Introduction

Under this heading, I will now discuss the group of related problems in which the patient continues to have physical symptoms and/or seek medical care when examination and investigation indicate that no causative physical disease can be identified. Thus, a physical symptom such as back pain can be clearly due to a physical pathology such as a prolapsed intervertebral disc. If the patient presenting with pain had no identifiable pathology after appropriate examination and investigation, the traditional approach was to tell the patient he had nothing wrong with him and discharge him.

In recent years, the obvious limitations of such an approach have become clear. Many patients without objective physical pathology do have health problems and are suffering; some unexplained symptoms reflect underlying mental disorder, such as depression or anxiety. In most, elements of psychosocial difficulty can be identified, and this was the part of the basis for the development of liaison psychiatry services.

Rather more controversially, the symptoms themselves can be taken as the basis of a 'functional' diagnosis, such as chronic pain syndrome, chronic fatigue syndrome, and others. These syndromes may be advocated by doctors of various disciplines, often with the support of patient groups, who sometimes vehemently deny any role for psychological factors in their genesis.

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