....
Chapter V: Mental and behavioural disorders
1. Organic (e.g. dementia)
2. Substance use
3. Schizophrenia & psychotic
4. Mood related
5. Neurotic, stress-related & somatoform disorders
6. Behavioural sydromes associated with physiological & physical factors
7. Personality disorders
8. LD
9. Developmental disorders
10. Childhood disorders (ADHD, conduct, etc)
Chapter XXI: Factors influencing health status and contact with health services
Z76.5 - Malingerer
1. Phobic anxiety disorders
2. Other anxiety disorders (panic, generalised anxiety)
3. Obsessive-compulsive disorder
4. Reaction to severe stress & adjustment disorders
5. Dissociative (conversion) disorders
6. Somatoform disorders
7. Other neurotic disorders (including neurasthenia)
Hypo-
chondriasis
Dissociative
(conversion)
disorders
Somatoform
disorders
Factitious
disorders
Malingering
Other disorders of adult personality and behaviour
1. Dissociative amnesia
2. Dissociative fugue
3. Dissociative stupor
4. Trance and possession disorders
5. Dissociative motor disorders
6. Dissociative convulsions
7. Dissociative anaesthesia and sensory loss
8. Mixed & other dissociative disorders (includes multiple personality disorder or DID)
Dissociation?
Loss of normal integration between past memories, awareness of identity and immediate sensations, and control of bodily movements
Ability to exercise a conscious and selective control is impaired
Presumed to be psychogenic in origin & closely associated with traumatic events or insoluble problems
Concepts derived from any one particular theory are not included among the criteria for diagnosis
The term "conversion" implies that the unpleasant affect is somehow transformed into the symptoms
Inidivuals may show a striking denial of problems that may be obvious to others, or lack of concern for the deficit
Symptoms tend to involve an aspect of the CNS over which voluntary control is exercised
Conversion - motor or sensory deficit
Dissociation - disturbance in consciousness
1. Somatization disorder
2. Hypochondriacal disorder
3. Somatoform autonomic dysfunction, somatoform
pain disoder, other
Somatization?
Repeated presentation of physical symptoms & persistent requests for medical interventions, in spite of repeated negative findings & reassurances by doctors
Presenting symptoms frequently change (esp when investigations exhausted); often chronic with complicated history of contact
Description of symptoms can be atypical, vague & inconsistent
The patient usually resists the idea of psychological causation
Histrionic behaviour; lack of concern for symptoms
The degree of understanding that can be achieved about the cause of symptoms is often disappointing for both patient and doctor
Illness behaviour: a life centered around the illness; preoccupation with the symptoms, high levels of anxiety re the symptoms
Some evidence for genetic transmission
Predisposing factors including physical or sexual abuse
Parental complaints of poor physical health during childhood
Various psychological and biological theories which suggest an expression of distress in physical terms - misinterpretation of sensations and reduced inhibition of sensory stimuli
Marked depression & anxiety often present
Over time there may be iatrogenic complications
Hypochondriasis?
Preoccupation with the possibility of having or developing a serious physical disorder; despite advice & repeated examinations and investigations being negative
Over-valued idea
Emphasis on presence of disorder rather than symptoms
Manifests with somatic complaints, a preoccuopation with appearance, frequent self-checking
Includes body dysmorphic disorder
Related to the neurotic personality disorders; high levels of introspection, distress, dissatisfaction; some regard as trait
Related to childhood adversity, illness in childhood, parental attitudes towards illness, over-dependence in childhood, craving of attention and protection
Somatosensory amplification & autonomic hyperactivity
Common in cultures where stigma attached to mental illness is strong
Psychiatric referral is often resented & label may be viewed as perjorative
Marked depression & anxiety often present; masked "depression"
1. Elaboration of physical symptoms for psychological reasons
2. Factitious disorder
3. Other
Factitious disorder?
Intentional production or feigning of symptoms or disabilities
Either physical or psychological
Can extend to self-inflicted injuries e.g. self injection
Motivation tends to be obscure though is presumably internal
A disorder of illness behavior and the sick role
Includes Munchausen's syndrome
Malingering?
"Conscious simulation"
Intentional production, feigning or exacerbation of symptoms or disabilities
Either physical or psychological
For secondary gain - e.g. financial, occupational, pharmaceutical, military or criminal
Inherent
Problems
Aetiology still poorly understood
Lack of clear operational definitions; imprecise diagnoses
Significant overlap and co-morbidity
Western dualist view of mind-body may be unhelpful
Difficult diagnoses to make; danger of being a "catch all" or "wastebasket" diagnosis
Difficult to establish a positive diagnosis due to the absence of definitive tests
Level of stigma; tests the Dr-patient relationship
Concepts
"MUS" wrongly implies no medical aetiology
Defines an illness by what it is not
May not be acceptable to patients
IAPT recommends giving a specific diagnosis of a syndrome (e.g. CFS, IBS, fibromyalgia, etc), or using the term "functional symptoms"
A relatively benign though loaded diagnosis

Terminology - "MUS"
Limitations of knowledge
MUS may represent an as yet undiscovered physical pathology
Diabetes, Lyme disease, MS & others would previously have fallen under this heading
Current limits of knowledge and available technology
Making the
Diagnosis
Making a formulation
Predisposing, precipitating and perpetuating factors
Biological, affective, behavioural, cognitive & social elements
Symptoms, disability & distress
Give an explanation & answer questions
Agree a treatment plan
General approach
Ensure adequate & appropriate level of investgation to exclude organic disease
Joint diagnosis and management plan between medical, psychiatric & GP; coordinated care
Liaison psychiatry can assist
Recognise symptoms as real
Discuss test results
Positive & confident diagnosis
General
Management
Treatment
Options
Anxiety management
Diary monitoring
Graded return to activities
Physical therapy
Self help programmes
Involvement of relatives
Psychotropic medication
CBT
Psychotherapy
Midfulness-based therapy
Group or family therapy
More specific psychiatric treatment
Reattribution model
Can be used by GPs or other non-mental health practitioners
3 stage model
Full history, health beliefs, social & family factors, feeling understood
Discuss results, acknowledge reality of symptoms, link physical with psychological & life
Explain & demonstrate how stress & anxiety can cause or worsen symptoms; ask about feelings
Trusting relationship with a primary responsible clinician; usually GP
Minimise contact with other practitioners
A balance; continue to be mindful of physical health co-morbidity, but avoid un-necessary investigations & iatrogenic harm
Prevent secondary complications
Treat any psychiatric co-morbidities
Understand worsening as an emotional communication
Focus on signs of disease rather than symptoms
Proactive rather than reactive management
Focus might be on managing to deal with symptoms rather than improving them
Diagnosis may need to be revised
Focus on signs of disease rather than symptoms
Primary care
Secondary care
Arnold, 26 year old male
2 previous contacts with psych
Age 16 (bullying, mild mixed symptoms) when referred to CMHT
Age 19 (anger, turbulent relationship, cannabis); CMHT & SW
PMH: migrane, admission with GI sx & constipation for 1 day, diagnosis of paralytic ileus & intestinal obstruction, strain of foot
Admitted WD12
Collapse; felt to be panic attack; some ongoing symptoms (dysphasia, blurred vision, headache)
Significant social stressors including recent sexual assault of daughter
Examination
Possible mild left-sided weakness - evolving; no organic cause
Positive Hoover's sign
Obs & bloods unremarkable; ECG, CXR, CT & MRI unremarkable
At liaison assessment
Power 3/5 on left side
Did not want family to know was seeing psych
Doesn't tend to talk to family & can't speak to fiancee due to her MH history
Baffled by symptoms, never before, surmised panic attack, worried re stroke
Nil on MSE
Keen for home
High EE when discussing daughter
Medically Unexplained Symptoms;
Dr Dan Hackley, Consultant in Liaison Psychiatry
Explaining the unexplained ?
£ COSTLY £
Treatment
costs
Length
of stay
Investigations
Poor
engagement
Delays in
diagnosis
High co-
morbidity
Frequent
re-
attendances
Time consuming
Uncertainty
Frustration
Full transcript