Download Medically Unexplained Physical Symptoms

Medically Unexplained
Physical Symptoms
MUPS are defines as complaints of physical
symptoms or signs for which there is no
adequate objective pathophysiologic
evidence to explain the distress. The
diversity of conditions that fall under this
classification remains a source of
controversy and paradox.
MUPS are encountered principally in
medical settings, where patients and
clinicians often are unfamiliar with
psychological explanations.
MUPS implies the presence of symptoms that do
not conform to known disease processes. MUPS
defines a predicament rather than a disorder, “a
way of drawing attention to a societal situation in
which the meaning of distress is contested.” It is
critical to accept that “unexplained” does not
necessarily imply purely psychological origins,
as the history of psychiatry is replete with
examples of disorders once considered
“functional,” that were subsequently proven to
result from “organic” processes.
Some patients may have vague symptoms
initially that appear to be “unexplained,”
only to manifest clearer evidence of
underlying disease later in the course of
illness (i.e. multiple sclerosis or
myasthenia gravis).
Is it normal for patients to occasionally seek
reassurance for transient physical
symptoms? What is the threshold for
distinguishing MUPS from “worriedwellness,” and should it depend on
symptoms, severity, chronicity, or
functional impairment? Is the degree of
conscious awareness versus volitional
control of reliable factor in distinguishing
MUPS disorders?
Sharpe and Mayou questioned the validity of
MUPS as a defining feature of somatoform
disorders and challenged the assumption
of psychogenesis in many of these
disorders. Ballas and Staab also
questioned contemporary criteria and
suggested classifying MUPS based on
organ systems.
EPIDEMIOLOGY
The direct and indirect economic costs
attributable to MUPS are staggering.
Patients with MUPS have increased
healthcare utilization rates, including
frequent visits, demands for tests,
unnecessary surgery, numerous
consultations, and hospitalizations.
The current financial cost of MUPS in the
United States exceeds $100 billion
annually. This does not include substantial
indirect costs of lost workplace productivity
and disability payments. Another burden
and hidden cost to society stems from
prescription and over-the-counter drug
sales targeting common minor ailments
and fueled by direct-to-consumer
advertising.
SPECIFIC SOMATOFORM
DISORDERS
Secondary MUPS Syndromes
Secondary MUPS syndromes encompass patients
with primary psychiatric disorders. A variety of
nonspecific physical complaints often are
associated. Up to 76% of patients hospitalized
for depression report multiple pain symptoms.
Vegetative symptoms form an integral part of
diagnostic criteria for depression, ruminate
about fatigue, weight loss, pain, “somatic
depression” or “masked depression,” these
physical ailments occur frequently in depression,
especially among the elderly.
MUPS are common among patients with
anxiety disorders and compromise a
significant component of diagnostic criteria
through activation of the autonomic
nervous system and comes to clinical
attention because of palpitations, chest
pain, dizziness, abdominal discomfort, and
other symptoms.
Patients with psychotic disorders –
schizophrenia, mood disorders, substance
induced psychosis, delusional disorder,
delirium, or dementia – also may present
with MUPS.
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Delusional Disorder – Somatic Type
Somatization Disorder
Conversion Disorder
Hypochondriasis
Body Dysmorphic Disorder
Pain Disorder
Factitious Disorders
Malingering
Early psychodynamic hypotheses were
based on studies of hysteria. Central to
this line of reasoning is the notion of
conversion as reflecting defense
mechanisms that symbolically transform
unconscious emotional trauma and conflict
into physical symptoms.
More recent work in mental cognitive
neuropsychology extends and clarifies
psychodynamic mechanisms underlying MUPS.
New ideas concern the development of
emotional processing from nonverbal,
subsymbolic expression in childhood to more
mature, adaptive and verbal abilities that allow
for translation of emotional states into
identifiable feelings on an abstract, logical and
reality-based level.
MUPS are the result of activation of or
regression to subsymbolic somatic
symptoms disassociated from verbal,
symbolic representations of feelings and
objects. Patients therefore experience
somatic signs only, detached from
psychological meaning – or in other words,
they exhibit alexithymia.
MUPS are associated somatoform disorders
remain an enormous problem in terms of
prevalence, personal suffering and
disability, and costs to society.
In the culture of the modern era,
characterized by increasing social,
political, and economic pressures to label
syndromes with or without scientific
support, to promote quick and profitable
remedies, and to control costs all at the
same time, the need for better
understanding of MUPS has never been
more compelling.