Somatoform disorders: a topic for education

Bass et al (2001) believe that somatoform disorders are ignored by psychiatrists and health service planners because of the nature of diagnostic practice, a current pre-occupation with only “serious mental illness”, limited experience of patients with medically unexplained symptoms in general hospital settings, and stigma. They do not mention whether they have found an increasing fear of litigation to be another contributing factor. Currently, it appears to play a part in delaying referral to psychological services while the patient is exhaustively investigated for any physical pathology. Any comment they might make regarding this practice would be of interest.

Certainly, as they mention, a lack of training of non-psychiatric practitioners in this area contributes greatly to non-referral within the general hospital setting. We would, however, dispute their comment that psychiatrists working in this area find that patients with somatoform disorders “comprise between one-third and one-half of all referrals to the liaison psychiatry service”. A review carried out several years ago of the nature of referrals to the consultation—liaison services of two general hospitals in Dublin City (Cullivanet al, 1997) suggests a much smaller number of such referrals. Over a 6-month period 491 patients were referred and patients with diagnoses falling into categories F40-F48 of ICD-10 (neurotic, stress-related and somatoform disorders) accounted for only 12% of referrals in one hospital and 15% in the other. As a significant number of the patients in these categories were suffering from adjustment disorders, the numbers diagnosed with somatoform disorders, formed an even smaller percentage of all referrals.

It is worth noting that these were the diagnostic categories provided by the psychiatrists who assessed these patients. The reason for the referrals given by the medical/surgical teams was “no organic cause for symptoms found” in just 1.7% of cases in one hospital and 10.2% in the other. Perhaps somatoform disorders are even more neglected than previously thought? Education of both psychiatric and non-psychiatric personnel regarding these disorders would appear to be in need of urgent review.