The assessment depends in part upon the setting. In some cases, for example, the patient on antipsychotic medication who complains of a shakiness of the hands, the most likely diagnosis (extrapyramidal side-effects of medication) will be obvious. Another common instance of side-effects of medication is the patient on tricyclic antidepressants, who complains of a dry mouth.
However, it is always important to remember that the emergence of a physical symptom could represent the first sign of an underlying physical disorder. This is particularly pertinent in new referrals, for example, to the outpatient clinic. Usually, it is the responsibility of the referring GP or other doctor to exclude physical disease. However, the psychiatrist must check that appropriate investigations have been done, and continue to remain on the alert and review the matter during the course of treatment. Otherwise, sooner or later, he will find himself in the unenviable position of having tried unsuccessfully to treat someone for, say, depressive illness, with low mood and lack of energy, when the underlying problem turned out to be anaemia or some other physical condition.
Somatic (physical, bodily, biological, or vegetative) complaints form part of the symptom pattern in all the common primary psychiatric disorders. Psychiatric conditions in which somatic complaints are particularly important include:
• Depressive illness (see Chapter 5): this is often associated with anorexia, weight loss, constipation, tiredness, and pain. Because of their pessimistic and hopeless cognitions, depressed patients may attribute these symptoms to physical disease of a serious and/or stigmatized kind, such as cancer or AIDS. Those with psychotic depression may develop full-blown delusions of having incurable illness.
• Anxiety states (see Chapter 6): autonomic overarousal, heightened muscle tension, and over-breathing can produce a wide range of bodily symptoms. Anxious patients may attribute these symptoms to serious physical disease; for example, they fear a heart attack if they experience palpitations.
• Schizophrenia and delusional disorders (see Chapter 4): somatic delusions and hallucinations may occur in schizophrenia and are sometimes bizarre; for example, the belief that the internal organs are upside down. Rare related conditions are characterized by fixed somatic delusions; for example, patients with monosymptomatic hypochondriacal psychosis might believe that their skin is infested with parasites or their bodies emit a foul smell.
Somatic presentations may arise because emotional problems carry a stigma in the patient's family or cultural setting, and/or because patients genuinely perceive the bodily symptoms to be predominant.
Many psychiatrically ill patients, perhaps especially those from ethnic minorities, first present to their doctors with somatic complaints. These patients are often referred to medical or surgical outpatient clinics because the psychological background is unrecognized. This can result in a long series of unhelpful and expensive hospital investigations and treatments.
Sometimes somatic symptoms have a demonstrable physiological basis, and sometimes they seem to result from misinterpretation of ordinary bodily sensations. Such misinterpretation may be based on past experience of physical disease in other people or in the patient himself.
The psychiatrist performs a service both to the patient and to medical colleagues if he is able to diagnose and treat such somatic presentations of the major mental illnesses.
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