Background

Physical symptoms can be painful or cause some distress. They can happen anywhere in our body and at any period. One would generally be able to identify the complaints and investigate efficiently to conclude the diagnosis and the reason for the pain. Sometimes, this distress might need treatment or subside on its own.

There can be times when a physical cause cannot be found, or even blood investigations and radiology might be of no help. These physical symptoms are called “Medically unexplained symptoms” (MUS). There is generally no known physical cause to explain the symptoms.

These individuals would principally present on the medical wards rather than in a mental health setting. It is inappropriate to label an individual as having a mental illness just because there is no medical explanation; nevertheless, there is a possibility that there may be a co-morbid illness aside from the medical illness.

Epidemiology

MUS accounts for 20-25 % of presentations in primary care. The figure increases to 33% in a Neurological setting. 

This leads to significant anguish, impaired functioning and impacts an individual’s day-to-day functioning, reducing their productivity and quality of life. The trust and confidence in the treating team eventually drop as they feel their concerns are not taken into consideration. Likewise, the treating team can feel frustrated and unsatisfied due to the difficulty in understanding and supporting such patients. 

One-tenth of NHS expenditure spent on the working population in England has been accounted for in the management of MUS.

Understanding Mind-Body Dualism

There is a dichotomous view or black-and-white thinking that an illness can be either medical or psychiatric. This is clinically valid in that they are two different entities. However, there is an intimate causal relationship between the two. The mind-body connection is the link between a person’s cognition and physical health. It is one’s thoughts, feelings, expectations, emotions, attitude and behaviour in response to these cognitions and physical health.

Theoretically, one can argue that the body and mind cannot exist separately. Clinically, there is an assumption that bodily symptoms always indicate bodily pathology, that mental illness demonstrates some psychopathology, and that they cannot coexist. Confusion arises especially when there are bodily symptoms without bodily pathology.

When someone is stressed at work, they experience a headache, back pain or shoulder pain. When embarrassed, they blush or experience a flush on the face. These are simple examples of mind and body interconnection where the mind influences the body.

There is no clear-cut distinction or line between physical and mental illness. For example, 20% of those with non-epileptic attack disorder may also have epilepsy. Likewise, panic disorder and chest pain can occur frequently following a heart attack.

Both mental and physical illness can, of course, also coexist. Studies say that around half of patients with MUS might be suffering from anxiety and depression. It could be both a causative factor and an impact of illness.

References

• A; WTAH. The Diagnostic and statistical manual of mental disorders, fifth edition alternative model of personality disorder [Internet]. Personality disorders. U.S. National Library of Medicine; [cited 2022 Dec 21]. Available from: https://pubmed.ncbi.nlm.nih.gov/35787119/
• RC PSYCH ROYAL COLLEGE OF PSYCHIATRISTS. (n.d.). Medically unexplained symptoms. [online] Available at: https://www.rcpsych.ac.uk/mental-health/problems-disorders/medically-unexplained-symptoms
• Academic.oup.com. [cited 2022Dec21]. Available from: https://academic.oup.com/book/41095/chapter/351140684 
• DS; IMLP. Medically unexplained symptoms [Internet]. The Medical clinics of North America. U.S. National Library of Medicine; [cited 2022 Dec 21]. Available from: https://pubmed.ncbi.nlm.nih.gov/24758967/ 
• Medically unexplained symptoms: Royal College of Psychiatrists [Internet]. www.rcpsych.ac.uk. [cited 2022Dec21]. Available from: https://www.rcpsych.ac.uk/mental-health/problems-disorders/medically-unexplained-symptoms 

Somatic symptom disorder

DSM-5 Criteria 

Criteria A 

One or more somatic symptoms that are distressing or result in significant disruption of daily life

Criteria B

Excessive thoughts, feelings, or behaviours related to the somatic symptoms or associated health concerns as manifested by at least one of the following:

1. Disproportionate and persistent thoughts about the seriousness of one’s symptoms
2. Persistently high level of anxiety about health or symptoms
3. Excessive time and energy devoted to these symptoms or health concerns

Criteria C

Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months)

With or without predominant pain

What is this?

Somatic symptom disorder is a diagnosis given when an individual focuses excessively on various bodily symptoms (physical) such as pain, muscle or body weakness, shortness of breath, feeling giddy, etc., to the extent that their day-to-day functioning is impacted. It represents their thoughts, feelings and behaviour (cognitive model) in relation to the physical symptoms. They can exist by themselves or along with a physical illness.

Pathophysiology

The exact pathophysiology is unknown. It could be due to heightened awareness of normal physical sensations in the body. The cognitive distortions, in turn, might interconnect these normal bodily sensations and interpret them in a catastrophic way, resulting in further heightened anxiety. 

Risk factors

There is no single cause for the disorder – multiple factors can increase the risk. It can run in families. Childhood adverse experiences, including abuse and difficult childhood, are a few factors. Reduced threshold for pain and touch sensation can add to the cause. Awareness of the illness and acceptance is a protective factor.

References

• A clinical approach to managing somatoform disorders [Internet]. [cited 2022Dec21]. Available from: https://wchh.onlinelibrary.wiley.com/doi/10.1002/pnp.119 
• Kurlansik SL, Maffei MS. Somatic symptom disorder [Internet]. American Family Physician. 2016 [cited 2022 Dec 21]. Available from: https://www.aafp.org/pubs/afp/issues/2016/0101/p49.html 
• Medically unexplained symptoms, somatisation and bodily distress [Internet]. Cambridge Core. Cambridge University Press; [cited 2022 Dec 21]. Available from: https://www.cambridge.org/core/books/medically-unexplained-symptoms-somatisation-and-bodily-distress/5905F1F140375541B31FC57D5BF7B439 
• MR; PJLM. Conversion disorder [Internet]. National Center for Biotechnology Information. U.S. National Library of Medicine; [cited 2022 Dec 21]. Available from: https://pubmed.ncbi.nlm.nih.gov/31855394/ 
• Page L, Wessely S. Functional somatic syndromes (Chapter 7) – handbook of liaison psychiatry [Internet]. Cambridge Core. Cambridge University Press; [cited 2022 Dec 21]. Available from: https://www.cambridge.org/core/books/handbook-of-liaison-psychiatry/functional-somatic-syndromes/91AD7051D2A460C888F67C73FC37A2F2 
• Somatisation: Medically unexplained symptoms | Oxford Textbook of Social Psychiatry | Oxford Academic (oup.com
• Mehta, U.M. and Chaturvedi, S.K. (2022). Somatisation. Oxford Textbook of Social Psychiatry, [online] pp.421–432. doi:10.1093/med/9780198861478.003.0044.

Fibromyalgia

What is this?

It is a common musculoskeletal condition with a variety of somatic symptoms. It is generally a chronic pain that is widespread across the body for more than 3 months. The pain could be felt in arms, legs, head, and chest and could be throbbing, aching, or burning-type pain. 

It is associated with extensive pain that is enduring. The other supplementary symptoms here include extreme sensitivity to pain, fatigue, sleep disturbance, cognitive difficulties, low mood, anxiety, etc. 

Other syndromes of MUS can coexist, including Irritable Bowel syndrome and chronic fatigue syndrome.

Prevalence

It is seen in around 3% of the population worldwide. It is more common in women than men. Apart from that, it is known to be more common in middle age and in lower socio-economic status groups. It is also more common in those who are unemployed.

Aetiology

1. Central sensitisation
2. Fear-avoidance
3. Physical deconditioning

Pathophysiology

CNS sensitisation plays a central role such that the brain amplifies signals from peripheries and by modifying cortical processing > They feel more pain than expected (hyperalgesia), or they might feel pain without a stimulus present (allodynia)> Fear of pain > They avoid activities > The physical activities are deconditioned > lead to complete rest which is the reasonable behaviour but maladaptive that can be reinforced by friends and family

Core symptoms

F	Fatigue and tiredness
F	Foggy- cognitive dysfunction, poor memory and concentration
I	Insomnia
B	Blues- Depression, Anxiety
R	Rigidity- stiff muscles and joints
O	Ouch, Ow!!- Chronic pain that is widespread in nature

Table 1: FFIBRO mnemonic. Epomedicine. Fibromyalgia: Mnemonic Approach [Internet]. Epomedicine; 2022 Mar 5 [cited 2023 Jan 9]. Available from: https://epomedicine.com/medical-students/fibromyalgia-mnemonic-approach/.

Assessment

History should be followed by a thorough physical examination and investigations

Management

Non-pharmacological methods should be offered initially 

• Psychoeducation and Exercise programme supervised by Physiotherapist
• CBT
• Self-management: Aiming to reduce disability and improve morale and well-being rather than reducing pain
• Stepped care: Graded physical exercise

Pharmacological method 

• Antidepressants
• Anticonvulsants as neuromodulator
• Management of comorbidity

References

• Epomedicine. Fibromyalgia: Mnemonic Approach [Internet]. Epomedicine; 2022 Mar 5 [cited 2023 Jan 9]. Available from: https://epomedicine.com/medical-students/fibromyalgia-mnemonic-approach/.
• Rahman, F., Underwood, M. and Carnes, D. (n.d.). CLINICAL REVIEW. [online] doi:10.1136/bmj.g1224.
• Clauw, D.J. (2014). Fibromyalgia. JAMA, 311(15), p.1547. doi:10.1001/jama.2014.3266.
• Psych Scene Hub. (2019). The Neuropsychiatry of Fibromyalgia – Etiology and Management. [online] Available at: https://psychscenehub.com/psychinsights/neuropsychiatry-of-fibromyalgia-etiology-and-management/
• Choy, E. (2015). ORL Fibromyalgia Syndrome. [online] doi:10.1093/med/9780198723233.001.0001.

Chronic Fatigue Syndrome/Myalgia Encephalomyelitis  

What is it?

Also known as Myalgia Encephalomyelitis, it is a complex disorder with chronic fatigue and multiple other somatic symptoms. It is accompanied by cognitive dysfunction and an inability to carry on with day-to-day activities. For a diagnosis to be reached, symptoms should last for 6 months. It is included in the ICD 11 under the section on Neurological problems. It is not a psychological illness. 

Epidemiology

It can affect both sexes but is 2-4 times more common in females.

Pathophysiology

The pathophysiology has not been established yet, but it is postulated that it could be neuro-immuno-endocrine related. 

NICE guidelines recommend a diagnosis if there is persistent fatigue for at least 6 weeks or longer and debilitating an individual’s functioning, which cannot be explained by another illness and also has all of the following:

• Debilitating fatigue, which is worsened by activity. It is not caused by excessive cognitive, physical, emotional or social exertion and is not relieved by rest.
• Post-exertional malaise in which worsening of symptoms is often delayed in onset by hours to days and, is disproportionate to the activity, and has a prolonged recovery time.
• Unrefreshing sleep, disturbed sleep, or both.
• Cognitive difficulties, including word-finding difficulties, slowed responsiveness, poor concentration and memory problems.

Risk factors

• Female sex
• Lower socio-economic status
• Lower physical activity
• Lower educational status
• Poor social adjustment
• Adverse childhood experiences
• Poor sleep and nutrition
• Genetics

Differential diagnosis

• Endocrinological causes- Diabetes, Cushing’s syndrome, Thyroid problems
• Haematological causes- Anaemia
• Malignancy
• Infections- HIV, Hepatitis, Tuberculosis
• Neurological- Parkinson’s, Dementia
• Mental illness
• Autoimmune conditions

Reference

• Afari, N. and Buchwald, D. (2003). Chronic Fatigue Syndrome: A Review. American Journal of Psychiatry, [online] 160(2), pp.221–236. doi:10.1176/appi.ajp.160.2.221.
• Sharpe, M. and Wessely, S. (2012). Chronic fatigue syndrome. New Oxford Textbook of Psychiatry, pp.1036–1043. doi:10.1093/med/9780199696758.003.0133.

Conversion disorder/ Functional neurological symptom disorder  

Conversion Disorder (also known as Functional Neurological Symptom Disorder [FNSD]) is an illness characterised by neurological complaints (either motor or sensory). These symptoms are irreconcilable with any other neurological conditions or illness. People with conversion disorder may experience some common features, including impaired vision, speech or hearing, weakness of upper or lower limbs, seizures and memory issues. 

Functional denotes abnormal CNS functioning VS Psychogenic refers to psychological causes

Clinical presentation

Motor symptoms

• Weakness, Paralysis
• Abnormal movements, tremors, shakes, seizures
• Gait abnormalities
• Abnormal limb posturing

Sensory symptoms

• Numbness
• Reduced or absent sensation
• Reduced or absent hearing
• Reduced or absent vision

Others

• Abnormal speech or abnormal volume
• Diplopia
• Difficulty swallowing or a lump in the throat
• Nonresponsive or Comatose
• General weakness

Epidemiology

• About 1/3rd of new patients seen in neurology clinics have symptoms that are either not at all or only partly explained by structural neurologic disease. About 1/5th of patients in general hospital settings might present with Conversion disorder.
• Usually seen in middle age (35 to 50).
• About a quarter of them have a co-morbid neurological disorder.
• NEAD- Non-epileptic attack disorder is seen in 2-5/10000

Criteria (DSM 5)

Criteria A

One or more symptoms of altered voluntary motor or sensory function.

Criteria B

Clinical findings provide evidence of incompatibility between the symptom and recognised neurological or medical conditions.

Criteria C

The symptom or deficit is not better explained by another medical or mental disorder.

Criteria D

The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.

Risk Factors

• Maladaptive personality
• Childhood abuse
• Neglect
• Stressful life events
• Similar neurological conditions in the family or the individual

Diagnosis

History 

In addition to the usual history, the following points are important to consider:

• Dissociation at the time of the disorder is a common feature
• Depersonalisation (feeling a part of themselves is unreal) and derealisation (Feeling everything around is unreal) are common features in FNSD. 
• Panic disorder can be a common presentation.
• La-belle indifference: This is about being cheerful despite the diagnosis of a disability. This can be a feature of conversion and or factitious disorder.

Examination

FNSD is not a diagnosis of exclusion. There can be some positive signs of functional disorder that can be elicited here.

Common features of Conversion disorder noted

1. Non- Epileptic Attack Disorder (NEAD)
   • Prolonged episode
   • Closed eyes during episode or resistance to opening
   • No injury to the tongue, No falls, No collapse
   • Crying during and after the episode
   • Ability to recall the whole incident 
   • Prolonged amnesia post-episode
2. Functional limb weakness
   • Hoover’s sign positive: Involuntary extension of the “normal” leg occurs when flexing the contralateral leg against resistance. To perform the test, the examiner should hold one hand under the heel of the “normal” limb and ask the patient to flex the contralateral hip against resistance (while the patient is supine), asking the patient to keep the weak leg straight while raising it.
3. Visual problems
   • Fogging test is where the individual can still read with the affected eye despite altering the lens in the normal eye
   • Tubular field vision at any distance
4. Tremor Test: Tremor entrainment test is a specialised test that helps to identify unilateral tremors that are functional

Management

Non-pharmacological 

• Psychoeducation
• CBT
• Physiotherapy

Pharmacological

• Management of depression and anxiety

Differential Diagnoses

• Neurological conditions
• Somatic symptom disorder
• Factitious disorder
• Dissociative disorder
• Body dysmorphic disorder
• Depression
• Anxiety disorders
• Panic disorder

References

• MR; PJLM. Conversion disorder [Internet]. National Center for Biotechnology Information. U.S. National Library of Medicine; [cited 2022 Dec 21]. Available from: https://pubmed.ncbi.nlm.nih.gov/31855394/ 
• Bass, C. (2012). Conversion and dissociation disorders. New Oxford Textbook of Psychiatry, pp.1012–1021. doi:10.1093/med/9780199696758.003.0130. 
• Peeling, J.L. and Muzio, M.R. (2020). Conversion Disorder. [online] PubMed. Available at: https://www.ncbi.nlm.nih.gov/books/NBK551567/
• Stonnington, C.M., Barry, J.J. and Fisher, R.S. (2006). Conversion Disorder. American Journal of Psychiatry, 163(9), pp.1510–1517. doi:10.1176/ajp.2006.163.9.1510.
• Nicholson, T.R.J., Stone, J. and Kanaan, R.A.A. (2010). Conversion disorder: a problematic diagnosis. Journal of Neurology, Neurosurgery & Psychiatry, [online] 82(11), pp.1267–1273. doi:10.1136/jnnp.2008.171306.
• Owens, C. and Dein, S. (2006). Conversion disorder: the modern hysteria. Advances in Psychiatric Treatment, [online] 12(2), pp.152–157. doi:10.1192/apt.12.2.152.

Factitious disorder

Factitious disorder, or Munchausen Syndrome, is named after Baron von Munchausen. He was an 18th-century German officer known to exaggerate the stories of his life. It involves the fabrication of physical or psychological signs or symptoms with no understandable remuneration. 

Factitious disorder is different from illness anxiety disorder and Somatic symptom disorder. In the former, patients are mindful that they are exaggerating, whereas sufferers of the latter two conditions actually believe and accept they have a disease.

Epidemiology

• The prevalence of factitious disorder is not known. This condition mainly involves deception and dishonesty, which makes it difficult to know the incidence. In hospital settings, it is probable that around 1% of them may meet the criteria.
• Factitious disorder is common among women and healthcare workers.
• In factitious disorder imposed on another (FDIA, or Munchausen syndrome by proxy), females are usually the perpetrators, and the majority of them are mothers.
• The onset is usually in the early 20’s.
• Individuals often have a history of numerous hospital admissions and are often keen to undergo invasive procedures.
• These incidents are usually sporadic. However, for some individuals, the pattern of behaviours can become enduring.
• The overall prognosis is usually poor. When challenged, the majority of individuals will refute their behaviours, and very few will seek treatment.
• For factitious disorder imposed on another (FDIA), it usually commences after an initial hospitalisation of their child or other dependent. For the victims of FDIA (–usually children), the mortality is commonly due to poisoning or suffocation and can be between 6 and 22%.

Risk factors

• Patients may have a history of abuse, exploitation or neglect as a child.
• The patient may have experienced a serious medical illness that led to complex, wide-ranging treatment during childhood.
• Past significant associations with a physician.
• They may have primary spiteful intentions towards the medical profession.

DSM 5 Criteria

Criteria A

Falsification (i.e. – deliberately feigning) of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception.

Criteria B

The individual presents himself or herself to others as ill, impaired, or injured.

Criteria C

The deceptive behaviour is evident even in the absence of obvious external rewards.

Criteria D

The behaviour is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder

Diagnosis

History

• Fabrication of medical or psychological signs and symptoms in oneself or others with high dishonesty
• They take surreptitious actions to misrepresent, stimulate or cause symptoms and signs of illness or injury with no obvious external rewards.
• They might overstate the symptoms, fabricate or even simulate them.
• There might be a pre-existing condition, but the deceptive behaviour, in turn, may lead to excess clinical intervention.
• They are at increased risk of causing harm to themselves or others.

Differential Diagnoses

• Somatic symptom disorder
• Malingering
• Conversion disorder
• Personality disorder

Management

• The primary treatment goal is to modify the individual’s behaviour and diminish misuse or overuse of medical resources and unnecessary investigations, which may have negative consequences for the patient.
• The primary treatment for factitious disorder is psychotherapy, including psychoanalytic therapy or psychodynamic therapy, cognitive behavioural therapy and family therapy. 
• Co-morbid psychiatric disorders should be recognised and treated.
• In factious disorder imposed on another, treatment is similar to those in factitious disorder, with the added concern about the safety of the potential victim.
  • Management often necessitates a team that comprises not only healthcare providers but also social services, foster care (when children are involved), law enforcers, professional regulatory bodies, and child welfare organisations.

References

• Merten, T. and Merckelbach, H. (2020). Factitious disorder and malingering. New Oxford Textbook of Psychiatry, pp.1342–1349. doi:10.1093/med/9780198713005.003.0132.
• bestpractice.bmj.com. (n.d.). Factitious disorders – Symptoms, diagnosis and treatment | BMJ Best Practice. [online] Available at: https://bestpractice.bmj.com/topics/en-gb/695
• Zeshan, M., Cheema, R. and Manocha, P. (2018). Challenges in Diagnosing Factitious Disorder. American Journal of Psychiatry Residents’ Journal, 13(9), pp.6–8. doi:10.1176/appi.ajp-rj.2018.130903.
• rona (2013). Factitious disorder (Munchausen’s syndrome). [online] www.rcpe.ac.uk. Available at: https://www.rcpe.ac.uk/journal/factitious-disorder-munchausens-syndrome [Accessed 24 Jan. 2023].
• Carnahan, K.T. and Jha, A. (2021). Factitious Disorder. [online] PubMed. Available at: https://www.ncbi.nlm.nih.gov/books/NBK557547/
• DT; BCW. Malingering and factitious disorder [Internet]. Practical neurology. U.S. National Library of Medicine; [cited 2022 Dec 21]. Available from: https://pubmed.ncbi.nlm.nih.gov/30425128/ 

Malingering Disorders 

This is the deliberate and premeditated false presentation of symptoms or health problems with the primary aim of accomplishing an external reward.

The external gain could be monetary, reimbursement from work, drugs-related, exemption from duty or legal issues. It could also be to gain external benefits such as evading work or obligation, looking for drugs, dodging trial (law), seeking attention, eluding military services, leave from school or paid leave from a job. 

It is not a mental illness.

Clinical presentation

• Overgeneralisation and exaggeration of symptoms
• Bizarre, inappropriate and inconsistent presentations
• No functional impairment outside of the diagnostic setting
• Excess claims, sick leaves
• Poor explanation between symptoms and facts
• No treatment found beneficial

Overall, both Malingering and Factitious disorders are abnormal healthcare-seeking behavioural conditions. The common feature is deception. Although it may be encountered in the clinical setting, malingering is not a diagnosis. To establish malingering is challenging. Symptoms from malingering are premeditated, and the motivation behind it is well calculated.

In malingering disorder, there is some external benefit, which is like a secondary gain. This distinguishes malingering from factitious disorder (a disorder in which a patient consciously creates physical or psychological symptoms to assume a sick role, the primary gain). Malingerers generally do not accept treatment, show poor compliance with management and stop complaining about the presumed illness only after obtaining what he or she wants.

There is no medication or intervention to cure malingerers. 

Causes/ Aetiology/ Associations

• Malingering has no precise cause but is associated with lower socio-economic conditions 
• Malingering is reported among convicts evading trial, students avoiding school, workforces dodging work, and homeless hoping for economic reimbursement and rations. 
• Drug abusers frequently forge some illness or sickness, sleeplessness just so that they can procure Diazepam or painkillers. 
• Malingering is noticed in people trying to avoid military service. 
• With regard to different personalities in malingering, histrionic and antisocial are comparatively more common.

Criteria -DSM-5 

• The medico-legal context of the presentation
• Marked discrepancy between the individual’s “claimed stress or disability” and “objective finding and observation”
• Lack of compliance with diagnostic evaluation, treatment regimen and follow-up care
• Presence of antisocial personality disorder 

Protracted and unrelenting thorough observation can divulge evidence of malingering because it is difficult for the person who is malingering to sustain uniformity and consistency with the incorrect or embroidered claims for lengthy periods.

The malingerer typically lacks understanding of the nuances of the feigned disorder. For example, someone complaining of nerve compression syndrome in the upper limb may be referred to occupational therapy, where the person who is malingering would be unable to predict the effect of true syndrome on tasks in an art shop or painting task. They might use simple techniques like adding contaminants to urine or heating a thermometer under a lamp to feign temperature to stay in the hospital.

Individuals malingering psychotic illness repeatedly overstress hallucinations and delusions but cannot impersonate formal thought disorders. They usually cannot fake blunted affect, concrete thinking, or impaired interpersonal relatedness. They frequently assume that dense amnesia and confusion are features of psychosis. 

It is observed that malingerers in ED work towards the external gain of obtaining shelter and or drugs whilst in offices or clinics, and their goal could be financial gains.

References

• Merten, T. and Merckelbach, H. (2020). Factitious disorder and malingering. New Oxford Textbook of Psychiatry, pp.1342–1349. doi:10.1093/med/9780198713005.003.0132.
• Tracy, D.K. and Rix, K.J.B. (2017). Malingering mental disorders: Clinical assessment. BJPsych Advances, 23(1), pp.27–35. doi:10.1192/apt.bp.116.015958.
• Turner, M. (1997). Malingering. British Journal of Psychiatry, 171(5), pp.409–411. doi:10.1192/bjp.171.5.409.
• Gorman, W.F. (1982). Defining malingering. Journal of Forensic Sciences, [online] 27(2), pp.401–407. Available at: https://pubmed.ncbi.nlm.nih.gov/7047677/
• Ubaid ullah Alozai and McPherson, P.K. (2018). Malingering. [online] Nih.gov. Available at: https://www.ncbi.nlm.nih.gov/books/NBK507837/
• DT; BCW. Malingering and factitious disorder [Internet]. Practical neurology. U.S. National Library of Medicine; [cited 2022 Dec 21]. Available from: https://pubmed.ncbi.nlm.nih.gov/30425128/ 
• PK; AUUMP. Malingering [Internet]. National Center for Biotechnology Information. U.S. National Library of Medicine; [cited 2022 Dec 21]. Available from: https://pubmed.ncbi.nlm.nih.gov/29939614/ 
• StatPearls. Malingering [Internet]. StatPearls. StatPearls Publishing; 2022 [cited 2022Dec21]. Available from: https://www.statpearls.com/articlelibrary/viewarticle/24687/

Illness Anxiety Disorder 

Background

Illness anxiety disorder is an illness where an individual is preoccupied with himself or herself either having or acquiring a grave undiagnosed medical illness. Somatic symptoms may or may not exist. Illness anxiety is similar to a generalised anxiety disorder that is focused exclusively on health concerns.

Individuals with illness anxiety disorder are more often seen in GP surgery and medical unit than in psychiatric settings. They have some medical illnesses that they are worried about.

Various comorbidities can coexist with illness anxiety disorders. It includes anxiety disorders, generalised anxiety disorders, OCD, panic disorder, somatic symptom disorder, and personality disorder.

Criteria for Diagnosis

Persistent preoccupation or fear about the possibility of having one or more serious, progressive or life-threatening illnesses.

The preoccupation is accompanied by either:

• Repetitive and excessive health-related behaviours, such as repeatedly checking the body for evidence of illness, spending inordinate amounts of time searching for information about the feared illness, repeatedly seeking reassurance (e.g., arranging multiple medical consultations); or
• Maladaptive avoidance behaviour related to health (e.g., avoiding medical appointments).

The symptoms result in significant distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning. If functioning is maintained, it is only through significant additional effort.

The course of illness anxiety disorder is uncertain. It is a longstanding relapsing condition. It can start usually in early and middle adulthood.

Risk factors

• Major stress
• Threatening life changes
• Childhood abuse
• Serious childhood illness
• Complex illness in the family

The diagnosis should be made with thoughtfulness in individuals whose thoughts about the disease are consistent with widely held, culturally endorsed beliefs. 

Signs and symptoms

• In illness anxiety disorder, a detailed assessment fails to identify a serious medical condition that accounts for the individual’s apprehensions.
• The individual’s anguish principally comes not from the physical issue itself but rather from the anxiety about the meaning, significance, or cause of the suspected medical diagnosis.
• The worry about undiagnosed disease does not respond to medical reassurance, negative diagnostic tests, or benign course.
• They may research their suspected disease disproportionately (e.g. – in Library, on the Internet, asking other people and researching) and repeatedly seek reassurance from family, friends, or physicians. This can cause frustrations for them as it can cause interpersonal strain.

Management

• Regular follow-up in outpatients and consistent care with the same team.
• Avoid unnecessary investigations and treatment
• Validating the patient’s experiences
• CBT
• Exposure therapy
• SSRIs such as fluoxetine may be an effective treatment 

References

• Noyes Jr., R. (2012). Hypochondriasis (health anxiety). New Oxford Textbook of Psychiatry, [online] pp.1022–1029. doi:10.1093/med/9780199696758.003.0131.
• Kenyon, F.E. (1964). Hypochondriasis: A Clinical Study. The British Journal of Psychiatry, [online] 110(467), pp.478–488. doi:10.1192/bjp.110.467.478.
• Starcevic, V. (2013). Hypochondriasis and health anxiety: conceptual challenges. British Journal of Psychiatry, 202(1), pp.7–8. doi:10.1192/bjp.bp.112.115402.
• Magariños, M., Zafar, U., Nissenson, K. and Blanco, C. (2002). Epidemiology and Treatment of Hypochondriasis. CNS Drugs, 16(1), pp.9–22. doi:10.2165/00023210-200216010-00002.
• Howes, O. (1999). Hypochondriasis: an overview with reference to medical students. BMJ, 319(Suppl S5), p.9911410. doi:10.1136/sbmj.9911410.

Dissociative Disorders

Diagnosis

This is the disruption in the normal integration of awareness, memory-recall and remembrance, identity, emotion, perception and insight, body representation, motor control and behaviour.

• Dissociative amnesia is the inability to recall important personal information, which is more than what could be explained by normal forgetfulness. The stress of remembering is even more traumatic.
• Localised amnesia is the most common and is the inability to recall a specific period of time or event, such as accidents or war incidents.
• Generalised amnesia is when an individual loses their entire identity and cannot remember their own life story. Sometimes, this can be as bad as losing or forgetting one’s own skills and talents.
• Selective amnesia is the inability to recall some parts of the traumatic incidents but not all.
• Continuous amnesia is when patients have no memory of events up to and including the present time.
• Systematised amnesia is where an individual loses memory for certain places or people.

Depersonalisation/ Derealisation

These are persistent or recurrent episodes of one or both depersonalisation and derealisation.

Depersonalisation is characterised by a feeling of unreality or detachment, or being an outside observer of one’s own thoughts, feelings, emotions, sensations, movements and actions. They might feel time sense distorted, numbed or even experience perceptual alterations.

Derealisation is when one experiences unreality or detachment from one’s surroundings. Surroundings are experienced as dream-like or foggy. 

Dissociative Identity Disorder

This was previously known as multiple personality disorder – with two or more personality traits in a single individual. In some cultures, it is known as possession. This disruption can alter their affect, behaviour, consciousness, memory, perception, cognition and or sensory-motor functioning. 

There can be difficulty in remembering everyday events. They cause distress and impact the patient’s day-to-day life.

These individuals report they suddenly become observers of their own speech and actions, and they even feel powerless about their situation. They may report multiple people or voices in themselves. They may report religious beings in their body. Sometimes, it could be a baby or a child versus an adult or older person.

References

• obo. (n.d.). Dissociative Disorders. [online] Available at: https://www.oxfordbibliographies.com/display/document/obo-9780199828340/obo-9780199828340-0164.xml#:~:text=Dissociative%20disorders%20are%20characterized%20by%20a%20disruption%20of [Accessed 24 Jan. 2023].
• Mitra, P. and Jain, A. (2021). Dissociative Identity Disorder. [online] PubMed. Available at: https://www.ncbi.nlm.nih.gov/books/NBK568768/
• Reinders, A.A.T.S. and Veltman, D.J. (2020). Dissociative identity disorder: out of the shadows at last? The British Journal of Psychiatry, [online] 219(2), pp.1–2. doi:10.1192/bjp.2020.168.
• www.uptodate.com. (n.d.). UpToDate. [online] Available at: http://www.uptodate.com/contents/dissociative-identity-disorder-epidemiology-pathogenesis-clinical-manifestations-course-assessment-and-diagnosis [Accessed 24 Jan. 2023].

An approach to medically unexplained symptoms: a Summary

1. Detailed history of complaints 
2. Detailed information about physical complaints 
3. Detailed mental health assessment 
4. Detailed psychological formulation, which includes precipitating, perpetuating, predisposing and perpetuating factors about his complaints- detailed stress factors 
5. Thorough physical examination to identify any physical illness  
6. Special tests as per individual diagnosis (Hoover’s sign) 
7. Blood investigations, radiological imaging 
8. Bio-psycho-social approach 
9. Agree on treatment goals and make a consistent plan 
10. Non- confrontational approach 
11. Medication should not be the first choice in treatment. Psychoeducation and psychological therapies need to be offered initially unless associated with mental illness. 
12. Cognitive behavioural therapy- therapist emphasises one’s thoughts, feelings and behaviour. Hence, they can help one to develop a better understanding of the illness and avoid maladaptive behaviours. 
13. Graded exercise therapy involves gradually increasing physical activity and thus improving their function. This especially would be helpful in chronic fatigue syndrome. 
14. Mindfulness-based therapy 
15. Pharmacotherapy- includes antidepressants and, if needed, antipsychotics depending upon the comorbidities such as anxiety, depression and psychosis.

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