Stepped care proposed for functional somatic syndromes
It has been shown that 25-50% of our patients present with physical symptoms for which there is no satisfactory pathological explanation.1 Our ability to manage these patients effectively is hampered by confusion over terminology and the controversy surrounding the classification of functional somatic syndromes.
In this review the authors argue that functional somatic syndromes should neither be regarded as a series of discrete medical syndromes, nor be lumped together as somatoform disorders with the implication of psychogenic origin. Instead they should be seen as a family of related and often overlapping conditions at the interface between medicine and psychiatry. For a list of common functional somatic syndromes, see table, below.
The review is based on evidence drawn from systematic reviews and meta-analyses published since 2001. Good quality evidence is mainly restricted to those syndromes that have well defined diagnostic criteria; there has been no research on patients with more than one syndrome and there is disagreement over relevant outcome measures (symptom relief vs functional improvement).
The evidence reviewed suggests that drugs acting on the CNS are more consistently effective across a range of functional somatic syndromes than drugs acting peripherally.
Psychotherapy and active behaviour therapy seem to be more effective than passive physical interventions, such as trigger point injections.
The authors propose a stepped care approach. Patients with uncomplicated functional somatic syndromes (which they do not define) require reassurance, positive explanation, symptomatic relief and advice regarding exercise. The authors caution against the use of the term ‘medically unexplained symptoms': patients need an adequate explanation, in biopsychosocial terms, of their symptoms.
Complicated functional somatic syndromes may be indicated by repeated presentations, persistent organic causal attribution, symptoms in two or more body systems or associated anxiety and depression.1
In these patients antidepressant treatment should be considered and patients should be helped to change their dysfunctional attributions and illness behaviour.
The review also found that childhood experience of abuse or neglect, parental ill health or enhanced parental responsiveness to illness in the child can increase the risk of functional somatic syndromes in later life. I have found that creating family trees with patients can provide insight (for example, in cases where a parent has only ever shown sympathy and interest when the patient is ill) and facilitate brief cognitive therapy.
Henningsen P, Zipfel S, Herzog W. Management of functional somatic syndromes. Lancet 2007;369:946-55Reviewer
Dr Phillip Bland