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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…