Accepted Manuscript Medically-Unexplained Neurological Symptoms: A Primer for Physicians Who Make the Initial Encounter Ashley Evens, BS, Lindsay Vendetta, BS, Kaitlin Krebs, BA, Priyantha Herath, MD PhD PII:
S0002-9343(15)00352-6
DOI:
10.1016/j.amjmed.2015.03.030
Reference:
AJM 12957
To appear in:
The American Journal of Medicine
Received Date: 12 March 2015 Revised Date:
17 March 2015
Accepted Date: 18 March 2015
Please cite this article as: Evens A, Vendetta L, Krebs K, Herath P, Medically-Unexplained Neurological Symptoms: A Primer for Physicians Who Make the Initial Encounter, The American Journal of Medicine (2015), doi: 10.1016/j.amjmed.2015.03.030. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Running Header: Psychogenic symptoms in general practice, Evans et al
MEDICALLY-UNEXPLAINED NEUROLOGICAL SYMPTOMS: A PRIMER FOR PHYSICIANS WHO MAKE THE INITIAL ENCOUNTER
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Ashley Evens BS1, Lindsay Vendetta BS1, Kaitlin Krebs BA2, & Priyantha Herath MD PhD2
School of Medicine, University of South Carolina, Columbia SC,
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6311 Garners Ferry Road Columbia, SC, 29209, USA.
2
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([email protected], [email protected])
Movement Disorders Program, Dept. of Neurology,
School of Medicine, University of South Carolina, Columbia SC
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8 Medical Park Road, Suite 420, Columbia, SC, 29203, USA.
Corresponding Author: Priyantha Herath MD PhD Director, Movement Disorders Program, Dept. of Neurology,
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8 Medical Park Road, Suite 420, Columbia, SC, 29203, USA. +1(803)545-6050. ([email protected])
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Funding Source: None Conflict of Interest: None Authorship: All authors had access to the data and a substantive role in writing the manuscript. Article Type: Review Key Words: Medically unexplained symptoms; Functional neurological Disorders; Movement Disorder; Psychogenic symptoms; Management Running header: psychogenic symptoms in general practice
ACCEPTED MANUSCRIPT Running Header: Psychogenic symptoms in general practice, Evans et al
Abstract: Medically unexplained symptoms are ubiquitous in clinical practice. Medical utilization costs of medically unexplained symptoms are projected at about $256 billion/year. When initially seen, these symptoms are often baffling, not only to the patients but also to the
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physicians who encounter them. Because of this, properly diagnosis them is generally seen as difficult at best, leading to massive overuse of unnecessary testing. Subsequently, their
management can also be cumbersome. All this burdens these patients with unnecessary costs,
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financially as well as emotionally. This primer discusses historical perspectives of these as well as the changing nomenclature, and outlines how to think about these complex symptoms and
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neurological findings that will enable a positive diagnosis rather than a diagnosis of exclusion. We also offer useful heuristic principles of their management so that the physician-patient relationships can be better maintained, and the quality of life of these patients can be improved
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by way of some simple, economical approaches.
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Introduction Many physicians encounter patients with symptoms not compatible with known anatomic and physiologic principles. Such symptoms tend to be baffling in their presentation and can test
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the best diagnosticians. Some reports estimate the incidence of medically unexplained symptoms to be about 22% of all reported symptoms at a primary care setting 1 and up to about 30% in some of the specialized tertiary care neurology clinics. 1-3 While many of these symptoms
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medically unexplained symptoms tend to be neurological in nature, they occur in all medical specialties3. Some examples include irritable bowel syndrome, fibromyalgia, chronic pelvic pain,
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and Globus hystericus, pseudo-seizures 4, 5 stroke mimics 6 and some types of amnesia 7, as well as abnormal movements. 8 Such medically unexplained functional movement disorders are one of the most prevalent disorders seen in neurological clinics.
An estimate of medical utilization costs of all different types of medically unexplained
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symptoms is said be about $256 billion/year. 9 The annual cost of functional movement disorders alone (which are only a small portion of the neurological symptoms of non-organic etiology) to the US healthcare is estimated to be over $ 20 billion, assuming that these symptoms represent
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10% of all medical costs. In neurology for example, movement disorder of non-organic disorders are so common enough that they are now referred to as a “crisis for neurology”.10
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At present, very little is known about the pathophysiological mechanisms of medically
unexplained symptoms. Because of this, it is often assumed that patients with medically unexplained symptoms s “make up their symptoms [for secondary gain].” 11 This leads to stigmatization of many patients who legitimately suffer from inexplicable and complex symptoms. In general, the evaluation and management of these patients is felt to be frustrating and unrewarding, and there is a prevailing, if anecdotal sense that “they take time away from
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those who really need our care” (personal communication, Herath). Because medically unexplained symptoms often occupy a gray area between the several medical specialties, for example, between neurology and psychiatry, no one is willing to take charge of the patient,
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leading to even more complex and difficult interactions —and because of this, patients may receive inadequate care, inappropriate and excessive “diagnostic” testing, dangerous or
ineffective therapies and multiple, often unnecessary referrals. As such these cases are very
have detrimental effects on patient’s quality of life. 12
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costly to everyone including the health care systems at large. In addition, non-organic disorders
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The purpose of this paper is to illuminate the current state of understanding of medically unexplained symptoms, and to establish basic heuristic principles of their management. It is important that clinicians take an interest in medically unexplained symptoms not only because an enormous amount of healthcare and quality of life costs are associated with them, but also
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because these patients often present in a primary care settings. A primary care practitioner, who happens to be the sentinel of these patients, must know how to listen and evaluate them based on some established principles, to arrive at a positive diagnosis, and then communicate to the
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patients what is often thought of as a difficult diagnosis. Also it is important to know when to refer to a specialist with interest in these symptoms, as this condition requires a dedicated team
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approach to maximize treatment success.
A Long History of Medically Unexplained Neurological Symptoms: The malady of inexplicable medical symptoms may have been recognized millennia ago.
The word hysteria comes has Greek roots “hystera,” which means uterus. 13, 14 Since this was originally identified in women, Greeks believed that hysteria occurs when women had
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unsatisfied sexual desires. Ancient remedies included pelvic or ovarian pressure.13 Similar symptoms have been referred to in ancient Egyptian writings as well. However, they believed this disorder occurred when the uterus had moved upward from its pelvic position to elicit odd
uterus would fall back down into place. 15, 16
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symptoms. They placed aromatic substances in women’s genital region, believing that their
Modern day concepts of hysteria came to the forefront of medicine in the late 19th
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century, when Charcot described how men too could also suffer from hysteria. With this, he attributed the illness to dysfunction of the central nervous system –that hysteria was not the
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physical result of [a traumatic episode], but the patient’s emotional response [to it]. 17 Joseph Breuer described the patient Anna O., who displayed unusual symptoms while taking care of her sick father. She developed a paralysis, headaches, intermittent deafness, visual disturbances, and temper tantrums during and after her father’s illness. 18 In order to correct her symptoms, Bruer
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asked Anna O. to recreate her memories and have a “purging” of her emotions, known as “emotional catharsis.” This was done with each of her symptoms until she was completely cured, which is a claim that has now been refuted. A few years later, Freud who was Breuer’s student,
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decided to study under Charcot, who believed hysteria was an outward symptom of an unconscious agitation. 19 Because Freud concluded that these symptoms were the result of
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repressed painful memories, he believed that listening to and observing his patients would help cure them. 13 As he did so, Freud, synthesized both Breuer’s cure and Charcot’s traumatic experience concepts to create what later became Psychoanalysis. 19 Later on, Babinski too contributed to this idea by postulating that the cause of hysteria was due to a cortical brain lesion, which he discovered by defining certain neurological signs to differentiate organic dysfunction of the central nervous system. 20
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Despite this extended history of descriptions, even today, there is no universal agreement on the nosology of these symptoms. For instance, many neurologists consider inexplicable neurological symptoms a “functional” or a “psychogenic neurological disorder”, while many
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psychiatrists discuss the possibility of a “conversion disorder” and actively seek exclusion of organic disease when they are not able to detect any psychological stressors as required by DSMIV. Given that only a modest proportion of patients report a physical or a psychologically
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traumatic event that precipitate their symptoms, it is often difficult to remember that while
assessment for emotional trauma is important, the diagnosis of a psychological etiology should
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not be withdrawn if a stressor is never found —and that long forgotten traumatic events may prompt the development of symptoms by providing a stimulus to those predisposed.
Hysterical, Functional vs. Psychogenic: How to Define Medically unexplained symptoms
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Naming a disease is no trivial issue. Everything that will subsequently happen to a patient — from conceptualization of the symptoms, to the logic behind the diagnosis and treatment— will hinge upon a precise label. Many terms have been used in an attempt to arrive at this, including
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hysteria, hypochondriasis, conversion disorder, psychogenic, and more recently, functional neurological disorder (Figure 1). At this time, there is no agreement as to which term is better,
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neither from an ontological nor a nosological standpoint. The term conversion disorder is not very useful as it provides no clinical information and
it does not allow a physiological formulation of the symptoms, leaving behind a great deal of uncertainty. Another popular term, “psychogenic symptoms” has been deemed more useful because it implies a potential clinical etiology, but it also tends to be one-dimensional. Additionally, that term fails to address the socio-biological factors that may have been
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contributory to medically unexplained symptoms, and a psychological stressor may never be found in most patients with these movement disorders. 21 Regardless, both terms are accompanied by an inherently attached stigma that often hampers communication, thereby
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limiting the acceptance by patients.11
It is in this context that the term “functional symptoms” had gained a degree of
acceptance. It denotes a physiological disturbance of the function of the nervous system and lacks
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any stigma engendered by it. However, it is argued that the term is ambiguous and is often used just to be politically correct. “Functional” also implies that structural pathology may not be
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apparent 22 and can be confusing. Despite this, studies have shown that the term “functional” is most accepted by patients, as opposed to “conversion”, “hysteria”, “medically unexplained,” or “psychosomatic”. 23, 24
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Clinical Presentation, and Diagnostic Approach:
In general, medically unexplained symptoms are most commonly seen in young women. Fairly often, they tend to have been employed in the medical profession, but no sex, age, or
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occupation is immune to this malady. Known risk factors include history of major stressful life events, sexual abuse, previous surgery, or other physical trauma. 25 The diagnosis of medically
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unexplained symptoms is in fact clinical, and relies on identifying features and patterns from the history (Table 1 and 2), and physical examination that are incongruent with organic neurological disorders.
In addition to performing a complete physical exam on these patients, there are several
bedside tests (Figure 2) that may be helpful in making a diagnosis of medically unexplainable neurological symptoms (Table 3).24
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A clear, incisive history where the patient is gently guided to characterize the details of the phenomenology of the symptoms is the most important contributor to a proper and an early diagnosis. Well-honed observational skills and less reliance on various tests is important, so as to
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proceed with an unbiased diagnostic process. Early inquiry about psychological factors might curtail the ability to engage the patient. Therefore, not overburdening the initial evaluation with a full psychiatric history is recommended. However, it is eventually important to ask questions
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about stressors (physical, emotional, sexual) and substance abuse. 22
One heuristic principle is that the more symptoms the patient has, the more likely it is
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that the primary symptom will not be due to a recognized organic disease. It is important to show early familiarity with the initial problem no matter how unusual it may seem. This is something that primary care practitioners could focus on to prevent the patient from feeling like he or she is a medical anomaly and that they are being “discarded” to some other specialist. 24 Clinicians
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should inquire about what the patient believes is wrong so that they may make a more personalized explanation later in the discussion. 26 Clearly, it is impossible to avoid all testing, because the presence of positive signs of a functional symptom does not exclude a comorbid
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underlying organic disease. 24, 26, 27 A simple, reassuring approach to preliminary testing might be to explain why they are being done and to assure that there are no underlying abnormalities
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causes, based on the physical examination. It is important, however, to warn patients about the chance of incidental findings on an MRI, for example, and that normal imaging does not exclude neurological disease. 26 Early referrals to a specialist neurologist, who has declared an interest in non-organic symptoms, can be an invaluable opportunity, as this can also help avoid having the patient undergoing unnecessary testing. It is also important to remember that a misdiagnosis after a thorough evaluation by a specialist is now known to be very unlikely. 28, 29
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Management: Since acceptance of the diagnosis of non-organic disorders is essential to treatment success, the way the diagnosis is delivered is very important. 24, 27 Using non-judgmental
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terminology that allows effective communication when the diagnosis is discussed is essential as counter-transference can be a major impediment at this stage. Some of the elements of this effective communication include telling the patient that you believe the patient and simply
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explaining what the patient does and does not have. Emphasizing that these symptoms are
common, potentially reversible, non-lethal, and that self-help is often a key element in clinical
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improvement, as well as a great way to improve trust and acceptance. We believe that such an approach improves patients’ confidence and sense of autonomy. Most patients can be easily reassured by emphasizing how the examination is normal; therefore, symptoms are most likely due to a malfunctioning neural pathway rather than a structural or a chemical defect. This also
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eliminates anxiety and unnecessary testing. Often, metaphors are extremely useful; for example, the analogy of a “computer that has a software defect than a hardware error”, or perhaps, phrases such as “symptoms are like a piano that’s out of tune,’’ or ‘‘it is like a short-circuit of the
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nervous system’’ are quite useful and lead to easy acceptance by the patients because they are non-judgmental and easy to understand 24.
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While the first step to improvement is having the patient understand the explanation
given by the specialist neurologist, we often recommend adding a psychiatrist to the treatment team to help manage previously untreated PTSD or other affective symptoms, 21 emphasizing that psychiatrists and neurologists usually work together along with the primary care providers. Telling the patient that their care is always a team approach and that all treating physicians will continue to be involved in their treatment can be useful.
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The diversity of reported therapeutic trials in medically unexplained symptoms demonstrates that multi-disciplinary collaborative care is ideal for these patients. Such treatment options include psychotherapy 31 and physical therapy. 24, 27, 32 On the other hand, acupuncture,
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hypnosis, EMG biofeedback, and repetitive transcranial magnetic stimulation seem to have no supportive literature other than anecdotal. Because of ethical considerations placebos are
generally not recommended as treatments. 21 An additional part of successful treatment is
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removal of unnecessary medications and avoidance of unnecessary tests and surgical treatments. 30
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If a patient feels that they are taken seriously, many will eventually become less defensive and open up about emotional symptoms and possible stressors. Their management involves a combination of psychotherapy, stress management, relaxation techniques, and pharmacological treatment when appropriate. 25, 31 There should be a discussion with the patient about trying an
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antidepressant, regardless of the patient’s mood or anxiety, because there is some data to suggest that SSRIs are useful in neurological medically unexplained symptoms. 27 Regardless of the therapeutic approach, the goal of treatment is to enable the patient to return to his or her previous
Prognosis:
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level of functioning. 25
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In general, at present, the prognosis for patients with medically unexplained symptoms
has been poor. Long-term follow-up studies have suggested that functional neurologic symptoms persist in most of these patients and only improve in roughly one-third. 23, 33, 34 It is not clear whether our own lack of understanding as caregivers has contributed to this. Good prognostic factors include good physical health and social life, perception of receiving good treatment, and elimination of a stressor, such as changed marital status. 22, 24 Beliefs about irreversibility or
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damage seem to be important prognostic factors and targets for treatment.35, 36 However, it is important to remember that even patients with poor prognostic factors respond well to treatment.
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Summary Medically unexplained neurological symptoms are common. They can be very disabling, and exceedingly distressing to the patients and their families. It is important to not make the diagnosis based on psychological grounds, but firmly based on positive physical signs of
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inconsistency or incongruity combined with a solid knowledge of neurological disease.
Compassionate neurologists and psychiatrists who are interested in holistically treating these
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patients, who offer careful and rational explanations of the diagnosis are in a good position to alter the trajectories of these patients, and should be important members of treatment teams in the
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management of these challenging patients.
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REFERENCES:
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1. Steinbrecher N, Koerber S, Frieser D, et al. The prevalence of medically unexplained symptoms in primary care. Psychosomatics. 2011;52(3):263-271. 2. Morriss R, Lindson N, Coupland C, et al. Estimating the prevalence of medically unexplained symptoms from primary care records. Public health. 2012;126(10):846-854. 3. Nimnuan C, Hotopf M, Wessely S. Medically unexplained symptoms: an epidemiological study in seven specialities. Journal of psychosomatic research. 2001;51(1):361-367. 4. Duncan R, Razvi S, Mulhern S. Newly presenting psychogenic nonepileptic seizures: incidence, population characteristics, and early outcome from a prospective audit of a first seizure clinic. Epilepsy & behavior : E&B. 2011;20(2):308-311. 5. Sigurdardottir KR, Olafsson E. Incidence of psychogenic seizures in adults: a populationbased study in Iceland. Epilepsia. 1998;39(7):749-752. 6. Behrouz R, Benbadis SR. Psychogenic pseudostroke. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association. 2014;23(4):e243-248. 7. Peritogiannis V, Zafiris S, Pappas D, et al. Conversion pseudodementia in the elderly: A review of the literature with case presentation. Psychogeriatrics. 2008;8(1):24-31. 8. Miyasaki JM, Sa DS, Galvez-Jimenez N, et al. Psychogenic movement disorders. 2003;30(Suppl 1):S94-S100 PB -. 9. Barsky AJ, Orav EJ, Bates DW. Somatization increases medical utilization and costs independent of psychiatric and medical comorbidity. Arch Gen Psychiatry. 2005;62(8):903910. 10. Hallett M. Psychogenic movement disorders: A crisis for neurology. Current Neurology and Neuroscience Reports. 2006;6(4):269-271. 11. Stone J, Carson A. Movement disorders: Psychogenic movement disorders: what do neurologists do? Nature reviews Neurology. 2009;5(8):415-416. 12. Hilderink PH, Collard R, Rosmalen JG, et al. How does ageing affect the impact of medically unexplained symptoms and medically explained symptoms on health-related quality of life? International journal of geriatric psychiatry. 2014. 13. Micale MS. Charcot and the idea of hysteria in the male: gender, mental science, and medical diagnosis in late nineteenth-century France. Medical history. 1990;34(4):363-411. 14. Shorvon S. Fashion and cult in neuroscience—the case of hysteria. Brain. 2007;130(12):3342-3348. 15. Cosmacini G. The long art: The history of medicine from antiquity to the present, 00. Rome Oxford University Press 1997. 16. Sigerist H. Primitive and Archaic Medicine: Oxford University Press 1951. 17. de Marneffe D. Looking and Listening: The Construction of Clinical Knowledge in Charcot and Freud Signs. 1991;17(1):71-111. 18. Hunter D. Hysteria, Psychoanalysis, and Feminism: The Case of Anna O. Feminist Studies. 1983;9(3):464-488. 19. Webster R. Why Freud Was Wrong: Sin, Science and Psychoanalysis: HarperCollins / Basic Books 1995. 20. J B. Hysteria: The Rise of an Enigma: Karger 2014. 21. Kranick SM, Gorrindo T, Hallett M. Psychogenic Movement Disorders and Motor Conversion: A Roadmap for Collaboration Between Neurology and Psychiatry. Psychosomatics. 2011;52(2):109-116.
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22. Peckham EL, Hallett M. Psychogenic movement disorders. Neurologic clinics. 2009;27(3):801-819, vii. 23. Carton S, Thompson PJ, Duncan JS. Non-epileptic seizures: patients' understanding and reaction to the diagnosis and impact on outcome. Seizure. 2003;12(5):287-294. 24. Stone J, Carson A. Functional neurologic symptoms: assessment and management. Neurologic clinics. 2011;29(1):1-18, vii. 25. Hinson VK, Haren WB. Psychogenic movement disorders. The Lancet Neurology. 2006;5(8):695-700. 26. Stone J. The bare essentials: Functional symptoms in neurology. Practical neurology. 2009;9(3):179-189. 27. Stone J, Carson A, Sharpe M. Functional symptoms in neurology: management. Journal of neurology, neurosurgery, and psychiatry. 2005;76 Suppl 1:i13-21. 28. Stone J, Hewett R, Carson A, et al. The ‘disappearance’ of hysteria: historical mystery or illusion? Journal of the Royal Society of Medicine. 2008;101(1):12-18. 29. Stone J, Smyth R, Carson A, et al. Systematic review of misdiagnosis of conversion symptoms and "hysteria". BMJ (Clinical research ed). 2005;331(7523):989. 30. Edwards MJ, Bhatia KP. Functional (psychogenic) movement disorders: merging mind and brain. The Lancet Neurology. 2012;11(3):250-260. 31. Abbass A, Kisely S, Kroenke K. Short-term psychodynamic psychotherapy for somatic disorders. Systematic review and meta-analysis of clinical trials. Psychotherapy and psychosomatics. 2009;78(5):265-274. 32. Edwards MJ, Stone J, Nielsen G. Physiotherapists and patients with functional (psychogenic) motor symptoms: a survey of attitudes and interest. Journal of neurology, neurosurgery, and psychiatry. 2012;83(6):655-658. 33. Jankovic J, Vuong KD, Thomas M. Psychogenic tremor: long-term outcome. 2006;11:501508 PB -. 34. Stone J, Sharpe M, Rothwell PM, et al. The 12 year prognosis of unilateral functional weakness and sensory disturbance. Journal of neurology, neurosurgery, and psychiatry. 2003;74(5):591-596. 35. Sharpe M, Stone J, Hibberd C, et al. Neurology out-patients with symptoms unexplained by disease: illness beliefs and financial benefits predict 1-year outcome. Psychological medicine. 2010;40(4):689-698. 36. Stone J, Carson A, Duncan R, et al. Symptoms 'unexplained by organic disease' in 1144 new neurology out-patients: how often does the diagnosis change at follow-up? Brain. 2009;132(Pt 10):2878-2888.
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Figure Legend Figure 1: Overlap between terminologies
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Figure 2: Examples of useful clinical examination findings seen in patients with neurological symptoms of non-organic origin
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Table 1: Characteristic features of many different kinds of medically unexplainable, non-organic neurological symptoms Inconsistent amplitude and frequency Disappearance when patient is distracted Tremor Absence of finger tremor Entrainment (tremor assumes the same frequency and rhythmicity of an external repetitive rhythm produced by the examiner) Inconsistent sustained movements over time Incongruous postures Dystonia Complaints of more pain than discomfort Early or initial lower extremity leg involvement
PseudoStrokes
Clinically, stroke like symptoms without any radiologic evidence of infarction on MRI
Parkinsonism
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Non-epileptic Seizures
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Myoclonus
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Gait
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Pseudodementia
Patient does not seem to adapt efficiently to gait problem (uneconomic postures, astasia-abasia:) Momentary fluctuation of gait and stance Excessive slowness Sudden buckling of knees without falls Normal limb power and sensation lying down, but inability to stand and walk Changing pattern of frequency, amplitude, and anatomic distribution Presence of a Bereitschaft potential (BP) before the movement: electroencephalogram and back averaging according to an electromyogram - the presence of a BP indicates that the voluntary motor system is being used for movement Maximum disability early in the disease course Excessive slowness Signs and symptoms worsening with emotional upset Functional resting tremor most likely present Stiffness present, with a quality of active resistance No cogwheel or axial rigidity Often, astasia-abasia (see above) Often, eyes shut during the event, resistant to opening Duration >2 sec Asynchronous, semi-purposeful limb movements Tongue biting usually only at the tip Side-to-side head shaking Prolonged atonia Incongruity between behavior in unstructured situations and conversations vs. performance on formal mental state evaluation, particularly in patients who are depressed
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Table 2: Features from the history suggestive of symptoms of non-organic etiology
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Precipitating event Abrupt onset/sudden remission of symptoms, evolution in to other symptoms over time Rapid progression to a maximum intensity within a very short time Inconsistent character in amplitude, frequency, or distribution over time Comorbid psychiatric disturbances, such as anxiety, depression, or multiple somatizations
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Table 3: Physical exam maneuvers used to diagnose functional neurological disorders
Postural Testing
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The Chair Test
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The Hoover Sign
The patient lies supine and places the heel of the weak leg into the examiner’s hand. When the patient is asked to push down, little or no movement occurs. Next, the opposite/strong leg is flexed at the hip. A positive sign indicates that with counter pressure, hip extension is noted on the weak leg. A positive postural test would show bizarre or extreme responses when the patient is pulled backward by the examiner. This test helps diagnose patients with a functional gait disorder. The patient is first asked to “walk” while seated in a chair with wheels. Then, the patient is asked to walk the same distance. Patients with functional gait disturbances will have difficultly walking, but will typically “walk” the chair without a problem. Patients with organic gait disorders have difficulty performing both tasks.
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Clinical Significance: •
Neurological symptoms of non-organic etiology in clinical practice are common and greatly diminish patient quality of life. Important aspects of making a proper positive diagnosis are the history and examination with recognition of incongruent clinical clues.
Heuristic principles in the management of these patients include non-judgmental empathy,
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avoidance of unnecessary testing, using metaphors to help explain, and utilizing cognitive
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therapy, SSRIs, and physical therapy.
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•
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•
S0002-9343(15)00352-6
DOI:
10.1016/j.amjmed.2015.03.030
Reference:
AJM 12957
To appear in:
The American Journal of Medicine
Received Date: 12 March 2015 Revised Date:
17 March 2015
Accepted Date: 18 March 2015
Please cite this article as: Evens A, Vendetta L, Krebs K, Herath P, Medically-Unexplained Neurological Symptoms: A Primer for Physicians Who Make the Initial Encounter, The American Journal of Medicine (2015), doi: 10.1016/j.amjmed.2015.03.030. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Running Header: Psychogenic symptoms in general practice, Evans et al
MEDICALLY-UNEXPLAINED NEUROLOGICAL SYMPTOMS: A PRIMER FOR PHYSICIANS WHO MAKE THE INITIAL ENCOUNTER
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Ashley Evens BS1, Lindsay Vendetta BS1, Kaitlin Krebs BA2, & Priyantha Herath MD PhD2
School of Medicine, University of South Carolina, Columbia SC,
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6311 Garners Ferry Road Columbia, SC, 29209, USA.
2
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([email protected], [email protected])
Movement Disorders Program, Dept. of Neurology,
School of Medicine, University of South Carolina, Columbia SC
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8 Medical Park Road, Suite 420, Columbia, SC, 29203, USA.
Corresponding Author: Priyantha Herath MD PhD Director, Movement Disorders Program, Dept. of Neurology,
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8 Medical Park Road, Suite 420, Columbia, SC, 29203, USA. +1(803)545-6050. ([email protected])
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Funding Source: None Conflict of Interest: None Authorship: All authors had access to the data and a substantive role in writing the manuscript. Article Type: Review Key Words: Medically unexplained symptoms; Functional neurological Disorders; Movement Disorder; Psychogenic symptoms; Management Running header: psychogenic symptoms in general practice
ACCEPTED MANUSCRIPT Running Header: Psychogenic symptoms in general practice, Evans et al
Abstract: Medically unexplained symptoms are ubiquitous in clinical practice. Medical utilization costs of medically unexplained symptoms are projected at about $256 billion/year. When initially seen, these symptoms are often baffling, not only to the patients but also to the
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physicians who encounter them. Because of this, properly diagnosis them is generally seen as difficult at best, leading to massive overuse of unnecessary testing. Subsequently, their
management can also be cumbersome. All this burdens these patients with unnecessary costs,
SC
financially as well as emotionally. This primer discusses historical perspectives of these as well as the changing nomenclature, and outlines how to think about these complex symptoms and
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neurological findings that will enable a positive diagnosis rather than a diagnosis of exclusion. We also offer useful heuristic principles of their management so that the physician-patient relationships can be better maintained, and the quality of life of these patients can be improved
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by way of some simple, economical approaches.
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Introduction Many physicians encounter patients with symptoms not compatible with known anatomic and physiologic principles. Such symptoms tend to be baffling in their presentation and can test
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the best diagnosticians. Some reports estimate the incidence of medically unexplained symptoms to be about 22% of all reported symptoms at a primary care setting 1 and up to about 30% in some of the specialized tertiary care neurology clinics. 1-3 While many of these symptoms
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medically unexplained symptoms tend to be neurological in nature, they occur in all medical specialties3. Some examples include irritable bowel syndrome, fibromyalgia, chronic pelvic pain,
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and Globus hystericus, pseudo-seizures 4, 5 stroke mimics 6 and some types of amnesia 7, as well as abnormal movements. 8 Such medically unexplained functional movement disorders are one of the most prevalent disorders seen in neurological clinics.
An estimate of medical utilization costs of all different types of medically unexplained
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symptoms is said be about $256 billion/year. 9 The annual cost of functional movement disorders alone (which are only a small portion of the neurological symptoms of non-organic etiology) to the US healthcare is estimated to be over $ 20 billion, assuming that these symptoms represent
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10% of all medical costs. In neurology for example, movement disorder of non-organic disorders are so common enough that they are now referred to as a “crisis for neurology”.10
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At present, very little is known about the pathophysiological mechanisms of medically
unexplained symptoms. Because of this, it is often assumed that patients with medically unexplained symptoms s “make up their symptoms [for secondary gain].” 11 This leads to stigmatization of many patients who legitimately suffer from inexplicable and complex symptoms. In general, the evaluation and management of these patients is felt to be frustrating and unrewarding, and there is a prevailing, if anecdotal sense that “they take time away from
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those who really need our care” (personal communication, Herath). Because medically unexplained symptoms often occupy a gray area between the several medical specialties, for example, between neurology and psychiatry, no one is willing to take charge of the patient,
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leading to even more complex and difficult interactions —and because of this, patients may receive inadequate care, inappropriate and excessive “diagnostic” testing, dangerous or
ineffective therapies and multiple, often unnecessary referrals. As such these cases are very
have detrimental effects on patient’s quality of life. 12
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costly to everyone including the health care systems at large. In addition, non-organic disorders
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The purpose of this paper is to illuminate the current state of understanding of medically unexplained symptoms, and to establish basic heuristic principles of their management. It is important that clinicians take an interest in medically unexplained symptoms not only because an enormous amount of healthcare and quality of life costs are associated with them, but also
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because these patients often present in a primary care settings. A primary care practitioner, who happens to be the sentinel of these patients, must know how to listen and evaluate them based on some established principles, to arrive at a positive diagnosis, and then communicate to the
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patients what is often thought of as a difficult diagnosis. Also it is important to know when to refer to a specialist with interest in these symptoms, as this condition requires a dedicated team
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approach to maximize treatment success.
A Long History of Medically Unexplained Neurological Symptoms: The malady of inexplicable medical symptoms may have been recognized millennia ago.
The word hysteria comes has Greek roots “hystera,” which means uterus. 13, 14 Since this was originally identified in women, Greeks believed that hysteria occurs when women had
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unsatisfied sexual desires. Ancient remedies included pelvic or ovarian pressure.13 Similar symptoms have been referred to in ancient Egyptian writings as well. However, they believed this disorder occurred when the uterus had moved upward from its pelvic position to elicit odd
uterus would fall back down into place. 15, 16
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symptoms. They placed aromatic substances in women’s genital region, believing that their
Modern day concepts of hysteria came to the forefront of medicine in the late 19th
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century, when Charcot described how men too could also suffer from hysteria. With this, he attributed the illness to dysfunction of the central nervous system –that hysteria was not the
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physical result of [a traumatic episode], but the patient’s emotional response [to it]. 17 Joseph Breuer described the patient Anna O., who displayed unusual symptoms while taking care of her sick father. She developed a paralysis, headaches, intermittent deafness, visual disturbances, and temper tantrums during and after her father’s illness. 18 In order to correct her symptoms, Bruer
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asked Anna O. to recreate her memories and have a “purging” of her emotions, known as “emotional catharsis.” This was done with each of her symptoms until she was completely cured, which is a claim that has now been refuted. A few years later, Freud who was Breuer’s student,
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decided to study under Charcot, who believed hysteria was an outward symptom of an unconscious agitation. 19 Because Freud concluded that these symptoms were the result of
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repressed painful memories, he believed that listening to and observing his patients would help cure them. 13 As he did so, Freud, synthesized both Breuer’s cure and Charcot’s traumatic experience concepts to create what later became Psychoanalysis. 19 Later on, Babinski too contributed to this idea by postulating that the cause of hysteria was due to a cortical brain lesion, which he discovered by defining certain neurological signs to differentiate organic dysfunction of the central nervous system. 20
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Despite this extended history of descriptions, even today, there is no universal agreement on the nosology of these symptoms. For instance, many neurologists consider inexplicable neurological symptoms a “functional” or a “psychogenic neurological disorder”, while many
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psychiatrists discuss the possibility of a “conversion disorder” and actively seek exclusion of organic disease when they are not able to detect any psychological stressors as required by DSMIV. Given that only a modest proportion of patients report a physical or a psychologically
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traumatic event that precipitate their symptoms, it is often difficult to remember that while
assessment for emotional trauma is important, the diagnosis of a psychological etiology should
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not be withdrawn if a stressor is never found —and that long forgotten traumatic events may prompt the development of symptoms by providing a stimulus to those predisposed.
Hysterical, Functional vs. Psychogenic: How to Define Medically unexplained symptoms
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Naming a disease is no trivial issue. Everything that will subsequently happen to a patient — from conceptualization of the symptoms, to the logic behind the diagnosis and treatment— will hinge upon a precise label. Many terms have been used in an attempt to arrive at this, including
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hysteria, hypochondriasis, conversion disorder, psychogenic, and more recently, functional neurological disorder (Figure 1). At this time, there is no agreement as to which term is better,
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neither from an ontological nor a nosological standpoint. The term conversion disorder is not very useful as it provides no clinical information and
it does not allow a physiological formulation of the symptoms, leaving behind a great deal of uncertainty. Another popular term, “psychogenic symptoms” has been deemed more useful because it implies a potential clinical etiology, but it also tends to be one-dimensional. Additionally, that term fails to address the socio-biological factors that may have been
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contributory to medically unexplained symptoms, and a psychological stressor may never be found in most patients with these movement disorders. 21 Regardless, both terms are accompanied by an inherently attached stigma that often hampers communication, thereby
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limiting the acceptance by patients.11
It is in this context that the term “functional symptoms” had gained a degree of
acceptance. It denotes a physiological disturbance of the function of the nervous system and lacks
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any stigma engendered by it. However, it is argued that the term is ambiguous and is often used just to be politically correct. “Functional” also implies that structural pathology may not be
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apparent 22 and can be confusing. Despite this, studies have shown that the term “functional” is most accepted by patients, as opposed to “conversion”, “hysteria”, “medically unexplained,” or “psychosomatic”. 23, 24
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Clinical Presentation, and Diagnostic Approach:
In general, medically unexplained symptoms are most commonly seen in young women. Fairly often, they tend to have been employed in the medical profession, but no sex, age, or
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occupation is immune to this malady. Known risk factors include history of major stressful life events, sexual abuse, previous surgery, or other physical trauma. 25 The diagnosis of medically
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unexplained symptoms is in fact clinical, and relies on identifying features and patterns from the history (Table 1 and 2), and physical examination that are incongruent with organic neurological disorders.
In addition to performing a complete physical exam on these patients, there are several
bedside tests (Figure 2) that may be helpful in making a diagnosis of medically unexplainable neurological symptoms (Table 3).24
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A clear, incisive history where the patient is gently guided to characterize the details of the phenomenology of the symptoms is the most important contributor to a proper and an early diagnosis. Well-honed observational skills and less reliance on various tests is important, so as to
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proceed with an unbiased diagnostic process. Early inquiry about psychological factors might curtail the ability to engage the patient. Therefore, not overburdening the initial evaluation with a full psychiatric history is recommended. However, it is eventually important to ask questions
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about stressors (physical, emotional, sexual) and substance abuse. 22
One heuristic principle is that the more symptoms the patient has, the more likely it is
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that the primary symptom will not be due to a recognized organic disease. It is important to show early familiarity with the initial problem no matter how unusual it may seem. This is something that primary care practitioners could focus on to prevent the patient from feeling like he or she is a medical anomaly and that they are being “discarded” to some other specialist. 24 Clinicians
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should inquire about what the patient believes is wrong so that they may make a more personalized explanation later in the discussion. 26 Clearly, it is impossible to avoid all testing, because the presence of positive signs of a functional symptom does not exclude a comorbid
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underlying organic disease. 24, 26, 27 A simple, reassuring approach to preliminary testing might be to explain why they are being done and to assure that there are no underlying abnormalities
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causes, based on the physical examination. It is important, however, to warn patients about the chance of incidental findings on an MRI, for example, and that normal imaging does not exclude neurological disease. 26 Early referrals to a specialist neurologist, who has declared an interest in non-organic symptoms, can be an invaluable opportunity, as this can also help avoid having the patient undergoing unnecessary testing. It is also important to remember that a misdiagnosis after a thorough evaluation by a specialist is now known to be very unlikely. 28, 29
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Management: Since acceptance of the diagnosis of non-organic disorders is essential to treatment success, the way the diagnosis is delivered is very important. 24, 27 Using non-judgmental
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terminology that allows effective communication when the diagnosis is discussed is essential as counter-transference can be a major impediment at this stage. Some of the elements of this effective communication include telling the patient that you believe the patient and simply
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explaining what the patient does and does not have. Emphasizing that these symptoms are
common, potentially reversible, non-lethal, and that self-help is often a key element in clinical
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improvement, as well as a great way to improve trust and acceptance. We believe that such an approach improves patients’ confidence and sense of autonomy. Most patients can be easily reassured by emphasizing how the examination is normal; therefore, symptoms are most likely due to a malfunctioning neural pathway rather than a structural or a chemical defect. This also
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eliminates anxiety and unnecessary testing. Often, metaphors are extremely useful; for example, the analogy of a “computer that has a software defect than a hardware error”, or perhaps, phrases such as “symptoms are like a piano that’s out of tune,’’ or ‘‘it is like a short-circuit of the
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nervous system’’ are quite useful and lead to easy acceptance by the patients because they are non-judgmental and easy to understand 24.
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While the first step to improvement is having the patient understand the explanation
given by the specialist neurologist, we often recommend adding a psychiatrist to the treatment team to help manage previously untreated PTSD or other affective symptoms, 21 emphasizing that psychiatrists and neurologists usually work together along with the primary care providers. Telling the patient that their care is always a team approach and that all treating physicians will continue to be involved in their treatment can be useful.
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The diversity of reported therapeutic trials in medically unexplained symptoms demonstrates that multi-disciplinary collaborative care is ideal for these patients. Such treatment options include psychotherapy 31 and physical therapy. 24, 27, 32 On the other hand, acupuncture,
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hypnosis, EMG biofeedback, and repetitive transcranial magnetic stimulation seem to have no supportive literature other than anecdotal. Because of ethical considerations placebos are
generally not recommended as treatments. 21 An additional part of successful treatment is
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removal of unnecessary medications and avoidance of unnecessary tests and surgical treatments. 30
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If a patient feels that they are taken seriously, many will eventually become less defensive and open up about emotional symptoms and possible stressors. Their management involves a combination of psychotherapy, stress management, relaxation techniques, and pharmacological treatment when appropriate. 25, 31 There should be a discussion with the patient about trying an
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antidepressant, regardless of the patient’s mood or anxiety, because there is some data to suggest that SSRIs are useful in neurological medically unexplained symptoms. 27 Regardless of the therapeutic approach, the goal of treatment is to enable the patient to return to his or her previous
Prognosis:
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level of functioning. 25
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In general, at present, the prognosis for patients with medically unexplained symptoms
has been poor. Long-term follow-up studies have suggested that functional neurologic symptoms persist in most of these patients and only improve in roughly one-third. 23, 33, 34 It is not clear whether our own lack of understanding as caregivers has contributed to this. Good prognostic factors include good physical health and social life, perception of receiving good treatment, and elimination of a stressor, such as changed marital status. 22, 24 Beliefs about irreversibility or
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damage seem to be important prognostic factors and targets for treatment.35, 36 However, it is important to remember that even patients with poor prognostic factors respond well to treatment.
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Summary Medically unexplained neurological symptoms are common. They can be very disabling, and exceedingly distressing to the patients and their families. It is important to not make the diagnosis based on psychological grounds, but firmly based on positive physical signs of
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inconsistency or incongruity combined with a solid knowledge of neurological disease.
Compassionate neurologists and psychiatrists who are interested in holistically treating these
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patients, who offer careful and rational explanations of the diagnosis are in a good position to alter the trajectories of these patients, and should be important members of treatment teams in the
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management of these challenging patients.
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REFERENCES:
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1. Steinbrecher N, Koerber S, Frieser D, et al. The prevalence of medically unexplained symptoms in primary care. Psychosomatics. 2011;52(3):263-271. 2. Morriss R, Lindson N, Coupland C, et al. Estimating the prevalence of medically unexplained symptoms from primary care records. Public health. 2012;126(10):846-854. 3. Nimnuan C, Hotopf M, Wessely S. Medically unexplained symptoms: an epidemiological study in seven specialities. Journal of psychosomatic research. 2001;51(1):361-367. 4. Duncan R, Razvi S, Mulhern S. Newly presenting psychogenic nonepileptic seizures: incidence, population characteristics, and early outcome from a prospective audit of a first seizure clinic. Epilepsy & behavior : E&B. 2011;20(2):308-311. 5. Sigurdardottir KR, Olafsson E. Incidence of psychogenic seizures in adults: a populationbased study in Iceland. Epilepsia. 1998;39(7):749-752. 6. Behrouz R, Benbadis SR. Psychogenic pseudostroke. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association. 2014;23(4):e243-248. 7. Peritogiannis V, Zafiris S, Pappas D, et al. Conversion pseudodementia in the elderly: A review of the literature with case presentation. Psychogeriatrics. 2008;8(1):24-31. 8. Miyasaki JM, Sa DS, Galvez-Jimenez N, et al. Psychogenic movement disorders. 2003;30(Suppl 1):S94-S100 PB -. 9. Barsky AJ, Orav EJ, Bates DW. Somatization increases medical utilization and costs independent of psychiatric and medical comorbidity. Arch Gen Psychiatry. 2005;62(8):903910. 10. Hallett M. Psychogenic movement disorders: A crisis for neurology. Current Neurology and Neuroscience Reports. 2006;6(4):269-271. 11. Stone J, Carson A. Movement disorders: Psychogenic movement disorders: what do neurologists do? Nature reviews Neurology. 2009;5(8):415-416. 12. Hilderink PH, Collard R, Rosmalen JG, et al. How does ageing affect the impact of medically unexplained symptoms and medically explained symptoms on health-related quality of life? International journal of geriatric psychiatry. 2014. 13. Micale MS. Charcot and the idea of hysteria in the male: gender, mental science, and medical diagnosis in late nineteenth-century France. Medical history. 1990;34(4):363-411. 14. Shorvon S. Fashion and cult in neuroscience—the case of hysteria. Brain. 2007;130(12):3342-3348. 15. Cosmacini G. The long art: The history of medicine from antiquity to the present, 00. Rome Oxford University Press 1997. 16. Sigerist H. Primitive and Archaic Medicine: Oxford University Press 1951. 17. de Marneffe D. Looking and Listening: The Construction of Clinical Knowledge in Charcot and Freud Signs. 1991;17(1):71-111. 18. Hunter D. Hysteria, Psychoanalysis, and Feminism: The Case of Anna O. Feminist Studies. 1983;9(3):464-488. 19. Webster R. Why Freud Was Wrong: Sin, Science and Psychoanalysis: HarperCollins / Basic Books 1995. 20. J B. Hysteria: The Rise of an Enigma: Karger 2014. 21. Kranick SM, Gorrindo T, Hallett M. Psychogenic Movement Disorders and Motor Conversion: A Roadmap for Collaboration Between Neurology and Psychiatry. Psychosomatics. 2011;52(2):109-116.
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22. Peckham EL, Hallett M. Psychogenic movement disorders. Neurologic clinics. 2009;27(3):801-819, vii. 23. Carton S, Thompson PJ, Duncan JS. Non-epileptic seizures: patients' understanding and reaction to the diagnosis and impact on outcome. Seizure. 2003;12(5):287-294. 24. Stone J, Carson A. Functional neurologic symptoms: assessment and management. Neurologic clinics. 2011;29(1):1-18, vii. 25. Hinson VK, Haren WB. Psychogenic movement disorders. The Lancet Neurology. 2006;5(8):695-700. 26. Stone J. The bare essentials: Functional symptoms in neurology. Practical neurology. 2009;9(3):179-189. 27. Stone J, Carson A, Sharpe M. Functional symptoms in neurology: management. Journal of neurology, neurosurgery, and psychiatry. 2005;76 Suppl 1:i13-21. 28. Stone J, Hewett R, Carson A, et al. The ‘disappearance’ of hysteria: historical mystery or illusion? Journal of the Royal Society of Medicine. 2008;101(1):12-18. 29. Stone J, Smyth R, Carson A, et al. Systematic review of misdiagnosis of conversion symptoms and "hysteria". BMJ (Clinical research ed). 2005;331(7523):989. 30. Edwards MJ, Bhatia KP. Functional (psychogenic) movement disorders: merging mind and brain. The Lancet Neurology. 2012;11(3):250-260. 31. Abbass A, Kisely S, Kroenke K. Short-term psychodynamic psychotherapy for somatic disorders. Systematic review and meta-analysis of clinical trials. Psychotherapy and psychosomatics. 2009;78(5):265-274. 32. Edwards MJ, Stone J, Nielsen G. Physiotherapists and patients with functional (psychogenic) motor symptoms: a survey of attitudes and interest. Journal of neurology, neurosurgery, and psychiatry. 2012;83(6):655-658. 33. Jankovic J, Vuong KD, Thomas M. Psychogenic tremor: long-term outcome. 2006;11:501508 PB -. 34. Stone J, Sharpe M, Rothwell PM, et al. The 12 year prognosis of unilateral functional weakness and sensory disturbance. Journal of neurology, neurosurgery, and psychiatry. 2003;74(5):591-596. 35. Sharpe M, Stone J, Hibberd C, et al. Neurology out-patients with symptoms unexplained by disease: illness beliefs and financial benefits predict 1-year outcome. Psychological medicine. 2010;40(4):689-698. 36. Stone J, Carson A, Duncan R, et al. Symptoms 'unexplained by organic disease' in 1144 new neurology out-patients: how often does the diagnosis change at follow-up? Brain. 2009;132(Pt 10):2878-2888.
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Figure Legend Figure 1: Overlap between terminologies
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Figure 2: Examples of useful clinical examination findings seen in patients with neurological symptoms of non-organic origin
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Table 1: Characteristic features of many different kinds of medically unexplainable, non-organic neurological symptoms Inconsistent amplitude and frequency Disappearance when patient is distracted Tremor Absence of finger tremor Entrainment (tremor assumes the same frequency and rhythmicity of an external repetitive rhythm produced by the examiner) Inconsistent sustained movements over time Incongruous postures Dystonia Complaints of more pain than discomfort Early or initial lower extremity leg involvement
PseudoStrokes
Clinically, stroke like symptoms without any radiologic evidence of infarction on MRI
Parkinsonism
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Non-epileptic Seizures
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Myoclonus
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Gait
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Pseudodementia
Patient does not seem to adapt efficiently to gait problem (uneconomic postures, astasia-abasia:) Momentary fluctuation of gait and stance Excessive slowness Sudden buckling of knees without falls Normal limb power and sensation lying down, but inability to stand and walk Changing pattern of frequency, amplitude, and anatomic distribution Presence of a Bereitschaft potential (BP) before the movement: electroencephalogram and back averaging according to an electromyogram - the presence of a BP indicates that the voluntary motor system is being used for movement Maximum disability early in the disease course Excessive slowness Signs and symptoms worsening with emotional upset Functional resting tremor most likely present Stiffness present, with a quality of active resistance No cogwheel or axial rigidity Often, astasia-abasia (see above) Often, eyes shut during the event, resistant to opening Duration >2 sec Asynchronous, semi-purposeful limb movements Tongue biting usually only at the tip Side-to-side head shaking Prolonged atonia Incongruity between behavior in unstructured situations and conversations vs. performance on formal mental state evaluation, particularly in patients who are depressed
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Table 2: Features from the history suggestive of symptoms of non-organic etiology
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Precipitating event Abrupt onset/sudden remission of symptoms, evolution in to other symptoms over time Rapid progression to a maximum intensity within a very short time Inconsistent character in amplitude, frequency, or distribution over time Comorbid psychiatric disturbances, such as anxiety, depression, or multiple somatizations
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Table 3: Physical exam maneuvers used to diagnose functional neurological disorders
Postural Testing
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The Chair Test
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The Hoover Sign
The patient lies supine and places the heel of the weak leg into the examiner’s hand. When the patient is asked to push down, little or no movement occurs. Next, the opposite/strong leg is flexed at the hip. A positive sign indicates that with counter pressure, hip extension is noted on the weak leg. A positive postural test would show bizarre or extreme responses when the patient is pulled backward by the examiner. This test helps diagnose patients with a functional gait disorder. The patient is first asked to “walk” while seated in a chair with wheels. Then, the patient is asked to walk the same distance. Patients with functional gait disturbances will have difficultly walking, but will typically “walk” the chair without a problem. Patients with organic gait disorders have difficulty performing both tasks.
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Clinical Significance: •
Neurological symptoms of non-organic etiology in clinical practice are common and greatly diminish patient quality of life. Important aspects of making a proper positive diagnosis are the history and examination with recognition of incongruent clinical clues.
Heuristic principles in the management of these patients include non-judgmental empathy,
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avoidance of unnecessary testing, using metaphors to help explain, and utilizing cognitive
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therapy, SSRIs, and physical therapy.
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