Tuesday, April 24, 2012


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She was in her thirties, pale faced, tearful, agitated, , holding her head in her hands. I recognized her � It was her second visit with almost same complaints to the emergency department, in which I was working as a junior casualty medical officer.

While giving her history she told me that she had similar episodes of throbbing head ach over the past several years. She also told me of having multiple other symptoms, such as pain in her legs, the rapid beating of the heart and abdominal pain in the past years, which no doctor had been able to determine the cause. After taking history and doing physical examination - that was unremarkable - I came to the conclusion that she was suffering from a somatoform disorder, a mental illness. I consulted my senior Casualty Medical Officer and gave her a painkiller injection - a common practice in that department to give symptomatic treatment to such patients without bothering to know the cause. After one hour she was symptom free. She thanked me and went away.

When she left I felt guilty � a practice, one quits as one becomes old in our profession - it was not a proper way to deal with such a patient. I should have told her that she was suffering from somatoform disorder, not physical but a mental illness and she should consult a psychiatrist. But in our country to refer someone to a psychiatrist means you are thinking that person is mad. It was not easy to deal with, despite that I regretted for not guiding her properly.

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It is now a well known fact that a large proportion of patients visiting general out-patient departments or private clinics do not have organic disease requiring medical treatment. It is very likely that these patients have somatoform disorder. Somatoform disorder or more commonly known as hysteria, is the presence of physical symptoms without an organic cause. In this disorder patient is not malingering, as wildly believed, but truly believes that he or she has an organic disease. There are five subtypes of somatoform disorder

· Somatization disorder

· Conversion disorder

· Somatoform pain disorder

· Hypochondriasis

· Body dismorphic disorder

It is not my aim to go in detail of each subtype. But in each type, though the symptoms are physical but there is no organic cause determined. Laboratory or other physical diagnostic procedures are normal or can not be related with patient’s symptoms. There is strong presumption that symptoms have a psychological origin. In these cases psychological conflicts may be translated into physical problems or complaints.

Person with this disorder present with multiple complaints of physical ailments over a long period. These begin before age 0. Most of the time there is a history, over the years, of chronic headaches, back pains, arthritis, muscle aches and cramps, or pelvic pain. It may also cause gastrointestinal problems, such as nausea, vomiting, diarrhea and food intolerance. It can also cause problems with sexual function. Some time there is one or multiple episodes over the life time, of abrupt loss of physical functioning such as muscular weakness, paralysis, loss of speech etc. Rarely even blindness may occur. Mostly in response to psychosocial stress such as pressure at home or working place, death of a spouse or loosing a job. These patients do not think themselves having a psychological problem and do not seek psychiatric treatment. They have long history of futile visits to doctor without proper diagnosis. To make the situation worst, mostly these patients are women - already a deprived section of our population. Who are never taken seriously by their families. Their sufferings are undermined. They suffer at the hands of doctors as well as society, and never get sympathy and proper treatment which they deserve. Their symptoms may be quite severe and persistent and effect their occupation and interpersonal relations. These patients more than often, suffer complications at the hands of physicians who can not perceive the psychological basis of their physical symptoms and may prescribe unnecessary medication which have their own side effects.

In our department they were never taken seriously, often jested as “functional” means they have no organic disease and sometime they were teased and mocked. Never even acknowledged as patients, they were none of our business. Not knowing how to deal with them they were gotten rid of, by prescribing them pain killers - the very convenient way of disposing them of. They were never properly guided and left for, doctor shopping, a term used in psychiatry books for their seeing different doctor, but never getting appropriate treatment. It would be unjustified, to solely blame the doctors. If doctors, who could not see their plight and were well aware of their disorders, would try to guide them properly. Nine out of ten patients were resistant to advise - specially their families. They felt insulted and were afraid if their disease disclosed, society would not accept them. They would not listen advise and insist on being treated by same doctor and never visit a psychiatrist.

In my opinion, the first and foremost measure which should be taken to

improve the situation of these unfortunate people is, to increase the literacy rate

of the country. Which has fallen to a critical level and is root cause of many vices in our society. It will be much less time-taking and pains-taking for doctors to advise a literate person on mental maladies and their treatment. On the other hand it will be much easier for a literate patient and her family to understand these disorders. They will be able to understand and take mental diseases like, other body disorders, which have their own specialists. Society with good literacy rate will also play its constructive role. Patients of mental maladies will not be made ashamed of their diseases by people around them.

Second measure - a less difficult task to accomplish than the above one - should be taken in giving psychiatry the importance, which it deserves. In most of our medical colleges psychiatry is not only not treated as other subjects but it is completely ignored. As a medical student we are taught every thing about a human body - its structure, its functions and its malfunctions - but its mind. Forgetting that it is the only thing which makes a man superior to other species. It is pity that only doctors who come into contact with psychiatry are those who have to take a medical licensing exam abroad. Rest of the doctors when start practicing medicine they see patients, who posses only bodies, completely ignoring their minds. When patient with psychiatric problems comes to a non-psychiatrist. Because poor patient never perceives him having a psychological problem often goes to a physician. The doctor is unprepared and helpless to deal with such patient. With proper education of psychiatry doctors would be familiar with basic mental disorders so that they could be recognized and treated appropriately.

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