Elsevier

Psychiatry

Volume 6, Issue 2, February 2007, Pages 63-66
Psychiatry

Some Problematic Patient Groups
Ethical issues in the management of somatoform disorders

https://doi.org/10.1016/j.mppsy.2006.11.004Get rights and content

Abstract

The somatoform disorders are a diverse group of conditions that are extremely common in primary and secondary care, but are only rarely seen by psychiatrists. Two important reasons for this are patient opposition to psychiatric diagnosis and the lack of convincing psychiatric models and treatments. Doctors managing these disorders will often find themselves in ethical conflict over the wish to provide treatment while respecting the patient’s autonomy. This is highlighted at the time of diagnosis, where doctors may be tempted to collude in giving a model they do not believe in order to create a therapeutic alliance. Though a path between these may be successfully negotiated, there are risks of harm to the patient, both through unnecessary investigations and by reinforcing the patient’s somatizing.

Section snippets

Definition and epidemiology

The somatoform disorders are a diverse set of disorders, including conversion disorder, somatization disorder and hypochondriasis, which are grouped together in DSM-IV (see Table 1).1 What they have in common is that the patient presents with medically unexplained somatic symptoms and the aetiology is judged to be substantially psychiatric. Medically unexplained symptoms are extremely common in both primary and secondary care, representing up to half of all presentations.2 Though only a

Autonomy vs. beneficence

In treatment. Working with patients who disagree with their diagnoses or treatment and working without sufficient evidence are nothing new to most psychiatrists. In a new-onset psychosis, a disagreement over diagnosis is the norm; in alcohol dependence, a disagreement over the need for treatment is to be expected. Yet diagnoses are made and treatments prescribed: the extent of their enforcement reflects the balance between the biomedical ethical principles of respect for autonomy, and

Conclusion

The relationship between the psychiatrist and the patient with a somatoform disorder can be fraught with difficulty and with ethical conflicts (see Table 2). The psychiatrist must engage sufficiently to provide treatment, whilst respecting the patient’s autonomy by an honest assessment. By the time the patient sees a psychiatrist he or she may already be hostile to a psychiatric model; there the psychiatrist must work to limit further iatrogenic harm, both in the form of unnecessary procedures,

Acknowledgement

Richard Kanaan was supported by a Biomedical Ethics Research Fellowship from the Wellcome Trust.

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