Assessment of incapacity 1. Identify the question The question \200\224 \200\230does this p atient have capacity? \200\231 is essentially meaningless. Incapacity law and common law in the UK presume capacity in adults, and incapacity law explicitly encourages the exercise o f residual capacity. Incapacity must therefore be assessed in relation to the particular de cision required of the patient and the nature of this decision should be estab- lished prio r to the interview. Additionally you should clarify with the medi- cal team what treatment is proposed, and what information has already been discussed with the patient. 2. Consider whether the patient has capacity to make the decision Incapacity cannot be pres umed on the basis of any individual patient factors (e.g. diagnosis of dementia, learning d isability, brain injury, mental disorder) 19_Semple_Chap19.indd 794 12/7/2012 4:30:28 PM CAPACITY AND CONSENT 795 but must be assessed speci \201 cally for each decision. The questions to ask are \200\224 for the decision required, does the patient have the ability to: \200 \200 \200 \200 \200 Make a decision? Understand the information relevant to the decision? Use or weigh that inf ormation in making the decision? Retain memory of the decision? Communicate the decision? For example, in considering whether a patient can refuse an amputation in the setting of os teomyelitis and early gangrene, we need to establish whether the patient is aware of the na ture of their illness, the treatment being offered to them, the risks and potential bene \201 ts associated with that treatment, and any alternative treatment options, as well as t he conse- quences of refusing treatment. 3. Evaluate the presence of psychiatric illness and determine whether it is in \202 uencin g the patient \200\231s decision Even if the patient \200\231s decision re \202 ects a fai r grasp of the elements of consent, it is necessary to determine whether their judgment is being in \202 uenced by mental illness. For example, if the patient with gangrene understa nds the nature of their infection and the risks of surgery versus delaying treatment, we wo uld not support their making a decision to avoid surgery if the decision was based on audit ory hallucinations telling them that they don \200\231t deserve to live. Therefore, a compr ehensive psychiatric assessment, screening for the presence of mental disorder, and includi ng an evaluation of how they have made their decision, is essential. The psychiatric evaluation for a capacity assessment needs to be com- prehensive, particula rly focusing on cognitive functions, reasoning and judgment; however, it is otherwise simil ar to any thorough psychiatric examination. The primary difference lies in the additional e xamination of how the patient has made similar choices in the past and what role psychi- at ric symptoms are playing in their current decision. 4. Gather additional information If the opinion is that the patient lacks capacity, then it will be important to establish: (1) what were the patient \200\231s views on the matter wh en greater capacity existed (e.g. did they discuss treatment outcomes with relatives?, is t here an advance directive?), (2) what are the views of the patient \200\231s rela- tives or carers?, is there a relative with surrogate decision-making powers (e.g. attorney, court-a ppointed deputy in England and Wales, or guardian in Scotland)? 5. Report and document opinion You should formally document your opinion and the reasons fo r it, as well as speaking to the treating team directly if at all possible. 1 This page should be read in conjunction with those pages in the Legal issues chapter desc ribing consent (b p. 870), treatment without consent (b p. 872), common law (b p. 874), and incapacity legislation (b pp. 876 \200\2239). 19_Semple_Chap19.indd 795 12/7/2012 4:30:28 PM CHAPTER 19 Liaison psychiatry 796 Medically unexplained symptoms 1: introduction A substantial proportion of patients present ing to primary care, or to any individual hospital specialty, will have symptoms for which, after adequate investigation, no cause can be found. Non-speci \201 c symptoms without un derlying organic pathology are very common and usually transient. Where they become prolong ed enough to merit medical attention they may present to any specialty, with presentations such as pain, loss/disturb- ance of function, and altered sensation. Symptom \200\230meani ng \200\231 The \200\230problem \200\231 of medically unexplained symp- toms (MUS) arises, in part, from the different meanings symptoms hold for patient and doctor. Patients presen t to doctors with illness (symptoms and behaviors); doctors diagnose and treat disease (pat hology and other recognized syndromes). The patient wants explanation and treatment for the ir symptoms and the route to this is generally through being given a diagnosis. If there is no recognized diagnosis available the doctor may respond with \200\230there \200\231s not hing wrong \200\231, expecting to be met with pleas- ure. The patient, however, is baf \202 ed \200\224there is \200\230something wrong \200\231 and the symptoms are still there . The doctor may then undertake a number of courses of action: continue to investigate in t he hope of \201 nding something; treat the patient anyway as a therapeutic trial; refer t o another specialty; or dismiss the patient. Psychiatric role The role of psychiatry in the assessment and manage- ment of these patients has changed substantially over recent years (hope- fully for the better). Formerly patients were referred \200\230at the end of the li ne \200\231, often after prolonged, inconclusive tests and unsuccessful interven- tions. Pa tients often misinterpreted (and resented) the referral as suggest- ing that symptoms were \200\230all in your mind \200\231, or were feigned. Psychiatrists sometimes took an overly narrow view of their role and responsibility, unhelpfully dismissing patients as having \200\230no psychotic or depressive ill- ness \200\231, or colluding with the patient \200 \231s desire for a \200\230clean bill of mental health \200\231 in order to return to trea tment-seeking behavior. We are currently at an early stage of our understanding of medicall y unexplained illnesses. While no specialty has all the answers in the management of this p atient group, psychiatry can offer: experience of the presentation of MUS across the hospit al specialties; ability to assess and treat the frequently comorbid depressive/anxiety symp toms; and a tolerance for diagnostic uncertainty and ability to take a long-term view of im provements. Misdiagnosis A frequently expressed concern doctors hold about this group of pa tients is the risk of \200\230getting it wrong \200\231 (often associated with poorly form ed worries about litigation). A long-held belief was that, despite repeated negative \201 ndings, all such patients (or a majority) would eventually be found to suffer from an orga nic disease which would, in retrospect, account for their symptoms. This concern was largel y based on older, poorly conducted studies with signi \201 cant methodological \202 aws. Recent follow-up studies suggest that the misdiagnosis rate for functional illness is 5% (e.g. comparable to other medical and psychiatric diagnoses 19_Semple_Chap19.indd 796 12/7/2012 4:30:28 PM MEDICALLY UNEXPLAINED SYMPTOMS 1: INTRODUCTION 797 such as idiopathic epilepsy and schizophrenia). This improvement has followed both the deve lopment of modern imaging and investigatory techniques, and the use of operational diagnost ic criteria for psychiatric diagnosis. Iatrogenic harm A problem common to all members of t his group of disorders is the potential for iatrogenic harm. These patients often accrue co nsiderable morbidity and even mortality due to excess negative investi- gations, irradiatio n, operative procedures, etc. Those disorders associated with chronic pain carry the risk o f iatrogenic opiate dependency. Often at the later stages of the patient \200\231s illness this secondary morbidity is more problematic than the original symptoms. A major positive i ntervention in these patients is therefore the avoidance of iatrogenic harm. Classi \201 c ation Patients presenting with somatic symptoms for which no adequate physical cause can be found make up a large and heterogeneous group in all clinical settings, from primary to te rtiary care. Our lack of full understanding of this group of disorders is re \202 ected in the confusing and disputed classi \201 cation system adopted. Our modern concepts arose f rom the concept of \200\230hysteria \200\231 \200\224of repressed emotions being expressed as phys- ical symptoms. There are differences between ICD-10 and DSM-IV in the classi \201 cation of this group of disorders and each classi \201 cation contains a number of di sputed and unsatisfactory categories. One dif \201 culty has been the residual old labels still in use; another has been the confusion of names indicating symptom and disorder; a th ird has been the substantial overlap between the syndromes described. Differential diagnosi s The differential diagnosis for relatively acute, isolated, medically unexplained symptoms includes: \200 Symptoms directly related to psychiatric disorders, such as depression, anxiety disorders, or psychosis. Functional somatic illness ( Conversion and dissociative disorders ( b p. 804 ). Pain disorders ( Somatization disorder ( Factitious disorder ( Malingering. Uncommon med ical syndromes which have not yet been diagnosed. Causative mechanisms These are currently unclear, but the follow- ing may play a part: patient psychological factors; patient \200 \231s health beliefs; affective state; underlying personality; degree of autonomic arousal; increased muscle tension; effects of hyperventilation; effects of disturbed sleep; effects of prolonged inactivity; impaired ability to \201 lter afferent stimuli. \200 \200 \200 \200 \200 \200 b p. 798). b p. 806). b p. 802). b p. 814). 19_Semple_Chap19.indd 797 12/7/2012 4:30:28 PM CHAPTER 19 Liaison psychiatry 798 Medically unexplained symptoms 2: clinical presentations Somatization This is the experienc e of physical symptoms with no \200\224or no suf \201 cient \200\224physical cause, with p resumed psychological causation. Somatization is a symptom of various disorders commonly se en in liaison psychiatry and may occur: (1) as a normal accompaniment of physical ill- ness es; (2) as a common presentation of depressive illness; (3) as a core component of illness ( \200\230functional somatic syndromes \200\231); (4) as part of a long-standing pattern of behavior ( \200\230somatization disorder \200\231). 1. As a normal accompaniment of physical illnesses Complaint of symptoms and help-seeking b ehavior is adaptive. All ill- nesses have emotional components which deserve attention. Bot h doctor and patient may be more comfortable dealing with specialty-appropriate symptoms (e .g. a patient presenting with pain post-radiotherapy may be articulating a desire for reass urance that the tumor has not recurred). While some doctors may be reluctant to deal with t he emotional con- text of illness, patients may have worries and express these as somatic c omplaints. These should often be understood as part of the emotional reaction to illness, n ot dismissed as \200\230functional overlay \200\231. Their appropriate treatment is via co nsultation with the responsible clinician. Psychological factors may (positively or negativ ely) in \202 uence outcome in treatment of physical illnesses by their effects on advice-s eeking, treatment compliance, and perceived quality of life. 2. As a common presentation of depressive illness A frequent cause of medically unexplained symptoms is somatized depres- sion and anxiety. Somatic complaints (e.g. pain, GI complain ts, weakness, loss of appetite) are common presentations of depression, with preva- lence i ncreased in certain subgroups (e.g. elderly, children, certain immi- grant populations). An xiety disorders (e.g. atypical panic attacks) can be the cause of unexplained cases of ches t pain and shortness of breath. Conversely, anxiety and depressive symptoms are a common \201 nding in both the physically ill and those with somatization. 3. As a core component of illness ( \200\230functional somatic syndromes \200\231) These co nditions are usually reported as individual clinical syndromes; however, several factors ar e common to them all. There is presenta- tion by the patient with symptoms which are sugges tive of an underly- ing organic illness; these symptoms cause distress; there is no identi \201 able organic illness which is suf \201 cient to explain the symptoms; and the cau- s ation is attributed to psychological factors which may be more or less apparent. A variety of presentations are seen across the medical and surgi- cal specialties: \200 \200 \200 \200 \200 Cardiology \200\224atypical chest pain. Respiratory medicine \200\224hyperventilation syndr ome (see GI medicine \200\224irritable bowel syndrome. Infectious diseases \200\224chronic fatigue syndrome. Rheumatology \200\224 \201 bromyalgia. b p. 356). 19_Semple_Chap19.indd 798 12/7/2012 4:30:28 PM MEDICALLY UNEXPLAINED SYMPTOMS 2: CLINICAL PRESENTATIONS 799 \200 \200 \200 \200 Neurology \200\224tension headache. ENT \200\224globus syndrome. General surgery \200\224un explained abdominal pain. Gynecology \200\224chronic pelvic pain. Dentistry \200\224atypica l facial pain. 4. As part of a long-standing pattern of behavior Somatization disorder (b p. 802). Hypocho ndriasis (b p. 808) This is the belief that one has a particular illness, despite evidence to the contrary \200\224usually takes the form of an over-valued idea, although is more rar ely frankly psychotic in nature. A particular form of hypochondriasis is dysmorphophobia (b p. 810): the belief that one has a signi \201 cant deformity. Conversion/dissociation (b p. 806) \200\230Conversion \200\231 or \200\230dissociation \200\231 is the theorized pro cess by which thoughts or memories unacceptable to the conscious mind are repressed from co nsciousness, and either \200\230con- verted \200\231 into physical symptoms, sometimes wit h symbolic meaning to the patient, or result in disruption to the normal integrated functio ning of the mind \200\224as evidenced in symptoms such as amnesia, fugue, or stupor. Factit ious symptoms Factitious symptoms are those which are inten- tionally produced or elaborate d, with the aim of receiving a medical diag- nosis. Where there is secondary gain (e.g. obt aining opiate prescription, obtaining legal compensation), this is referred to as malingeri ng. 19_Semple_Chap19.indd 799 12/7/2012 4:30:28 PM CHAPTER 19 Liaison psychiatry 800 Medically unexplained symptoms 3: management principles Accepting cases for assessment Psyc hiatrists should be reluctant to accept patients for assessment of MUS where signi \201 ca nt doubt still exists in the treating doctor \200\231s mind as to the diagnosis (e.g. where signi \201 cant fur- ther investigations are planned). They should also be reluctant to b e put in the position of \200\230last hurdle \200\231 before an otherwise planned interven tion (e.g. \200\230I \200\231ll perform your operation if the psychiatrist gives the go-ah ead \200\231). Management principles De \201 nitive treatments validated by RCT evidence a re not currently available for MUS. In addition, these patients present a heterogeneous gro up, in terms of presentation, \200\230psychological mindedness \200\231, and severity. Non etheless, the following principles may be helpful. Management should include: (1) thorough assessment; (2) con \201 - dent diagnosis; (3) clear explanation; (4) minimization of iatr ogenic harm; (5) empirical use of potentially bene \201 cial treatments; and (6) considera tion of involvement in treatment trials. Assessment \200 Prior to the consultation, obtain the full hospital case records for all specialties. Discu ss the case with the GP and obtain copies of GP records if available. Clarify whether the p atient is seen in other hospitals or health care services and aim to obtain these records. Establish whether there are any pending investigations and what the patient has been told a bout their presumed diagnosis. At the interview: establish full details of current symptoms ; circumstances of symptom onset; and \200\230life context \200\231 of symptom development . Explore their illness beliefs: speci \201 c worries about cause and possible prognosis; ask the patient to describe their understanding of their symptoms and what they feel they m ay represent. Full details of past medical history (may be reticent \200\224 \200\230no pro blems before current symptoms \200\231 or overly dramatic); what were they told at the time by the doctors treating them? Remember to explore possible psychiatric differential diagno ses \200\224 full mental state as normal, even if no symptoms spontaneously mentioned. Obse rve patient in waiting room/onward/entering and leaving room \200\224be alert to inconsiste ncies in symptoms. Diagnosis \200 \200 A positive and con \201 dent diagnosis is crucial. Be willing to make organic and non-orga nic diagnosis (e.g. where there is undoubted organic disease but also signi \201 cant MUS morbidity). Acknowledge the patient \200\231s distress and disability; a diagnosis of MUS s hould not mean to the patient that you believe that there is \200\230nothing wrong with th em \200\231. 19_Semple_Chap19.indd 800 12/7/2012 4:30:28 PM MEDICALLY UNEXPLAINED SYMPTOMS: MANAGEMENT PRINCIPLES 801 Explanation \200 Terminology in this \201 eld is variable, imprecise, and potentially offensive (e.g. supr atentorial, hysterical). The terms \200\230functional illness \200\231 or \200\230medical ly unexplained illness \200\231 are generally acceptable to patients. Begin with a clear ex planation of what is (and what is not) wrong: \200\230You are suffering from a functional, not structural, problem of your nervous system. This is a common problem which we have see n in other patients. \200\231 Various analogies may be used as appropriate (e.g. computer h ardware vs. software problem; piano working, but out of tune). Emphasize what can and canno t be done: \200\230We can help train the body to function normally again \200\231, \200 \230We might not be able to pinpoint the exact cause \200\231. Allow the patient to query w hat you have said (you should have allowed suf \201 cient time at the end of the interview ). Allow carers/ relatives to become involved in this exploration of your explanation. Copy your clinic letter to the GP and the hospital professionals caring for patient. Consider, in certain situations, copying the letter to patient. Minimize iatrogenic harm \200 In all MUS patients, be aware of the risk of iatrogenic harm and justify any risks taken by bene \201 t to the patient, over and above the grati \201 cation of seeming to give the patient \200\230what they want \200\231. Accept that there may be a chronic illness which can be managed, but not \200\230cured \200\231. Appropriately investigate In planning furt her investigations in patients with MUS, greater weight should be placed on objective rathe r than subjective change. Clear verbal, written (and in some cases, face-to-face) communica tion between all involved professionals is especially crucial in this group of patients: ev eryone should \200\230know what \200\231s going on \200\231. Accept that there will be a p roportion of severe cases who are unable to leave the sick role and who must be managed by changing how the system responds to them. \200 genuinely new symptoms. Empirical use of potentially bene \201 cial treatments \200 Often there is improvement in patient perception of symptoms following con \201 dent diagn osis and explanation. All patients with prominent depressive/anxiety symptoms should have t hese treated in the normal way. Consider empirical trial of antidepressant medication even where affective features are not prominent. Consider use of physiotherapy to aid regaining of functional loss. Consider referral for assessment for formal psychotherapy. Consider ref erral to other resource (e.g. pain management). \200 \200 Involvement in treatment trials \200 Little is known about the course of these disorders over time and less about appropriate tr eatments: consider patients for involvement in research. 19_Semple_Chap19.indd 801 12/7/2012 4:30:28 PM CHAPTER 19 Liaison psychiatry 802 Somatization disorder Somatization disorder is a disorder in which there is repeated presen ta- tion with medically unexplained symptoms, affecting multiple organ sys- tems, \201 rs t presenting before the age of 40. It is usually chronic in adults. In children, it usually involves one or a few organ systems, often for shorter periods of time. At all ages, it is associated with signi \201 cant psychologi- cal distress, functional impairment, and risk of iatrogenic harm. Full-blown somatization disorder or \200\230Briquet \200\231s syndrom e \200\231 probably represents the severe end of a continuum of abnormal illness behavior. Clinical features Somatization disorder patients have long, complex medical histories ( \200\230fat- \201 le \200\231 patients), although at interview they may mini- mize all but the most recent symptomatology. Symptoms may occur in any system and are to some extent su ggestible. The most frequent symptoms are non-speci \201 c and atypical. There may be disc repancy between the sub- jective and objective \201 ndings (e.g. reports of intractable p ain in a patient observed by nursing staff to be joking with relatives). Symptoms are usu- ally concentrated in one system at a time but may move to another system after exhausting d iagnostic possibilities in the previous one. The patient \200\231s life revolves around the illness as does their family life. There is excessive use of both medical services and alt ernative therapies. Diagnosis is usually only suspected after negative \201 ndings begin to emerge because no rmal medical practice is to take a patient \200\231s complaints at face value. The key diag nostic feature is multiple, atypical, and incon- sistent medically unexplained symptoms in a patient under the age of 40. Chronic cases will have had large numbers of diagnostic proc edures and surgical or medical treatments. There is high risk of both iatrogenic harm and i atrogenic substance dependence. Hostility and frustration can be felt on both sides of the doctor \200\223patient relationship with splitting (b p. 830) between members of the treati ng team. Psychological approaches to treatment are hampered by ongoing investigations of ev er rarer diagnostic possibilities and by the attribution of symptoms to \201 ctitious but \200\230named \200\231 medical entities. Two-thirds of patients will meet criteria for another psychiatric dis- order, most commonly major depressive or anxiety disorders. There is also association with personality disorder and substance abuse. Patients characteristically deny emotional symptoms or attribute them directly to physical handicaps \200\224 \200\230the only reason I \200\231m depressed is t his constant pain \200\231. Etiology Observable clinical association with childhood illness es in the patient and a history of parental anxiety towards illness. Increased frequency of somatization disorder in \201 rst-degree relatives. Possible neuropsychiatric basis to t he disorder with faulty assessment of normal somatic sensory input. Association with childh ood sexual abuse. Epidemiology Lifetime prevalence of 0.2%. Markedly higher rate in partic ular populations. 5:4 ratio 5:1. Age of onset is childhood to early 30s. Differential diagn osis Undiagnosed physical disorder: particularly those with variable, multi-system presenta tions (e.g. SLE, AIDS, porphyria, 19_Semple_Chap19.indd 802 12/7/2012 4:30:28 PM SOMATIZATION DISORDER 803 tuberculosis, multiple sclerosis). Onset of multiple symptoms for the \201 rst time in pa tients over 40 should be presumed to be due to unexposed physical disease. Psychiatric diso rder: major affective and psychotic ill- nesses may initially present with predominately so matic complaints. Diagnosis is by examination of other psychopathology, however over half o f somatization disorder patients exhibit psychiatric comorbidity. Other somatoform disorder s: distinguish from: hypochondriasis (presence of \201 rm belief in particular disorder), somatoform pain disorder (pain rather than other symptoms is prominent), conversion disord er (functional loss with- out multi-system complaints), factitious disorder (intentional pr oduction or feigning of physical symptoms to assume sick role), and malingering (intentiona l production of false or grossly exaggerated physical symptoms with external motivation). I n practice the main distinction is between the full and severe somatization disorder and so matization as a symptom in other disorders. Assessment (see b p. 800). Establish reasons fo r referral, experience of illness, attitudes to symptoms, personal and psychiatric history, and fam- ily perspective. Initial management (see management principles, b p. 800) Make, d ocument, and communicate the diagnosis. Acknowledge symptom sever- ity and experience of di stress as real but emphasize negative investigations and lack of structural abnormality. Re assure patient of continuing care. Attempt to reframe symptoms as emotional. Assess for and treat psy- chiatric comorbidity as appropriate. Reduce and stop unnecessary drugs. Conside r case conference involving GP and treating physicians. Educate parents/family. Ongoing management \200 \200 Regular review by single, named doctor. Reviews should be at planned and agreed frequency, avoiding emergency consultations. Symptoms should be examined and explored with a view to t heir emotional \200\230meaning \200\231. Avoid tests \200\230to rule out disease \200\231 : investigate objective signs only. All secondary referrals made through one individual. Di sseminate management plan. These patients can exhaust a doctor \200\231s resources \200\224 plan to share the burden over time. \200 \200 \200 Some evidence for the effectiveness of patient education in symptom re-attribution, brief c ontact psychotherapy, group therapy, or CBT if the patient can be engaged in this. Prognosi s Poor in the full disorder; tendency is for chronic morbidity with periods of relative rem ission. Treatment of psychiatric comorbidity and reduction of iatrogenic harm will reduce o verall morbidity. Key for recovery in children and adolescents is rehabilitation and return to usual activities as soon as possible. 19_Semple_Chap19.indd 803 12/7/2012 4:30:28 PM CHAPTER 19 Liaison psychiatry 804 Somatoform pain disorder In somatoform pain disorder there is a complaint of persistent sev ere and distressing pain which is not explained or not adequately explained by organic path ology. The causation of the symptom is attributed to psy- chological factors. This disorder is diagnosed where the disorder is not better explained by somatization disorder, another psychiatric diagnosis, or psychological factors in a general medical condition. All pain is a subjective sensation and its severity and quality as experi- enced in an indi vidual are dependent on a complex mix of factors including the situation, the degree of aro usal, the affective state, the beliefs about the source, and \200\230meaning \200\231 of t he pain. The experience of pain is modi \201 ed by its chronicity and associations and the re is a \200\230two-way \200\231 relationship with affective state, with chronic pain pred isposing to depressive illness, while depressive illness tends to worsen the subjective exp erience of pain. Comorbidity In common with the other somatoform disorders there is substan tial overlap with major depression ( 40% in pain clinic patients) and anxiety disorders. Su bstance abuse (including iatrogenic opiate dependency) and personality disorder patients ar e over-represented. Epidemiology No population data are available. The prevalence of patien ts with medically unexplained pain varies by clinical setting; higher in inpatient settings , particularly surgery, and highest in pain clinic patients. Differential diagnosis Elabora tion of organic pain, malingering (e.g. patient with opiate dependency seeking opiate presc ription), genuine organic cause with absence of other manifestations (e.g. sickle cell cris is, angina). Assessment History from patient and informants, length of history (may be mini mized), relationship to life events, general somatization, experience of illness, family at titude to illness, periods of employment, treatments, beliefs about cause, comorbid psychia tric symptoms. Management (see management principles, b p. 800). It is important to recogni ze and treat occult comorbid depression. It is often helpful to adopt an atheoretical appro ach: \200\230let \200\231s see what works \200\231, and to resist pres- sure for \200\230 all or nothing \200\231 cure or a move to investigation by another spe- cialty. Opiates are not generally effective in chronic pain of this type and add the risk of dependence. Psych ological treatments: these are directed towards enabling the patient to manage and \200 \230live with \200\231 the pain, rather than aspiring to eliminate it completely; can inclu de relaxation training, biofeedback, hypnosis, group work, CBT. Pain clinics: these are gen er- ally anesthetist-led with variable psychiatric provision. They offer a range of physica l treatments such as: antidepressants, transcutaneous electrical nerve stimulation (TENS), anticonvulsants, and local or regional nerve- blocks. 19_Semple_Chap19.indd 804 12/7/2012 4:30:29 PM This page intentionally left blank CHAPTER 19 Liaison psychiatry 806 Conversion (dissociative) disorders In conversion or dissociative disorders there is a loss or disturbance of normal motor or sensory function which initially appears to have a neuro logical or other physical cause but is later attributed to a psycho- logical cause. These d isorders were initially explained by psychodynamic mechanisms \200\224repression of unaccep table conscious impulses and their \200\230conversion \200\231 to physical symptoms, somet imes with symbolic meaning. In ICD and DSM, the presumed psychodynamic mechanisms are not p art of the diagnosis, although the initiation or worsening of the symptom or de \201 cit i s often preceded by con \202 icts or other stressors. Symptoms are not produced intentiona lly and the presence of \200\230secondary gain \200\231 is not part of the diagnosis. Clas si \201 cation ICD-10 and DSM-IV classify these disorders differently. In ICD-10 dissociat ion and conversion are used synonymously, with dissocia- tion preferred as it does not impl y a de \201 nite psychological explanation. All expressions of such disorders are classi \201 ed together under the heading \200\230F44, dissociative (conversion) disorders \200 \231. In DSM-IV \200\230conversion \200\231 refers to motor or sensory de \201 cit, while \200\230dissociation \200\231 refers to disturbance in func- tion of consciousness. Conve rsion disorders are classi \201 ed with the somato- form disorders, while dissociative dis orders are classi \201 ed separately. Clinical features These vary depending on the area a ffected but the following are commonly seen: \200 Paralysis affected. Flaccid paralysis is common initially but severe, established cases may develop contractures. Often active movement of the limb is impossible during examination b ut synergistic movement is observed (e.g. Hoover \200\231s test: the patient is unable to r aise the affected limb from the couch but is able to raise the unaffected limb against resi stance with demonstrable pressing down of the heel on the \200\230affected \200\231 side). Loss of speech (aphonia) There may be complete loss of speech, or loss of all but whispere d speech. There is no defect in comprehension and writing is unimpaired (and becomes the ma in method of communication). Laryngeal examination is normal and the patient \200\231s voca l cords can be fully opposed while coughing. Sensory loss anatomical structure rather than reality (e.g. \200\230glove \200\231 distribution, marked \200\230midline splitting \200 \231). Seizures Non-epileptic seizures are found most commonly in those with genuine epilep sy. The non-epileptic attacks generally occur only in the presence of an audience, no injur y is sustained on falling to the ground, tongue biting and incontinence are rare, the \200 \230seizure \200\231 consists of generalized shaking, rather than regular clonic contractio ns, and there is no post-ictal confusion or prolactin rise. Amnesia to organic mental disor der, and too severe to attribute to ordinary forgetfulness. Usually patchy and selective am nesia \200\224true global amnesia is rare. There is expectation of recovery and usually a h istory of recent traumatic event gradually emerges. One or more limbs or one side of the face or body may be The area of loss will cover the patient \200\231s beliefs about Memory loss, most often for recent events, not attributable 19_Semple_Chap19.indd 806 12/7/2012 4:30:29 PM CONVERSION (DISSOCIATIVE) DISORDERS 807 Here there is dissociative amnesia plus a history of travel Fugue outside the patient \200 \231s normal environs. The patient may \200\230come to \200\231 far from home, without mem ory of how they came to be there, and with a variable amnesia for other personal informatio n. Although there is amnesia for the period of fugue, the patient has apparently functioned normally during this time (e.g. able to buy travel tickets, etc.). Again recovery can be e xpected in time, and a history of recent traumatic events is commonly found. Diagnosis The diagnosis will usually be suspected due to the non- anatomical or clinically inconsistent nature of the signs. It is established by (1) excluding underlying organic dis ease, or demonstrating minor disorder insuf \201 cient to account for the symptoms; (2) \201 nding of \200\230positive signs \200\231 (i.e. demonstration of function thought to b e absent); (3) a convincing psycho- logical explanation for the de \201 cit. Additionally helpful though non-speci \201 c is a prior history of conversion symptoms or recurrent som atic complaints or disorder, family or individual stress and psychopathology (recent stress , grief, sexual abuse) or the presence of a symptom model. Treatment Clear presentation of diagnosis in collaboration with the treating medical team. Aim to present the diagnosis as positive (empha- sizing the likelihood of recovery) rather than negative ( \200\230we could n \200\231t \201 nd anything; it \200\231s all in your head \200\231). In general, avoid interventions which could maintain the sick role or prolong abnormal function (e.g. provisi on of crutches to those with dissociative gait disturbance) and instead consider interventi ons directed towards graceful resumption of normal function (e.g. physiotherapy). Treat psy chiatric comorbidity if present. Controlled treatment studies are absent, CBT, IPT, support ive psychotherapy, family therapy, biofeedback are all potentially helpful. Prognosis For a cute conversion symptoms, especially those with a clear precipitant, the prognosis is good, with expectation of complete resolu- tion of symptoms (70 \200\22390% resolution at follow -up). Poorer outcomes for longer-lasting and well-established symptoms. 19_Semple_Chap19.indd 807 12/7/2012 4:30:29 PM CHAPTER 19 Liaison psychiatry 808 Hypochondriasis Hypochondriasis is the preoccupation with the fear of having a serious dise ase which persists despite negative medical investigations and appro- priate reassurance wi th subsequent distress and impaired function. Clinical features The central and diagnostic clinical feature is the pre- occupation with the idea of having a serious medical condition , usually one which would lead to death or serious disability. The patient repeat- edly rum inates on this possibility and insigni \201 cant bodily abnormalities, normal variants, no rmal functions, and minor ailments will be interpreted as signs of serious disease. The pat ient consequently seeks medical advice and investigation but is unable to be reassured in a sustained fashion by negative investigations. The form of the belief is that of an over-valued idea; the patient may be able to accept th at their worries are groundless but nonetheless be unable to stop dwelling and acting on th em. Where the belief in illness is of delusional intensity, the patient should be treated a s for delusional disorder (b p. 220). Etiology As in somatization disorder there may be a h istory of child- hood illness, parental illness, or excess medical attention-seeking in the parents. Childhood sexual abuse and other emotional abuse or neglect are associated. In on e aetiological model, individuals with a combination of anxiety symptoms and predisposition to misattribute psychical symp- toms, seek medical advice. The resulting medical reassuran ce provides temporary relief of anxiety which acts as a \200\230reward \200\231 and makes further medical attention-seeking more likely. Epidemiology Equal sex incidence. Very varia ble prevalence depending on group studied (0.8% \200\22310.3%), higher in secondary care. D ifferential diagnosis The main differentiation is from the feared physical disease. In most cases this is straightforward, but the possibility of an early, insidious disease with vag ue physical signs and normal baseline investigations should be considered. Comorbidity High (>50%) incidence of generalized anxiety disorder. Hypochondriasis may also coexist with ma jor depressive illness, OCD, and panic disorder. Examination of the time course of symptom develop- ment and most prominent clinical features helps to distinguish primary hypochondri asis from a secondary clinical feature of these disorders. Management \200 Initial that symptoms with no structural basis are real and severe. Aim to plan continuing relationship and review, not contingent upon new symptoms. Explain negative tests and resis t the temptation to be drawn into further exploration. Patients will in the early stages of ten change or expand symptomatology. Emphasize aim to improve function. Break cycle of reas surance and repeat presentation \200\224family education may help in this. Allow patient time to ventilate their illness anxiet-ies. Clarify 19_Semple_Chap19.indd 808 12/7/2012 4:30:29 PM HYPOCHONDRIASIS 809 Pharmacological bene \201 t, even in the absence of depressive symptoms. Try \202 uoxeti ne 20mg, increasing to 60mg, or imipramine up to 150mg. Psychotherapy Behavioral therapy (r esponse prevention and exposure to illness cues); CBT (identify and challenge misinterpreta tions, substitution of realistic interpretation, graded exposure to illness-related situati ons, and modi \201 cation of core illness- beliefs), 75% symptom reduction in one controll ed trial.1 Uncontrolled trials demonstrate antidepressant 1 Warwick HM, Clark DM, Cobb AM, et al. (1996) A controlled trial of cognitive \200\223beha vioral treatment of hypochondriasis. Br J Psychiat 169: 189 \200\22395. 19_Semple_Chap19.indd 809 12/7/2012 4:30:29 PM CHAPTER 19 Liaison psychiatry 810