MANAGEMENT OF MEDICALLY UNEXPLAINED PHYSICAL SYMPTOMS
Moderator: Dr. C.J. John, Speakers : Dr. Sujit Vasudevan, Dr.C.P. Somanath, Dr. T.V. Ravi
Medically Unexplained Physical Symptoms -are defined as those physical symptoms that are not attributable to or are out of proportion to identifiable disease. This very common clinical problem in general medical practice is often branded as “functional overlay”, “Hysteria” “Psychosomatic”etc. Chronic fatigue Syndrome, Fibromyalgia, Functional Bowel diseases etc are clinical entities that have strong psychological roots. Medically unexplained symptoms or somatisations are major presentations in a spectrum of psychiatric disorders that may range from mild and transitory illness to chronic and disabling.
Somatisation Disordersare chronic conditions more common in females with onset before age of 30. They have multiple symptoms related to various organ systems that are not supported by clinical examination or investigations. They have intense preoccupation with these symptoms. There is associated depression & anxiety.
In Pain Disorder, persistent pain in one or two sites having no organic basis is the major complaint.
Conversion disorderis an acute and dramatic onset disorder precipitated by emotional crisis and present with one or more symptoms or deficit affecting voluntary motor or sensory function. Symptoms or deficit are not intentionally produced or feigned. It may cause significant distress & impairment in functioning.
Hypochondriasisrefers to a condition in which the patient insists that he has a particular disorder like cancer or AIDS, rather than nonspecific complaints. Repeated tests or consultations will not convince him.
In Body Dysmorphic Disorder there is an excessive concern about appearance and preoccupation with imagined defect. The subjective distress & functional impairment is high and patient may insist on even surgical correction. The concern may involve hair, face, nose, lips, teeth, genital organs etc. The above disorders together are classified as Somatoform Disorders.
Factitious Disorder(also known as Munchausen’s syndrome) is a disorder in which the patient feigns physical or psychiatric symptoms so that they can assume a sick role. It is common in lonely persons with poor social support. Symptoms may be self induced diarrhea, epistaxis etc. Sometimes mothers can present with symptoms induced in child (Munchausen’s syndrome by
proxy). Malingering is an intentional production of symptoms to deceive others to achieve some immediate gains or escape
from punishment. This is a medico legal issue.
Somatisations in Children:11% boys and 15% girls above the age of eight years have been found to have stress related somatisations. Conversion disorders are common. Those with School Phobia have various somatic complaints especially in the morning
at the time when they have to go to school.
Somatisation as a masked presentation of other Psychiatric
Disorders:Many depressives may present predominantly with somatic symptoms. It is important to identify and treat these
masked depressions. Similar presentations are common in Generalized Anxiety Disorders. Panic disorder, a form of intense anxiety may present with acute and short lived disturbing symptoms pertaining to cardiovascular & gastrointestinal systems. There are a
group of patients who hold a false belief that they are infested by
parasites and even experience the sensations of parasites crawling
on their body. Delusional Parasitosis is treated by antipsychotic
medications. There can be other types of somatic delusions also.
Tips for management:Discuss the findings and investigations
with patient and reassure them about benign nature of symptoms.
Never tell him “All this is only in your head” or that they are imagined and not real symptoms. Be sympathetic and understand his
predicament. There is a thinking process in these people that amplifies trivial bodily sensations as serious and attributes to a major physical disorder.T ry to reattribute this. The symptom of head ache can be explained to be due to muscle tension caused by the physiological pulling induced by emotional stress. For alleviating
the distress of physical symptoms, techniques like biofeedback,
meditation and relaxation exercises etc can be used. Pharmacotherapy with antidepressants or anxiolytics are beneficial when co-morbid depression or anxiety is present. Duloxetine may be
beneficial in Pain disorders. It is important to avoid polypharmacy
and unnecessary investigations. Psychotherapy to enhance coping
skills can be done. In conversion disorders it is essential to cut down the undue attention given to the symptoms to achieve
symptom removal. The conflict that has caused the symptom
needs to be addressed. Referral to or liaison with psychiatrists to
be done when ever needed.