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Flashcards in Patient with medically unexplained physical symptoms Deck (20):
1

In what circumstances might you consider a medically unexplained symptoms (3)

Features do not correspond with/not in accordance with known illness
Signs not present
No indication on laboratory, imaging etc

2

Broad categories of "medically unexplained"

Somatiform
Conversion
Factitious and malingering

3

Define somatiform disorders and types (3)

Symptoms are suggestive or/take form of physical illness without detectable structural/neurophysiological abnormality

Somatic symptom
Illness anxiety
Body dysmorphia

4

Define somatic symptom disorder

One + somatic symptoms->significant disruption in life
+Thoughts, feelings, behaviours
- disproportionate/persistent thoughts about the significance
- ++anxiety about health symptom
-++time and energy devoted to symptoms
State of being symptomatic >6 months

5

Common somatic complaints

• Gastrointestinal: nausea, vomiting, diarrhoea, constipation,
food intolerance, abdominal pain.
• Sexual or reproductive: loss of libido, ejaculatory or
erectile dysfunction, irregular menses, menorrhagia,
dysmenorrhoea.
• Urinary: dysuria, frequency, urinary retention,
incontinence.
• Neurological: paralysis, paraesthesia, sensory loss,
seizures, difficulty swallowing, impaired coordination
or balanc

6

Illness anxiety disorder

Preoccupation will acquiring a serious disease
Somatic complaints not present, or minor
Excessive anxiety
Excessive health related behaviours
>6 months
Not better explained by something else

7

Conversion disorder

Functional neurological symptom disorder->psychic stressors present as somatic
One + motor or sensory function
Evidence on physical exam of incompatibility
Not better explained by something else
Causes significant distress

8

Specific symptom types in conversion disorder

Weakness/Paralysis
Abnormal movement
Swallowing
Speech
Attacks/seizures
Anaesthesia/sensory
Special sensory

9

Factitious disorder on self and by proxy

Falsification of S&S, or induction of injury
Presents themselves to be ill/impaired/injured
Deception in absence of identifiable external reward
Not better explained by anything else

By proxy->when falsify illness of other

10

Malingering

Secondary gain

11

Differential diagnosis

Somatoform disorders
• Somatization disorder
• Hypochondriacal disorder (including body dysmorphic
disorder)
• Somatoform autonomic dysfunction
• Persistent somatoform pain disorder
Factitious disorder
Malingering
Other psychiatric conditions
• Anxiety disorders
• Mood disorders
• Psychotic disorders
• Dissociative disorders
Insidious multi-systemic disease

12

Possible systemic disease

SLE
MS
HIV
+PTH
Malignancy
Chronic infection

13

History

• Do you often worry about your health?
• Are you bothered by many different symptoms?
• Are you concerned you may have a serious illness?
• Are you concerned about your appearance?
• Do you find it hard to believe doctors when they tell
you that there is nothing wrong with you?

14

Examination

Complete examination

15

Etiology

Genetic
Childhood sexual abuse
Physical distress rewarded
Stressor

16

Course and prognosis

Waxing and waning
Chronic
Conversion can resolve on its own

17

Is there a role of pharmacotherapy

When co-existing psychological disorders ameniable to medications

18

Role of the GP

• Arrange to see patients at regular fixed intervals, rather than reacting to the patient’s frequent requests to be seen
• Increase support during times of stress for the patient
• Take symptoms seriously, but also encourage patients to talk about emotional problems, rather than just focusing on
physical complaints
• Limit the use of unnecessary medication, especially those that may be abused (e.g. benzodiazepines, opiates)
• Treat coexisting mental disorders (e.g. anxiety, depression)
• Limit investigations to those absolutely necessary
• Have a high threshold for referral to specialists
• If possible, arrange that patients are only seen by one or two doctors in the practice to help with containment and to
limit iatrogenic harm
• Help patients to think in terms of coping with their problem, rather than curing it
• Involve other family members and carers in the management plan
• Consider referral to a psychiatrist or psychotherapist

19

What os La Belle indifference

Inappropriate lack of concern for one's disability

20

Difference between conversion, factitious and malingering

In conversion, production of symptoms is unconscious, in the other two it is conscious.