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what is the brief diagnostic criteria for somatisation disorder?
- 1. at least 2 years of multiple variable physical SYMPTOMS for which no adequate physical explanation has been found
- 2. persistent REFUSAL to accept advice/reassurance from several Drs that there is no physical explanation for the symptoms
- 3. impairment of social/family functioning attributable to symptoms and the resulting behaviour
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what is undifferentiated somatoform disorder?
- the complete picture of somatisation disorder is not fulfilled eg not very forceful or dramatic or fewer complaints
- but must be no physical basis for symptoms
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what is hypochondriacal disorder?
- need both 1 and 2
- 1. (can be a or b)
- a) persistent belief that theatre is at least one serious PHYSICAL ILLNESS underlying the presenting symptoms even though repeated investigations and examinations have identified no adequate physical explanation,
- or
- b) a persistent preoccupation with a presumed deformity or disfigurement
- 2. persistent refusal to accept the advice and reassurance of several different doctors that there is no physical illness or abnormality underlying the symptoms
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how can you differentiate between delusional disorder and hypochondriacal disorder?
- in hypochondriacal disorder - they do not have the same FIXITY as those in depressive and schizophrenic disorders with somatic delusions.
- A disorder in which the patient is CONVINCED that he or she has an unpleasant appearance or is physically misshapen should be classified under delusional disorder
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what is persistent somatoform pain disorder?
- persistent severe and distressing pain
- not fully explained by a physiological process or physical disorder
- pain often assoc with emotional conflict or psychosocial problems of sufficient severity to suggest that they are the main causal factor
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what is factitious disorder?
- conscious faking of symptoms to deceive doctors
- may do self inflicted cuts or injection of toxic substances or put blood in urine sample
- patient is aware of deception but little or no insight into motives
- motive is to stay in sick role
- usually assoc with marked abnormalities of personality or relationships
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what is munchausen syndrome?
- form of factitious disorder 'hospital addiction'
- totally invented history
- usually present as emergency eg acute abdomen or haemetemesis
- may give false name
- aim to have intervention eg major surgery and often have multiple scars
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what is munchausen by proxy?
- form of factitious disorder
- carer or parent fabricates illness symptom in a child or vulnerable adult
- form of child abuse
- can cause death of child!
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what is malingering?
- faked illness where subject is conscious BOTH of making up symptoms and purpose or nature of potential gain
- eg benefits or medical discharge from work
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what is dissociative (conversion) disorder?
- usually acute
- after major stress
- often dramatic eg fits, amnesia, blindness
- patients convert an unbearable emotion into a physical phenomenon eg really stressed and then claims she's paralysed but clearly isn't
- patients often not distressed by their symptoms - belle indifference
- the disorder may reduce initial psychological distress or also have secondary gains
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how is factitious disorder different from dissociative (conversion) disorder?
- factitious: conscious
- dissociative: unconscious
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in factitious disorder are patients conscious that symptoms are not of physical origin?
yes
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in factitious disorder are patients aware of motivation?
no
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in malingering are patients conscious that symptoms are not of physical origin?
yes
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in malingering are patients aware of motivation?
yes
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in conversion disorder are patients conscious that symptoms are not of physical origin?
no
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in conversion disorder are patients aware of motivation?
no
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what is the definition of a medically unexplained symptoms?
person experiences a physical symptom for which NO CLEAR ORGANIC PATHOLOGY is found
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what is somatisation?
person experiences and communicates psychological distress in the form of physical symptoms and seeks medical help for them
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what are predisposing factors for somatisation?
- 1. stigma or unacceptability of presenting with or acknowledging psychological distress
- 2. history of parental illness or tendency to somatise during childhood
- 3. positive reinforcement of sick role during childhood
- 4. serious physical illness or physical/mental/sexual abuse in childhood
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what are the 6 main principles of assessment in you suspect MUS?
- 1. explore pts belief systems about the symptoms
- 2. pts expectations for investigation or treatment
- 3. impact of symptoms on their life
- 4. why seeking help NOW in particular?
- 5. screen for psychological morbidity
- 6. screen for symptoms of depression (low mood, sleep, appetite, energy) and anxiety (as may indicate somatic presentation of psychological problems)
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what is the way of assessing chronic MUS?
- 1. review past medical records esp if large look for recurring patterns
- 2. reassess psycho symptoms and treat
- 3. physical examination and investigation if new illness or symptoms
- remember few physical diagnoses result from further investigation more than 6/12 from 1st presentation
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what are the various management strategies for chronic somatisation?
- 1. pt coping not curing
- 2. acknowledge reality of symptoms
- 3. empowering explanations (not rejecting)
- 4. aim to broaden the agenda with the pt
- 5. proactive not reactive eg arrange regular fixed interval appt
- 6. consistent approach amongst dr - eg have 1 dr
- 7. reduce drugs
- 8. avoid over ix
- 9. CBT, relaxation
- 10. realistic goals
- 11. support to return to normal life
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what is the f:m ration in somatisation disorder?
10:1
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what is the f:m ration in hypochondriacal disorder?
1:1
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