• Somatoform disorders
• neuropsychiatry

A wise senior clinician taught that ‘it's easier to know what to do than what it is.’ All physicians have patients with physical complaints that are puzzling and unexplained. Those with somatic symptoms such as headache, dizziness and fatigue may be referred to a neurologist for further evaluation. The paper by Carson et al (see page 810) investigates those neurology outpatients, referred from their primary care physicians, and documents the personal and social cost of those who have symptoms ‘unexplained by organic disease.’1

Neurologists rated a cohort of 3781 patients as to whether they considered the symptoms as either ‘largely’ or ‘completely’ explained (controls) or ‘not at all’ or ‘somewhat’ explained (cases) by ‘organic’ disease. Patients were rated for physical and mental health status and unemployment. A substantial minority (30%) were unexplained ‘cases.’ Their diagnoses, discussed in a previous paper,2 include headache (26%), conversion (18%), functional (9%), primary psychiatric diagnosis (6.7%), pain (5.5%), dizziness (2.8%), fatigue (2.5%), cognitive (1.9%) and posthead injury (1.7%). These unexplained cases had a worse physical- and mental-health status, and a higher level of emotional distress. While unemployment was similarly high (50%), cases were more likely unemployed for health reasons and to receive disability benefits.

While this study clearly documents the large number of patients whom neurologists cannot determine an ‘organic aetiology,’ there is no significant information available that may shed light on causation. For example, while these patients were referred by their primary care physician, were they also evaluated by a psychiatrist? Somatic symptoms frequently accompany psychiatric disorders, such as depression, anxiety and post-traumatic stress disorder. Headaches are associated with depression. In individuals who have suffered trauma, psychiatric disorder, and not a traumatic brain injury, increases the likelihood of self-reported functional impairment.3 Post-traumatic stress disorder is more strongly correlated with ‘postconcussive’ symptoms, health and psychosocial outcome than is the occurrence of traumatic brain injury.4

Patients with ‘unexplained’ disease are in distress and utilise significant medical and social resources. The reaction of many physicians is to conclude that these patients need to be treated by someone else, since they do not have a disorder in our specialty. Labelling these individuals as having a disorder that is ‘unexplained by organic disease’ implies this is not a ‘real’ disorder, and the symptoms are ‘all in your head.’

We must not allow ‘unexplained’ to translate into ‘untreatable.’ These patients require an approach that carefully evaluates the presence of recognised neuropsychiatric disorders and presents these findings in an atmosphere of encouragement and optimism.5 Effective interventions (pharmacotherapy, cognitive behavioural therapy, exercise, etc) are available and may help alleviate symptoms. After an evaluation where there is no ‘organic disease,’ the patient needs to be told the good news: you do not have multiple sclerosis, epilepsy, etc, and we can help.