Carlos J. Rubinstein*
Professor Faculty of Medicine, Universidad de Buenos Aires, Argentina
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Every physician faces daily technical, ethical and intellectual challenges, linked to both diseases treated as sick to attend, the availability or lack of means of diagnosis, treatment and consultations, and the general situation of the institution where it is exercising. But nothing is more disconcerting to the general practitioner and the patient who have unexplained symptoms (Rubinstein, 2013). Symptoms in question do not relate to those presented when still not manifest the pathophysiology of a clinical entity; unexplained symptoms are those that disorient, which do not adhere to the expected evolution, multiply, not consistent with the story that the patient makes his discomfort, manifest protean, rare, ultimately unnatural from the practice to which the general practitioner is accustomed (Agreda & Yanguas, 2001). These symptoms are related to a particular group of patients, known generically as psychosomatic patients, who are often mentioned disparagingly as "difficult patients"; these patients may generate different feelings in the doctor: frustration, anxiety, boredom, anger, and difficulty in carrying forward the relationship. However, it must be remembered that the essential difficulty of the general practitioner to psychosomatic disorders arises from both the medical worldview and the current reality of the exercise of the profession.
Psychosomatic diseases are those in which the origin of the disease is linked to mental processes, but there is organ damage. We must not lose sight of the essential: all psychosomatic illnesses can be dangerous, disabling, and some of its complications, fatal (e.g. perforation of duodenal ulcer, a flare or a hypertensive emergency)
In medicine, diseases are manifested by the appearance of indicators that show the presence of a specific disease entity, which has an etiology, one pathophysiology, clinic, prognosis and treatment given. These indicators arise both from objective evidence of disease (signs) and the subjective perception of the patient about his illness (symptoms). For psychoanalytic theory (Freud, 1900), neurotic symptoms are caused unconscious formations between two conflicting desires. Neurotic symptoms are moved symbols and condensate through partnerships, and can only be understood by the free association of analytic treatment. The origin of the neurotic symptom is the return of the repressed. Lacan (1964) described the neurotic symptoms linguistic equivalence: it replaced the condensation and displacement described by Freud by the concepts of metaphor and metonymy. The metaphor (word that condenses and moves to another figuratively), and metonymy (which means one thing with another name that serves as a sign) language form chains through partnerships can lead to decipher the symptom, a incomprehensible metaphor at the start of treatment and understandable to end. In the neurotic symptom, the patient asks about your symptoms. If the patient begins his personal analysis, their questions will take to produce linguistic chains, related to its history and its myths, with favorable results for treatment.
But the psychosomatic patient does not ask himself about his suffering: it falls within the body itself, in isolation from any relationship with the psychological. That is why psychosomatic patients move from one treatment to another without finding a solution. Psychosomatic illness does not create a metonymic chain, nor is metaphorical, so the symptom is not interpretable. This difference is essential: psychosomatic symptoms do not belong to the same field of neurotic symptoms
What is significant is that most of psychosomatic patients initially attending general practitioners, hence are referred to interconsultation in different specialties, they make large amounts of studies and are not referred to mental health until much later, when that disease that cause these symptoms (because they are always diseases, unless it be the lie of a psychopath) they have a close relationship with nature mental discomfort (Mathers, Jones & Hannay, 2005); to complicate the picture, not just general practitioners become disoriented before them, but often the patient is wrongly labeled by psychologists and psychiatrists too little enlightened. For that reason it is important to differentiate demonstrations known as somatization of conversive episodes, hypochondriacal complaints, psychosomatic illness and delusions referred to the body, because although at first glance they all have a certain family resemblance, differ in terms of origin, prognosis and treatment (Schwartz & Weiss, 1990). Due to the overload of patients in health care systems, the short time available, vocational training, and the difficult diagnosis of psychosomatic illness, the general practitioner tends to focus on the physical symptoms of the disease, forgetting or ignoring the true cause of the problem. Then, in the best case, anxiety and psychosomatic indicated mental health patient is derived, but generally happens that the patient derives different specialties and multiple studies are required, so after a while the patient returns the office with the same problem unresolved, or other different symptoms (Maergetts, 2004). In the end, the doctor derives the patient to a psychologist because everything is "a problem of nerves." However, people with these ailments do not quite understand what happens and are reluctant to go to a psychologist because they do not understand the reason for the referral. And if the general practitioner is not always easy to differentiate a psychosomatic disorder from another, also the case with many psychologists, so the vicious cycle lasts, the patient seeks the opinion of another doctor and everything restarts.
It is noticeable that the problem is complex, and it is expected that the number of patients with "unexplained" symptoms increases, because the root of the disorder is merged with the current, postmodern, globalized, threatening and paranoid times.
One final thought: it is necessary to clarify the different aspects of general practitioners psychosomatic diseases, promoting interdisciplinary discussion, integrated circuits referral to mental health teams, work difficulties in the doctor-patient relationship, but above all, not forget that it is chronic, potentially fatal diseases, which are accompanied by great suffering during their evolution.
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Maergetts, E. (1950). The early history of the word psychosomatic. Canadian Medical Association Journal, 63,402-404.
Mathers, N., Jones, N., & Hannay, D. (1995). Heartsink patients: a study of their general practitioners. British Journal of General Practice, 45, 293-296.
Rubinstein, C. (2013). El médico general ante los síntomas inexplicables. En: Fenómenos psicosomáticos. (Comp. H. Becerra) Pág. 121-159. RV Ediciones, Buenos Aires.
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