presentation Jonathan Pimm at Primhe Masterclass Croydon 01/11/2010

1. Medically Unexplained
symptoms
Jonathan Pimm
Consultant psychiatrist in primary
care
Primhe, Croydon Nov 2010

2. The Psychiatric Diagnoses
• Somatisation disorder
• Hypochondriasis
• Somatoform Autonomic dysfunction
• Persistent pain disorder
• Dissociation/conversion disorders
• IBS, fibromyalgia, NEADs, etc.
• Panic, anxiety, depression

3. Symptoms of GAD
Cognitive
And
Physical

4. 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.

5. Physical and drug-related disorders
• Differential diagnoses

6. 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.

7. Outcomes
• Depression
• MUSs
• UB

8. Outcome of depression, incident cases
0
20
40
60
80
100
120
0 2 4 6 8 10 12 14
Months
%sick

9. 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
ProportionRecovered
Women (Observed) Men (Observed) Simulated
Observed and Simulated Episode Duration Data, by Sex

10. Outcome of medically unexplained symptoms,
incident cases
0
20
40
60
80
100
120
0 2 4 6 8 10 12 14
Months
%sick

11. Outcome of Unemployment, incident cases
0
20
40
60
80
100
120
0 2 4 6 8 10 12 14
Months
%Unemployed

12. 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
Percentagepfindividuals

15. David Freud’s report -

16. Differential diagnoses
• Malingering
• Factitious disorder

19. 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 – predisposing
3) What has been happening that might have
triggered off the symptoms – precipitating
4) What if anything has changed since then -
perpetuating

20. Treatments
• Drugs
• Psychological

21. Treatments
• Drugs – SSRIs, NSRIs, TCAs,
pregabablin, combinations
• Psychological – primary, secondary
(psychology, Crisis Intervention Service,
Dual Diagnosis)

23. When should treatment be offered
contd.
• The other crucial component is how
motivated is the patient to attend?
• A common scenario??

24. By Tony Kendrick, professor of primary medical care

25. Will the guidelines (NICE) improve
the situation?

26. 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.

27. Final thoughts
• Research points
towards a multi-
disciplinary, case
managed approach.
• Clearly this has cost
implications.
• Layard and the future

28. 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
Percentagepfindividuals