Abstract
The common feature of the somatoform disorders is the presence of physical symptoms that suggest a general medical condition (that is, they have the form of a somatic disorder), but no general medical condition can be detected. Under this umbrella, the Diagnostic and Statistical Manual of Mental Disorders (4th edn; DSM-IV) groups somatization disorder, conversion disorder, pain disorder, hypo-chondriasis and body dysmorphic disorder. 1 One overlapping classification is ‘medically unexplained physical symptoms’, 2 which, in addition to somatoform disorders, includes chronic fatigue syndrome, fibromyalgia and ‘Gulf War Syndrome’. Another overlapping classification comes from the emerging field of ‘environmental medicine’, 3 and includes multiple chemical sensitivities, idiopathic environmental intolerance, sick building syndrome, candida syndrome and burnout syndrome. An important Australian work argues that repetitive strain injury is a somatoform disorder. 4 It is probable that new labels are attached to old disorders, in part, because patients refuse to accept a psychiatric diagnosis.
The question of why doctors dislike treating people with somatoform disorder is important. These are common disorders. Somatization disorder prevalence has been estimated at 0.5-1.0% 5 and 1.3%, 6 and conversion disorder is more prevalent than commonly recognized. In a recent Australian prevalence study, chronic pain was reported in 17.1% of male and 20.0% of female subjects. 7 Hypochondriasis has a prevalence of 4-9% in general medical practice and body dysmorphic disorder is probably more prevalent than previously thought. 1 The disability of such
patients is frequently great. In the Australian pain study, 7 11% of male and 13.5% of female subjects reported some degree of interference with daily activities caused by pain. Somatization disorder may result in greater functional disorder than chronic organic disease. 5 The prevalence of emotional distress among people with unexplained syndromes (such as irritable bowel syndrome) is greater than in patients with comparable medical conditions (such as inflammatory bowel diseases), 8 and the cost of treating such disorders is high. 9
Bass et al. identify four reasons why somatoform disorders are neglected. 5 First, they point out that current psychiatric diagnostic practice results in the more common presentations of somatoform disorders being relegated to poorly validated ‘undifferentiated somatoform disorders’, which have received little research attention. Second, it is suggested that clinicians and planners have a ‘current preoccupation’ with ‘serious mental illness’, which is usually taken to mean schizophrenia and bipolar disorder. Third, it is argued that most psychiatrists do not work in general hospitals and therefore have limited experience of patients with medically unexplained symptoms, and finally, it is contended that these patients believe they have a physical illness and do not seek psychiatric assistance.
We examined the related question, ‘why do doctors dislike treating people with somatoform disorder?’, hoping to contribute to discussion that is necessary for improvements in patient care.
LITERATURE AND ANALYSIS
It is common knowledge that many health professionals dislike treating patients with somatoform disorder, but for professional reasons, negative attitudes are seldom fully expressed in print. Patients with somatoform-like disorders have been characterized as querulous, self-preoccupied, irritable and difficult. 10 Depressed patients with hypochondrical features have been described as ‘demanding’. 11
Pilowsky et al. compared pain clinic patients to family medicine clinic patients using the Illness Behaviour Questionnaire. 12 They found that pain clinic patients demonstrated significantly more ‘disease conviction’ and ‘somatic preoccupation’ and were significantly more likely to ‘deny life problems unrelated to their physical problem’ than the family medicine clinic patients. Because medical practitioners frequently hold the opposing view, disagreements can be anticipated.
Fishbain et al. examined 283 chronic pain patients using the DSM-III and found that 62.3% of men and 55.1% of women met the criteria for personality disorder. 13 In a recent review of the field, Weisberg found that personality disorders are significantly greater in the pain population than in the general population or in medical or psychiatric populations. 14 Personality disorder frequently results in an ‘adverse impact on the social environment’. 15 Although health professionals have training to assist them in dealing with such impacts, they are not invincible and many find dealing with people with personality disorder to be emotionally difficult.
The confidence of doctors was shaken by eminent psychiatrist Elliot Slater in 1965. 16 Conversion disorder was regarded as the result of unconscious conflict resulting in elevated emotions that the patient could not manage. This disorder had been extensively described in the psychoanalytic literature and was not uncommonly diagnosed. Slater conducted an 8 year follow up on patients who had been diagnosed with hysteria and found that many had gone on to develop organic disorders. Hence he described hysteria as ‘a delusion and a snare’. Subsequent, more searching studies have confirmed the diagnosis of conversion disorder, 17 but the disconcerting reverberations of Slater's paper persist.
Pilowsky emphasized relevant sociological concepts. 18 He drew on the work of Parsons, who argued that the ‘sick role’ carries obligations and privileges for sick people. 19 Failure to behave in the expected manner may lead the ‘sick person’ into conflict with the community in general and with the doctor in particular.
The obligations include that the sick person must (i) accept that the role is ‘undesirable’, a role that the person would prefer to avoid; (ii) cooperate with others so as to achieve ‘health’; and (iii) utilize the services that society regards competent in diagnosis and treatment. Clinical experience is that at least some, perhaps many, somatoform patients (i) appear to ‘enjoy’ the sick role, rather than regard it as undesirable; (ii) do not cooperate in the usual manner, frequently seeking other health-care provider opinions and ceasing or varying recommended medication regimens; and (iii) ‘over-utilize’ the services the society regards as appropriate, as well as utilize others that society does not regard as being appropriate.
The privileges of the sick role include that the person is (i) not regarded as responsible for his/her state, that is, he/she is regarded as not producing this state by an act of will and is therefore not malingering/faking; (ii) accepted as someone who requires care; and (iii) entitled to exemptions from normal obligations, such as going to work. These are valuable privileges. They translate to free access to emotional, physical and financial support, benefits that ordinarily must be earned through the personal expenditure of energy.
The first privilege, that of not being held responsible for his/her current state, can be re-cast as the primary obligation, that is, the patient should not be responsible for his/her state. Once the doctor and the community accept that the ‘candidate’ sick person has not produced his/her state by an act of will, the other privileges follow.
This leads to a major reason why some doctors dislike treating people with somatoform disorders: that is, they do not believe the condition of a particular patient is beyond his/her control. A fundamental problem is that many health professionals do not believe/know that the somatoform disorders are beyond the control of patients. Given the high prevalence, financial cost and suffering of those with somatoform disorders, the failure of students and doctors to ‘get the message’ that the somatoform disorders are not within conscious control, is a major failing of the educational systems.
In the sociological context, the doctor has the role of deciding which people receive the sick role. The doctor will find this a stressful responsibility, all the more so if he/she does not understand the nature of the somatoform disorders.
The task of believing that people with somatoform disorders are not responsible for their states may be more difficult because the somatoform disorders are classified as ‘mental disorders’ and may be considered therefore to be less ‘real’ than the so-called physical disorders. In these circumstances, if the somatoform disorders could be removed from the category of mental disorder, ‘believing’ would become easier.
Kendell demolished the distinction between mental and physical illness. 20 He pointed out that people, not bodies or minds, develop illnesses, and that when they do, both mind and body are usually involved. He pointed out, for example, that the first manifestation of most infections is the subjective feeling of malaise, and that the most characteristic of all so-called mental disorders, depression, has a genetic basis and responds to physical treatment. To this may be added that the symptoms of depression include disorders of physical movement. 21 Kendell estimated that the differences between mental and physical illnesses are differences in quantity rather than quality and are no more profound than the differences between the circulatory and digestive system disorders. 20 Wilhelm Griesinger had earlier reached similar conclusions in his influential book, Pathologie und Therapie de Psychischen Krankheiten. 22 Kendell concluded that allocation of disorders to categories is determined primarily by the kind of medical specialist who treats patients presenting with the particular syndrome, and that the distinction between mental and physical disorders is ‘a meaningless anachronism’. 20 It follows that patients with the somatoform disorders are no more responsible for their symptoms than patients with epilepsy or migraine.
Wessely et al. considered ‘functional somatic syndromes’ such as irritable bowel syndrome and chronic fatigue syndrome. 8 They concluded that the similarities outweigh the differences and that the existing diagnostic system was of limited value. They voiced a similar argument to that of Kendell, stating in respect of the functional somatic syndromes, ‘the existence of specific somatic syndromes is largely an artefact of medical specialization’. The clinician is aware of this situation, if not as an esoteric argument, certainly at a practical level, and consequently may find the work unfulfilling.
Current evolution theory holds that selection advantage is conferred by reciprocal altruism. Selection advantage relies on benefits outweighing the costs incurred by any action. If the individual can be assisted to survive and the cost to helpers is low, helping may occur. 23 There are advantages to the simulation of disability such as the opportunity to withdraw from physical attack or aversive physical tasks. Birds fake broken wings to draw predators away from eggs and predators fake disability as a means of catching scavengers.
Humans are alert to such ‘social cheating’. In evolutionary terms, wasting energy may compromise survival. Consequently, non-reciprocators are recognized and excluded from help-giving. 24 Thus, strong skepticism about medically unexplained symptoms may not be simply a result of poor professional training, but may be rooted in animal evolution.
DYNAMIC FACTORS OF PROBABLE IMPORTANCE
Dynamic factors operating in both the doctor and the patient are probably important in disrupting the care of people with somatoform disorders. Many rest on observations made in the aforementioned paragraphs. This material is extensive and can be summarized as follows.
(1) The doctor who does not believe that the somatoform disorders are beyond the will of the patient may think (i) he/she is being tricked or fooled; (ii) the patient is placing the doctor in a difficult position, causing him/her to provide drugs and services in a manner in which his/her peers would not approve; (iii) the ‘patient’ is receiving benefits to which he/she is not entitled.
(2) The somatoform disorders are difficult to manage effectively and most doctors have little if any specific training. Thus the doctor may feel stressed by (i) the awareness of his/her limited knowledge/skill, and consequent threat to self esteem; (ii) the perceived loss of control of the clinical situation/patient-doctor relationship.
(3) To defend against the threat posed by awareness that his/her symptoms arise from an illness of the
unacceptable category of ‘mental illnesses’, the patient may deny the existence of such illness.
(4) The patient may become aware of the doctor's skepticism regarding the nature of his/her condition, or of the doctor's apprehension or limited knowledge/skill in the area, and respond by (i) criticizing or humiliating the doctor; (ii) demanding additional investigations/procedures to ‘prove’ the organic nature of his/her condition.
(5) The patient may be frustrated/angered by the doctor's inability to find a physical cause for his/her condition such that consequences 4 (i, ii) come into effect.
DISCUSSION
This paper is ‘superficial’. The danger of depth is that one may get bogged before getting across the field. In discussing dynamic factors, we have avoided psychoanalytic theory. The unconscious is yet another legitimate stratum that may be laid over the aforementioned ideas, bringing with it the concepts of transference and counter-transference, in positive but more particularly, negative form.
Two points can be accepted: (i) many doctors dislike treating people with somatoform disorder; and (ii) some rare individuals consciously malinger/fake illness to gain financial rewards and avoid aversive physical tasks.
The Macquarie Dictionary defines fake as ‘anything made to appear otherwise than it actually is’, and ‘pretend’. The somatoform disorder symptoms are fake physical symptoms; the somatoform symptoms, dizziness, aches and breathlessness are fake symptoms, in so far as they do not arise from the usual and expected explanation, that of pathology in somatic organs.
It is important to be clear on three points. Although the somatoform disorder symptoms are fake somatic symptoms, (i) these are real symptoms of somatoform disorder; (ii) somatoform disorder patients do not fake their symptoms; and (iii) somatoform disorder is a real disorder.
Fake somatic symptoms indicate either malingering or the real condition of somatoform disorder. This distinction is easier to make than sometimes feared. Malingering is marked by a clear financial or physical benefit, the somatoform disorder is marked by suffering, in spite of the symptoms being fake (in so far as they are not the expression of a medical disorder).
Patients with somatoform disorder may be challenging, but most doctors with experience of this disorder do not doubt that such patients suffer greatly. Accordingly, the doctor has a moral and professional responsibility to provide care. Why do doctors dislike treating patients with somatoform disorders? The nub of the present argument is that the presence of suffering suggests somatoform disorder, a disorder marked by fake somatic symptoms but a nevertheless real disorder.
Acceptance of the legitimacy of the patient's claim to the sick role allows the doctor to release the other privileges of that role, such as the obligation to attend and perform work. This acceptance is also communicated to the patient and mutual dissatisfaction is lessened.
Frequently, perhaps, the doctor does not accept the nature of the disorder, and holds the somatoform patient responsible for his/her symptoms. This circumstance should be amenable to change and additional educational efforts on the key features of the somatoform disorders may provide a way forward.
Our training systems have let patients and doctors down. Renewed efforts are required such that the distinction between mental and physical disorders is widely seen to be ‘a meaningless anachronism’. 20