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

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Months

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Weeks

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Women (Observed) Men (Observed) Simulated

Observed and Simulated Episode Duration Data, by Sex

Outcome of medically unexplained symptoms, incident cases

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Outcome of Unemployment, incident cases

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The outcomes of depression, medically unexplained symptoms and unemployment together

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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

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