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