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What should we say to patients with symptoms unexplained by disease? The “number needed to offend”

BMJ 2002; 325 doi: (Published 21 December 2002) Cite this as: BMJ 2002;325:1449
  1. Jon Stone, research fellow in neurology (,
  2. Wojtek Wojcik, medical studenta,
  3. Daniel Durrance, medical studenta,
  4. Alan Carson, consultant neuropsychiatristb,
  5. Steff Lewis, medical statisticiana,
  6. Lesley MacKenzie, sister in neurology outpatientsa,
  7. Charles P Warlow, professor of medical neurologya,
  8. Michael Sharpe, reader in psychological medicineb
  1. a University Department of Clinical Neurosciences, Western General Hospital, Edinburgh EH4 2XU
  2. b University Department of Psychiatry, Royal Edinburgh Hospital, Edinburgh EH10 5HF
  1. Correspondence to: J Stone

    Most doctors make a diagnosis and offer treatment to patients whose symptoms turn out to be unexplained by disease.1 In such cases a diagnostic label is important in signifying to the patient and family that the doctor is taking the problem seriously and accepts the complaints as real. Some diagnostic labels, particularly those that sound “psychological,” can be perceived by patients as offensive by implying that the patients are “putting on” or “imagining” their symptoms or that they are “mad.”2

    Various potentially suitable diagnoses are available to doctors. “Hysteria” was the traditional term and is still sometimes used. “Functional nervous disorder” was used in the late 19th century to denote symptoms arising from disordered nervous functioning,3 but in the 20th century this was superseded by terms that implied psychogenesis, such as psychosomatic.4 In the past 20 years more neutral descriptive terms such as “medically unexplained …

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