Terminology

Non-specific symptoms that have no immediate organic explanation are extremely frequent in the general population (1,.,2) and in all medical settings.(3) Most are transient, but a substantial minority are persistent, disabling, and often associated with frequent consultation (see ChaptĀ§.L5i2,.2). The terminology is unsatisfactory. Many terms have been used, including psychiatric terms such as hysteria and hypochondriasis (historical words now used with more precise definitions) and more general terms including functional symptoms, somatization, somatoform symptoms, functional overlay. Somatization is the most widely used general term. It was introduced at the beginning of the twentieth century by Stekl, a German psychoanalyst, and implied the presentation of emotional distress as bodily symptoms. (4) More recently, somatization has become a popular general term, both as a process and as a category. Some current definitions are very broad, covering both the perception of bodily sensations and consultation; most implicitly suggest that physical symptoms are an alternative expression of emotional distress, for example 'a tendency to experience and communicate psychological distress in the form of somatic symptoms and to seek medical help for them'.(5) However, current evidence suggests that distress and the severity and number of physical symptoms are close correlates rather than alternatives. A much narrower approach has been to use criteria that require physical symptoms to be accompanied by anxiety or affective disorder satisfying standard criteria. (6) Because of the lack of an agreed definition and the aetiological assumptions that it conveys, somatization is an unsatisfactory term.

Another word that is widely used in rather the same manner as somatization is somatoform, a term coined in DSM-III to describe a new category of disorders, which included traditional psychiatric disorders such as hysteria, hypochondriasis, and so-called Briquet's syndrome, together with newly proposed categories.

A different and much broader descriptive approach has been to refer to 'medically unexplained symptoms'. This has advantages of describing a clinical problem without assumptions of aetiology, but is unsatisfactory in that it wrongly implies that there is in fact no medical explanation. It may be preferable to refer to unexplained medical symptoms (or, as in the primary care version of ICD-10, to unexplained physical symptoms). All cultures seem to recognize categories of non-specific symptoms in which there is no major sinister organic cause, and most have descriptive terms for them.

This chapter is concerned with medically unexplained symptoms whether or not they are associated with psychiatric disorder. In Cha.pterS.^.^, such symptoms are described as being very frequent in the general population and in the primary care setting. Most are transient, but a proportion are persistent. Those which are most persistent and disabling and those in which there are multiple unexplained physical symptoms are most likely to be associated with psychiatric disorder.

Only a very small proportion of unexplained physical symptoms are seen by psychiatrists and psychologists and are unsurprisingly likely to be diagnosed as suffering from psychiatric disorder.

The remainder of this chapter is largely concerned with specific psychiatric categories. It is essential to be aware from the outset that these categories are provisional and also that many people who present to doctors with unexplained symptoms do not suffer from a diagnosable psychiatric disorder. Even so, psychological and social factors may be of considerable importance in aetiology and psychological and psychiatric treatments often play a major role.

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