Controversial Ideas in Medicine

The nuff-nuff is the bane of our existence. That person who comes in complaining of tummy pain or feeling weak or some vague and inconsistent symptomatology completely without medical explanation and almost certainly psychological in nature. They have some tawdry and dreary sort of social background and probably reside in a slumlike place (oh boo-hoo). They have all sorts of medications for somatic relief. The endones and pethidines and maxolons and valiums. Not to mention the psychiatric pharmacopoeia of zolofts and efexors and zyprexas. Some of them drink and smoke too much (but not enough, sadly). We do all the tests (or just enough to satisfy ourselves) and find nothing while they abuse us for "not caring". So we send them home, kicking and screaming while they threaten "if you send me home I will be back here tomorrow" (which we know is true). And sit back exhausted but relieved that they've finally left. They are the bane of our existence, the nuff-nuffs. The bane. But would you know that:

• Schizophrenia and other psychotic illnesses
• Depression, anxiety
• Personality disorders
• Substance abuse

are all associated with greater rates of illness and mortality? Multiple presentations to hospital are a bad sign that there is something going wrong- whether it be physical or psychiatric. Or both for that matter. Even worse, as they say "you can't prove a negative"; in other words there are many for whom we do not find the real answer (even though it exists). Additionally, chronic diseases lead to significant psychiatric burden- people become depressed, anxious, sometimes even epileptics have psychological "pseudo-seizures". And the mentally ill just do not look after themselves properly. So what do you do when faced with the nuff-nuff? There is I suppose only one thing you can do - exclude organic pathology while treating the psychiatric disorder.

• Approach things with an open mind each time. Ask yourself "why" and be prepared for a complex answer. Sometimes people with worsening disease become anxious and depressed and present to hospital even without a need to. Sometimes it is a cry for help. Sometimes despite mostly being psychiatrically unwell or having a pathological personality there is genuinely a medical cause for the symptoms.
• Involve a psychiatric team early. Sometimes the diagnosis is psychiatric and this in itself is the main thing.
• Keep a high index of suspicion for both organic and psychiatric disease- nuff-nuffs get sick too (and sometimes die)
• Have a sympathetic but professional attitude; be caring but consistent and do not get too wound up in the transferred anxiety.
• Do not get angry, violent or abusive. Additionally do not take on their stresses as your own.
• Be as prepared for gratitude as for the potential to be verbally abused for your approach (and don't take it too personally)
• Exclude dangerous things
• Do what your duty of care towards your patient behoves you to do; do not discriminate on the basis of psychiatric illness.

Doctors are angered by these patients for more than one reason. We are educated to believe that only organic disease is "real" or "significant". But even more than that, being (often unconsciously) manipulated and having large amounts of angst and anxiety offloaded onto us - and then finding that the underlying cause is not what it seems- makes people feel betrayed or lied to (even if that is not the conscious aim of the patient). But why should we feel betrayed? A psychiatric diagnosis (even that of a somatoform or personality disorder) is still a medical - and pathological- condition that causes harm. Often the best thing we can do for these people is to acknowledge their underlying issues and refer appropriately. Sometimes that is all they have been hoping for.