The “Functional” Medical Out-Patient

Abstract

Every medical out-patient clinic contains a percentage of patients who are examined, investigated and eventually discharged, no structural lesion having been found to account for their symptoms. The term “functional” is used in this paper to describe such patients; i.e. those who have a disorder of the function but not of the structure of an organ, whether or not the disorder is regarded as primarily psychogenic. The purpose of this investigation is to examine carefully these out-patients and try to identify them more clearly by comparison with those in whom structural disease can be detected, with particular reference to the mental state.

Psychological illness in medical outpatients

“…The incidence found in this study (29-4 %), is very close to the average (27-3 %) in eleven different surveys of medical outpatients reviewed by Davies (1964). Brodman et al (1952), found a similar incidence of 30 % while Maclay (1965) found that 26 % of a personal series ofmedical outpatients suffered from a psychological illness. In all of these studies the figures quoted refer to purely psychological cases and exclude combination of organic and psychological diagnoses in the same patient.…”

“…Several studies have concentrated on the medical outpatient population (Roberts & Morton, 1952;Culpan, Davies & Oppenheimer, 1960;Sainsbury, 1960;Mannucci, Friedman & Kaufman, 1961;Stoeckle, Zola & Davidson, 1962;Davies, 1964;Maclay, 1965) while others have demonstrated a similar problem in surgical outpatients (Zwerling et al, 1955;Culpan et al, 1960), in gynaecological clinics (Bryson, 1945;Morris & O'Neill, 1958;Culpan et al, 1960), and in a casualty department (Mestitz, 1957) while Priest (1962) covered this particular problem in the course of a large (1000 cases) survey of outpatients in general. The incidence found in this study (29-4 %), is very close to the average (27-3 %) in eleven different surveys of medical outpatients reviewed by Davies (1964).…”

Reasons against referral to the psychiatrist

“…Percentage of psychiatric Specialty morbidity (or of Percentage of referrals 'functional disorders') to the psychiatrist General medicine 43-5 (Pemberton, 1951) 14 (Fleminger & Mallett, 1962) 38-51 (Culpan & Davies, 1960 3-8 (Kenyon & Rutter, 1963) 16-2 (Priest, 1962 04-2-8 (Bridges, Koller & Wheeler, 1966) 26 (Maclay, 1965) 4'2 (Crisp, 1968) 14 (Forsyth & Logan, 1968) Neurology 5 (Jacobs & Russell, 1961) 4-6 (Crisp, 1968 General surgery 5-21 0-16 (Fleminger & Mallett, 1962) 0-37 (Kenyon & Rutter, 1963) 2 (Crisp, 1968) …”

“…Percentage of psychiatric Specialty morbidity (or of Percentage of referrals 'functional disorders') to the psychiatrist General medicine 43-5 (Pemberton, 1951) 14 (Fleminger & Mallett, 1962) 38-51 3-8 (Kenyon & Rutter, 1963) 16-2 (Priest, 1962 04-2-8 (Bridges, Koller & Wheeler, 1966) 26 (Maclay, 1965) 4'2 (Crisp, 1968) 14 (Forsyth & Logan, 1968) Neurology 5 (Jacobs & Russell, 1961) 4-6 (Crisp, 1968) General surgery 5-21 0-16 (Fleminger & Mallett, 1962) 0-37 (Kenyon & Rutter, 1963) 2 (Crisp, 1968) Gynaecology 38 (Morris & O'Neill, 1958) 0-18 (Fleminger & Mallett, 1962) 10 (Munro, 1969) 0-59 (Kenyon & Rutter, 1963) All specialties 0-7 (Fleminger & Mallett, 1962) The lack of readily available psychiatric facilities The patients' dislike of being referred to a psychiatrist The disadvantage to patients of being labelled as mental cases Psychological complaints are often made worse by medical attention Psychiatric illness is largely incurable A feeling that treatment of neurotic patients is the job of any doctor The delay in receiving reports on patients referred to psychiatric clinic Lack of satisfactory rapport between you and the psychiatrist Unsatisfactory division of responsibility Any others sent to 106 consultants comprising all non-psychiatric clinicians who were on the staff of six hospitals in the area of the North East Metropolitan Regional Board. The hospitals were selected for the comprehensive nature of their clinical service and the demographic variety of the areas served by them.…”

Consultation and Evaluation

“…Estimates of the prevalence of psychiatric morbidity in medical outpatient clinics vary widely, i.e. from approximately 50-80% (1,3,4,6,7,8,11,13,14,15). In a survey of patients attending the General Outpatient department of the Mount Sinai Hospital of New York for ten years or longer, psychiatric disorder could be diagnosed in 73.5% (12).…”