CME: CLINICAL PRACTICE AND ITS BASIS

difficult to help them 2. They often attend several different specialist services and are subjected to extensive but unproduc- Psychiatry tive investigation and treatment 3.

Edited by Professor Simon Wessley MRCP, MRCPsych Professor of Symptoms Epidemiological and Liaison Psychiatry and Dr Khalida Ismail MRCP, MRCPsych Clinical Lecturer in Liaison Common MUS include 4: Psychiatry • pain (including back, chest and abdominal pain, and headache) Department of Psychological Medicine, fatigue Guy’s, King’s & St Thomas’ School of Medicine, London • • dizziness • funny turns, and • feelings of weakness. Medically Definition and terminology Syndromes Medically unexplained (somatic) symp- unexplained toms (MUS) refer to symptoms that are Rather confusingly there are parallel disproportionate to identifiable physical medical and psychiatric classificatio n symptoms and disease. The various terms that have been schemes for syndromes of MUS. used to describe this category of clinical syndromes problem are listed in Table 1. Functional syndromes. The medical clas- sification emphasises the type of The significance of medically symptom and lists ‘functional syn- Michael Sharpe MD MRCP MRCPsych , Reader unexplained symptoms and dromes’ by specialty or organ system in Psychological Medicine, University of syndromes (Table2). These functional syndromes Edinburgh Department of Psychiatry, Royal overlap in their symptoms, aetiology and Edinburgh Hospital MUS constitute a major part of the work treatment5. of most doctors, particularly in primary Clin Med JRCPL 2002;2:501–4 care, and account for a third of new hos- Psychiatric syndromes. The psychiatric pital outpatient referrals 1. Patients with classification emphasises the number of MUS may suffer severe disability and dis- symptoms and associated psychological tress and their doctors generally find it factors. The main categories are listed in Table3 and discussed further below. Table 1. Terminology.

Medically unexplained The implication of these parallel classifi- Simple operational term, but with the potential disadvantage of suggesting that cations is that most patients will qualify psychological and psychophysiological explanations are not ‘medical’ for both a medical and a psychiatric diagnosis. A combined medical/ psychi- Functional atric diagnosis such as ‘irritable bowel Originally meaning a disturbance of bodily function rather than structure. Unfortunately, now often used pejoratively to mean ‘all in the mind’ syndrome/anxiety disorder’ is probably more useful than either alone. Somatisation Widely used term implying a psychological problem expressed somatically. Best restricted to cases where the somatic symptoms are an expression of identifiable Aetiology emotional disorder The precise aetiology of many MUS is Conversion unknown. Biological, psychological and Used specifically to refer to loss of function such as weakness of a limb. Like 6 somatisation, implies (usually without good evidence) that the symptoms are due to a social factors all play a role . There is ‘conversion’ of psychological problems recent evidence for physiological abnor- malities in the nervous and endocrine Somatoform systems7. The degree to which each of Diagnostic category in the psychiatric classifications of DSM and ICD. Intended to be purely descriptive, but obviously linked to the idea of somatisation these factors contributes probably varies from case to case. T able 4 provides a DSM = Diagnostic and Statistical Manual (of Mental Disorders), ICD = International Classification of summary of possible aetiological factors. Diseases. Perpetuating factors are especially

Clinical Medicine Vol 2No 6November/December 2002 501 CME Psychiatry

Table 2. Functional somatic syndrome by specialty. depression or anxiety. They may be clas- sified by the predominant symptom. Specialty Functional somatic syndrome Pain is dignified by its own category of Gastroenterology Irritable bowel syndrome ‘somatoform pain disorder’ , but other Non-ulcer dyspepsia symptoms are put together as ‘undiffer- Gynaecology Premenstrual syndrome entiated somatoform disorder’ . It is Chronic pelvic pain unclear whether calling these symptoms Rheumatology Fibromyalgia ‘somatoform’ adds anything to a simple Cardiology Atypical or non-cardiac chest pain description. Respiratory medicine Hyperventilation syndrome Infectious diseases (Chronic postviral) fatigue syndrome Somatisation disorder (Briquet’s syn- Neurology Tension headache drome): chronic multiple complaints. A Non-epileptic attacks relatively rare condition is somatisation Dentistry Temporomandibular joint dysfunction disorder (or Briquet’ s syndrome). This Atypical facial pain term is used to describe patients, mostly Ear, nose, and throat Globus syndrome women, who have a lifelong history Allergy Multiple chemical sensitivity of multiple recurrent somatic com- plaints which usually include ‘ conver- sion’ symptoms. important as targets for treatment. For Somatic presentation of anxiety. Another Conversion disorder. This disorder pre- example, a person may be predisposed common cause is anxiety, both in a gen- sents as loss of function of a body part, by virtue of genetics or childhood eralised form (generalised anxiety dis- usually a limb, or abnormal body move- experience8 to develop irritable bowel order) and in an episodic severe form ments. It is not thought to be produced syndrome. It may have been precipitated (panic disorder) (Table5). intentionally (as with factitious disorder by infection and psychological stress, and and malingering) but rather ‘ subcon- then perpetuated by neurophysiological Predominant worry about disease: health sciously’. In reality, the distinction is mechanisms, fear of gastrointestinal anxiety or hypochondriasis. Patients with difficult. disease, social stress, chronic anxiety and severe worry about disease may present iatrogenic factors (egoverinvestigation) 9. with MUS. These fears may persist despite Factitious disorder. Patients with facti- repeated medical reassurance and lead to tious disorder deliberately feign or simu- repeated requests for investigation. late illness to obtain medical care. The Differential diagnosis term factitious disorder is preferable to Disease Simple somatoform disorder. This cate- the eponym Münchausen’ s syndrome. gory is descriptive for a single or small The main medical differential diagnosis number of somatic complaints that are Malingering. Malingering is not a med- is from symptoms due to disease. unexplained by disease and do not ical diagnosis but the deliberate simula- Difficulties are likely to involve rare appear to be simply expressions of tion or exaggerati on of physical or diseases and unusual presentations of common diseases. The emergence of a ‘missed’ disease is the exception rather Table 3. The main psychiatric categories of medically unexplained symptoms . than the rule after careful assessment of a Medically unexplained symptom Psychiatric category patient. Predominant worry Hypochondriasis about disease Psychiatric syndromes Predominant concern Somatisation about symptoms It is worth seeking evidence of specific somatic presentation of depression • and anxiety psychiatric MUS syndromes as they have a small number of symptoms: simple implications for management. • somatoform disorders • chronic multiple symptoms: somatisation Somatic presentation of depression. One of disorder (Briquet’s syndrome) the commonest causes of MUS is undiag- Loss of function Conversion disorder nosed depression. Because depression is Dislike of body parts Body dysmorphic disorder (erroneously) thought of as a purely Deliberate deception Factitious disorder (including Münchausen’s ‘mental’ illness, the somatic symptoms syndrome) and malingering are forgotten (Table 5).

502 Clinical Medicine Vol 2No 6November/December 2002 CME Psychiatry

Table 4. Aetiology of medically unexplained symptoms . Table 6. General management of medically unexplained symptoms. Predisposing PrecipitatingPerpetuating Initial managemen t Biological Genetic Acute illness/Neurophysiological and other Exclude disease, but avoid injury mechanisms unnecessary investigation or referral Psychological Childhood abuse Stresses Concern and beliefs about Demonstrate to the patient that you symptoms believe his or her complaints Anxiety or depression Abnormal illness behaviour Give reassurance about absence of disease Social Childhood illness Life events Iatrogenesis and lack of ‘models’ effective treatment Give a positive explanation including, Financial and other gain from but not overemphasising, being ill psychological factors Behaviour of family and others Encourage a return to normal functioning

Further management Table 5. Somatic presentation of depression and anxiety. Consider ‘antidepressant’ drugs (even if not depressed) Somatic presentationSymptom Consider referral for cognitive Depression Fatigue behavioural therapy More frequent pain complaints If very disabled, consider referral for Loss of weight and appetite rehabilitation Loss of libido In severe forms, there may be negative ruminations on health that can be delusional uncommon, and a balance needs to Anxiety Fatigue Dizziness be struck between the risk of Paraesthesiae missing disease and the potential for Chest pain and palpitations psychological harm resulting from Shortness of breath (especially ‘getting enough breath in’) excessive investigation. psychiatric symptoms for obvious and why they are excessively worried General management (Table 6) understandable gain (eg monetary about the symptoms (health Reassurance and advice compensation). anxiety) and allow appropriately targeted education and reassurance Patients with MUS require reassurance to be given. that there is no evidence of disease, a Patient assessment 4 Seek evidence of ‘stress’. Life stresses positive and credible explanation for Assessment of a patient should include may be a contributory factor. Most their symptoms, and practical advice on 10 the following: patients find ‘stress’ to be a more what to do next . 1 Clarify the presenting symptoms. For acceptable explanation than a example, what does the patient psychiatric diagnosis. ‘Antidepressant’ drugs mean when he or she complains of 5 Seek evidence of depression and Antidepressant drugs are most useful fatigue? Is it lack of energy anxiety. This is often best done when the patient is depressed but can (non-specific), sleepiness towards the end of the consultation also be effective when they are not. A (suggesting sleep problem) or lack of so that patients do not feel they are systematic review of antidepressants for motivation (suggesting depression)? being dismissed as ‘just psychiatric’. MUS found them to be moderately A useful approach is to empathise 2 Has the patient other symptoms? It is effective11. worth asking for an exhaustive list of with the understandable distress symptoms. The greater the number, resulting from the symptoms. Psychological therapies the more likely it is that they will be 6 Physically examine the patient. This medically unexplained. Do they wax may reveal unsuspected signs of The most w idely used management and wane? Multiple varied disease. It also helps to convince approaches are behavioural or cognitive symptoms over a long time suggest patients that they have been taken behavioural treatment (CBT). CBT aims somatisation disorder. seriously and properly assessed. to help patients improve by examining 3 Ask patients what they think or fear is 7 Do appropriate investigation. Note their way of thinking about and coping wrong with them. This can reveal that misdiagnosis is relatively with their symptoms 12.

Clinical Medicine Vol 2No 6November/December 2002 503 CME Psychiatry

Rehabilitation programmes Conversion disorder 3Fink P. Surgery and medical treatment in persistent somatizing patients. J Psychosom Patients with significant disability may An early return to function should be Res 1992;36:439–47. benefit from an out-or inpatient rehabil- encouraged for the acute case of conver- 4Kroenke K, Spitzer RL, Williams JB, itation programme. These have been sion disorder. Physiotherapy may be Linzer M et al. Physical symptoms in primary care. Predictors of psychiatric shown to be effective for pain complaints. useful. Evidence of depression should be disorders and functional impairment. Arch sought, and the patient offered an Fam Med 1994;3:774–9. Specific management opportunity to talk about stressors. In 5Wessely S, Nimnuan C, Sharpe M. chronic cases, treatment is more difficult Functional somatic syndromes: one or Hypochondriasis and may require referral to a physical many? Review. Lancet 1999;354:936–9. 6Mayou RA, Bass C, Sharpe M (eds). rehabilitation service. It is appropriate to reassure patients that Treatment of Functional Somatic Symptoms . Oxford: Oxford University Press, 1995. they do not have the disease they fear, Prognosis 7Sharpe M, Carson A. ‘Unexplained’ somatic but repeated reassurance can worsen symptoms, functional syndromes, and their concern with disease and should be The prognosis is often poor for patients somatization: do we need a paradigm shift? avoided. Associated depressive disorder Review. Ann Intern Med 2001;134(9 Suppl, referred to a specialist service. Symptoms should be treated. CBT has been shown part2):926– 30. may persist for years, especially if 8Hotopf M, Mayou R, Wadsworth M, to be effective for hypochondriasis. untreated13. The prognosis is best for Wessely S. Childhood risk factors for adults patients who had good functioning with medically unexplained symptoms: Somatisation disorder before the onset of the complaint, and results from a national birth cohort study. Am J Psychiatry 1999;156:1796–800. whose symptoms are expression s of The prognosis is poor and the aim must 9Drossman DA. Gastrointestinal illness and uncomplicated depressive and anxiety the biopsychosocial model. Review. J Clin be to prevent iatrogenic damage. It is disorders. It is worst for patients with Gastroenterol 1996;22:252–4. worth seeking evidence of depression long-standing multiple symptoms and 10 The Psychological Care of Medical Patients; and, where found, treating it. severe disability 14. Recognition of Need and Service Provision . Joint report of the Royal College of Physicians and the Royal College of Factitious disorder Psychiatrists. London: RCP, 1995. References 11 O’Malley PG, Jackson JL, Santoro J, Supported confrontation is required. Tomkins G et al. Antidepressant therapy This means presenting patients with the 1Nimnuan C, Hotopf M, Wessely S. for unexplained symptoms and symptom evidence that they have been manufac- Medically unexplained symptoms: an syndromes. Review. J Fam Pract 1999;48: turing symptoms, together with the epidemiological study in seven specialities. 980–90. 51 12 Kroenke K, Swindle R. Cognitive-behav- acknowledgement that they have an JPsychosom Res 2001; :361–7. 2Mayou RA, Sharpe M. Patients whom ioral therapy for somatization and emotional problem and need psycho- doctors find difficult to help. An important symptom syndromes: a critical review of logical help. Ideally, this is done jointly and neglected problem. Psychosomatics controlled clinical trials. Review. Psychother by physician and psychiatrist. 1995;36: 323–5. Psychosom 2000;69:205–15. 13 Potts SG, Bass CM. Psychological morbidity in patients with chest pain and normal or near-normal coronary arteries: a long-term Key Points follow-up study. Psychol Med 1995;25: 339–47. Medically unexplained (somatic) symptoms (MUS) account for a third of medical 14 Bass C, Murphy M. Somatoform and per- outpatients and are associated with significant disability and distress sonality disorders: syndromal comorbidity and overlapping developmental pathways. There is a considerable overlap in our understanding of the aetiology and Review. J Psychosom Res 1995;39:403–27. treatment of the so-called functional syndromes

There are parallel psychiatric and medical classifications of MUS. This is confusing. In practice, it may be helpful to use both to make a compromise diagnosis (egfibromyalgia with anxiety)

There is growing evidence for biological correlates of MUS

Both antidepressant drugs and cognitive behavioural treatment have been found to be effective in meta-analyses of trials

KEY WORDS: antidepressant drugs, cognitive behavioural therapy, functional somatic symptoms, medically unexplained symptoms (MUS), somatoform

504 Clinical Medicine Vol 2No 6November/December 2002