Surprising as it may sound, there is only one psychiatrist for every 100,000 patients in Pakistan. The country has a dearth of professionals who deal with mental health

On October 8, 2005, a severe earthquake struck the Northern Areas of Pakistan, as a result of which 73,000 people lost their lives. The quake also left 3.5-million people homeless, mainly in the Pakistan-controlled Kashmir and some parts of the North West Frontier Province. Among other things, the tragedy exposed the glaring shortcomings in the healthcare services at various levels available in our country. In the aftermath of the quake, more patients began to visit their primary care doctors for symptoms that were medically unexplained. Doctors working at primary care centres were flooded with such patients having little clue to managing psychological problems. The majority of the doctors resorted to prescribing tranquilisers which led to drug-dependence syndromes in patients.

Pakistan has a dearth of professionals that deal with mental health. According to recent estimates, there is one psychiatrist for 100,000 people in Pakistan. Most of these professionals are centred or working in the urban areas. Almost 67 per cent population resides in the rural areas to which mental healthcare is delivered by general physicians. It is imperative that these physicians be trained in recognising and treating common mental disorders. The lack of training in psychiatry at the under-graduate level makes these physicians ignorant of psychological problems. As if it was not enough, the awareness of general psychological aspects of life among the masses is also shrouded in myths and misconceptions.

In this regard, the media can play an important role. In western countries the media is used constructively in systematically disseminating evidence and information on the general medical or psychological wellbeing of the people. Bearing all of this in mind, a brief review of medically unexplained symptoms and their management is presented below.

Symptoms are defined as medically unexplained when the clinical presentation and symptoms are incompatible with known physical illness, and/or absence of relevant physical signs and/or absence of laboratory investigations supporting a diagnosis of a physical illness. They can also be defined as distinctive subjective sensation or a personal observation in relation to the body, which the patient describes as abnormal.

Somatisation is a process in which the patient has an inappropriate focus on physical symptoms and psychosocial problems are denied. According to Kleinman and Kleinman (1985), “Somatisation is the expression of personal and social distress in an idiom of bodily complaints with medical help seeking. It refers to the presence of physical complaints which are not associated with organic pathology or are grossly in excess of what is expected from pathology.”

Though somatisation is viewed as a process by which patients with anxiety and depression or other psychiatric illnesses get to see a doctor, it has a considerable heuristic appeal. This notion also has a number of disadvantages.

Numerous scientific studies confirm a link between natural disasters and medically unexplained symptoms. Studies have also revealed increased reporting of physical symptoms in persons with the post-traumatic stress disorder (PTSD).

The post-traumatic disorder, codified in diagnostic and statistical manual (DSM-III) of American Psychiatric Association (APA, 1980), has now become the subject of debate with respect to its nature and origins. It has been argued that the PTSD for most part is a western disorder that occurs because of the lack of civilian exposure to death and disaster. The nature and type of traumatisation also play a role in shaping the symptoms. A short-term unexplained traumatic event (Type I trauma) leads to typical PTSD symptoms of intrusive ideation, avoidance, and hyper-arousal reaction. A sustained and repeated ordeal stressors (Type II) lead to complex symptoms constellations; memories are typically fuzzy and spotty because of dissociation. It may lead to an altered view of the self and the world, accompanying feelings of shame, guilt and worthlessness. Type II trauma is more likely to lead to longstanding character-logical and interpersonal problems as evidenced from increased detachment form others, restricted range of affect, and emotional labiality. It can lead to “complex PTSD reactions” and the disorder of extreme stress.

There are a number of possible explanations for the co-existence of medically unexplained symptoms and the post-traumatic disorder. One possible explanation is that physical symptoms are an integral part of post-traumatic stress disorder symptom (PTSD) constellations. Physical symptoms can also be directly caused by stressors responsible for the PTSD.

The cognitive representation of illnesses describes how an individual constructs an internal representation of what is happening when they experience physical or psychological symptoms. Typical patients ask the following five questions:

• What is it (identity)?

• Why has it happened (cause)?

• How long will it last (timeline)?

• What effects will it have (consequences)?

• What can I do to make it go away (cure or control)?

A study carried out by psychiatrist working in Sri Lanka describes the variable focus of healthcare providers and patients. Doctors are always interested in answering the first two questions of diagnosis and etiology while patients are concerned about the timeliness, the consequences and the control of symptoms.

There are certain general steps that facilitate the management of patients with medically unexplained symptoms in primary care. There is growing evidence of the benefit of the patient and health practitioner interaction.

Patients generally become confused when ambiguous messages are given by their doctors. They may explicitly say nothing is wrong with you and follow it up with the prescription containing five medications. Patients are left wondering if nothing is wrong with them than how come the doctor has prescribed so many medicines. This needs to be looked into by all the doctors.