Patients commonly present to doctors with symptoms or complaints. Complaints are usually of pain and alterations in structure or function of body organs or regions. Doctors are like Sherlock Holmes. Their aim is find out what is wrong with the patient. This exercise is based on the data he is able to collect by history (accurate description of the difficulty including its location, factors associated with onset and termination, duration, nature or quality, other accompanying symptoms etc) and physical examination (aimed to uncover objective evidence to support the symptom – findings like swelling, warmth, restriction of movements or altered sounds during heart beats, breathing etc).
Usually the doctor rules out serious conditions by the above methods, makes an informed guess (provisional diagnosis) about the likely cause of the symptom and prescribes treatment like drugs, dietary changes or other advice. He may order additional tests to confirm or rule out other causative conditions. All this looks fairly simple and straight forward.
Sometimes the doctor senses that the patients’ complaints and objective evidence (obtained by physical examination or tests) do not match. Some patients do not show concern even when they are told that they have serious diseases. Others are not relieved by such pronunciations by the doctor and appear unconvinced, tense and worried.
Both these situations need special attention. Many of the patients who fail to get relief from modern medicine later seek help in alternative systems of medicine as there is no conflict between them and experts in these fields. Practitioners of alternate systems have a very ill defined concept about basic anatomy, physiology and pathology. They are not worried about the mismatch between subjective report and objective evidence like experts in modern medicine. They are in a primitive state (or post modern state with contextual interpretation of reality) and happily listen to long narration of bizarre symptoms uncritically.
The emotional relief obtained from this ventilation may be partly responsible for the therapeutic gains obtained. Some who fail to get relief even from them, flock to faith healers or quacks and demigods out of desperation.
Doctors of modern medicine need to rethink why they are helpless or driven to desperation by such patients. We need to be tuned in to the cues of emotional distress voiced by the patients, and hone up our skills as counselors and emotional healers.
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1 week ago
8 comments:
Dear Harish,
How much useful fMRI in somatoform disorders?
What is the current knowledge on the molecular level abnormality/explantion for this disease?
Is it disorder of BRIAN or MIND?
Please comment
Dear Dr Vijayan, Thanks for the queery. I have not come across any study that have used fMRI to study patients with Somaoform disorders. I remember a study that looked at patients with conversion disorder - paresis of limb. This study examned the brain using functional imaging (I think it used regional blood flow) while the patients were asked to move the paralized limb. It showed that the motor areas responsible for initiation of the movement become active. But soon another area implictaed in the emotion pathway (the anterior cingulate and medial frontal areas) are also activated. This might be preventing execution of the movement. The conclusion is that the patient is not faking. He genuinely intends to move his limb as directed, but the emotional centers are intervening to block the movement. This confirms what we tell the patients and relatives. " He is not faking or acting. He is unable to move because some nerves are blocke because of tension or felings". The next question is unwanted as it is neither useful or possible to do this.
Dear Harish...
The ebook of chris Frith (forwarded by you) has mention of plenty of studies on normal and damaged brain using fMRI.
I stongly feel this as another interesting research area which can provide fundamental information on the functioning of brain and mind....Please pass on other related studies you come across...
as pediatrician we happened to see quite a large number of cases in our day to day practice..!
ihi harish, i have a 10 year old patient who came to me with resp infection, but mother was complaining that this boy is excessively fearful, asking questions like ' will i die' , and afraid of the night, but appears to do things normally otherwise, not clinically mentally retarded, but he sometimes says ' somebody is coming' etc when nobody comes. This has been going on , increasing gradually over the years. I was thinking about whether to sent him to a psychiatrist or a child psychologist, because the parents were a little scared of the malayalam word for psychiatrist. I would like to know what is the correct step to follow in such cases. Thank you
Hi Sashi,
Do not send anyone to a Psychologist if you do not know the Psychologist well – it is my opinion. I have seen that some Psychologists discourage the use of drug treatment that may further augment the parent’s or patient’s fear of approaching a Psychiatrist. They describe the side effects of drug treatment at the inappropriate time and manner and they hide important benefits of drugs. Psychologists are more expensive than Psychiatrists and they consume a lot of time too. They may not be affordable to all. Your patient should not become a victim of counseling business.
There are good Clinical Psychologists but you should know one. I think that the ‘boy’ may be suffering from hallucinations, paranoia or hypochondria but it is not my profession and I do not have any knowledge in psychiatry. Dr.Harish will be able to diagnose it properly and if they are not far away, try to send them to him. Most of the psychiatrists do not rule out the possibilities of other serious physiological problems. I have read that the problems like thyroid/hormone variations or brain tumors can cause symptoms of mind-brain disorders. Drugs work faster than psychotherapy. It is possible to switch to psychotherapy after the patient becomes stable.
I think all doctors should have basic knowledge of psychiatry. Mild cases should be handled in primary care.
Thank you.
hi ajeesh, thank you very much for the advice. The boy has normal school performance, maybe excessive discussions in front of chidren about illnesses, death, etc in very vivid language, which our people are particularly prone to, might be a factor. We can't take too much time to discover these things especially when there are patients with physical illnesses waiting for relief. Thanks for telling me, i did not think of psychologists that way, especially child psychologists. Anyway they came to me with a physical illness which i treated, and if they come again i can send him to harish. They were asking whether they can go to some thangal, and i thought better a psychologist, but as i realise now, they can also be harmful, especially if they make any adverse remarks about drugs. Thank you.
I shall definitely forward any studies I come across which is relevant. Regarding Sashi's query on the child, I think we have to rule out anxiety disorders first of all. If it is only an infrequent occurance, it may subside with simple reassuance. It is ok to send to any qualified mental health professional, but as Ajeesh suggested you shoulod be confident that he doen no harm. Unfortunately we come across such 'specialists' in all shapes and colors. There are even psychiatrists who give drugs without justification. Hence send the child to someone you are confident and comfortable with. Many mild cases can be managed with simple psychological methods or short course of drugs.
Thank you.
Dear Harish........
Absence of suffient number of trained medical social workers(and money for rehabilitation programmes) as part of the medical team for the comprehensive managemnt of cases you discussed incomplete(.....like maligering,somatoform disorders etc) .
Another (sad) unhealthy situation.
(In addition to proper management this is required for the proper feedback to the treating physician.)
Poverty of our society and attitude of the doctors (minimum time devoted for recording/reporting/research) make our medical professionals to totally dependent on western literature for all medical information and to answer the queries of our patients and students....even if we see thousands of cases..!Is there any sign of change in recent time,with new generation of doctors?
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