The doctor has to consider, especially in the case of undifferentiated illness, whether the patient has a 'hidden agenda' for the presentation. 3 Of course, the patient may be depressed (overt or masked) or may have a true anxiety state. However, a presenting symptom such as tiredness may represent a 'ticket of entry' to the consulting room. It may represent a plea for help in a stressed or anxious patient. We should be sensitive to patients' needs and feelings, and as listening, caring, empathetic practitioners provide the right opportunity for the patient to communicate freely.
Deep sexual anxieties and problems, poor self-esteem, and fear of malignancy or some other medical catastrophe are just some of the reasons patients present to doctors. The author has another checklist (Table 15.6) to help identify the psychosocial reasons for a patient's malaise. In the author's experience of counselling patients and families the number of problems caused by interpersonal conflict is quite amazing and makes it worthwhile specifically exploring the quality of close relationships, such as those of husband-wife, mother-daughter and father-son. Identification and transference of illness, symptoms and death, in particular, are important areas of anxiety to consider. Patients often identify their problems with relatives, friends or public personalities who have malignant disease. Other somatoform disorders and the factitious disorders, including the fascinating Munchausen's syndrome, may be obvious or extremely complex and difficult to recognise. The bottom line is that patients are often desperately searching for security and we have an important role to play in helping them.
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