A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Overview

Key Facts
Background
Investigation
Treatment
The Rest

References:

Reviews
Articles

Date last formally reviewed: 12/01/2012

Medically Unexplained Physical Symptoms (MUPS)

Key facts:

Authors: Matthew Viveier
Top Tips: Try to think of the patient as challenging not annoying. They need a consistent carer

Key Differential Diagnoses

Medically explained symptoms
Acute psychiatric disorder

Key Investigations

Try to do as few as possible
Rule out life-threatening disease, with:
A few ‘rule-out’ tests (eg ECG, CRP, D-dimer)

Key Treatments

Think of patient as challenging, not annoying
Alert senior
Avoid discharging/rejecting patient without considering further management
Contact GP

Background

Patients with MUPS are often treatly badly in EDs; seen as an annoyance; labelled as ‘nutters, mad or regulars’. They deserve better. Consider them a challenge; and you may be able to help them with an empathetic approach

The Dancing Mania, Hendrick Hondius (1642); a historical example of MUPS?

Introduction

Patients with MUPS commonly present to the emergency department (ED) but are rarely considered in acute/emergency medicine teaching or literature. Management of these patients is frequently more challenging than if there is an obvious organic pathology
The standard approach is to rule out all possible physical causes with extensive investigation, and then to either tell the patient that there is 'nothing wrong' or refer them to a psychiatrist. A more positive approach can be taken
Patients presenting with unexplained physical symptoms will clearly be a heterogenous group. This is immediately problematic when thinking about their management, as the term puts no specific emphasis on a diagnostic category. Further complicating this is the poor validity and reliability of some of the diagnoses MUPS suggests, the frequent overlap between different conditions and potentially the unacceptability to patients of such a term, which brackets psychosomatic illnesses with malingering
The term 'functional disorder', meaning literally a disorder of function - has been suggested as a more precise and therefore more acceptable term. Physicians working in an emergency care setting may have multiple challlenges in managing these patients, particularly when their presentation is chronic. There is only a brief amount of time to assess them. Their beliefs may be deeply entrenched and difficult to change
Because they force clinicians outside their usual role into an area in which they may have relatively little expertise, and they may find fault with the help that is offered, they can be deeply frustrating to work with - and may provoke hostile feelings in the clinician, which must be recognised and managed
If a patient is making you angry, they may have a MUPS. But it could be you. Ie because the patient is frustrating you, you are not listening to them, and you may miss the diagnosis
Most doctors have some functional symptoms

Summary of disorders presenting as MUPS (can be seen as overlapping dimensions)

Physical Symptoms of Mental Illnesses

Anxiety disorders, eg panic disorder
Depressive illness
Psychosis eg paranoid schizophrenia (may be bizarre)

Functional Disorders (see below)

Somatoform disorders
Hypochondriasis
Dissociative (conversion) disorders
Somatoform pain disorder

Presentation of Symptoms for Secondary Gain

Malingering- (e.g. for attention, accommodation, escape
from adverse social/ legal circumstances, for compensation)
Munchausen’s Syndrome
Illicit substance use

Personality Disorder

All the above are expressed in the context of the patient's personality. All are likely to be more common in individuals suffering from a disordered personality, e.g. borderline personality disorder, dependant personality disorder, histrionic personality disorder, dissocial personality disorder

Physical Pathology

May be minor or undetectable

Functional Disorder: Types

Hypochondriasis

= preoccupation with the presence of one or more serious diseases, in the absence of relevant organic disease, that persists despite medical reassurance
It contrasts with somatisation in that the preoccupation is with a specific disease rather than specific symptoms

Somatisation disorder = symptoms experienced over long time periods; not intentionally produced and are experienced as real; examples include:

Cardiology – non-cardiac chest pain, benign palpitation
Gastroenterology – irritable bowel syndrome, non-ulcer dyspepsia
Rheumatology – fibromyalgia, repetitive strain injury
Immunology – multiple chemical sensitivity
ENT – globus syndrome
Neurology – conversion disorders, non-epileptic attacks, chronic benign headache
Gynaecology – chronic pelvic pain
Paediatrics – non-specific abdominal pain
Renal – loin pain haematuria, urethral syndrome

Dissociative disorder (formerly hysteria or conversion)

= the presentation of neurological symptoms that cannot be explained by physical disorder
It includes paralysis, sensory loss, amnesia, coma, fugue states, and non-epileptic attacks (pseudoseizures). It differs from somatisation in that there must also be physical signs of altered or lost function
Patients may exhibit ‘la belle indifference’, in that they appear inappropriately unconcerned about their often florid symptoms (this however is not a reliable sign)
There is usually secondary gain from the loss of function (eg student with a wrist drop, just before an exam). The pattern of symptoms and signs tends to reflect lay views of the human body’s functioning rather than medical understanding. For example, the pattern of sensory loss will often not correspond with that caused by any genuine neurological lesion

Somatoform (formerly psychogenic) pain disorder

= persistent pain in a single organ system, the duration or intensity of which cannot be explained in physical terms
Many cases are precipitated by trauma such as a road traffic accident. Common examples are neck and back pain. Pain, rather than any diagnostic implications, is the focus of attention, in contrast to hypochondriasis

Definitions (somatisation is an aspect of functional disorders)

MUPS = physical symptoms for which no relevant organic pathology can be found. Somatisation is a normal phenomenon. We all do it. However, some patients suffer severely from excessive somatisation
A person who is experiencing physical symptoms as a result of psychological or social distress is said to be somatising
The word 'somatisation' comes from the Greek word 'soma' meaning ‘body’. Psychosomatic medicine addresses the mind relationship between the mind (the ‘psyche’) and body (the ‘soma’)
True somatisation is an unconscious process

Epidemiology

Uncertain. Difficult to establish rates of presentation to EDs, due to difficulty diagnosing ('proving a negative'), and blurred boundaries between diagnostic labels
Medically unexplained symptoms overall are very common, comprising up to half of all consultations in primary care and up to one third of those in hospital outpatient clinics
Prevalence data for emergency department (ED) populations are very limited
One study found the rates of somatisation and somatoform disorder in a UK ED to be 3.8%; this a very low figure however and is likely to be a small fraction of the patients for whom somatisation is a problem

Aetiology

Unknown. The aetiology of functional disorders is likely to be complex
Somatised social and psychological distress, mental illnesses, secondary gain and minor or undetectable physical pathology can overlap and influence one another
It is therefore not helpful to think of a single explanatory cause. Families may teach their members to experience distress in terms of physical rather than social or psychological terms
In addition, the expression of bodily distress appears to be influenced more broadly by culture

Factors that maintain MUPS

Expressions of clinical uncertainty
Unnecessary investigation
Ambiguous or contradictory advice
Reassurance that nothing is wrong without an adequate causal explanation
Appearing to reject the reality of the patient’s symptoms

Charcot demonstrates a case of 'hysteria'

Clinical Lesson at the Salpêtrière. A. Brouillet (1887). "Blanche" (Marie Wittman) is supported by Dr. Joseph Babinski

Symptoms

Any; remember, even though symptoms are somatised, they are real to the patient (ie they exist)
Clues include
- Poorly explained symptoms
- Too many symptoms (from too many systems); or use of strange adjectives/adverbs eg "rumbling in my chest"

Key questions

“Have you ever had this problem before?”
“How is your mood at the moment?”
“Have you ever seen a psychiatrist or had any help with your nerves?”

Signs

Inconsistent, illogical or varying signs (eg in conversion disorder sensory loss which doesn’t correspond to nerve distributions

Their perception

You may not perceive that their problem is real. But it is real to them
The pain is a pain, to them. Think about, what is their agenda? Ie, what do they want from you? Diagnosis, explanation, your time
They may not expect treatment, or a cure; especially if they have had the problem for some time

The boy/girl that cries wolf

Even though previously the patient has been diagnosed with a functional illness, this time, they may be having a MI

Investigation

Investigation Principles

Best not to investigate (especially if has been fully investigated for current problem before)
If it has, but you feel, that this time, there is still a possibility of missing a serious disease, use the minimum number of ‘rule-out’ tests (eg ECG, Troponin T or D-dimer, CRP; all of which have a high negative predictive value)
Try to avoid tests with high false positive results (eg CT). Do not do screening tests (by definition have a high positive predictive value)
If hasn’t, a useful 'simple' screen is FBC, CRP, U+E, LFT, Bone, CXR, ECG

'Rule out' Medicine

Related to the 4h target, there is a growing trend in EDs for ‘rapid rule out’ of certain medical conditions. The greatest focus has been on rapid rule out of ischaemic heart disease, but other examples include PE and SAH
For patients with MUPS this is a 'double-edged' sword. Its good to rule out serious organic disease in them quickly. But its not good as it tends to lead to rapid and cursory investigation and discharge, with no real explanation of what is wrong with them, or what they could do about it: "all the tests are negative, we don't know whats wrong with you, goodbye" etc

Differential diagnoses

Medically explained symptoms (organic disease)
Acute psychiatric disorder

Treatment

Be aware that you may be part of the problem

Treatment (you)

Be aware that you may be part of the problem, and make the patient worse, by handling them insensitively, over-investigating them fuelling further anxiety, expressing clinical uncertainty, giving unnecessary treatment, or giving ambiguous or contradictory advice, all of which are likely to increase anxiety and provoke the desire for further investigation
Doctors’ explanations of functional disorders have been analysed and three types of explanation identified:
- Rejection (commonest): the reality of the symptoms is denied, negative results equated with absence of cause, and an imaginary disorder or stigmatising psychological problem implied
- Collusion:the doctor simply agrees with the patient’s explanatory belief
- Empowerment: positive explanations involving empowerment are uncommon. In these, the doctor provides a plausible psychophysiological mechanism, (e.g. the doctor may explain that anxiety triggers release of hormones such as adrenaline, causing the heart to speed up and the gut to contract, causing pain, or that depression lowers the pain threshold) removes blame, and provides opportunities for self help. Empowering explanations are clearly the ideal as they legitimise the patient’s suffering and ally rather than alienate the patient and doctor
Time. Taking a little extra time to provide a robust explanation to patients with negative results may be worthwhile in the longer term, by reducing the likelihood of such patients re-presenting with the same problem. Results of investigations should be given in an unambiguous way e.g. “the results were completely normal” vs “the results were normal for your age”
Better explanation - may be facilitated by the provision of simple written materials for the different diagnostic categories. An ED (or CCU), for example, might provide three patient leaflets: two for ‘rule ins’ such as STEMI/NSTEMI and angina; and one for a ‘rule out’ such as non-cardiac chest pain

Treatment (patient/ED role)

The best treatment is establishing a therapeutic relationship with a single physician. This is not desirable or possible in the ED; and few ED doctors are trained for it. Nonetheless as a junior, you can alert a senior to the possibility. He/she can inform the GP who may be able to treat the patient; or refer on, to someone who specialises in MUPS for example a psychiatrist or clinical psychologist
Some patients become frequent attenders at the ED, where they are likely to see an inexperienced junior doctor who is not familiar with the nature of their condition or experienced in management; and therefore much more likely to make referrals and order investigations. Try not to!
Ensuring that old records are available whenever these patients present is essential, and computerised hospital records can aid identification. You can help with this issue. It can also help to have a management plan agreed by senior staff for patients with stereotyped multiple presentations, placed prominently in their notes (preferably ED as well as inpatient notes)

Treatment of Somatisation (1)

This depends on the patient. The approach has to be flexible. Aim to acknowledge the reality of the patient's symptoms while preventing unnecessary investigation
With the most challenging cases it may not always be possible to enter a dialogue about the origin of the symptoms. At the least, however, the patient can be told that the condition is not life threatening, and that currently not all causes of the symptom in question can be explained
This does not undermine the patient’s somatic explanatory style (which might make them feel threatened, increasing anxiety and possibly anger). What needs to be avoided is entrenching the patient in a hostile relationship with medical staff. While still in the investigation phase, “final” investigations for particular symptoms, may need to be negotiated with the patient in advance
Within the ED the process of recovery and/or adaption can be begun. One can state that gradual recovery is to be expected, which helps protect the patient’s self esteem. If possible, reward healthy behaviour with attention. A graduated programme of tasks-to-achieve can be set; and praise and attention should be focused on achievement rather than the expression of pain etc
With more flexible patients it may be possible to pick up on cues concerning psychosocial factors. While taking the history, doctors should be aware of psychosocial cues from the patient, for example, references to distressing life events and difficulties, or negative affects. Doctors should show the patient that they have noted these, and explore them if they are encouraged to do so
The most difficult patients are unlikely to change chronic ingrained patterns of thinking and behaviour in the context of a brief interview in the ED - this can be a long term undertaking. However if patients are treated sensitively, they may eventually concede to be seen by a psychiatrist or clinical psychologist:

Treatment of Somatisation (2): Referral to Mental Health Specialist

It is essential to be honest about referral to a mental health specialist, and it may be helpful to establish the clinician’s credentials, for example “I would like you to see Dr X, who is a psychiatrist. He sees a lot of people with very similar problems and is often able to help them”, or “He is a particular expert in treating people who have chronic pain”
Subsequent treatment may involve psychiatric treatment of any mental illness, programmes of cognitive behavioural therapy, and potentially longer term psychotherapy, (particularly if there are issues with the patient’s personality); depending on the formulation of the case and how able the patient is to engage
Ideally there will be well established psychiatric liaison cover or local expertise to draw on. However services that provide psychological medicine and liaison psychiatry are patchy in the UK, despite the prevalence of this cluster of presentations - and the associated cost to the NHS, the individual and the economy
Services in other countries are better developed, particularly in Germany, where “psychosomatic hospitals” admit patients under the care of physicians and treatment takes place in conjunction with psychotherapists. Could current management of these patients be improved in your area?