Patient with medically unexplained physical symptoms

Question 1

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

Answer 1

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

Question 2

Broad categories of “medically unexplained”

Answer 2

Somatiform
Conversion
Factitious and malingering

Question 3

Define somatiform disorders and types (3)

Answer 3

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

Somatic symptom
Illness anxiety
Body dysmorphia

Question 4

Define somatic symptom disorder

Answer 4

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

Question 5

Common somatic complaints

Answer 5

• 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

Question 6

Illness anxiety disorder

Answer 6

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

Question 7

Conversion disorder

Answer 7

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

Question 8

Specific symptom types in conversion disorder

Answer 8

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

Question 9

Factitious disorder on self and by proxy

Answer 9

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

Question 10

Malingering

Answer 10

Secondary gain

Question 11

Differential diagnosis

Answer 11

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

Question 12

Possible systemic disease

Answer 12

SLE
MS
HIV
\+PTH
Malignancy
Chronic infection

Question 13

History

Answer 13

• 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?

Question 14

Examination

Answer 14

Complete examination

Question 15

Etiology

Answer 15

Genetic
Childhood sexual abuse
Physical distress rewarded
Stressor

Question 16

Course and prognosis

Answer 16

Waxing and waning
Chronic
Conversion can resolve on its own

Question 17

Is there a role of pharmacotherapy

Answer 17

When co-existing psychological disorders ameniable to medications

Question 18

Role of the GP

Answer 18

• 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

Question 19

What os La Belle indifference

Answer 19

Inappropriate lack of concern for one’s disability

Question 20

Difference between conversion, factitious and malingering

Answer 20

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