The term medically unexplained symptoms refers to physical symptoms for which there is either no or insufficient evidence of any underlying conventional disease/disorder process. There is a wide spectrum of severity ranging from essentially normal experience (e.g. an occasional headache) to symptoms which result in severe and long-standing disability. Where symptoms group together in clusters suggestive of a link to a particular bodily system, they have been termed functional somatic syndromes. The term somatoform disorders refers to a specific set of formal psychiatric diagnoses involving conditions which predominantly present with physical symptoms or a worry about physical disease. Only people at the more severe end of the medically unexplained symptoms spectrum meet criteria for one of the somatoform disorders and there is considerable dissatisfaction with the current psychiatric classification system for these conditions, which is discussed later in this chapter.

Functional somatic syndromes

By the time most people with medically unexplained symptoms are referred to a liaison psychiatrist, they are likely to have picked up a label of one or more of the functional somatic syndromes (e.g. irritable bowel syndrome, functional dyspepsia, fibromyalgia). Many different functional syndromes have been described over the past 30 years according to different symptom clusters (Table 6.1). There is considerable overlap in symptoms between different functional conditions and somatoform disorders, yet most of these syndromes are studied as if they are discrete conditions within particular medical specialties, with a focus on the specific set of somatic symptoms, which are specialty specific.

There is still uncertainty as to the degree of overlap of these conditions and the relative common factors they may share. In one study, Fink et al (2007) studied 978 patients admitted to hospital from primary care and a medical and neurological department who scored highly on somatic screening measures. They found that patients complained of a median of five functional somatic symptoms (women six and men four). Principal component analysis identified three symptom groups explaining 37% of the variance: cardiopulmonary, musculoskeletal and gastrointestinal. Further analysis showed that the symptom groups were not discrete and patients were likely to report symptoms from different groups, suggesting that the groups were different manifestations of a common latent phenomenon: bodily distress.

Competencies for all psychiatrists

As specified for all doctors, plus the following.

• Full biopsychosocial assessment of patients, across the age range, with physical health problems, physical symptoms and mental health symptoms or psychological distress, including:

1. • somatisation/medically unexplained symptoms

2. • adjustment disorder

3. • the interrelationship of depression and anxiety on chronic medical conditions, for example diabetes, asthma, chronic obstructive pulmonary disease.

• Mental state examination in difficult circumstances:

1. • intensive care units

2. • breaking bad news

3. • variable conscious level

4. • lack of privacy.

• Assessment of self-harm across the age range, including children

• To advise competently on the treatment of patients with chronic mental health problems while in the general hospital

• Knowledge of medical and surgical treatments and conditions that have an impact on mental state

• Anxiety, depression and psychotic states in in-patients in medical and surgical settings

• Assessment of general medical and surgical admissions

• Demonstrate knowledge of management of alcohol and substance misuse problems in medical and surgical settings

• Diagnose psychiatric symptoms in the presence of confounding severe physical illness and biological symptoms (e.g. cancer, renal disease, severe trauma)

• Implementation of appropriate management plans, including the use of basic psychological, social and environmental interventions as well as psychotropic use from the British National Formulary

• Use risk assessment to advise management plan

• Review notes and drug cards, including investigations and results

• Awareness of medical, surgical and nursing assessment and management plan in the general hospital and its interaction with mental state

• Assessment of patient in A&E

• Identification of medically unexplained symptoms

• Identification, investigation and advice on the immediate management of delirium

• Basic management of patients with eating disorders in medical and surgical settings

• Criteria for referral and signposting to other mental health services including liaison

• Management of behavioural disturbance in medical and surgical settings including:

1. • assessment

2. • environmental measures

3. • use of appropriate drug treatments

4. • management of delirium tremens

5. • management of other drug withdrawal states.

Physical illness is stressful. However, given time and appropriate help and support, most people can adjust to even the most serious, disabling and life-threatening conditions. Coping with illness is a dynamic process and people have to make a series of adjustments as they assimilate new information, manage their emotions and make appropriate adjustments to their family life and social situation. Chronic illness usually involves having to go through this process many times as different complications of the illness arise over time.

Approximately a quarter of people with physical illness develop mental health problems as a consequence of the ‘stress’ of their physical condition. The process of adjustment fails and people develop depression, anxiety, panic or some other form of mental disorder. If anxiety and depression develop in the context of physical illness, recovery from the physical condition is impeded, pain can become more difficult to control, confidence to participate in rehabilitation programmes is reduced, and in extreme cases the patient can come to believe that they are a burden on their family or the hospital and would be better off dead. Physical illness in the elderly is a major risk factor for suicide.

Factors which influence response to illness

Illness perception

One of the most important determinants of coping with illness is how individuals perceive their illness. Leventhal's self-regulation model of health and illness is a useful framework for understanding people's response to illness (Leventhal et al, 1980). In this model the formation of a cognitive representation of an illness is viewed as the critical first step prior to the adoption of coping behaviours to manage that health threat. Leventhal et al define illness representations as patients’ own implicit common sense beliefs about their illnesses. The representation is viewed as a schema that is formed, activated and modified in response to stimulus information about the illness. Information sources may include symptoms, lay information from personal or vicarious experience, and expert information from medical practitioners. Illness representations are considered to be multidimensional, comprising five main components: identity, perceived consequences, timeline, perceived cause, and control/cure (Box 5.1).

Biopsychosocial assessment of patients

Carry out a full biopsychosocial assessment of patients, in medical and surgical settings, with physical health problems, physical symptoms and mental health symptoms, impaired mental well-being or psychological distress, including:

1. • systematic documentation of the chronology of the patient's medical history, including use of timelines

2. • working with other clinical members of the liaison team

3. • know the epidemiology and common presentations of psychological problems in medical and surgical settings

4. • use of appropriate questionnaires in medical & surgical settings and recognise their limitations.

Guidance

The trainee should be observed interviewing a patient who is not previously known to them. This competency will usually be assessed using an Assessed Clinical Encounter (ACE); however, subcomponents may be assessed using a mini-ACE (e.g. in the context of a patient review).

Construct

The trainee should be able to take a history in a physically ill patient or in a patient with medically unexplained symptoms, exploring aspects such as previous medical problems, family illness and associated life events or ongoing stressors. Trainees should focus on the importance of timelines and illness chronology, as well as exploring the patient's understanding of their illness. Trainees should utilise the full range of available information, such as patient notes, informants, carers and staff on the ward. They should also be able to suggest, initiate and interpret appropriate investigations, including physical investigations and collecting corroborative information.

Mental state examination

Carry out a basic mental state examination identifying specifically:

• mood

• psychosis

• delirium

• insight

• understanding.

Guidance

This could be done with a new patient or during a ward review, most commonly using a mini-ACE. Several workplace-based assessments will be required to cover the range and depth of psychopathology.

Construct

The trainee should be able fully to differentiate between overvalued ideas, delusions, illusions and hallucinations, and explore the patient's health beliefs, expectations and understanding. The trainee should be able to diagnose delirium (acute confusional state), using appropriate history-taking and examination, including cognitive testing. Trainees should explore all perceptual areas and use appropriate questions in order to determine mood disturbance in physically ill patients.

Capacity

Be able to determine capacity, based on an understanding of the concepts.

Biopsychosocial assessment of patients

Carry out a full biopsychosocial assessment of patients, in medical and surgical settings, with physical health problems, physical symptoms and mental health symptoms, impaired mental well-being or psychological distress, including:

Guidance

The trainee should be observed interviewing a patient who is not previously known to them. This competency will usually be assessed using an Assessed Clinical Encounter (ACE); however, subcomponents may be assessed using a mini-ACE (e.g. in the context of a patient review).

Construct

The trainee should be able to take a history in a physically ill patient or in a patient with medically unexplained symptoms, exploring aspects such as previous medical problems, family illness and associated life events or ongoing stressors. Trainees should focus on the importance of timelines and illness chronology, as well as exploring the patient's understanding of their illness. Trainees should utilise the full range of available information, such as patient notes, informants, carers and staff on the ward. They should also be able to suggest, initiate and interpret appropriate investigations, including physical investigations and collecting corroborative information.

Mental state examination

Carry out a basic mental state examination identifying specifically:

Guidance

This could be done with a new patient or during a ward review, most commonly using a mini-ACE. Several workplace-based assessments will be required to cover the range and depth of psychopathology.

Construct

The trainee should be able fully to differentiate between overvalued ideas, delusions, illusions and hallucinations, and explore the patient's health beliefs, expectations and understanding. The trainee should be able to diagnose delirium (acute confusional state), using appropriate historytaking and examination, including cognitive testing. Trainees should explore all perceptual areas and use appropriate questions in order to determine mood disturbance in physically ill patients.