Diagnostic Issues

Diagnosing somatoform illness is important in order to offer relevant psychiatric treatment and to avoid unnecessary medical intervention. A much-quoted study by Eliot Slater in the 1960s suggested that the rate of misdiagnosis was very high and questioned the validity of hysteria as a diagnostic entity. Recently, the advent of noninvasive investigative techniques (e.g., brain imaging and video telemetry) and the better characterization of neurological disease patterns have made the exclusion of organic pathology easier and more reliable. Indeed, recent studies of patients with both acute and chronic unexplained symptoms suggest that neurological illness is rarely missed in these patients.

Currently, the gold standard for the diagnosis of somatoform illness involves a combination of careful history taking, the judicious use of investigations to rule out significant organic disease, and the assessment of psychiatric morbidity. The exclusion of organic pathology is essential, although it is often difficult to establish the right balance between the benefits and dangers of further investigations. Moreover, the presence of organic disease does not exclude the possibility of somatization; it is therefore important to assess all patients for unexplained symptoms or disability. The clinical history may reveal many features that support a positive diagnosis of somatoform illness, including the inconsistency and implau-sibility of symptoms, a previous history of unexplained symptoms, and psychosocial stressors preceding the development of symptoms. The successful alleviation of symptoms in response to placebo, suggestions, or psychological treatment also supports a positive somatoform diagnosis.

In some cases, symptoms are consistent and plausible and there may be few or no additional diagnostic features in evidence. For example, although DSM-IV explicitly requires the presence of psychosocial stressors for a firm diagnosis of both conversion and somatoform pain disorder, obvious stressors are absent in many cases. Even when present, establishing a causal link between such stressors and physical symptoms can be extremely difficult and involves considerable subjectivity. Other clinical features previously thought to be characteristic of somatoform illness have been found to have little or no diagnostic validity. For example, historically it has been thought that patients suffering from unexplained symptoms display an unusual lack of concern over the condition, so-called la belle indifference. However, research indicates that patients with somatoform illness show no more indifference to their physical condition than do patients with organic illness. The traditional notion that unexplained medical symptoms are exclusive to individuals of low socioeconomic status has also been disputed.

Even in cases in which positive somatoform features are present, many physicians are reluctant to diagnose somatoform illness for fear of missing an underlying physical illness. However, in the clear absence of pathology following appropriate investigation, and particularly if positive signs are present, a diagnosis of somatoform illness can be safely made. In cases in which somatoform illness is suspected but an organic explanation cannot be ruled out unequivocally, careful follow-up is often the best diagnostic tool.

Breaking Bulimia

Breaking Bulimia

We have all been there: turning to the refrigerator if feeling lonely or bored or indulging in seconds or thirds if strained. But if you suffer from bulimia, the from time to time urge to overeat is more like an obsession.

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