- WHAT ARE MEDICALLY UNEXPLAINED PSYCHIATRY SYMPTOMS (MUPS)?
They are physical symptoms that prompt the sufferer to seek health care but remain unexplained even after an appropriate medical evaluation. Various terms like functional somatic symptoms [FSS], somatisation symptoms, medically unexplained physical symptoms [MUPS] have tried to provide a label to these symptoms but none of them could clearly explain it.
- Why to talk about MUPS?
MUPS are associated with a high proportion of population wide disability and health care utilization. A US study has shown that the total incremental cost spent on MUS/somatization is around $256 billion per year (Vs $132 billion spent on diabetes).
PSYCHIATRIST OR PHYSICIAN?
General practice has a key role in the management as at least 20-30% of primary care patients have MUS. Many of the known syndromes are evaluated by the different medical specialties.
Whether MUS-A primary phenomenon? Or is it a substitute for psychological distress?
There is a parallel increase in the number of medically unexplained symptoms and degree of overt psychological distress reported by the patients.
- Whether MUS a primary phenomenon??- Why can’t we say for sure?
- Which all symptoms are medically explainable and which are unexplainable?
- Can we rule out organicity for sure- If so then how many tests must we do? / where do we draw the line?
- Recall bias- for lifetime symptoms.
Assessment for MUS?
First t is to rule out an organic cause as evidence suggests that only 4% of the symptoms become explainable in conversion disorders. List out the complaints, look through the evolution and course of symptoms, set the target symptoms and always keep a differential diagnosis.
How many investigations can actually rule out organicity for sure???
- Review the old records--Avoid procedural duplication.
- Do the relevant investigations that can rule out the differentials.
- Before ordering a test spend some time explaining what a normal result means, other possible reasons for the symptoms.
Do negative results really help??
It is how we communicate the result to the patient that matters. Problems of Over investigation and treatment can lead to increased ‘illness behavior’.
Engaging patients with somatic symptom disorder with any psychological management is challenging. Their quest for medical cause behind physical symptoms and doubts about the relevance of psychological intervention interfere with treatment compliance.
- Screen the patient for anxiety and depressive disorder
- Use a screening questionnaire- GHQ/PHQ.
- Can ask for any traumatic experiences or childhood adverse events.
Is there any other emotional distress presenting as physical distress?
- What is the patient’s model of illness?
- Is the patient in a predicament of some sort? Any Dilemmas?
- Who are the patient’s allies??
LET THE PATIENT SPEAK
- What is his concern about the symptom?
- What does he expect from you?
- His health-related beliefs and assumptions
- Why wasn’t he satisfied with the previous evaluation?
- Encourage them to speak about their psychological distress.
COMMUNICATING WITH THE PATIENT
WHAT TO TELL THEM AND WHAT NOT?
- Never say ‘Nothing is wrong.
- In communicating the diagnosis with the patient, it is important to admit uncertainty if investigations are incomplete/inconclusive.
- Diagnostic interview techniques can help clinicians exclude structural disease.
- Pre and post investigation counseling could be beneficial.
HOW TO MANAGE MUS?
- Mechanism is mostly unclear.
- Antidepressant: (TCA, SSRI, SNRI) action may involve processing pain on a central as well as peripheral level, also address co-morbid depression.
- Apart from antiepileptic effects, they can also produce analgesic, anxiolytic, and sedative effects. Pregabalin is more potent than Gabapentin and is administered at lower doses.
- COGNITIVE BEHAVIORAL THERAPY-Reattribution.
- Third-wave CBT
- PROBLEM SOLVING TREATMENT.
- BIOFEEDBACK THERAPY
- Psychodynamic therapies.
- Humanistic therapies. An example is person-centred therapy
- Integrative therapies, e.g. cognitive analytical therapy.
BEHAVIORAL ACTIVATION TRAINING - Graded activity training
PHYSICAL ACTIVITY TRAINING-Supervised aerobic exercise training and yoga
Dr. Ariya R Nair, Resident
Centre for Psychiatry and Clinical Psychology
Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala.