31. medically unexplained symptoms

8/12/2019 31. Medically Unexplained Symptoms

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154 Medically Unexpla ined Symp tom smedical problems that require treatment. Th is scenario can be especially dem anding w hen som atiza-tion occurs in the context of chr onic medical illness. Thus the clinician must m aintain a balance:helping the patient with underlying psychiatric p roblems w hile remaining attuned to unfolding med-ical conditions. Careful psychiatric assessment helps to identify classic patterns of psychopathology,which may gu ide the evaluator to consider the possibility of u nrecognized m edical conditions.3 What are the common characteristics of somatoform disorders?Som atoform disorders present with physical sym ptoms that are not fully explained by clearmedical disorder, the effects of substance abuse, or other psychiatric synd romes. The phy sical symp-toms are ot intentional and not under voluntary co ntrol. There are five general categories:

Somatoform DisordersCATEGORY KEY CHARAC TERISTICS

Conversion disorde1

Hypochondriasis

Som atization disorder Multiple symptoms-pain, gastro intestinal,sexual dysfunctionSymptom s vary over timeChronic condition-often with extensive treatment historyNot intentionalSymptom s affect voluntary motor or sensory systemSymptom s do not conform to neuroanatomic structuresMay reflect, symbolically, past or current s tressorPatient may not be upset by the symptomsNot intentionalChronic preoccupation with having a serious diseasePatient misattributes symptom or test resultsPreoccupation not solely due to affective statusPreoccupation with an im agined defect in physical appearanceMay exaggerate mild anomalyPain is the central featureMay begin after specific injuryCan lead to serious functional impairment and medication overuse

Body dysmorphic disorderChronic pain syndrome

4 Describe somatization disorder.Previously somatization disorder was referred to as hysteria or Briquets syndrome. It is achronic fluctuating condition that usually begins after the age of 30 and extends over many years.Th e patient presents with mu ltiple sympto ms, including pain, gastrointestiiial symptomatology, neu-rologic symptoms, and sexual dysfunction, which may vary considerably over time. He or she mayhave a long history of past extensive treatment, including surgery. Typically, the patient seeks outmultiple providers because of dissatisfaction with prior treatment, and m ay end up on com plex com-binations of medications because of frustration on the part of both patient and physician. Significantimpairments in work and social functioning are com mo n.As described in the Diagnostic and Statistical Manual-N patients should have a history of pain inat least four different sites: two d ifferent gastrointestinal symptoms other than pain, a t least one sexu alsymptom, and o ne neurologic symptom. Sym ptoms vary in type and frequency across cultures andcountries, and between genders. In North Am erica, somatization disorder is more commonly found inwom en; up to 2 of women and less than 0.2 of men have a lifetime prevalence of this disorder.

5. What is revealed in the work-up of a patient with somatization disorder?The work-up of the patient with somatization disorder usually reveals a positive history of multi-ple medical and surgical treatments, current symp toms without abnormal laboratory test results, and aphysical exam that fails to identify objective findings that explain subjective complaints. As withother patients with unexplained medical sym ptoms, past treatment may give rise to new sym ptoms, aswell as clear physical findings. For example, the p atient m ay have had an exploratory laparotomy, andas a result he or she now is experiencing persistent sym ptomatic cramping pain due to adhesions.


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Medically Unexplained Symptoms 1556. Describe conversion disorder.Conversion disorder presents w ith deficits of the voluntary motor or sensory neurologic system,and often m imics recognized neurologic or o ther medical conditions. As with somatization disorder,the sym ptom s are not intentionally produced; rather, underlying psychological factors are expressed

in physical symptoms. Co mm on presentations include loss of sensation in a single limb or part of alimb, double vision, blindness, deafness, difficulty with swallowing, and paralysis.On careful exam, the symp toms typically d o not conform to recognized anatomic pathways. Forexample, a classic sensory loss due to conversion disorder may conform to a glove or stocking distri-bution. Recognize, however, that unusual distributions of sensory and m otor loss can occur in som eneurologic disorders, such as multiple sclerosis.7. How are underlying psychological factors expressed physically in conversion disorders?Historically, conversion reactions have been thoug ht to sym bolize unresolved c onflict. For ex-ample, the patient who feels guilt-ridden b ecause he o r she stole something loses all ability to movethe hand that grabbed th e object. Such conversion sym ptoms m ay occur in patients w ith a history of

physical and emotional abuse o r borderline personality disorder.Conversions disorders are likely to be associated closely in time with an acute stressor.However, the stressor itself may b e mild and important only as a symbolic representation of pastpsychological trauma o r conflict. For examp le, a patient who suffered oral rape may develop troublewith swallowing (som etimes called globus hystericus) o n viewing a movie that depicts sexual vio-lence. Most patients (but not all) do not concurrently remem ber the earlier event; gagg ing is feltwithout an accompanying m emory of trauma or conflict.8 Are these patients seeking pity and sympathy?Wh ile reinforcing social responses m ay occur, the conversion disorder is thought to derive pri-

marily fro m inner psychic gain. In the previous exam ple (Question 7), the muffled ability to speakmay represent the individuals earlier sense of suffocation and gagging as an abused child. Th e innerconflict also m ay have been caused by the au thority figures threat to kill the patient if he or she toldanyone and/or by the patients inner sham e or guilt.Because the early event commonly is forgotten or poorly remem bered and only the symbolic phys-ical symptom is experienced, the patient with a conversion disorder may present with m inimal upset.This reaction ha s been termed la belle ind ifference. In other instances, the patient may be confusedand even terrified by the new symptom, even while having no anx iety about the actual trauma.9. Describe hypochondriasis.Hypochondriasis refers to a chronic preoccupationwith and fear of having a serious disease. Ittypically is based on the individuals continual m isperception of bodily sym ptoms and/or test results,and may occur in the context of a well-recognized and diagnosed illness, such as diabetes, or in theabsence of known illness. The preoccupation persists despite all reasonable medical testing and reas-surance; it may cover a wide range of body functions and systems o ver time as various evaluationsdem onstrate healthy functioning. Although the preoccupation cannot be attributed solely to the pres-ence of com orbid anxiety, depression, obsessive-compulsive disorder, or psychotic disorder, it maybe associated with these conditions.Hypochondriasis may occur at any age. The course is usually chronic, with waxing a nd w aningsymptoms and presentations. It seems to be equally comm on in men and women and may be madeworse by the diagnosis of new m edical problems.

10. What should the physician guard against in treatinga hypochondriac?Hypochondriacs frequently doctor shop when dissatisfied by the responsivity of their currentphysician. Doctor shopping m ay occur in response to failure to diagnose a condition, but morecommonly occurs when a physician unwittingly becomes irritated by the patients persistent com-plaints. Su ch irritation may manifest as avoidance behavior-failure to return phone calls, abrupt re-ferral to a psychiatrist without careful preparation, or unwillingness to reassure the patient for theumpteenth time that the dark urine does not represent kidney failure.


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156 Medically Unexplained S y m p t o m s11. What is the treatment for hypochondriasis?Treatment of the hypo chondriac should include careful assessment and reassessment fo r comor-bid psychiatric disorders. Particularly important is aggressive treatment of symptomatic anxiety, de-pression, and frank delusions, which may w orsen hypoch ondriacal complaints and/or occur inresponse to the chronic fear of disease. Although h ypochondriasis and chronic som atization disordershould be considered as separate entities and are differentiated by the hypochondriacs intense pre-occupation, in practice they exist on a continuum .12 How does hypochondriasis differ from body dysmorphic disorder?Question 13).13. Describe body dysmorphic disorder.Body dysmorphic disorde r refers to preoccupation w ith an imagined defect in physical appear-ance. The sense of defect may occur in response to a mild phys ical anomaly or with no identifiable traceof abnormality. A comm on ex ample is the person obsessed with the ugliness of his or her nose becauseof a small bump. Distress frequently leads to a search for cures through techniques such as plasticsurgery or dental treatment. The patient frequently is tormented with feelings of inadequacy and maygo to extreme lengths to resolve them; make-up, exercise, and diet may be part of important rituals.Clearly, the intense focus of western culture o n physical beauty provides a setting for a contin-uum of concern about bodily perfection. Body dysmorphic disorder represents an extreme of thiscontinuum . In anorexia nervosa the fo cus is on be ing too f at; thus, the patient uses diet-relatedmethods rather than surgery to cure the problem.14. Describe pain disorders.

Pain disorders are characterized by a specific, predominant foc us on pain as the presentingsym ptom . The pain usually do es not follow established anatom ic patterns. However, it may be im-possible to differentiate from established medical cond itions such as lumb ar disc disease. Althoughwork-ups typically are negative, prior invasive treatment may lead to physical findings that com-pletely m uddy the diagnosis (see Question 5). Indeed, pain disorders m ay develop after prior injuryor treatment, which provides so m e pathophysiologic explanation for the symptom s.Pain disorders may occur throughout the lifespan and are more com mon in women than men.Th e course may be persistent a nd lead to severe function al impairment and extensive use of painmedication.15. How are pain disorders assessed and treated?

Pay careful attention to the presence of com orbid depression, which may present with painsymptoms. Psychotic and anxiety disorders also may feature pain, as one of an array of sym ptoms.The managem ent of chro nic pain syndromes is described at length in Chapter 69. Rehabilitationprograms combining behavioral an d physical therapies may b e helpful in so me patients. Externalgains (e.g., social, financial) may affect the success of treatment, but as with somatization disorder,the primary cause is inner psychic gain.16 Describe malingering.The essential feature of malingering is an intentional causing or faking of physical or psycholog-ical symptoms m otivated by external incentives. Such incentives may b e m onetary or related to avoid-ance of work , prosecution , or military service; they also may involve the goal of obtaining drugs.Several factors are suggestive of underlying malingering. M ost commonly, the symp tom is com-plex a d o r vague, and the patient is involved in a law suit because of an injury or accident. The dis-crepancy between the sym ptom atic presentation and the apparent physical findings may be marked.Lack of cooperation in the evaluation process and poor com pliance with recommended treatment arealso comm on. Finally, the presence of an antisocial personality disorder may suggest malingering ina patient presenting w ith unexplained sy mpto ms associated with possible external rewards or moti-vations. Thu s malingering, unlike som atoform disorders, is motivated primarily by external gain.

Hypochondriasis doe s not focu s on a specific, circum scribe d conc ern about appearance (see


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Medically Unexplained Symptoms 15717 Describe factitious disorder.In factitious disorder, external factors may be present, but they play a minor role in providing sup-port or reinforcem ent for symp toms. The motivation for a factitious disorder appears to derive from as-suming the role of a sick person . Factitious disorders may involve fabrication of subjective complaints,such as headache; self-inflicted injury; and/or exaggeration of pre-ex isting med ical conditions.Patients with factitious diso rder usually engage in som e form of lying. They may present withvague, inco nsistent histories, often with a dramatic flair. Patients often have prior experience w ithmedical routines and are know ledgeable about medical terminology. They eagerly await work-up re-sults, and their com plaints may change with normal or negative findings. They even ask for m ultipleinvasive procedures. Patients usually deny any suggestion that sym ptoms are self-induced or exag-gerated and upon confrontation usually discharge themselves, only to appear in another emergencydepartment or clinic.The onset of factitious disorder is usually in adolescence or early adulthood. Although it may in-volve only a few episodes, chronic patterns often develop; in som e instances, the patient travels tomultiple cities-even countries-seeking hospitalization.18. What is Miiuchausens syndrome?An extreme form of chronic, recurrent factitious disorder that typically involves wandering fromplace to place and taking o n a lifestyle that centers on repeated evaluation, treatment, an d hospital-ization. The extensive wandering and search for different treatments m ay result from confrontationsby angry hospital staff. However, it is not entirely clear whether the wandering and the accompany-ing disorder can be prevented by alternative treatment approaches.Severe factitious disorders also have been described in children. The parent reports symp toms inthe child in the manner described in adults. Termed Miinchausens by proxy (see Chapter 81 , thissyndrome should be considered as a possible instance of child abuse and reported to appropriate au-thorities under the guidance of state and local laws.19. How are malingering and factitious disorder distinguished from somatoform disorders?

Malingering Factitious DisorderMotivated by external gain (e.g,. winningSymptom s intentionally caused or feignedPoor cooperation in evaluation andMay be accompanied by antisocial

Motivated by assumption of the sick roleSymptom s fabricated a n d o r injuryHistory vague and confusingPatients may g o from hospital to hospital

a lawsuit) self-inflictedtreatment Often chronicpersonality disorder seeking careSomatoform DisordersMotivated by inner, psychic gainUnintentional, involuntaryMay be result of past or current, traumaticstressor

20. Describe a general approach to the patient with unexplained medical symptoms.The management of unexplained medical sym ptoms is a series of recurring steps.In the acute presentation careful assessment of the medical symptoms, physical findings,

and associated psychological responses m ay be followed by thoughtful, nonjudgmental reassurancewhen the sy mptom s are relatively m ild, circumscribed, and of recent origin. The psychoeducationalapproach (info rmation, reassurance, and explanation of pro bable cau se) is often sufficient, and thesymp toms remit. For exam ple, a child may present with headaches before school is to begin.Explo ration of the stress may help the parents and child to find methods of reassurance that alleviatethe source of the anxiety-based symptoms.Such an approach can be used in combina tion with more in-depth medical assessment. For ex-ample, a patient hospitalized for treatment of a compound fracture of the left leg spontaneously de-


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I 8 Medically Unexplained Symptomsveloped paresis in the good leg. The paresis appeared to have no anatomic basis. Assessment by aconsulting neurologist confirmed the initial evaluation by the primary physician. The consultantssuggestion that the sym ptoms would im prove gradually over time w as sufficient; over the followingseveral days of recuperation the symp toms completely remitted.

When symptoms are persistent and/or severe further steps are warranted, including moremedical evaluation and detailed psychosocial assessment to identify psychological factors and socialtriggers. Th e laboratory and physical findings should be presented unambiguously and in a nonjudg-mental manner. The trea tme nt plan m ay requ ire negotiation with the patien t to set limits on thenature of investigations, specialty referrals, and unwarranted treatment.Avoid sim plistic dual m odels in w hich the diagnosis is either physical or mental. Present, as part ofthe medical evaluation, a psychological explanatory model of the s ymp tom process using w ords thatare both understandable and safe. The model can indicate that the symptoms m ay be stress-related.21. Wont the patient balk at any suggestion that symptoms are stress-related?Sometimes; but the approach recommended can improve patient acceptance. As one part of thisapproach, underline that stress-related symptoms are jus t as real as symptoms produced by a clearmedical illness. For exam ple, the patient fearing cancer needs to understand that the presenting symp-tom, if it is said to be stress-related, is just as imp ortan t to you a5 if it were caused by cancer.Furthermore, emphasize that the suggested treatments for som atoform d isorders are jus t as real astreatments fo r feared medical con ditions, though they differ.Careful assessment also shou ld include evaluation for comorb id psychiatric con ditions such asdepression, anxiety, personality disorders, and p sychosis. It is helpful to have a single medical doctoror team approach in treating the chro nic somatisizing patient. The team m ay include a physician anda mental health professional w ho work eithe r in the sam e institution or in close collaboration. Beopen and honest at all steps of the treatment. Sneaking in a psychiatric referral leads only togreater mistrust and resistance to treatment recom mendations.22. How can the physician facilitate the process?Consistency and flexibility are both important. Avoid unnecessary, new medical assessments.Offer a clear, sensible, and consistent pronouncement of your findings and recommendations.Patients often need to hear repeatedly w hat the doctor thinks, why h e or she thinks it, and why a spe-cific treatment is or is not recomm ended.At times of increased anxiety, flexibility may be requ ired. For example, the patient who is chron-ically w om ed about renal failure may require periodic (and superficially unnecessary) simple kidneyfunction tests to demonstrate kidney health. Letting the patients concerns help to dictate evaluationand treatment decisions provides a sense of control. Continual renego tiation with the patient is essen-tial. Flexibility also is warranted because in the course of chronic som atisizing problem s other psychi-atric disorders commonly develop (e.g., the hypochondriac may require antidepressant treatment).Likew ise, inflexibility may lead to missing the diagnosis of newly em erging medical illness.Finally, by maintaining a consistent, stable, nonjudgmental attitude the physician helps patientsto feel understood, encourag ing continuation of treatment and avoiding doctor shop ping.23. Are specific treatment approaches applied differentially to the different forms of somato-form disorders?There a re more sim ilarities than differences in treating patients with medically unexplained symp-toms. As noted, the severity and chronicity of the complaint are important determinants of the initialapproach . Add itionally, certain therapeu tic variations derive from the type of somatoform disorder.Patients with body dysmorphic disordermay benefit from a supportive therapeutic approachthat helps the patient to understand possible sources of the distorted beliefs. Cognitive-behavioraltherapy m ay be useful (see Chapte r 41). Beliefs abou t body sh ape and deformity are so powerful,however, that short-term cogn itive approaches are unlikely to lead to radical improvem ent. Thu s,they should be considered in the context of chronic management that helps the patient to avoid re-cuiTent, invasive treatment. T he d istorted perceptions can be so severe as to becom e delusional; suchpatients may respond to low doses of antipsychotic medication.


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Medically Unexplained Sym pt om s I59A focused approach is less likely to be effective in somatization disorder and hypochondri-

asis because of the broad range of symptoms and complaints. In all instances the therapy for chronicconditions needs to be considered as long-term and supportive. Recognition of serious underlyingpsychological problems may no t only guide therapy but also serve to allay the doctors s ense ofbeing used and abused by the patient, thereby helping to maintain a positive therapeutic alliance.Especially in patients with conversion disorder hypnotherapy and/or other methods for exploringsources of particular stress may bring ou t unresolved conflicts and concerns that were not previouslyidentified. Uncovering such issues can be useful in treating conversion symptoms.24 What is especially important to remember in caring for patients with medically unex-plained symptoms?The therapist and physician must recognize that these patients often p roduce intense em otionalreactions in the caretaker. They m ay arouse ang er by repeated com plaints and disturbances as wellas cause emb arrassment with multiple v isits to the em ergency departmen t, seeming to representtreatment failures in the eyes of the clinician and possibly his or her colleagues. Furthermore,chronic demands for pain m edications and letters to housing boards and emp loyers may lead theclinician to feel used by the patient. Remember that while external gain may be a secondary motiva-tion for som e symptoms in som e patients, it is usually not the primary causal factor.25. How do approaches to treatment differ for patients with factitious disorder or malingering?In many ways the ap proaches to treatment are similar. Th e critical differential with the m alin-gering patient is recognizing tha t the patient alway s has another, external goal; consistency and clar-ity are required so that the patient understands what the physician is recommending. Many suchpatients leave treatment because they d o not obtain an external reward. The patient with factitiousillness also may leave treatment if the drive for the sick role comes in conflict with the physiciansunwillingness to perform more invasive tests.26. How are medical symptoms associated with other psychiatric conditions differentiatedfrom those associated with somatoform and factitious disorders and malingering?Three psychiatric syn drom es most comm only present w ith subtle and sometimes vague physicalsymptoms: depression, anxiety, and psychosis. Diagnosis depends on a careful history that exploresfor the symptom s of each psychiatric disorder. When the patient presents with sym ptom s suggestiveof either anxiety or depression, such as headaches or other bodily pains, a trial of appropriate med-ication may be usefu l. Such therapeutic trials are also valuable because anxiety and depressive disor-ders may well coexist with som atoform conditions. Treatment of the comorbid psychiatric conditionmay lead to considerab le improvement in the som atoform disorder. In addition, sym ptom atic treat-ment of depression, anxiety, and psychosis often is more effective than treatment of chronic somati-sizing conditions.

BIBLIOGRAPHY1 Bass C, Benjamin S: The managem ent of chronic som atisation. Br J Psychiatry 162:472480, 1993.2. Reference deleted.3. Kellner R: Psychosom atic syndromes, somatization and somatoform disorders. Psychother Psychosom61:4-24, 1994.4 Kellner R: Somatization: Theories and research. J Nerv Mental Dis 178:15&160, 1990.5. Lipowski ZJ: Somatization: The concept and its clinical application. Am Psychiatry 145:1358-1368, 19886. Margo KL, Margo GM : The problem of somatization in family practice. Am Fam Physician 1873-1 879,7. Mayou R: Som atization. Psycho ther Psychosom 59:69-83, 1993.8. Som atoform disorders. Diagnostic and Statistical Manual-IV. Wash ington, DC , Am erican Psych iatric9. Wise MG, Ford CV: Factitious disorders. Prim Care 26:315-326, 1999.

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Association, 1994.

31. medically unexplained symptoms

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