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SOMATIC PRESENTATIONS: TREATMENT |
From the Department of Psychiatry, Oxford University, Oxford, UK.
Address correspondence to Richard Mayou, Department of Psychiatry, Warneford Hospital, Oxford, OX3 7JX, UK. E-mail: richard.mayou{at}psych.ox.ac.uk
ABSTRACT
Objective: To consider whether the many types of treatments for mental disorders—both those specifically targeting illness mechanisms and nonspecific elements—are also effective in treating functional symptoms and syndromes. The paper discusses the need for well-organized care that emphasizes early treatment and recognition of more complex problems in primary and secondary medical care.
Methods: Evidence from a wide range of research and clinical experience is used to identify and illustrate general themes.
Results: Despite a limited evidence base, it is clear that both specific and nonspecific interventions that are effective with mental disorders are also effective in treating functional complaints. They are also helpful in the management of maladaptive reactions to physical disorders. Delivery is most effective as stepped care.
Conclusions: There is a particular need for more evidence on the effectiveness of the nonspecific elements of treatment and of their most appropriate delivery by nonspecialists in general medical settings. Experience with a variety of treatment methods will enhance our understanding of psychological and other etiological variables and thereby influence the development of improved definitions in Diagnostic and Statistical Manual of Mental Disorders—5th Edition. It is argued that a main focus of review of somatoform disorder should be the resolution of conceptual problems.
Key Words: treatment • functional • somatoform • classification • mental
Abbreviations: CBT = cognitive behavior therapy.
INTRODUCTION
This special issue of Psychosomatic Medicine is concerned with the very large clinical and public health problem of persistent and limiting somatic symptoms that are not explained by organic pathology (1,2). They rarely present to psychiatrists and psychologists, being mainly treated in primary care and outpatient clinics where they are regarded as difficult to treat. Consultation with alternative, complementary, and nonmedical healers is also very frequent. The large size of the clinical problem means that the few of us with specialist skills need to set out the evidence base and its implications for the whole range of treatments that can be used by nonspecialists in all medical settings in all cultures. This paper concentrates on "nonspecific" treatments and delivery in routine care. The latter means placing a much greater emphasis than at present on simple early interventions and also on better methods to identify those requiring more intensive treatments. It raises issues about the greater use of specialist expertise to develop and evaluate care programs and to train and supervise nonspecialists.
Our answers to the question posed in the title of this paper depend on first clarifying the nature of the clinical problems, etiology, and the many approaches to treatment in specialist and nonspecialist settings (3–5).
Nomenclature, Classification, and Treatment Priorities
Somatoform complaints are known under a bewildering variety of other names, for example, somatization and medically unexplained symptoms, or as we prefer "functional symptoms and syndromes" (5). Most presenting complaints are short lived and there is usually no additional psychiatric disorder, but the more persistent and disabling problems are likely to be associated with one or more diagnosable Diagnostic and Statistical Manual of Mental Disorders—4th Edition (DSM-IV) disorder:
The authors of Somatoform Disorders for DSM-III focused on what they believed to be uncommon and specific subcategories, such as hypochondriasis and somatization disorder. In practice (and with a considerable widening of diagnostic concepts in DSM-IIIR), it has become apparent that almost all persistent functional or physically unexplained symptoms satisfy criteria for somatoform disorder, most usually the nonspecific categories that are defined only in terms of physical symptoms—undifferentiated somatoform disorder, pain disorder, somatoform disorder not otherwise specified. Because these latter conditions are very frequent in clinical practice, they deserve to be a priority in the program leading up to DSM-V and International Classification of Diseases-11 (ICD-11).
Etiology
Traditionally DSM, ICD, and Western clinical practice have, despite protestations to the contrary, been dualist in their separation of mind and body explanations. Although this has resulted in much uncertainty and acrimony about the causes of functional syndromes and symptoms, it is encouraging that it is now widely accepted that etiology should be seen as an interaction between bodily perceptions (physiological or minor pathological) and psychological interpretation or attribution (3,5). Cognitive interpretations are affected by culture and social setting, personality, health beliefs and experience, mental state, and the reactions of others including doctors. Complaints and disability are maintained by physiological, psychological, behavioral, iatrogenic, and social variables. In addition, it is ever more apparent that mental states often have physiological consequences.
There is no division in this etiological model between physically "explained" and "unexplained" categories, rather a spectrum from the largely physical (myocardial infarction) to the largely psychological (conversion, palpitation as a symptom of panic). Many conditions are intermediate (low back pain, irritable bowel); some, like chronic fatigue, are highly controversial with vocal lay groups unwilling to accept that psychological variables make any contribution to perception of symptoms or to disability. The model also makes explicit the close similarities in the patterns of psychological reactions to whole spectrum of somatic complaints from those of entirely psychological origin to those associated with major organic pathology. This means that, in working with our patients, whether or not there is probable pathology, we can combine from the outset appropriate physical investigation with efforts to minimize psychologically determined distress and disability.
A more dispassionate and open-minded understanding of etiology is basic to devising and implementing more effective treatments. It provides a rationale, which is clearly understandable and acceptable to patients, for all those attempting to treat them and allows us target treatments on modifying causal "biopsychosocial" variables.
Treatment Priorities
Other papers in this symposium issue provide valuable systematic reviews of the evidence of treatment efficacy largely based on randomized clinical trials of specialized interventions in selected populations with diagnosed somatoform disorder or with common symptoms. The complementary standpoint of this paper emphasizes the urgent public health need to develop and evaluate both efficacy and pragmatic effectiveness for treatments, which can be delivered to very large numbers of people. This will need to be provided by primary care practitioners and their teams without expert psychological or psychiatric knowledge. There are four main clinical priorities:
Evidence About Treatment
In contrast to the very considerable evidence about treatments for common mental disorders (i.e., anxiety and depression), we know little about their effectiveness for functional symptoms not accompanied by conspicuous psychological features. Kroenke in this symposium issue (8) considers the modest evidence relating to populations defined in terms of somatoform diagnoses, such as somatization disorder, hypochondriasis, and body dysmorphic disorder, but finds no studies of the much more frequent nonspecific somatoform categories. We must therefore rely on the findings of clinical trials relating to individual types of functional symptoms (e.g., dizziness) and syndromes (e.g., chronic fatigue) and on a very few accounts of consecutive clinic attenders with mixed types of symptoms (9–11). Although diagnoses are usually not specified in these studies, we can reasonably assume most participants could have been given somatoform or other psychiatric diagnoses.
Whereas systematic reviews of the management of functional problems have necessarily focused on specialist interventions, we must keep in mind the whole range of potential treatments. These can be classified into five groups:
Symptomatic Treatments
Symptomatic measures are common in treating common mental disorder, for example, anxiolytic and hypnotic medication and practical help and advice. They have a similar role in managing distress associated with functional symptoms. In addition, physical symptomatic treatments, such as analgesics, have an important role in relieving pain and other somatic symptoms and promoting recovery. However, they are largely ineffective in modifying inappropriate cognitions and behaviors. For example, diagnosing and treating esophagitis is helpful in many of those who present with chest pain, but it is only a partial answer when such patients are convinced that their symptoms are due to heart disease.
"Specific" Treatments
Interventions which are "specific" in that they are precisely targeted at psychological states and processes are effective in the treatment of common mental disorders; they are also effective for some functional conditions (as reviewed elsewhere in this symposium issue). For example, antipsychotic drugs are useful in the symptomatic management of delusional health beliefs and antidepressant medication is effective in the treatment of some functional symptoms, especially where there is clear evidence of a depressive disorder (10). However, the latter are not in fact specific to low mood in that they have other therapeutic actions and are effective in some pain syndromes.
Effective cognitive behavior therapy (CBT) treatments of anxiety and other disorders are highly specific treatments with their components targeted to psychological symptoms and processes. They are often similarly effective when directed to functional symptoms, not only for the somatic symptoms of anxiety and depressive disorders but also for somatoform problems, such as hypochondriasis and chronic pain (8,11).
The effectiveness of relatively "specific" treatments for some functional symptoms leads to several conclusions:
Nonspecific Treatments
Nonspecific elements are fundamental to all good medical care. They have a major role in the treatment of mental disorders and our textbook of psychiatry for medical students (12) states (page 256): "Certain basic procedures are involved in all psychological treatment whatever additional techniques may be employed" and then lists: developing a therapeutic relationship; listening to patients’ concerns; provision of information; explanation and advice; allowing the release of emotion; improving morale; reviewing and developing assets and encouragement of self help. These procedures depend on the fundamental importance of doctor-patient communication (13) and encouraging self-care (14) and family involvement.
Similar methods seem to be equally effective for functional symptoms and in managing maladaptive responses to major physical conditions. Despite the clinical importance of nonspecific elements, the extent and the quality of evidence about their specification and delivery are limited (4). Even so, it is very clear that even though nonspecific in their applications, they need to be as clearly specified, evaluated, and delivered as all other treatments. It is evident that some apparently common sense and widely recommended measures, such as giving out information booklets and simple reassurance, are largely ineffective (15). Nonspecific interventions should not be taken for granted as within the basic skills of all physicians, but deserve much greater attention and more critical evaluation, followed by better training.
Complementary Medicine and Traditional Healers
Complementary and alternative treatments are very commonly used in Western countries (16); elsewhere, traditional therapies are both widely practiced and generally accepted as being valuable. For example, traditional herbal medicine is an integral part of Chinese medical services. Although these treatments do not have the specific therapeutic actions that are claimed for them, some of their components are similar to those of orthodox psychological therapies. Jerome Frank (17) powerfully argued that patients may be helped by the sympathetic reassurance and encouragement that traditional therapies usually offer, but he also pointed out that they may also suffer as a result of harmful advice and by being dissuaded from seeking effective orthodox care. For countries with few health services, it is an important public health issue as to how traditional healing can be encouraged to complement and promote the best use of scarce specialist medical and psychological resources. More generally, it is worrying that the failure of orthodox medicine to convince patients has allowed far too many people to turn to expensive and ineffective alternative practitioners.
Organization of Care
The efficient organization of care is essential if we are to help much greater proportions of those who need and would benefit from treatment. Stepped care (4) is considered to be the most effective and efficient way of delivering care for individuals with potentially chronic physical and mental problems, for example, the treatment of depression in those with diabetes (18).
Example of Noncardiac Chest Pain
The management of the functional symptom of noncardiac chest pain provides a good example of the general issues. It is very frequent and more common in almost all clinical settings than angina. It is most likely to be due to minor, often unidentified, physical causes such as muscle strain or esophagitis. A 30-year program of research has consistently found that, despite reassurance, a sizable proportion of sufferers continue to suffer pain and disability and believe that they have undiagnosed heart disease (23,24). The characteristics, associations, and clinical course have many similarities with angina. Chronic pain is due to an interaction of chest sensations attributable to physiological or minor pathology and psychological, behavioral, and social factors. Iatrogenic factors are prominent in maintaining maladaptive beliefs and behaviors.
Psychological assessment indicates that in addition to this Axis III diagnosis, Axis I psychiatric diagnoses are common: occasionally depression, more often anxiety disorder or somatoform disorder. There may be no psychiatric diagnosis. Interventions for persistent symptoms that have been proven in randomized clinical trials include:
Overall, we can conclude that antidepressant medication can be useful in the minority of subjects with diagnosable depressive or panic disorder. More importantly, psychological treatments based on CBT principles are effective with a greater number of patients with maladaptive beliefs and behaviors, whether or not they also suffer from a psychiatric disorder. Such findings lead to recommendations for stepped care as a basis for routine care:
In recent research, we have been interested in developing treatment packages that address the conspicuous failures of reassurance and communication in managing newly presenting patients; these communication failures seem to maintain and even exacerbate misinterpretations, symptoms, and disability. Qualitative studies in a rapid access chest pain clinic have shown that simple changes to the presentation of explanation and advice with encouragement of self-help and improved discharge letters resulted in both improved outcome and satisfaction (24). We also found that the same approach was valuable in treating psychological aspects of newly presenting angina with patients reporting themselves as being much more satisfied after the changes were made to clinic organization and communication (24).
In other research, we described the poor outcome of another common and rather similar functional presentation to cardiologists—benign palpitation. A randomized controlled trial demonstrated the significant benefit of a further appointment with a cardiac nurse, who offered well-specified explanation, discussion, and advice. Also, a 3-month follow-up assessment enabled professionals to identify those patients who required more specialist psychological treatment (25). Further studies have confirmed that early rehabilitation by nurses and CBT after patients had suffered myocardial infarction resulted in reduced worry and more rapid return to full activities (26).
A final worthwhile conclusion from such evaluations of psychological interventions is that they provide us with information about the psychological processes underlying symptom formation and maintenance and determining interpretation and behavior.
CONCLUSIONS
We have considered a wide range of clinical impressions and research of rather varied quality which, taken as a whole, leads to generally encouraging conclusions about the benefits of psychological and psychiatric treatments of functional symptoms:
Implications for Classification
It is often argued that the introduction of the category of Somatoform Disorder in DSM-III has been useful in drawing attention to common and important clinical problems. This may be true for psychiatrists and psychologists, who are usually concerned with a more chronic and severe minority who usually have an additional psychiatric diagnosis. In contrast, the majority of primary care doctors and others who treat the very large majority of functional problems do not understand or use the terminology and classification. We must both revise our classification and (equally important) present them in a manner that helps rather than hinders the choice, design, and delivery of treatments and that is understood and accepted by patients.
It has been argued elsewhere that the fundamental problems of the present DSM and ICD classifications are not due to lack of evidence but are conceptual (3) and that these can be resolved. The evidence reviewed here (and elsewhere in this symposium issue) suggests that it would be helpful for DSM-V and ICD-11:
Implications for Research
There is a pressing need for more and better quality clinical trials of the whole range of types of intervention. This paper argues that such research should place a greater emphasis on simple early treatments (specific and nonspecific) that could be used by nonspecialists. This means more evaluation in primary care populations and a greater interest in guided self-help and other interventions not dependent on scarce specialist skills and greater cultural awareness.
Evaluations of efficacy must lead to pragmatic research on effective delivery. This inevitably means large multicenter randomized trials. Their findings should be a basis for changes to training of specialists and nonspecialists in all relevant health professions. They will also require those of us who have a special expertise to modify our clinical practice and to develop considerably our contributions as teachers and supervisors of others. These final conclusions on developing much better training for all involved in care are perhaps the most important of all in that they are basic to change but have received far too little attention.
NOTES
Received for publication January 31, 2007; revision received July 9, 2007.
This article is being co-published by Psychosomatic Medicine and the American Psychiatric Association.
DOI:10.1097/PSY.0b013e31815b00a6
REFERENCES
This article has been cited by other articles:
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  J. E. Dimsdale, V. Patel, Y. Xin, and A. Kleinman Somatic Presentations A Challenge for DSM-V Psychosom Med, November 1, 2007; 69(9): 829 - 829. [Full Text] [PDF]
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