Title: Physical complaints without an identifiable medical cause
Course: Non-Communicable Diseases, Emergency Care and Mental Health Part 2 - Ethiopia (Full)

Physical complaints without an identifiable medical cause

It is a common experience in primary healthcare that a person comes with a physical complaint but no medical cause can be found. The most common explanations for this situation are:

- A medical cause is actually present, but can't be detected with the facilities available.
- The physical complaint is due to undetected depression or anxiety.
- The physical complaint is due to somatisation. This is when mental or social distress (e.g. chronic poverty, marital problems) comes out as a physical symptom (Figure 16.1). Often the person doesn't realise that this is happening. For example, a woman who is distressed because she is not able to get pregnant may develop a chronic headache as a result of her distress. Somatisation can also occur as part of depression.

Figure 16.1 A person with multiple physical complaints characteristic of somatisation.

Studies from Ethiopia have shown that around one in five people attending a general medical out-patient clinic with a physical symptom actually have an undetected mental health problem. This is very similar to the situation in other countries. It is important to recognise when a person's physical health complaint is being caused by an underlying mental health problem, otherwise there is a risk that they will repeatedly attend health services without getting relief. They may spend a lot of money on traditional treatments that don't help, or may receive inappropriate treatment or investigations; for example, they may be given antimalarial medication for a headache that is actually caused by depression. Ultimately, they continue to suffer and be disabled because they don't get the treatment they really need.

Some of the physical symptoms that can be caused by depression or anxiety are shown in Table 16.1.

Table 16.1 Physical symptoms in depression and anxiety.

Depression | Anxiety
Loss of appetite

Weight loss

Fatigue

Low energy

Headache

Multiple aches and pains

Constipation
Tremor/shaking

Sweating

Poor digestion

Tense muscles

Heart racing

Shortness of breath

Chest pains

Dizziness/fainting

In Ethiopia, there are some other physical complaints that seem to be more typical of somatisation than a medical illness or condition. These are listed in Box 16.1. In your area you may know of some additional physical symptoms that people use to express their mental or social distress. Make a note of them here.

Box 16.1 Common somatisation symptoms in Ethiopia

- Burning sensations on the head or body
- Buzzing in ears
- Crawling sensations under the skin
- Stabbing/pricking pains
- Fluid in the head
- Back pain.

Some indicators that physical symptoms might be related to a mental illness or somatisation are as follows:

- Medical investigations give no abnormal results
- The person has three or more physical complaints
- The physical symptoms don't fit in with usual patterns of any known disease
- Other features of depression (e.g., low mood, hopelessness, loss of interest, guilt, etc.) or anxiety (e.g., excessive worry) are also present (depression was covered in Study Session 12 and you will learn more about anxiety in Section 16.2)
- The symptoms are chronic
- The person has repeatedly consulted healthworkers.

Read Case Study 16.1 about Mrs Abeba carefully. List which features of her case are indicators of possible mental health problems and which features make it more likely that she has a physical health problem.

Case Study 16.1 Mrs Abeba

Mrs Abeba is a happily married woman with two healthy children. The family does not have any major financial concerns. One morning she noticed a pain in her lower back while she was picking up a bundle of wood. She tried to ignore the pain but it quickly became worse and would not go away. The pain was particularly bad in the mornings and became so severe that she would often cry. Antipain medication only helped for a short while before the effect wore off. She was seen by a hospital doctor three times within just two weeks, but he was not able to find anything significantly abnormal. There was a small cyst which the doctor removed in case it was the reason for the pain. However, the pain continued. The doctor thought the pain was due to a mental disorder and referred her to a mental healthworker.

Indications that Mrs Abeba's back pain could have a physical cause are: that the pain is very severe, it is the only symptom Mrs Abeba has, there is no evidence of depression/anxiety and there are no obvious psychosocial stressors (i.e. stressful circumstances in her life). On the other hand, the doctor could not find any cause and the pain had become chronic, which could suggest a psychosocial cause.

This is a real case. Mrs Abeba went on to develop some other symptoms – including fluid coming out of her spine and loss of feeling in her leg – and was eventually diagnosed as having tuberculosis of the spine. This example shows the importance of keeping an open mind and being prepared to review the original diagnosis when new information becomes available.

Even if you think an unexplained physical complaint is due to mental illness, review if new symptoms develop – don't miss a physical cause!