Medically unexplained symptoms and bodily distress

Question 1

Medically unexplained symptoms are those that cause a patient some form of physical or psychological symptoms, but cannot be explained by standard tests and patients do not present to health care professionals. Why is this important?

1 - has significant cost implications
2 - can cause significant stress
3 - can cause loss of functioning for the individual
4 - high use of healthcare settings to try and diagnose the symptoms
5 - all of the above

Answer 1

5 - all of the above
- estimated to affect 1in 5, but this is though to be much higher

Question 2

Which of the following is NOT a predisposing risk factors for developing medically unexplained symptoms?

1 - Parental ill health during childhood
2 - Illness during childhood
3 - Childhood adversity or abuse
4 - Personality traits
5 - Gender
6 - Having a long-term condition
7 - Family history of a long-term condition
8 - all of the above

Answer 2

7 - all of the above
- for example a patient with MS may be more sensitive to symptoms than other patients, such as abnormal pins and needles

Question 3

Which of the following is NOT a precipitating risk factors for developing medically unexplained symptoms?

1 - Infection
2 - Physical illness
3 - Trauma
4 - Psychosocial stressors
5 - Occupation
6 - Lack of sleep
6 - all of the above

Answer 3

6 - all of the above
- these are all triggers that may occur that then lead to symptoms

• triggers can be a combination of biopsychosocial

Question 4

Which of the following is NOT a perpetuating risk factors for developing medically unexplained symptoms?

1 - physiological (sleep disruption)
2 - social (loss of role, i.e. retired)
3 - depressive episodes
4 - cognitive (catastrophising)
5 - behavioural (avoidance behaviours)

Answer 4

3 - depressive episodes

Question 5

What % of patients with medically unexplained symptoms also have a mental disorder such as anxiety or depression?

1 - 5%
2 - 25%
3 - 50%
4 - >75%

Answer 5

3 - 50%

Question 6

Can having a physical diagnosis such as an MI increase the chance of medically unexplained symptoms?

Answer 6

• yes

Question 7

Although there is no specific guidelines on treating patients with medically unexplained symptoms, which of the following could be used?

1 - Sleep hygiene
2 - Treat co-existing psychiatric disorders
3 - Managing physical
4 - Address stress management
5 - General health/diet/exercise advice
6 - Antidepressants
7 - Psychological therapy (CBT)
8 - all of the above

Answer 7

8 - all of the above
- key os to focus on modifiable maintaining factors

Question 8

According to the ICD-11, which 2 of the following would come under the Disorders of bodily distress or bodily experience?

1 - bodily distress disorder
2 - hypochondriasis
3 - body dysmorphic disorder
4 - bodily integrity disorder

Answer 8

1 - bodily distress disorder
4 - bodily integrity disorder

Question 9

Bodily distress disorder (BDD) is a new diagnosis from ICD-11 that comes under the category Disorders of bodily distress or bodily experience. Which of the following provides the appropriate explanation of BDD?

1 - bodily symptoms that are distressing and persistent
2 - excessive attention directed toward the symptoms
3 - symptoms can manifest by repeated contact with health care providers
4 - all of the above

Answer 9

4 - all of the above

• typically appropriate clinical investigation and reassurance do not the help

Question 10

Bodily integrity disorder (BID) is a new diagnosis from ICD-11 that comes under the category Disorders of bodily distress or bodily experience. Which 2 of the following provides the appropriate explanation of BID?

1 - intense, persistent desire to become physically disabled in a significant way (e.g. major limb amputation)
2 - harmful consequences from desire to become disabled such as preoccupation with desire, harm to functioning, or attempts to become disabled resulting in damage to health
3 - bodily symptoms that are distressing and persistent
4 - excessive attention directed toward the symptoms

Answer 10

1 - intense, persistent desire to become physically disabled in a significant way (e.g. major limb amputation)
2 - harmful consequences from desire to become disabled such as preoccupation with desire, harm to functioning, or attempts to become disabled resulting in damage to health

• essentially patient wants to become disabled, and this desire has associated risks to the patients health

Question 11

Dissociative neurological symptom disorder (DNSD) is a new diagnosis of the ICD-11 that comes under the category Dissociative disorders, which is essentially a disconnection between you and something. Which of the following is NOT part of the DNSD diagnosis criteria of ICD-11?

1 - patient has motor, sensory or cognitive symptoms
2 - patient has an involuntary disconnect in the normal integration of motor, sensory or cognitive functions
3 - symptoms last at least several hours
4 - clinical findings are consistent with a recognised disease of the nervous system (eg a stroke), other medical condition (eg head injury) or mental disorder
5 - functional disorder must be present
6 - not due to the effects of a substance/medication/other disorder

Answer 11

4 - clinical findings are consistent with a recognised disease of the nervous system (eg a stroke), other medical condition (eg head injury) or mental disorder

• typically symptoms do NOT align with clinical findings and cannot be explained by investigations

Question 12

Dissociative neurological symptom disorder (DNSD) is a new diagnosis of the ICD-11 that comes under the category Dissociative disorders, which is essentially a disconnection between you and something. One sign used when trying to diagnose a patient with DNSD according to the diagnosis criteria of ICD-11 is the Hoover sign. What is this sign used for?

1 - able to differentiate between cardiac chest pain no chest pain
2 - able to differentiate between fibromyalgia and RA
3 - able to differentiate between organic and functional weakness in lower limbs
4 - all of the above

Answer 12

3 - able to differentiate between organic and functional weakness in lower limbs

• functional = damage to peroneal nerve causing weakness in dorsiflexors
• organic = weakness of dorsiflexors but no clear cause of weakness based on clinical investigation

Question 13

Hypochondriasis is a new diagnosis of the ICD-11 that comes under the category of Obsessive-compulsive
or related disorders. Which of the following is NOT part of the diagnostic criteria according to ICD-11 for Hypochondriasis?

1 - persistent preoccupation or fear about the possibility of having one or more serious, progressive or life-threatening illness (symptoms are likely to be absent)
2 - repetitive, excessive health-related behaviours (eg checking for evidence of illness, excessive searching for information about the illness, repeatedly seeking reassurance, eg by arranging multiple medical consultations)
3 - maladaptive avoidance behaviour related to health (eg avoiding medical appointments)
4 - no distress or significant functional impairment required

Answer 13

4 - no distress or significant functional impairment required

• this is incorrect
• for any of these types of diagnoses there musty be significant distress and functional impairment

Question 14

Do patients with Hypochondriasis have any insight?

Answer 14

• yes
• can be variable though and some may have not accept this

Question 15

Which 2 of the following can be used to treat patients with Hypochondriasis?

1 - SSRI to treat the anxiety
2 - Deep brain stimulation
3 - Cardioversion
4 - Psychological therapy (CBT)

Answer 15

1 - SSRI to treat the anxiety
4 - Psychological therapy (CBT)

Question 16

Which of the following categories according to the new ICD-11 guidelines does Body dysmorphic disorder fit into?

1 - Disorders of bodily distress
or bodily experience
2 - Dissociative disorders
3 - Obsessive-compulsive
or related disorders
4 - Factitious disorder

Answer 16

3 - Obsessive-compulsive
or related disorders

• patients obsess about their appearance and often demand plastic surgery

Question 17

In all of the different categories below, which one is associated with an intention to the action that they are presenting with?

1 - Disorders of bodily distress
or bodily experience
2 - Dissociative disorders
3 - Obsessive-compulsive
or related disorders
4 - Factitious disorder

Answer 17

4 - Factitious disorder
- these patients make up symptoms and stories

Question 18

Factitious means to artificially create or develop something. Imposed on self is a new diagnosis according to ICD-11 that comes under the category of Factitious disorders. Which of the following is NOT part of the diagnostic criteria for imposed on self according to ICD-11?

1 - intentional feigning, falsifying, inducing or aggravating symptoms
2 - symptoms are only medical or psychological symptoms
3 - act on oneself Or imposed on another person (usually a child dependent)
4 - associated with identified deception, but not always motivated by external reward such as money or time off work
5 - seek treatment or otherwise present themselves as unwell

Answer 18

2 - symptoms are only medical or psychological symptoms
- symptoms can be medical or psychological

Question 19

Factitious means to artificially create or develop something. Imposed on self is a new diagnosis according to ICD-11 that comes under the category of Factitious disorders. What was factitious disorders previously referred to as?

1 - Munchausen syndrome

Question 19

Factitious means to artificially create or develop something. Imposed on self is a new diagnosis according to ICD-11 that comes under the category of Factitious disorders. What was factitious disorders previously referred to as?

1 - Munchausen syndrome
2 - Hypochondriasis
3 - Malingering
4 - Body dysmorphic disorder

Answer 19

1 - Munchausen syndrome

Question 20

Factitious means to artificially create or develop something.

• Imposed on self = you say the problem is about yourself (munchausen syndrome)
• Imposed on others = you say someone close to you has a problem, such as your children (munchausen syndrome by proxy)

When considering imposed on others, why is this dangerous?

1 - often involves children and is a form of child abuse
2 - high mortality rate
3 - difficult to detect
4 - all of the above

Answer 20

4 - all of the above

Question 21

What is Malingering?

1 - feigning physical or psychological symptoms with no motivation for external reward
2 - feigning physical or psychological symptoms with motivation for external reward
3 - exacerbating medical physical or psychological symptoms with no motivation for external reward
4 - exacerbating medical physical or psychological symptoms with motivation for external reward

Answer 21

2 - feigning physical or psychological symptoms with motivation for external reward
- reward may be money, drugs, avoiding criminal prosecution or time off work

• the key difference between this and Factitious disorder is the motivation for reward, or lack of motivation