Medically Unexplained
Physical Symptoms
for GP trainees
Dr Sarah Burlinson
Consultant in Liaison Psychiatry
Royal Oldham Hospital
Pennine Care NHS Trust
Aims
Appreciate how common these are
Increase assessment skills
Recognise associated psychiatric
diagnoses
Strategies to manage in primary care
Simple scenarios
Complex patients
List 8 common physical
symptoms which are often
medically unexplained?
Common Medically Unexplained
Symptoms
Pain
Fatigue
Dizziness
Headache
Ankle swelling
Breathlessness
Insomnia
Numbness
What % of these are found to have a
medical cause when followed up for 1
year?
76%-100%
51%-75%
25%-50%
0-24%
These common symptoms…..
At 1 year: only 10-15% due to organic cause
(Katon 1998)
Prompt < 50% of primary care consultations
10% of patients with ‘MUS’ diagnosed with
organic disease at 18 months FU (Morriss
2007)
How common are MUS in NP in
Primary Care?
76%-100%
51%-75%
25%-50%
0-24%
Are they more or less common in
Secondary Care OP clinics?
How common are MUS?
Primary Care
20% of new GP consultations
1/3 of these persist
Secondary Care
25-50% of new medical out-patients
Chronic MUPS/ somatisation disorder
0.5-4 % community prevalence
Impact of MUS
Patients
Psychological
Physical
Social
Staff
Frustration/ demoralisation
‘Heart sink’ patient
Resources
Investigations/ admissions/clinics/medication
Possible mechanisms
Autonomic arousal
Muscular tension
Hyperventilation
Hyper-vigilance
Mood disorder
De-conditioning
Predisposing/ precipitating &
maintaining factors
Female
Parental ill-health/ childhood
adversity
Life events
Past/ current psychiatric illness
Health care response
Secondary gain
Name 6 psychiatric disorders which
are associated with or which cause
MUS.
Associated Psychiatric
Disorders
Anxiety/ depressive illness
Somatoform disorders
Somatisation disorder
Somatoform pain disorder
Hypochondriacal disorder
Dissociative disorder (Hysteria)
Factitious disorder (Munchausen’s)
Delusional disorder
Substance misuse
Detecting Depression in MUPS
HOPELESS
HELPLESS
WORTHLESS
Pervasive low mood
Lack of enjoyment
Poor concentration
Irritability
Guilty feelings
Sleep disturbance
Poor appetite
Diurnal variation
Low libido
Reduced energy
Anxiety: Physical Symptoms
Palpitations
Dizziness
‘Butterflies’
Nausea
Tremor
Tingling
Dry mouth
Wanting the toilet
Muscle tension
Hyperventilation
Chest pain
Lump in throat
Somatisation Disorder
>2 years multiple and variable medically
unexplained physical symptoms
Preoccupation & distress
Repeated consultations
Refusal to accept medical reassurance
> 6 from a list
Undifferentiated SD & Somatoform Pain
Disorder
Hypochondriacal disorder
Persistent belief of the presence of a
serious disease
Preoccupation/ distress/ disability
Refusal to accept medical
reassurance
Dissociative Disorder
(Hysteria)
Sudden loss of function
Temporal link with stressful event/
situation
No medical explanation
Delusional Disorder
Single or set of related delusions
Hallucinations/ thought disorder rare
Relatively well functioning
Themes include
Hypochondriacal
Erotomanic
Persecutory
Factitious Disorder
Intentional feigning of symptoms
Aim is to receive medical care
Often marked personality disorder &
interpersonal difficulties
(Malingering- different motive e.g:
Financial
Avoid court/ conscription)
Management
Case note review
Clinical assessment and Ix
Will simple explanation work?
Is this depression/ anxiety?
Is there another psychiatric
disorder?
Management
Reattribution
Acknowledging reality of symptoms
Feeling understood
Making the link
Antidepressant
May reduce symptoms even if not depressed
Psychotherapy
Cognitive behaviour therapy
Psychodynamic interpersonal therapy
Management of Chronic
Somatisation
Regular fixed intervals
Bio-psychosocial approach
Reduce drugs
Treat mood disorder
Limit referrals / investigations
Reduce expectation of cure
Summary
MUS:
common and treatable
associated with mood disorders
Mild/ recent onset:
Reattribution techniques
Antidepressants/ psychotherapy
Chronic (somatisation disorder):
Complex/ time consuming
Clear management plan
Resources
http://www.rcpsych.ac.uk/expertadvi
ce/problems/medicallyunexplainedsym
ptoms.aspx
http://www.neurosymptoms.org/