Studies of patients referred to neurologists have consistently shown that in 10–30% of cases no anatomical or

physiological causation for symptoms can be found (Carson 2000; Allet 2006). Such symptoms, which range
from isolated non-epileptic seizures to debilitating multiple neuropathies, are frequently described as
‘functional’.

Engagement
Engagement is a key issue with patients who have medically unexplained symptoms, and a crucial factor is
finding ways of engaging them in a psychological process when they may be seeking a medical explanation and
cure. The first stage is to clarify the patient’s understanding of why they have been referred and what
they hope to achieve from attendance. It is essential that members of the treatment team make it clear they do
not think that the patients are ‘mad’ or that their symptoms are ‘all in the mind’, as these are commonly held
and understandable fears (White 1997). Usually patients will have made many attempts at trying to manage or
improve their symptoms, and although some of these behaviours may ultimately be unhelpful it is a useful
engagement tool to highlight the helpful things that they are already doing.

Session 1
During the first session the patient must be allowed time to describe how their symptoms began and how they
have affected their life. This information is then reflected back to the patient, often using the five areas
assessment model.

During sessions 5 and 6 we usually introduce cognitive techniques for managing and challenging unhelpful
thoughts. By now, patients can usually keep thought diaries with some degree of success and begin to identify
patterns of thinking such as perfectionism and expectations of themselves that are unrealistic in the face of their
current symptoms.

Sessions 7 and 8
We continue to consolidate changes that patients have managed to make in their cognitions and activity levels
or behaviours. This can often be a good time to work on assertiveness and communication skills, which patients
can find helpful when explaining their illness and how it restricts them to health professionals, employers and
family.

“The term medically unexplained symptoms names a predicament, not a specific disorder” wrote Kirmayer,
Groleau, Looper, and Dao (2004). In the papers we have reviewed it is used in three overlapping ways: (a) to
refer to the occurrence of symptoms in the absence of obvious pathology; (b) to refer to individual clinical
syndromes such as chronic fatigue syndrome (CFS) and irritable bowel syndrome (IBS); (c) to refer to a subset
of the DSM-IV somatoform disorders category.

Four groups of psychiatric disorders comprise the more severe and/or persistent presentations of medically
unexplained symptoms: somatoform disorders, factitious disorders, other psychiatric disorders (e.g.,
anxiety and depression), and malingering
Describe malingering.
The essential feature of malingering is an intentional causing or faking of physical or psychological symptoms
motivated by external incentives. Such incentives may be monetary or related to avoidance of work,
prosecution, or military service; they also may involve the goal of obtaining drugs. Several factors are
suggestive of underlying malingering. Most commonly, the symptom is complex a d o r vague, and the patient
is involved in a law suit because of an injury or accident. The discrepancy between the symptomatic
presentation and the apparent physical findings may be marked.

Describe factitious disorder.

In factitious disorder, external factors may be present, but they play a minor role in providing support or
reinforcement for symptoms. The motivation for a factitious disorder appears to derive from assuming the role
of a sick person. Factitious disorders may involve fabrication of subjective complaints,such as headache; self-
inflicted injury; and/or exaggeration of pre-existing medical conditions. Patients with factitious disorder usually
engage in some form of lying. They may present with vague, inconsistent histories, often with a dramatic flair.
Patients often have prior experience with medical routines and are knowledgeable about medical terminology.
They eagerly await work-up results, and their complaints may change with normal or negative findings. They
even ask for multiple invasive procedures. Patients usually deny any suggestion that symptoms are self-induced
or exaggerated and upon confrontation usually discharge themselves, only to appear in another emergency
department or clinic.
The onset of factitious disorder is usually in adolescence or early adulthood. Although it may involve only a
few episodes, chronic patterns often develop; in some instances, the patient travels to multiple cities-even
countries-seeking hospitalization.