When pain can be a problem of the mind

OCT 10 was World Mental Health Day and the theme for this year was “Mental Health in the Workplace”. Associate Professor Dr Xavier Pereira’s call for greater awareness, “Need support for good mental health” ( The Star, Oct 14), should extend to the medical profession too.

Psychiatry is indeed a “Cinderella” specialty in the field of medicine. This is understandable considering the amount of time allocated to it in the undergraduate medical curriculum. Furthermore, the time allocated is skewed towards hospital management of psychotic patients, like schizophrenia (not the best way to instil interest in a subject), rather than community management of depressed and anxious patients.

Psychoses account for less than 10% of all psychiatric illnesses. Medical students are taught from day one to ask for symptoms when taking history from their patients and to look for physical signs in their clinical examination. Even medical investigations are geared towards looking for positive results.

But there are many medical conditions that are functional in nature, meaning that patients experience symptoms but there are no physical signs upon examination.

Neurologists see tension headaches, cardiologists see non-cardiac chest pains, chest physicians see hyperventilation syndrome, gastroenterologists see irritable bowel syndrome and orthopaedic surgeons see chronic backache.

There are also no findings upon investigation. For example, only one in 2,000 CT brain scans done for patients with headaches reveal a brain tumour and 70% of gastroscopy done for patients with “gastric” pains are normal.

Because of their training, doctors are uneasy when they encounter patients who have symptoms but no sign or when investigations draw a blank. In these situations, a doctor may respond by doing more tests, incurring extra cost, or “over-diagnose” (reading too much into some minor findings which may not be significant).

Many doctors are afraid of missing a cancer in a patient in this current litigious society. Nevertheless, once a physical ailment has been excluded by investigations, there will come a point in time when a doctor needs to consider whether a patient’s symptoms are psychosomatic (mind affecting body) in nature.

Some basic knowledge of psychiatric diagnosis and management would be helpful for all doctors as there are only about 350 psychiatrists serving the whole population of Malaysia.