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{{Short description|Type of medical diagnosis}}
{{Short description|Type of medical diagnosis}}
A '''wastebasket diagnosis''' or '''trashcan diagnosis''' is a vague [[diagnosis]] given to a patient or to medical records department for essentially non-medical reasons.<ref name="trashcan diagnosis">{{cite web |url=http://patients.about.com/od/glossary/g/trashcandx.htm |title=trashcan diagnosis |access-date= 2008-03-29}}</ref> It may be given when the patient has an obvious but unidentifiable medical problem, when a doctor wants to reassure an anxious patient about the doctor's belief in the existence of reported symptoms, when a patient pressures a doctor for a label, or when a doctor wants to facilitate bureaucratic approval of treatment.
A '''wastebasket diagnosis''' or '''trashcan diagnosis''' is a vague [[diagnosis]] given to a patient or to medical records department for essentially non-medical reasons. It may be given when the patient has an obvious but unidentifiable medical problem, when a doctor wants to reassure an anxious patient about the doctor's belief in the existence of reported symptoms, when a patient pressures a doctor for a label, or when a doctor wants to facilitate bureaucratic approval of treatment. It differs from a [[diagnosis of exclusion]] in that a wastebasket diagnosis is a diagnostic label of doubtful value, whereas a diagnosis of exclusion is characterized by the diagnosis being arrived at indirectly (through the process of excluding all other plausible causes). Unlike a vague wastebasket diagnosis, the diagnostic label arrived at through a process of exclusion may be precise, accurate, and helpful.


The term may also be used pejoratively to describe disputed medical conditions.<ref name=pmid12759275>{{cite journal |author=Smith TL |title=Vasomotor rhinitis is not a wastebasket diagnosis |journal=Arch. Otolaryngol. Head Neck Surg. |volume=129 |issue=5 |pages=584–7 |year=2003 |pmid=12759275 |doi=10.1001/archotol.129.5.584 |url=http://archotol.ama-assn.org/cgi/pmidlookup?view=long&pmid=12759275}}</ref><ref name=pmid1649737>{{cite journal |vauthors=Rauh SM, Schoetz DJ, Roberts PL, Murray JJ, Coller JA, Veidenheimer MC |title= Pouchitis--is it a wastebasket diagnosis? |journal=Dis. Colon Rectum |volume=34 |issue=8 |pages=685–9 |year=1991 |pmid=1649737 |doi=10.1007/BF02050351|s2cid= 20265782 }}</ref><ref name=pmid853276>{{cite journal |author=Napodano RJ |title=The functional heart murmur: a wastebasket diagnosis |journal=J Fam Pract |volume=4 |issue=4 |pages=637–9 |year=1977 |pmid=853276}}</ref><ref name=pmid13703254>{{cite journal |author=GAMBILL EE |title=So-called mesenteric adenitis. A clinical entity or wastebasket diagnosis? |journal=Minn Med |volume=43 |pages= 614–6 |year=1960 |pmid=13703254}}</ref><ref name=pmid696591>{{cite journal |author=Eastman M |title=Senility: the 'diagnostic wastebasket' |journal=Am Pharm |volume=18 |issue=10 |page=53 |year=1978 |doi=10.1016/S0160-3450(15)32615-5 |pmid=696591}}</ref> In this sense, the term implies that the condition has not been properly classified. It can carry a connotation that the prognosis of individuals with the condition are more heterogeneous than would be associated with a more precisely defined clinical entry.<ref name=pmid18240339>{{cite journal |author=Freeman HJ |title=Refractory celiac disease and sprue-like intestinal disease |journal=World J. Gastroenterol. |volume=14 |issue=6 |pages=828–30 |year=2008 |pmid=18240339 |doi= 10.3748/wjg.14.828 |pmc=2687049 |doi-access=free }}</ref> As diagnostic tools improve, it is possible for these kinds of wastebasket diagnoses to be properly defined and reclassified as clinical diagnoses.<ref name=pmid16400833>{{cite journal |author=Herndon RM |title=Multiple sclerosis mimics |journal=Adv Neurol |volume=98 |pages=161–6 |year= 2006 |pmid=16400833}}</ref>
The term may also be used pejoratively to describe disputed medical conditions.<ref name=pmid12759275>{{cite journal |author=Smith TL |title=Vasomotor rhinitis is not a wastebasket diagnosis |journal=Arch. Otolaryngol. Head Neck Surg. |volume=129 |issue=5 |pages=584–7 |year=2003 |pmid=12759275 |doi=10.1001/archotol.129.5.584 |url=http://archotol.ama-assn.org/cgi/pmidlookup?view=long&pmid=12759275}}</ref><ref name=pmid1649737>{{cite journal |vauthors=Rauh SM, Schoetz DJ, Roberts PL, Murray JJ, Coller JA, Veidenheimer MC |title= Pouchitis--is it a wastebasket diagnosis? |journal=Dis. Colon Rectum |volume=34 |issue=8 |pages=685–9 |year=1991 |pmid=1649737 |doi=10.1007/BF02050351|s2cid= 20265782 }}</ref><ref name=pmid853276>{{cite journal |author=Napodano RJ |title=The functional heart murmur: a wastebasket diagnosis |journal=J Fam Pract |volume=4 |issue=4 |pages=637–9 |year=1977 |pmid=853276}}</ref><ref name=pmid13703254>{{cite journal |author=GAMBILL EE |title=So-called mesenteric adenitis. A clinical entity or wastebasket diagnosis? |journal=Minn Med |volume=43 |pages= 614–6 |year=1960 |pmid=13703254}}</ref><ref name=pmid696591>{{cite journal |author=Eastman M |title=Senility: the 'diagnostic wastebasket' |journal=Am Pharm |volume=18 |issue=10 |page=53 |year=1978 |doi=10.1016/S0160-3450(15)32615-5 |pmid=696591}}</ref> In this sense, the term implies that the condition has not been properly classified. It can carry a connotation that the prognosis of individuals with the condition are more heterogeneous than would be associated with a more precisely defined clinical entry.<ref name=pmid18240339>{{cite journal |author=Freeman HJ |title=Refractory celiac disease and sprue-like intestinal disease |journal=World J. Gastroenterol. |volume=14 |issue=6 |pages=828–30 |year=2008 |pmid=18240339 |doi= 10.3748/wjg.14.828 |pmc=2687049 |doi-access=free }}</ref> As diagnostic tools improve, it is possible for these kinds of wastebasket diagnoses to be properly defined and reclassified as clinical diagnoses.<ref name=pmid16400833>{{cite journal |author=Herndon RM |title=Multiple sclerosis mimics |journal=Adv Neurol |volume=98 |pages=161–6 |year= 2006 |pmid=16400833}}</ref>
⚫
Wastebasket diagnoses are often made by medical specialists, and referred back to primary care physicians for long term management.


⚫
Wastebasket diagnoses are often made by medical specialists, and referred back to primary care physicians for long term management.{{Fact|date=May 2024}}
== Specific diagnoses ==

== Examples ==
Common wastebasket diagnoses include:
Common wastebasket diagnoses include:
* [[Chronic fatigue syndrome]] (when applied to fatigue of unknown origin)<ref name="Eludes" /><ref name=":0">{{Citation |last=Moldofsky |first=Harvey |title=Nonrestorative Sleep, Musculoskeletal Pain, Fatigue in Rheumatic Disorders, and Allied Syndromes: A Historical Perspective |date=2015 |work=Sleep Medicine |pages=423–431 |editor-last=Chokroverty |editor-first=Sudhansu |url=http://link.springer.com/10.1007/978-1-4939-2089-1_48 |access-date=2024-05-01 |place=New York, NY |publisher=Springer New York |language=en |doi=10.1007/978-1-4939-2089-1_48 |isbn=978-1-4939-2088-4 |pmc=7122008 |editor2-last=Billiard |editor2-first=Michel}}</ref>
* [[Chronic fatigue syndrome]] (when applied to undiagnosed fatigue)<ref name="Eludes" />
* [[Fibromyalgia]] (when applied to undiagnosed pain)<ref name="Eludes" />
* [[Fibromyalgia]] (when applied to pain of unknown origin)<ref name="Eludes" /><ref name=":0" />
* Subclinical [[hypothyroidism]]{{citation needed|date=December 2018}}
* Subclinical [[hypothyroidism]]{{citation needed|date=December 2018}}
* Seronegative [[rheumatoid arthritis]]{{citation needed|date=December 2018}}
* Seronegative [[rheumatoid arthritis]]{{citation needed|date=December 2018}}
* [[Irritable bowel syndrome]]<ref>{{Cite web |date=2016-11-01 |title=Why You Should Never Settle for an IBS Diagnosis |url=https://bellalindemann.com/blog/never-settle-ibs-diagnosis |access-date=2023-07-08 |website=Bella Lindemann |language=en-US}}</ref><ref>{{Cite magazine |date=2022-03-07 |title=The Mysteries and Underdiagnosis of SIBO |url=https://time.com/6155603/sibo-symptoms-diagnosis-difficult/ |access-date=2023-07-08 |magazine=Time |language=en}}</ref>
* [[Irritable bowel syndrome]]<ref>{{Cite web |date=2016-11-01 |title=Why You Should Never Settle for an IBS Diagnosis |url=https://bellalindemann.com/blog/never-settle-ibs-diagnosis |access-date=2023-07-08 |website=Bella Lindemann |language=en-US}}</ref><ref>{{Cite magazine |date=2022-03-07 |title=The Mysteries and Underdiagnosis of SIBO |url=https://time.com/6155603/sibo-symptoms-diagnosis-difficult/ |access-date=2023-07-08 |magazine=Time |language=en}}</ref><ref name=":0" />
* [[Chronic pain]] syndromes{{citation needed|date=December 2018}}
* [[Chronic pain]] syndromes<ref name=":0" />
* [[Interstitial cystitis]] ("bladder pain syndrome"){{citation needed|date=December 2018}}
* [[Interstitial cystitis]] ("bladder pain syndrome")<ref name=":0" />
* [[Costochondritis]] (when applied to undiagnosed chest pain)<ref name="Eludes" />
* [[Costochondritis]] (when applied to chest pain of an unknown source)<ref name="Eludes" /><ref name=":0" />
* [[Gastroesophageal reflux]] (when applied to undiagnosed chest pain)<ref name="Eludes">{{cite web |url= https://www.nytimes.com/2008/03/25/health/views/25case.html |title=When the Disease Eludes a Diagnosis |access-date=2008-03-29 |author=Barron H. Lerner, MD |date=25 March 2008 |work=New York Times |quote=For example, many patients with chest pain carry a diagnosis of costochondritis (inflammation of the chest wall bones) or gastroesophageal reflux (regurgitation of stomach acid into the esophagus). These are real conditions. But they tend to generate little interest from many physicians, who may refer to them as 'wastebasket diagnoses,' offered when nothing more serious has turned up. The frustration of patients who believe that the medical profession takes these types of ailments too lightly has led groups of them to form alliances to publicize their illnesses. Foremost among them are fibromyalgia, a syndrome involving muscular and other pains, and chronic fatigue syndrome...}}</ref>
* [[Gastroesophageal reflux]] (when applied to chest pain of an unknown source)<ref name="Eludes">{{cite web |url= https://www.nytimes.com/2008/03/25/health/views/25case.html |title=When the Disease Eludes a Diagnosis |access-date=2008-03-29 |author=Barron H. Lerner, MD |date=25 March 2008 |work=New York Times |quote=For example, many patients with chest pain carry a diagnosis of costochondritis (inflammation of the chest wall bones) or gastroesophageal reflux (regurgitation of stomach acid into the esophagus). These are real conditions. But they tend to generate little interest from many physicians, who may refer to them as 'wastebasket diagnoses,' offered when nothing more serious has turned up. The frustration of patients who believe that the medical profession takes these types of ailments too lightly has led groups of them to form alliances to publicize their illnesses. Foremost among them are fibromyalgia, a syndrome involving muscular and other pains, and chronic fatigue syndrome...}}</ref><ref name=":0" />
* [[Shin splints]], which is a label given to multiple separate conditions<ref>{{Cite book |last=Pfeffer |first=Glenn B. |url=https://books.google.com/books?id=Vx0xDwAAQBAJ&newbks=0&printsec=frontcover&pg=PA669&dq=%22wastebasket+diagnosis%22+%22diagnosis+of+exclusion%22&hl=en |title=Operative Techniques: Foot and Ankle Surgery E-Book |last2=Easley |first2=Mark E. |last3=Hintermann |first3=Beat |last4=Sands |first4=Andrew K. |last5=Younger |first5=Alastair S. E. |date=2017-08-15 |publisher=Elsevier Health Sciences |isbn=978-0-323-51191-9 |pages=669 |language=en |quote=...the wastebasket diagnosis of 'shin splints' which can be stress fractures, periostitis, or exertional compartment syndrome.}}</ref>


[[Reactive hypoglycemia]] has been used as a trashcan diagnosis for people who complain about normal physiological reactions to being hungry. In these cases, the labels are offered when nothing more serious can be identified.<ref name="Eludes" /> [[Bronchitis]] may be used as a trashcan diagnosis to label sick children.<ref name="FisherBoyce2005">{{cite book|author1=Randall G. Fisher|author2=Thomas G. Boyce|author3=Hugh L. Moffet|title=Moffet's Pediatric Infectious Diseases: A Problem-oriented Approach|url=https://books.google.com/books?id=LGOB8BJBKkoC&pg=PA145|year=2005|publisher=Lippincott Williams & Wilkins|isbn=978-0-7817-2943-7|pages=145–}}</ref>
[[Reactive hypoglycemia]] has been used as a trashcan diagnosis for people who complain about normal physiological reactions to being hungry. In these cases, the labels are offered when nothing more serious can be identified.<ref name="Eludes" /> [[Bronchitis]] may be used as a trashcan diagnosis to label sick children.<ref name="FisherBoyce2005">{{cite book|author1=Randall G. Fisher|author2=Thomas G. Boyce|author3=Hugh L. Moffet|title=Moffet's Pediatric Infectious Diseases: A Problem-oriented Approach|url=https://books.google.com/books?id=LGOB8BJBKkoC&pg=PA145|year=2005|publisher=Lippincott Williams & Wilkins|isbn=978-0-7817-2943-7|pages=145–}}</ref>

A diagnosis like fibromyalgia is not invariably a wastebasket diagnosis; many "trashcan" labels can be applied specifically and appropriately, and they are considered wastebasket diagnoses only when they are applied to pain or other common symptoms whose origin or cause cannot be determined.<ref>Chelimsky, Thomas C. 2009. “CHAPTER 9: Pain.” In ''Clinical Adult Neurology'', 149–65. Demos Medical Publishing, LLC. {{ISBN|9781933864358}}.</ref>

Different specialists provide different wastebasket labels to the same sets of symptoms.<ref name=":0" /> For example, in response to a person with chronic pain but no detected medical pathology, a rheumatologist might label the symptoms [[fibromyalgia]], a specialist in [[physical medicine and rehabilitation]] might diagnose [[regional pain]], an [[orthopedic surgeon]] will call it [[chronic pain syndrome]], and a [[chiropractor]] will claim that there is a problem with [[Vertebral subluxation|alignment of vertebrae in the spine]].<ref name=":0" /> Other specialties similarly focus on their specialty, producing the wastebasket labels from their own fields.<ref name=":0" />


Some diagnoses are being used as trashcan diagnoses in response to unintentional incentives. For example, government-run schools in the United States get additional funding for providing services to students with [[autism spectrum disorder]]s, so some children with atypical behavior patterns are labeled as having ASD so the school can more easily obtain funding for special education services.<ref>{{cite news |title=Autism 'epidemic' largely fueled by special ed funding, shift in diagnosing |author=Stobb, Mike |url= http://www.autismtoday.com/articles/Autism%20%27epidemic%27%20largely%20fueled.asp?cat=1 |quote=The recent explosion of cases appears to be mostly caused by a surge in special education services for autistic children, and by a corresponding shift in what doctors call autism. |year=2007}}</ref>
Some diagnoses are being used as trashcan diagnoses in response to unintentional incentives. For example, government-run schools in the United States get additional funding for providing services to students with [[autism spectrum disorder]]s, so some children with atypical behavior patterns are labeled as having ASD so the school can more easily obtain funding for special education services.<ref>{{cite news |title=Autism 'epidemic' largely fueled by special ed funding, shift in diagnosing |author=Stobb, Mike |url= http://www.autismtoday.com/articles/Autism%20%27epidemic%27%20largely%20fueled.asp?cat=1 |quote=The recent explosion of cases appears to be mostly caused by a surge in special education services for autistic children, and by a corresponding shift in what doctors call autism. |year=2007}}</ref>

Latest revision as of 05:43, 1 May 2024

A wastebasket diagnosis or trashcan diagnosis is a vague diagnosis given to a patient or to medical records department for essentially non-medical reasons. It may be given when the patient has an obvious but unidentifiable medical problem, when a doctor wants to reassure an anxious patient about the doctor's belief in the existence of reported symptoms, when a patient pressures a doctor for a label, or when a doctor wants to facilitate bureaucratic approval of treatment. It differs from a diagnosis of exclusion in that a wastebasket diagnosis is a diagnostic label of doubtful value, whereas a diagnosis of exclusion is characterized by the diagnosis being arrived at indirectly (through the process of excluding all other plausible causes). Unlike a vague wastebasket diagnosis, the diagnostic label arrived at through a process of exclusion may be precise, accurate, and helpful.

The term may also be used pejoratively to describe disputed medical conditions.[1][2][3][4][5] In this sense, the term implies that the condition has not been properly classified. It can carry a connotation that the prognosis of individuals with the condition are more heterogeneous than would be associated with a more precisely defined clinical entry.[6] As diagnostic tools improve, it is possible for these kinds of wastebasket diagnoses to be properly defined and reclassified as clinical diagnoses.[7]

Wastebasket diagnoses are often made by medical specialists, and referred back to primary care physicians for long term management.[citation needed]

Examples[edit]

Common wastebasket diagnoses include:

Reactive hypoglycemia has been used as a trashcan diagnosis for people who complain about normal physiological reactions to being hungry. In these cases, the labels are offered when nothing more serious can be identified.[8] Bronchitis may be used as a trashcan diagnosis to label sick children.[13]

A diagnosis like fibromyalgia is not invariably a wastebasket diagnosis; many "trashcan" labels can be applied specifically and appropriately, and they are considered wastebasket diagnoses only when they are applied to pain or other common symptoms whose origin or cause cannot be determined.[14]

Different specialists provide different wastebasket labels to the same sets of symptoms.[9] For example, in response to a person with chronic pain but no detected medical pathology, a rheumatologist might label the symptoms fibromyalgia, a specialist in physical medicine and rehabilitation might diagnose regional pain, an orthopedic surgeon will call it chronic pain syndrome, and a chiropractor will claim that there is a problem with alignment of vertebrae in the spine.[9] Other specialties similarly focus on their specialty, producing the wastebasket labels from their own fields.[9]

Some diagnoses are being used as trashcan diagnoses in response to unintentional incentives. For example, government-run schools in the United States get additional funding for providing services to students with autism spectrum disorders, so some children with atypical behavior patterns are labeled as having ASD so the school can more easily obtain funding for special education services.[15]

History[edit]

Fake diagnoses are not a modern invention. Medicine around the world has a long history of using and abusing the concept of trashcan diagnoses, from "rectifying the humors" to marthambles to neurasthenia to garbled Latin-sounding names which were made up to impress the patient's family.[16][17][18]

Management[edit]

The medical community is often split on the best approach to managing a wastebasket diagnosis. The biggest challenge for a physician is maintaining their interest and desire to see the patient through their illness.[19] Antidepressants and cognitive therapies are commonly employed, speaking to the possible emotional basis that underpins these diagnoses or the physician's effort to psychopathologize the patient whose disorder the physician can not identify.[20]

See also[edit]

References[edit]

  1. ^ Smith TL (2003). "Vasomotor rhinitis is not a wastebasket diagnosis". Arch. Otolaryngol. Head Neck Surg. 129 (5): 584–7. doi:10.1001/archotol.129.5.584. PMID 12759275.
  2. ^ Rauh SM, Schoetz DJ, Roberts PL, Murray JJ, Coller JA, Veidenheimer MC (1991). "Pouchitis--is it a wastebasket diagnosis?". Dis. Colon Rectum. 34 (8): 685–9. doi:10.1007/BF02050351. PMID 1649737. S2CID 20265782.
  3. ^ Napodano RJ (1977). "The functional heart murmur: a wastebasket diagnosis". J Fam Pract. 4 (4): 637–9. PMID 853276.
  4. ^ GAMBILL EE (1960). "So-called mesenteric adenitis. A clinical entity or wastebasket diagnosis?". Minn Med. 43: 614–6. PMID 13703254.
  5. ^ Eastman M (1978). "Senility: the 'diagnostic wastebasket'". Am Pharm. 18 (10): 53. doi:10.1016/S0160-3450(15)32615-5. PMID 696591.
  6. ^ Freeman HJ (2008). "Refractory celiac disease and sprue-like intestinal disease". World J. Gastroenterol. 14 (6): 828–30. doi:10.3748/wjg.14.828. PMC 2687049. PMID 18240339.
  7. ^ Herndon RM (2006). "Multiple sclerosis mimics". Adv Neurol. 98: 161–6. PMID 16400833.
  8. ^ a b c d e Barron H. Lerner, MD (25 March 2008). "When the Disease Eludes a Diagnosis". New York Times. Retrieved 2008-03-29. For example, many patients with chest pain carry a diagnosis of costochondritis (inflammation of the chest wall bones) or gastroesophageal reflux (regurgitation of stomach acid into the esophagus). These are real conditions. But they tend to generate little interest from many physicians, who may refer to them as 'wastebasket diagnoses,' offered when nothing more serious has turned up. The frustration of patients who believe that the medical profession takes these types of ailments too lightly has led groups of them to form alliances to publicize their illnesses. Foremost among them are fibromyalgia, a syndrome involving muscular and other pains, and chronic fatigue syndrome...
  9. ^ a b c d e f g h i j Moldofsky, Harvey (2015), Chokroverty, Sudhansu; Billiard, Michel (eds.), "Nonrestorative Sleep, Musculoskeletal Pain, Fatigue in Rheumatic Disorders, and Allied Syndromes: A Historical Perspective", Sleep Medicine, New York, NY: Springer New York, pp. 423–431, doi:10.1007/978-1-4939-2089-1_48, ISBN 978-1-4939-2088-4, PMC 7122008, retrieved 2024-05-01
  10. ^ "Why You Should Never Settle for an IBS Diagnosis". Bella Lindemann. 2016-11-01. Retrieved 2023-07-08.
  11. ^ "The Mysteries and Underdiagnosis of SIBO". Time. 2022-03-07. Retrieved 2023-07-08.
  12. ^ Pfeffer, Glenn B.; Easley, Mark E.; Hintermann, Beat; Sands, Andrew K.; Younger, Alastair S. E. (2017-08-15). Operative Techniques: Foot and Ankle Surgery E-Book. Elsevier Health Sciences. p. 669. ISBN 978-0-323-51191-9. ...the wastebasket diagnosis of 'shin splints' which can be stress fractures, periostitis, or exertional compartment syndrome.
  13. ^ Randall G. Fisher; Thomas G. Boyce; Hugh L. Moffet (2005). Moffet's Pediatric Infectious Diseases: A Problem-oriented Approach. Lippincott Williams & Wilkins. pp. 145–. ISBN 978-0-7817-2943-7.
  14. ^ Chelimsky, Thomas C. 2009. “CHAPTER 9: Pain.” In Clinical Adult Neurology, 149–65. Demos Medical Publishing, LLC. ISBN 9781933864358.
  15. ^ Stobb, Mike (2007). "Autism 'epidemic' largely fueled by special ed funding, shift in diagnosing". The recent explosion of cases appears to be mostly caused by a surge in special education services for autistic children, and by a corresponding shift in what doctors call autism.
  16. ^ Thompson, C.J.S. (January 24, 2003) [1928]. Quacks of Old London. Kessinger Publishing. p. 80. ISBN 978-0-7661-3609-0. Retrieved February 11, 2012.
  17. ^ Grossman, Anne Chotzinoff, Lisa Grossman Thomas, Patrick O'Brian (2000). Lobscouse & Spotted Dog: Which It's a Gastronomic Companion to the Aubrey. W. W. Norton & Company. pp. 249–250. ISBN 978-0-393-32094-7.{{cite book}}: CS1 maint: multiple names: authors list (link)
  18. ^ Burke, Peter; Roy Porter (22 October 1987). The Social history of language. Cambridge University Press. pp. 89–90. ISBN 978-0-521-31763-4.
  19. ^ Lerner, Barron H. (March 25, 2008). "When the Disease Eludes a Diagnosis (Published 2008)". The New York Times – via NYTimes.com.
  20. ^ Servan-Schreiber, David; Tabas, Gary; Kolb, N. Randall (March 1, 2000). "Somatizing Patients: Part II. Practical Management". American Family Physician. 61 (5): 1423–8, 1431–2. PMID 10735347 – via www.aafp.org.
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