Book Review

Treatment of Functional Somatic Symptoms

N Engl J Med 1996; 334:1411-1412May 23, 1996

Article

Treatment of Functional Somatic Symptoms
Edited by Richard Mayou, Christopher Bass, and Michael Sharpe. 452 pp. New York, Oxford University Press, 1995. $57.50. ISBN: 0-19-262499-7

Based on papers presented at a conference held in Oxford, United Kingdom, in 1992, this book is a valuable addition to the small body of practical knowledge regarding medically unexplained somatic symptoms. The contributors are experienced psychiatrists from the United Kingdom and the United States whose collective wisdom converges in suggesting that the care of patients with unexplained somatic symptoms should transcend the basic questions asked by most of us harried and skeptical internists: Is the patient really unwell? Is the symptom all in his or her mind? Does the symptom deserve medical treatment?

Instead, the book promotes a refreshing paradigm that attempts to shift the emphasis away from multiple and frustratingly unavailing physical and laboratory evaluations and toward the realization that both patient and physician may benefit from the recognition of these symptoms as the maladaptive expression of emotional distress or psychopathology. The patient and physician are allies who need to undergo a process of “reattribution,” which requires, in sequence, making the patient feel understood, broadening the agenda to include emotional issues, and making the link between physical symptoms and psychoemotional factors. The process of making the patient feel understood aims to reassure the patient that he or she is being taken seriously and in the process explores social and family factors, health beliefs, and emotional cues. Broadening the agenda starts naturally with a straightforward discussion of the results of clinical evaluation, followed by an acknowledgment that the symptoms are real, and ending with a reframing of the problem that will emphasize the importance of the physical, psychological, and social dimensions uncovered by the examination. Finally, making the link between physical symptoms and psychoemotional or psychosocial distress is done through explanation, demonstration, and projection or identification.

Successful reattribution opens the way for specific cognitive, behavioral, and pharmacologic interventions aimed at improving the patient's functional status. For example, for patients with the chronic fatigue syndrome, the goal is to increase activity by overcoming the patient's fear of failure and the short-term increase in symptoms. The cognitive components will serve to educate the patient about the syndrome, modify beliefs about the occurrence of symptoms, challenge a tendency toward excessive perfectionism, and formulate realistic expectations. Behavioral strategies are used to sever the association between the occurrence of symptoms and the stopping of activities and then to encourage compliance with a graded increase in activity. Finally, given the substantial association between the chronic fatigue syndrome and depressive and anxiety disorders, selective treatment with serotonin-reuptake inhibitors or tricyclic agents is recommended, and the book offers judicious guidelines with respect to the choice of drugs, dosage, side effects, and compliance. Similarly clear guidelines are offered for the treatment of irritable bowel syndrome and abdominal pain, chronic pelvic pain, chest pain and palpitations, premenstrual syndrome, back pain, multiple symptoms, and hypochondriasis. Issues regarding children and the elderly are given appropriate attention.

The book is superlatively free of any mind–body dualism, has depth, and conveys discernment and sober optimism, much-needed qualities in guiding a patient toward successfully coping with illnesses dominated by medically unexplainable symptoms.

Peter Manu, M.D.
Long Island Jewish Medical Center, Glen Oaks, NY 11004