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 BOOK REVIEWS

Medically Unexplained Symptoms, Somatisation and Bodily Distress: Developing Better Clinical Services

Richard Balon, MD

Wayne State University, Detroit, MI, USA

Edited by Francis Creed, Peter Henningsen, and Per Fink. New York, NY: Cambridge University Press; 2011; ISBN 978-0-521-762236; pp 266; $90 (hardcover).

Many patients present to physicians with various physical symptoms such as different pains, headaches, dizziness, bloating, and numbness that cannot be medically explained, ie, do not fit into the picture of any recognized physical illness. As the Preface to the book focusing on these symptoms, Medically Unexplained Symptoms, Somatisation and Bodily Distress, points out, “these symptoms are the fifth most common reason for patients visiting doctors in the USA” (p vi). The text of the Preface further emphasizes the “suffering endured by patients who have persistent symptoms without appropriate treatment,” and “…the high cost associated with these symptoms because of frequent doctor visits, expensive investigations, and the associated disability” (p vi). Finally, as noted (p vi), the classification and nomenclature of these symptoms is unclear and could be confusing to patients and health care systems. These symptoms usually encompass both body and mind. However, the health care system is divided into “mental” and “physical” domains and labels such as “medically unexplained symptoms” are not helpful and understandable to many. Thus, the authors propose using the term “bodily distress” as more useful and practical (p vi).

The international team of editors from the United Kingdom, Germany, and Denmark, and authors from Europe, North America, and Asia put together a volume addressing the concerns outlined in the Preface and more in 10 chapters. These chapters cover the topics of somatization, unexplained symptoms, and bodily distress in traditional and less traditional ways, focusing on 1) epidemiology: prevalence, causes, and consequences; 2) terminology, classification, and concepts; 3) evidence-based treatment; 4) current state of management and organization of care; 5) barriers to improving treatment; 6) gender, lifespan, and cultural aspects; 7) medically unexplained symptoms in children and adolescents; 8) identification, assessment, and treatment of individual patients; 9) training; and 10) achieving optimal treatment organization in different countries: suggestions for service development applicable across different health care systems.

The chapter on epidemiology discusses the prevalence of unexplained medical symptoms, somatoform disorders, and functional somatic syndromes (eg, irritable bowel syndrome, fibromyalgia, chronic fatigue, temporomandibular joint pain, and multiple chemical sensitivity) in different settings first. These symptoms seem to be quite common, occurring in approximately 6% of the population, 16% of primary care patients, and up to 33% of patients in secondary care clinics. Somatization is associated with female sex, fewer years of education, low socioeconomic status, other psychiatric disorders, and recent stressful life events (p 15). Finally, people who suffer from ≥1 functional somatic symptoms have impairment of health status or quality of life (p 21). The following chapter (which should have been the first chapter because it deals with terminology and specifies what is what) debates the use of terms such as bodily distress disorder, psychosomatic disorder, and others, and comes to the conclusion that “functional somatic disorder/syndrome” is probably the best acceptable label for medically unexplained symptoms. Nevertheless, the authors advocate that the terms “bodily distress syndrome” and “complex somatic symptom disorder” are a definite improvement over the previously used labels for terminology and classification in this area. The terminology discussion is still a bit confusing, yet less so than in the past.

The chapter on evidence-based treatment is a standard review of the literature, which, in a way, is not very helpful because it does not provide much specific clinically oriented advice, although there are a few pieces of advice. The authors cite the United Kingdom’s National Institute for Health and Clinical Excellence guideline for treatment of irritable bowel syndrome (IBS) recommending that tricyclic antidepressants be used as a second-line of treatment for this disorder when laxatives, loperamide, or antispasmodics do not help (p 82). They also cite 5 treatments conceptualized for functional somatic symptoms—peripheral pharmacology (eg, antispasmodics for IBS), central pharmacology (eg, antidepressants for analgesia), active behavioral intervention (eg, exercise), passive physical interventions (eg, tender point injections), and interventions aimed at changing the doctor’s behavior (eg, reattribution training) (p 86-87). They also mention that antidepressants are effective for fibromyalgia and IBS, but not chronic fatigue syndrome. Interestingly, stimulants and modafinil are not discussed as treatment options for chronic fatigue, although these medications seem to intuitively make sense for treating this syndrome.

The 4 following chapters, the current state of management and organization of care; barriers to improved treatment; gender, lifespan, and cultural aspects; and medically unexplained symptoms in children are standard fare on these topics. Importantly, 1 of the barriers to improving treatment are the doctors themselves as they try to elicit psychological causes for symptoms when the patient is reluctant to disclose them explicitly and having problems overcoming their own insecurity in dealing with the patient’s need for emotional support (p 127). The part on cultural syndromes includes a very good discussion, among others, of “dhat” syndrome.

Chapter 8, which focuses on identification, assessment, and treatment of individual patients, probably is the best part of the book; it could stand alone and satisfy the reader with its (finally!) specific recommendations. These specifics include a stepped-care approach to treatment with some detailed suggestions, including a consultation letter formulation (part of a vignette) and an example of a biopsychosocial scheme for the case of non-cardiac chest pain. I found the discussion of explanation, reassurance, and broadening the explanatory model of treatment useful. This model includes 4 important tasks: explanation on how somatic symptoms can develop in the absence of underlying physical illness; specific actions that the patient can take to manage the symptoms themselves; self-treatment; and reassuring the patients that one will continue to try to help them in a collaborative way with a view to attaining better coping and less impairment (p 192-193). The chapter also discusses activation and specialized treatments such as cognitive-behavioral therapy (CBT), modified CBT for hypochondriasis (aka health anxiety), psychodynamic interpersonal therapy, and various pharmacotherapies (including a very good proposal for a stepped-care approach to the treatment of pain, namely antidepressants). This chapter made me realize an interesting fact: other fields appreciate and utilize tricyclic antidepressants more than psychiatry!

The last 2 chapters on training and organization of optimal treatment in different countries are again standard fare and not very interesting for a busy clinician, but probably interesting for policy makers.

This is an uneven and a bit choppily organized volume. As I noted, some parts are very interesting—especially the treatment chapters—and primary care physicians and consultation-liaison psychiatrists will find it useful. Policy makers and professors may find some interest in the rest of the book. Nevertheless, this book brings to the forefront a fairly important, yet misunderstood and neglected, area of medically unexplained symptoms, which is the borderland between psychiatry and the rest of medicine. As such, it provides the reader with some insight to this area and some valuable recommendations.