Medically Unexplained symptoms Jonathan Pimm Consultant psychiatrist in primary care Primhe, Croydon Nov 2010
Jun 02, 2015
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