Jonathan pimm 011110
Post on 02-Jun-2015
830 Views
Preview:
DESCRIPTION
Transcript
Medically Unexplained symptomsJonathan Pimm
Consultant psychiatrist in primary care
Primhe, Croydon Nov 2010
The Psychiatric Diagnoses
• Somatisation disorder• Hypochondriasis• Somatoform Autonomic dysfunction• Persistent pain disorder• Dissociation/conversion disorders• IBS, fibromyalgia, NEADs, etc.• Panic, anxiety, depression
Symptoms of GAD
Cognitive
And
Physical
Symptoms of GAD
Cognitive – concentration, indecision, losing control, fear of dying, apprehension, on edge, excessive worry etc.
And Physical – increased motor restlessness,
tremor, muscular pain, headaches, difficulty breathing, palpitations, butterflies in the stomach, increased GIT activity, and nausea, urinary symptoms etc.
Physical and drug-related disorders
• Differential diagnoses
Physical and drug-related disorders
• Differential diagnoses – endocrine, hyperthyroidism, hypercortisolaemia, hypoglycaemia, hyperparathyroidism.
• Cardiac – arrhythmias, MI, etc.• Respiratory – asthma, COPD, PE, pneumonia• Vitamin deficiencies esp. Vit B12• Epilepsy • Phaeochromocytoma• Note Alcohol, caffeine (Red Bull), cocaine etc.
Outcomes
• Depression
• MUSs
• UB
Outcome of depression, incident cases
0
20
40
60
80
100
120
0 2 4 6 8 10 12 14
Months
% s
ick
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
2 5 8
11
14
17
20
23
26
29
32
35
38
41
44
47
50
Weeks
Pro
po
rtio
n R
ec
ov
ere
d
Women (Observed) Men (Observed) Simulated
Observed and Simulated Episode Duration Data, by Sex
Outcome of medically unexplained symptoms, incident cases
0
20
40
60
80
100
120
0 2 4 6 8 10 12 14
Months
% s
ick
Outcome of Unemployment, incident cases
0
20
40
60
80
100
120
0 2 4 6 8 10 12 14
Months
% U
nem
plo
yed
The outcomes of depression, medically unexplained symptoms and unemployment together
0
20
40
60
80
100
120
0 2 4 6 8 10 12 14
Months
Per
cen
tag
e p
f in
div
idu
als
David Freud’s report -
Differential diagnoses
• Malingering• Factitious disorder
Who should be treated and when?
• A balance has to be decided upon who to treat and when?
Important to know:- 1) How long has the patient been suffering with
the complaints?2) What is the background to the onset of the
symptoms – predisposing3) What has been happening that might have
triggered off the symptoms – precipitating4) What if anything has changed since then -
perpetuating
Treatments
• Drugs
• Psychological
Treatments
• Drugs – SSRIs, NSRIs, TCAs, pregabablin, combinations
• Psychological – primary, secondary (psychology, Crisis Intervention Service, Dual Diagnosis)
When should treatment be offered contd.
• The other crucial component is how motivated is the patient to attend?
• A common scenario??
By Tony Kendrick, professor of primary medical care
Will the guidelines (NICE) improve the situation?
Neurosis should be managed like a chronic disease?
• Depression, Scott, J, BMJ 2006; 332 : 985 doi: 10.1136/bmj.332.7548.985 (Published 27 April 2006), Editorial.
Final thoughts
• Research points towards a multi-disciplinary, case managed approach.
• Clearly this has cost implications.
• Layard and the future
The outcomes of depression, medically unexplained symptoms and unemployment together
0
20
40
60
80
100
120
0 2 4 6 8 10 12 14
Months
Per
cen
tag
e p
f in
div
idu
als
top related