For many reasons, it is important to discuss and understand these unexplainable physical symptoms. They will be a potential problem following the war and trauma. This issue is highlighted by leading international health agencies and the work they cite in the recommendation of its management comes from our research in Sri Lanka. The numbers of doctors who have necessary skills to detect and manage these patients are limited and have to be further increased to meet the new workload.

Therefore, I have given priority to discuss unexplainable physical symptoms in today’s article. My attempt is to highlight the significance of this issue in order to convince the policy planners first so that they can take prompt and appropriate steps to detect and manage this group of patients among IDPs , ex-combatants, service personnel and the ordinary public affected by war and trauma. Such an exercise will undoubtedly save millions of rupees in healthcare expenditure. Secondly, this article aims to sensitise the doctors who will be involved in service provision to the above categories of people because they can provide the most appropriate scientifically proven (evidence based) care. Thirdly, this article may inform the people who may be suffering from such symptoms prompting them to seek appropriate help themselves.

Our research carried out in Sri Lanka shows that, even outside war and other disaster situations, these unexplainable psychical symptoms are common. The people who suffer from these symptoms are usually very distressed, they are disabled by their perceived symptoms so that they are unable to perform their routine work. They are not satisfied with the services they received in spite of consulting many different categories of doctors and being heavily investigated. They over-use existing health services incurring disproportionate healthcare costs to the health services. Therefore, these symptoms have implications for the patient, family, society, care providers and the health care system.

Numerous research publications from many different parts of the world confirm a link between the disasters, trauma and medically unexplained symptoms. Therefore after tsunami we took steps to convert 15 years of research by us in Sri Lanka into service provision. We trained around 400 doctors to identify patients with medically unexplained symptoms and manage them appropriately. A poster was developed to raise awareness among doctors, and a referenced manual was printed. This programme was funded by the WHO and supported by the Ministry of Health. This is just one example of how we used the tsunami as a window of opportunity to translate research into evidence based practices. We extended our training even to Pakistan and Sichuan China, by training doctors on this neglected population of patients with medically unexplained symptoms after the recent earthquakes in Kashmir and Sichuan province in China. Inter Agency Standing Committee (IASC - headed by the WHO) guideline on mental health and psycho social support in emergency settings, has incorporated this work and recommended it as an important post disaster intervention.

(http://www.who.int/hac/network/interagency/news/iasc_guidelines_mental_health_psychososial_upd2008.pdf)

In this manual they have highlighted medically unexplainable symptoms as one of the main issues seen in those affected by emergency settings. The guidelines state that ‘ People with mental disorders may initially present at primary health care (PHC) facilities to seek help for medically unexplained physical symptoms’.

Therefore, The Inter-Agency Standing Committee (IASC) in one of its action sheets, on specific psychological and social considerations in provision of general health care, emphasizes the importance of appropriate management (after exclusion of physical causes). They cite our treatment methods developed at the Institute for Research and Development in Sri Lanka and provide its work as a key resource. (See the manual below - available free at the web www.ird.lk)

These are symptoms not fitting a known physical illness or a disease entity, and the doctors are unable to elicit relevant physical signs and the relevant laboratory investigations are not supporting a diagnosis of a recognised physical illness.

However this does not mean that the patients are lying. Their perceptions or the symptoms are genuine but there is no serious underlying physical cause for the symptoms. However, patients remain very worried over serious illness which becomes their preoccupation.

Yes they are. They are not malingerers. Perception of the symptoms is real and not imagined. They are not deliberately producing symptoms. But they are not suffering from a serious physical illness either.

What are the common symptoms?

The common symptoms detected in three studies carried out at Sri Jayewardenepura Hospital Outpatients Department in 1990, 1997 and 2000 include:

1. Chest pain including pain at the back of the chest

2. Abdominal pain including lower abdominal pain

3. Abdominal cramp

4. Pain in the limbs

5. Pain in the joints

6. Numbness over various parts of the body

7. Headaches

8. Lifelessness

9. Pain along spine

10. Lower backache

11. Faintish feeling

12. Shortness of breath

13. Burning sensation over various parts of the body

14. Loss of appetite

15. Sleep disturbance

16. Puffiness of the abdomen (bloating)

17. Fatigue

They are just like symptoms seen with physical illness but the significance is that the combination of these symptoms does not fit into known physical illnesses.

Burden of Medically Unexplained Symptoms

It is the disproportionate distress and the disability which has a major impact on their lives. In our research it was revealed that these patients go repeatedly to various doctors seeking reassurance and treatment. For an example, if we compare with an average Sri Lankan, they would only go to a health institution four times a year. But these patients will do so sixteen times on average. There were some who had over 50 consultations a year.

There is a tendency to consult medical specialists and alternative care providers.

In one of our studies out of sixty eight patients suffering from medically unexplainable symptoms, it was revealed that sixty three of them had consulted general practitioners. In addition thirty nine of them also consulted physicians, nine consulted surgeons, thirty three consulted traditional healers, ten went to Neurologists, seven had seen cardiologists, and four ENT surgeons. Thirty two were admitted at least once during previous six months. Only two went to psychiatrists. Psychiatric referrals are usually unpopular with these patients. This over-utilisation of services is one of the main contributors to the great economic cost of these patients.

Patients with medically unexplained symptoms are more likely to go on sick leave and/or show more restricted activity than patients without such symptoms. These patients are generally considered ‘difficult to manage’ by the doctors.

Impact on the family

The disproportionate distress and disproportionate disability experienced by the patients with medically unexplained symptoms may result in the family becoming over involved. The patient may be relieved of his/ her usual day-to-day responsibilities because of the perceived disability. However, such actions tend to reinforce the patient’s beliefs and dysfunctional behaviours rather than helping to resolve them. Therefore they should be assisted to return to their normal work gradually than making them totally dependent.

Yes, they can be treated. The only two research studies reported from the developing world, as to how to treat them has been done by our team in Sri Lanka with the support of our colleagues from the Institute of Psychiatry, Kings College, University of London. Based on this research we have produced this poster highlighting what to do and what not to do. These simple steps will be able to help some of those. The others may need more specific treatment given by those who are trained to do so. They can be ordinary doctors who have had the appropriate training. Therefore we are making arrangements to distribute this to appropriate agencies dealing with IDPs.

We highlight this work not because it is our work but only because of its relevance and significance to the present context. As scientists with social responsibility, to us research has a value beyond just academic publications that may gather dust in shelves. Therefore we believe that we have a duty and a responsibility to disseminate local research with a view of aiding service development. We are only taking this window of opportunity as we did after tsunami, but with more courage and determination. It is especially important at a time in which the Sri Lankan nation is awakening to a new era. Usually we are used to rely on research done in the developed world. This is because not much research takes place in our part of the world. We have shown by analyzing five leading medical journals such as British Medical Journal, The Lancet, New England Journal of Medicine, Annals of Internal Medicine and Journal of American Medical Association that only 6.5% research is published from the developing world where 90% of population lives. We have also showed by analysing six leading psychiatric journals published in Europe and USA, only 6% of research is published from developing world. Therefore it is important to use local research for local service development particularly when it has also attracted local as well as international attention.

However, the irony and one sad reality has to be highlighted about the resistance by a handful who think that health services especially mental health is their inheritance and have consistently attempted to hinder the progress and shift of focus of mental health care to a primary care and public health perspective. Defeating territorial marking based on personal agenda by such enemies of progress has to be defeated. Taking on issues such as these have become part and parcel of the work essential to do justice to the most needy and who should be the ultimate beneficiaries of tax payer’s money. They deserve high quality service provision established collectively by working with the great majority of honest and dedicated professionals within the profession of mental health. =