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
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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
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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
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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
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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?
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Examination
Complete examination
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Etiology
Genetic
Childhood sexual abuse
Physical distress rewarded
Stressor
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Course and prognosis
Waxing and waning
Chronic
Conversion can resolve on its own
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Is there a role of pharmacotherapy
When co-existing psychological disorders ameniable to medications
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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
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