Medically Unexplained Physical Symptoms

1. Medically Unexplained Physical Symptoms

2. 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.

3. MUPS are encountered principally in medical settings, where patients and clinicians often are unfamiliar with psychological explanations.

4. 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.

5. 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).

6. Is it normal for patients to occasionally seek reassurance for transient physical symptoms? What is the threshold for distinguishing MUPS from “worried-wellness,” 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?

7. 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.

8. EPIDEMIOLOGY

9. 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.

10. 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.

11. SPECIFIC SOMATOFORM DISORDERS

12. 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.

13. 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.

14. Patients with psychotic disorders – schizophrenia, mood disorders, substance induced psychosis, delusional disorder, delirium, or dementia – also may present with MUPS.

15. Delusional Disorder – Somatic Type • Somatization Disorder • Conversion Disorder • Hypochondriasis • Body Dysmorphic Disorder • Pain Disorder • Factitious Disorders • Malingering

16. 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.

17. 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.

18. 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.

19. MUPS are associated somatoform disorders remain an enormous problem in terms of prevalence, personal suffering and disability, and costs to society.

20. 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.