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  1. What is the psychiatric differential diagnosis for patients with unexplained physical symptoms?

  2. How can factitious disorder (Münchausen syndrome) be differentiated from malingering?

  3. What is conversion disorder, and how is this different from factitious disorder?

  4. What are the best practices in the care of patients with Münchausen syndrome and related conditions?

Patients who present with multiple unexplained somatic symptoms pose a significant diagnostic and management challenge for any physician. Such patients are common in medical settings, representing approximately one-third of primary care patients. The most common presenting symptoms include chest pain, fatigue, headache, and dizziness; when such symptoms go unexplained the work-up can involve unnecessary—and even dangerous—tests and procedures, as well as substantial medical cost. Figure 231-1 provides a diagnostic algorithm to assist in the evaluation of a patient who presents with multiple unexplained somatic symptoms.

Figure 231-1

Diagnostic considerations in the patient with multiple unexplained symptoms.

Table 231-1 outlines the major tenets of the approach to patients with multiple unexplained somatic symptoms. Before one meets with the patient, it may be helpful to consider that the individual may be difficult to interview (eg, providing a vague and/or elusive history, or being argumentative or hostile). The specific approach to a given patient with multiple symptoms depends largely on the type of physical complaints for which the patient presents. However, regardless of the chief complaint, a thorough history is critical to the evaluation of true medical and neurologic illnesses; importantly, this interview should not be conducted while one is performing the physical examination. The medical history in such a patient helps the practitioner to determine if the patient is actually experiencing the symptom reported, if the symptom has been exaggerated or feigned (eg, as in factitious illness and malingering), if there is a pathophysiological basis for the medical or neurologic complaints, if there is a characteristic pattern of symptoms, and if the patient meets criteria for a somatoform disorder.

Table 231-1 A Diagnostic Approach to the Patient Who Presents with Multiple Unexplained Somatic Symptoms

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