Unexplained medical symptoms (including chronic fatigue)

Unexplained medical symptoms (including
chronic fatigue)
Unexplained medical symptoms - F45.0 including chronic fatigue - F48.0 *†
*The current ICD-10 classification does not distinguish between adults and adolescents. † Click here for a
discussion of coding of chronic fatigue.
Presenting complaints
• Recurrent physical complaints unexplained by a medical disorder.
• Common symptoms are abdominal pains, headaches, muscle and joint pains.
• Less commonly seen is an inability to control or lack of sensitivity in parts of the body, sensory
deficits, sudden and unexpected spasmodic movements resembling epileptic seizures.
• Fatigue is commonly associated with other unexplained symptoms or sometimes it can be the
main presenting symptom.
Diagnostic features
• There are recurrent, persistent, medically and psychiatrically unexplained physical symptoms.
• There are often several simultaneous physical symptoms.
• There may be marked sleep and appetite changes.
• Children with chronic fatigue children are tired, easily fatigued and exhibit a poor response to rest.
• There is impairment resulting from symptoms, most noticeably school absence.
• There are frequently associated mood or behavioural changes or full co-morbid psychiatric (often
emotional [anxiety, depressive]) disorders.
• Pain and chronic fatigue can last for months or years.
• Sudden loss of movement may have a more acute course.
• It often follows a trigger illness (eg an episode of diarrhoea and vomiting leading to recurrent
abdominal pains; trauma in loss of movement; a ‘flu’-type infection or Epstein-Barr virus infection
in chronic fatigue).
• There may be parental concern about the symptoms and medical consultations.
• Any child who has missed 15 school days in a month should have the cause assessed.
Differential diagnosis
• A full history and physical examination are necessary. Referral to specialist paediatric services
will be required when indicated medically, in protracted cases and in severely impaired children.
• Investigations are as for adult guidelines, to exclude an explanatory medical disorder. For
example, investigations for chronic fatigue should include full blood count, CRP (or ESR), thyroid

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function tests, urea and electrolytes, blood sugar and liver function tests, tests for glandular fever.
If clinically indicated, screening for gluten-sensitive enteropathy or autoimmune disease might be
helpful.]
• School phobia (phobic anxiety disorder).
• Generalized anxiety - F41.1 (adult) and/or Panic disorder - F41.0 (adult)
• Depressive disorder- F32#
• Eating disorders - F50
Essential information for patient and family
• Recurrent unexplained physical symptoms (eg headaches, abdominal pains and fatigue) are very
frequent in children and adolescents (about 10% in the general population). Severely
incapacitating problems are far less common.
• Few children develop explanatory physical illness at a later stage
• Encouraging maintenance of or gradual resumption of normal activities is helpful
General management and advice to patient and family
• The fact that the symptoms are not an indication of medical illness does not mean that they are
not real or only ‘in the child's mind’.
• Explore carefully what the child and parents think about what the symptoms mean and give
detailed explanations about what illness the child does NOT have.
• Enquire about any perceived stresses to the child in school (working too hard, putting themselves
under pressure, preoccupied with criticism from teachers or unsympathetic pupils, occasionally
bulling) and at home (discord, separations, other stresses).
• Help the child and family look for solutions for the above (including relief of school pressure), as
this can help towards recovery.
• Understand parental concerns about the child.
• Support the development of a regular sleep routine and dietary advice, when appropriate.
• Encourage reduction of attention (verbal and non-verbal) to physical symptoms and an increase
in joint pleasant and enjoyable activities.
• Relaxation exercises can be helpful with symptoms such as headaches.
• Emphasize the importance of gradual re-integration to school (total or gradually increasing).
Some sort of educational support is often indicated, and home tuition may be appropriate; if so, it
is usually short term.
• Encourage parents to bring the child to surgery if in doubt about symptoms rather than missing
school.
Medication
• SSRIs are suitable, if there is associated depression or incapacitating anxiety.

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• The usual pain-relieving agents can be helpful sometimes.
Liaison and referral
• Liaison with school and/or educational department is often helpful.
• Community therapists (eg physiotherapists or local pain services) might be helpful in some cases.
• Refer to paediatric services when further medication investigations and opinion are required, and
in protracted or incapacitating cases.
• Refer to Child and Adolescent Mental Health Services, ideally liaison psychiatric services if
available, if there is suspected:
- co-morbid psychiatric disorders
- suicidal risk
- no improvement despite the above measures.
Resources for patients and families
Association of Young People with ME (AYME) 01908 373 300
Email: info@ayme.org.uk; website: http://www.ayme.org.uk
Gives support and advice to young people with ME.
Chronic Fatigue Syndrome: A Clinical Perspective. A Sonkey and MJJ Thompson, University of
Southampton, distributed by Oxford Education Resources Ltd., PO Box 106, Kidlington, Oxford OX5 1JY;
website: http://www.oer.co.uk.
Video. Young people affected by Chronic fatigue syndrome and their parents describe the condition.
Specialists explain what causes the condition, and why it can be so difficult to diagnose. The successful
multidisciplinary regime adopted by Southampton is described; this combines a steady controlled
increase in physical and mental activity, a structured daily timetable and a graded exercise programme,
with (as appropriate) medication, cognitive behavioural therapy and family therapy.

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