The Mental Health Act (1983) | Insanity and the Law
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Child and Adolescent
While the aim of medicine is generally seen as being the search for a biological explanation of illness, some individuals will present to their doctors with symptoms for which no medical explanation is forthcoming. When these symptoms persist despite normal investigation and treatment, it is important to consider mental health as a possible cause. This entry looks at the somatoform disorders, in which real symptoms are produced by the mind, along with factitious disorder and malingering in which the symptoms are in some way fake.
Somatoform disorders are those in which an individual suffers genuine physical symptoms, but no physical or neurological abnormality can be found. These symptoms are neither faked nor under the control of the individual, and are thought to be of psychological origin. The term 'conversion disorder' is in some cases used to describe a specific form of somatization featuring 'conversion' of psychological pain into physical pain.
Somatization disorder – in this condition, the individual suffers from many different symptoms over a time scale of years. These include urinary, sexual and menstrual problems, skin problems, gut problems, paralysis, loss of hearing, balance or vision, and so-called 'pseudoseizures'. These symptoms may change often, but tend to cause some sort of disability either directly or through the individual's attempts to cope. The individual tends not to accept reassurance that nothing is physically wrong with them, and may end up having numerous unnecessary investigations.
Persistent somatoform pain disorder – this is a specific form of somatisation in which the individual suffers from severe pain that cannot be properly explained. The pain usually varies in line with the psychological pain that underlies it.
Somatoform autonomic dysfunction – in this condition, the individual suffers from symptoms relating to the autonomic system: tremors, flushes, palpitations, sweating, bloating, flatulence, urinary frequency, hyperventilation and so forth. These will generally be clustered around a particular organ; for instance, an individual may complain of palpitations, hot flushes and a rapid heart beat, putting all these down to an inexplicable heart problem.
Hypochondriacal disorder – whereas a somatising individual will arrive with a list of symptoms that need treating, a person with hypochondriacal disorder will arrive asking for a test for a disease. These individuals become excessively worried by the quite usual sensations that others usually ignore. In fact, hypochondriacs will often remain concerned even after several doctors have examined and reassured them, although they are sometimes reassured for a while after receiving a negative test result. There is a differentiation to be made between hypochondriacal disorder and hypochondriacal delusions, the latter being a form of psychosis in which the individual is unshakably convinced that they have a serious illness.
In all these cases, it is important that the doctor excludes any realistic possibility of a physical problem before going on to reassure the individual. This can be done by explaining that their symptoms are very real, but that the underlying cause is likely to be an emotional one. The emphasis should be on dealing with this cause and coping with, rather than curing, the symptoms.
Factitious Disorder and Malingering
Factitious disorder and malingering are included in this entry because they may lead to the same presentation as the somatisation disorders, and because factitious disorder may well have an underlying mental health component. In both cases, the individual will complain of symptoms or illnesses they do not have, and may in some cases create fake physical signs by taking medication or contaminating test samples.
In malingering, the individual deliberately pretends to be ill with a view to gaining something, be it medication, state benefits or evasion of a prison sentence. On the other hand, factitious disorder, aka Munchausen's syndrome, does not involve an end goal as such, with the individual simply aiming to receive medical treatment. As with somatisation, the underlying problem in Munchausen's is psychological pain; however, the symptoms here are self-induced and the aim is to be cared for. In Munchausen's syndrome by proxy, a parent or carer deliberately causes an illness in a child or other dependent in order to gain medical attention for the latter. This may be through the use of medication or poisonous substances, and so it is important that a diagnosis is made and the child is protected from further harm. At the same time, it is vital that this diagnosis is not used incorrectly due to the embarrassment and disruption of normal life that this may cause.