Jonathan pimm 011110

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

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Jonathan pimm 011110

  1. 1. Medically Unexplained symptoms Jonathan Pimm Consultant psychiatrist in primary care Primhe, Croydon Nov 2010
  2. 2. The Psychiatric Diagnoses • Somatisation disorder • Hypochondriasis • Somatoform Autonomic dysfunction • Persistent pain disorder • Dissociation/conversion disorders • IBS, fibromyalgia, NEADs, etc. • Panic, anxiety, depression
  3. 3. Symptoms of GAD Cognitive And Physical
  4. 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. 5. Physical and drug-related disorders • Differential diagnoses
  6. 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. 7. Outcomes • Depression • MUSs • UB
  8. 8. Outcome of depression, incident cases 0 20 40 60 80 100 120 0 2 4 6 8 10 12 14 Months %sick
  9. 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. 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. 11. Outcome of Unemployment, incident cases 0 20 40 60 80 100 120 0 2 4 6 8 10 12 14 Months %Unemployed
  12. 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
  13. 13. David Freud’s report -
  14. 14. Differential diagnoses • Malingering • Factitious disorder
  15. 15. 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
  16. 16. Treatments • Drugs • Psychological
  17. 17. Treatments • Drugs – SSRIs, NSRIs, TCAs, pregabablin, combinations • Psychological – primary, secondary (psychology, Crisis Intervention Service, Dual Diagnosis)
  18. 18. When should treatment be offered contd. • The other crucial component is how motivated is the patient to attend? • A common scenario??
  19. 19. By Tony Kendrick, professor of primary medical care
  20. 20. Will the guidelines (NICE) improve the situation?
  21. 21. 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.
  22. 22. Final thoughts • Research points towards a multi- disciplinary, case managed approach. • Clearly this has cost implications. • Layard and the future
  23. 23. 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

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