Recent Developments in the Understanding and Management of Functional Somatic Symptoms in Primary Care

Per Fink; Marianne Rosendal

Disclosures

Curr Opin Psychiatry. 2008;21(2):182-188. 

In This Article

The Concept of Functional Somatic Symptoms

One lasting conceptual issue is whether a functional disorder is of a mental or physical nature, and thus the language we use is imbued with terms that presuppose body and mind dualism, that is somatization, somatoform disorder, and medically unexplained conditions. The issue of physical versus psychiatric has given rise to an intense debate among experts in recent years.[8,9] One group of authors[4] favours abolishing the whole category of somatoform disorders from the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV and the ICD-10. They argue that the diagnoses are stigmatizing, that most of the patients are treated in primary care, and that general psychiatry neglects somatoform disorders.[4] Therefore, the disorder should be moved from axis I to axis III (medical conditions) of the DSM-V.[10,11,12] Other experts[9] argue for retaining the diagnostic group of somatoform disorders because it is well founded and accepted among patients and doctors in some cultures, and moving these disorders from axis I to axis III will not solve anything. Germany is one of the countries in which the diagnosis somatoform disorder seems well accepted. This could be a result of a well developed specialized clinical service for patients with functional disorders, which signifies that the patients' disorders are taken seriously and treatment possibilities exist. Also training GPs about FSSs may change doctors' attitudes to these patients.[13]

Except for the problem of stigmatization, which functional disorders share with mental disorders, the classification discussion (mental or physical) seems academic from a primary care perspective, as GPs must care for all types of patients. For GPs, two other problems are more important. First, the classification must reflect the spectrum of severity encountered in primary care, ranging from banal complaints that do not need further examination or treatment to chronic cases.[2,14] The mild conditions are poorly covered in the current ICD-10 and DSM-IV. In the International Classification of Primary Care (the ICPC-2),[15] used in primary care in a number of countries, mild cases are included as symptom diagnoses. Symptom diagnoses are applied when symptoms cannot be attributed to specific diagnoses mapped to the ICD-10 and they include symptoms that need to be clarified, symptoms that do not require further examination or treatment, and persistent symptoms that do not match a specific diagnosis. A self-limited symptom may be a pathological process or part of normality, but as it attracts medical attention it needs to be classified. Improvements in the ICPC-2 have been suggested to specify moderate FSSs.[16] Furthermore, Fink et al.[2] suggested that the adjustment disorder category be extended to include a physical symptom subtype. They also suggested that severe forms of functional somatic disorders have to be viewed as disorders in their own right and not just as a process of somatization that is secondary to another condition.

This leads to the second important point from a primary care perspective: the classification has to be exclusive in that patients are diagnosed unambiguously with only one condition. Currently patients with identical clinical pictures may receive different diagnostic labels.[1,2,3] The fact that patients' diagnoses are dependent on the treating doctors and on the available treatment possibilities associated with particular diagnoses is not satisfactory. There seems to be a general agreement among experts that most of the current somatoform diagnostic categories of the DSM-IV and ICD-10 are abolished and somatization disorder, undifferentiated somatoform disorder, somatoform pain disorder and corresponding diagnoses on the ICD-10, including autonomic dysfunction and neurasthenia, are combined.[10,17] Different names have been suggested, for example bodily distress disorder,[1] physical symptoms disorder,[10] and multiform somatoform disorder.[18] The hypochondriasis diagnosis would be retained but the name changed to health anxiety disorder. The diagnostic criteria need revision, however, and new and more valid criteria have been proposed.[19,20]

In epidemiological studies, the number of somatic symptoms is often used to identify patients with FSSs. Symptom count by symptom screening questionnaires may be appropriate in studies and as a diagnostic aid in for example primary care, as there is an inverse association between the number of symptoms and the probability of a medical/surgical condition being present (very few well defined physical diseases present with multiple symptoms). From a classification point of view, however, this approach is less appealing as the number of symptoms is on a continuum, and it is impossible to establish a natural cut-off point for the number of symptoms to define FSSs.[1] Thus, a symptom count approach is not appropriate for making clinical diagnoses.

A classification needs a more solid basis than expert panels and consensus.[21,22] Robins and Guze[23] and later Kendell[24] have listed a range of strategies to scientifically establish the validity of clinical syndromes: first, to identify and describe the syndrome by 'clinical intuition' or cluster analysis; second, to demonstrate boundaries or 'point of rarity' between related syndromes by statistical methods; third, to perform follow-up studies to establish a distinct course or outcome; fourth, to perform therapeutic trials to establish a distinct treatment response; fifth, to conduct family studies establishing that the syndrome 'breeds true'; and, finally, to demonstrate the association with some more fundamental abnormalities - anatomical, biochemical, or molecular.

Three more rules should be added to the list. First, the patients have to be sampled from appropriate populations; second, it is necessary to confirm the results in cross-validation studies; and, third, the patients must be assessed by an appropriate method.

The considerable overlap in symptoms and diagnostic criteria between FSSs is probably due to the fact that criteria have been developed in small, unrepresentative samples from subspecialty clinics and by consensus. These criteria have been tested using inappropriate designs - case-control studies or confirmatory analytical approaches.[3,25,26] As patients referred to a specialized service are selected according to the presenting symptoms, the various FSSs may simply be an artefact of the medical specialization.[1,2,3] For example, the diagnosis of fibromyalgia has arisen from rheumatology departments. The somatization disorder came from an exploratory study by Perley and Guze.[27] Based on the symptoms reported by 39 female patients admitted to a psychiatric ward and diagnosed with 'hysteria', they set up diagnostic criteria for hysteria later named Briquettes syndrome. The somatization disorder diagnoses were introduced in the DSM-III and were a modification of Briquettes syndrome. Although the diagnostic criteria have been included in later permutations of the DSM classifications, their heritage is still unmistakable.

Many studies have relied on predefined symptom lists derived from the DSM symptom lists, and widely used diagnostic instruments like the Composite International Diagnostic Interview (CIDI) and the Diagnostic Interview Schedule (DIS) only explore symptoms included in the DSM. Thus criteria that go beyond the original symptom lists are not explored. Few studies have used instruments like the Present State Examination (PSE)/ Schedules of Clinical Assessment in Neuropsychiatry (SCAN) or tailored instruments that are not diagnosis bound.

New empirical studies indicate that physical symptom profiles can be used to classify patients with functional disorders. Fink et al.[1] disclosed symptom clustering and a distinct pattern of cardiopulmonary, musculoskeletal/pain, and gastrointestinal symptom factors in an exploratory factor analysis based on SCAN data. These three symptom clusters have also been reported in other studies,[2,28,29] which warrant their validity. Maybe more importantly, the new cluster approach is easily incorporated into a neurobiological framework; that is, the symptoms are hypothesized to be caused by hyperactivity of the autonomic nervous system and the hypothalamic-pituitary-adrenocortical axis.[1] Musculoskeletal symptom factors may be attributed to dysfunction of the reticular system located within the brain stem and the medulla. Hence, the syndromes may represent a stress response mediated through physiological and cerebral pathways. The cluster approach also embraces the functional somatic syndromes, suggesting that they may be different expressions of a common phenomenon.[2,28] This hypothesis may point to a new expanding research area in functional disorders: the neurobiological and neurophysiological basis of the disorders.[2,30]

In this review we have not touched upon the important aspect of the psychopathology of functional disorders. We need to identify characteristics of the disorders that go beyond physical symptoms, for both diagnostic and treatment purposes. It seems that patients are being punished for the shortcomings of the healthcare system and the doctors' lack of knowledge about these conditions. This has influenced the views on somatoform disorders; many regard these patients as 'over-utilizers' of healthcare or resistant to reassurance. Examples of important studies on psychopathology that may have implications for future classification and management include the following: Rief et al.,[31] who demonstrated that patients with somatoform disorders paid selective attention to medical information; Frostholm et al.,[32] who displayed the importance of patients' illness perceptions and uncertainties; and Frostholm et al.[33] and Salmon et al.,[34] who published a series of studies on doctor-patient interactions and the patients' illness beliefs. Deary et al.[35] reviewed cognitive models for FSSs.

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