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  3. Functional Somatic Syndromes
  • Cited by 8
  • Edited by Peter Manu, Albert Einstein College of Medicine, New York
Publisher:
Cambridge University Press
Online publication date:
January 2010
Print publication year:
1998
Online ISBN:
9780511549700
DOI:
https://doi.org/10.1017/CBO9780511549700
Subjects:
Medicine: General Interest, Psychiatry and Clinical Psychology, Medicine, Psychiatry
Information

Book description

Functional somatic syndromes are defined as physical syndromes without an organic disease explanation, demonstrable structural changes, or established biochemical abnormalities. This book reviews the state of scientific and clinical understanding of the nine most common functional somatic syndromes. For each syndrome, expert authors provide a brief historical perspective, a current definition, a case presentation, confirmatory and contradictory research findings, a discussion of the leading pathogenetic hypotheses, and guidelines for diagnosis and treatment. Advice is given for the determination of disability of patients with these medically unexplained disorders, and both medical and psychiatric interventions are described. Stressing the importance of a sound therapeutic relationship as a basis for treatment, this is an invaluable resource for professionals in primary care and many other disciplines.

Reviews

‘ … an outstanding volume … The book is both scholarly and clinically useful … modestly priced and well produced. It should be mandatory for any mental health professional who has either the courage or confidence to work with such disorders.’

Source: Psychosomatics

‘Manu has clearly asked his contributors to attempt to integrate biological and psychosocial findings in each of the disorders discussed, and this is one of the book’s strengths.’

Source: The British Journal of Psychiatry

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Contents

Contents
  • 1 - Definition and Etiological Theories
    pp 1-7
  • View abstract

    Summary

    Functional somatic syndromes are physical illnesses without an organic disease explanation and devoid of demonstrable structural lesion or established biochemical change. The degree to which these syndromes have been characterized as unique entities is variable. In 1989 two Harvard Medical School researchers J.I.Hudson and H.G.Pope Jr. published an analysis of the association between fibromyalgia and psychopathology. They formulated three explanatory hypotheses: fibromyalgia is the cause of psychopathology; fibromyalgia is the effect of psychopathology; fibromyalgia and psychopathology are the result of a common underlying morbid process. For fibromyalgia, Robert Kellner suggested that physical disease, psychopathology and low serotonin concentration cause abnormalities in non-rapid eye movement sleep. Kellner also addressed the tendency for clustering of functional somatic syndromes, a prominent feature of the work of Hudson & Pope and D.Stewart. Kellner's work has been continued and expanded in the latest contribution to the evolution of ideas regarding the etiology of these syndromes.
  • 2 - Chronic Fatigue Syndrome
    pp 8-31
  • View abstract

    Summary

    A thorough investigation of the prevalence and incidence of chronic fatigue syndrome (CFS) was conducted by the Centers for Disease Control and Prevention (CDC) in four geographically distinct metropolitan areas in the USA. The humoral immunity of patients with CFS was comprehensively studied in a CDC investigation of an alleged community outbreak. Muscle fatigue and a substantial decrease in exercise tolerance are ubiquitous among patients with CFS. Ineffective treatment modalities for CFS studied in a doubleblind, full-dose placebo-controlled trials in the USA include the antiviral agent acyclovir, a naturopathic regimen of liver extract, folic acid and cyancobalamin, intravenous gammaglobulin, and the antihistamine terfenadine. The term CFS describes a set of nonspecific symptoms associated with persistent or relapsing fatigue. Research studies have confirmed that the majority of patients with CFS are white middle-aged women with a high prevalence of current major depression and somatization disorder and abnormal personality traits.
  • 3 - Fibromyalgia Syndrome
    pp 32-57
  • View abstract

    Summary

    Fibromyalgia syndrome (FMS) is characterized by complaints of generalized musculoskeletal pain and the finding on physical examination of tenderness in characteristic regions. Approximately one-third of patients date the onset of their FMS to a traumatic experience such as a motor vehicle accident or to an event such as an illness. The prevalence of FMS has been studied in a number of settings including outpatients, private and hospital clinic populations, as well as community settings. The economic repercussions of FMS are enormous. One estimate suggests that long-term disability payments for FMS in Canada may cost the insurance industry as much as $200 million per year. An alteration in sleep physiology was hypothesized to be the underlying cause of FMS. There is a variable spectrum of complaints and findings in patients with FMS. Mild FMS is found in the community in patients who do not feel the need to seek medical attention.
  • 4 - Irritable Bowel Syndrome
    pp 58-79
  • View abstract

    Summary

    The irritable bowel syndrome (IBS) is the prototypic functional bowel disorder in terms of its heterogeneous nature, multifactorial pathogenesis and requirement for individualized diagnosis and treatment. The surge of scientific interest in IBS during the past two decades has brought increased awareness that both the traditional biomedical model of disease and a purely psychiatric explanation are inadequate keys to understanding and treating IBS. Most researchers and clinicians accept the ability of the multinational Rome symptom criteria to identify IBS in epidemiological surveys and play a dominant diagnostic role in clinical practice. Many patients with symptoms typical of IBS can be confidently diagnosed after the performance of flexible sigmoidoscopy and a complete blood count. IBS is a common functional disorder which is best understood from the biopsychosocial concept of illness in which both biological and psychosocial factors influence symptom experience, behavior and outcome.
  • 5 - Premenstrual Syndrome
    pp 80-97
  • View abstract

    Summary

    This chapter reviews the diagnostic issues, epidemiological variables, pathogenetic hypotheses and the treatment options available to treat premenstrual syndrome (PMS). Premenstrual dysphoric disorder (PMDD) is the diagnosis in the DSM-IV that describes the severest form of PMS in menstruating women. Epidemiological studies of women with PMS or PMDD examining age, menstrual cycle characteristics, socioeconomic variables, lifestyle variables or cognitive attributions fail to show a consistent association with PMS. Although the symptoms of PMS clearly vary with the phases of the menstrual cycle, studies of the hypothalamic-pituitary-gonadal (HPG) axis in women with PMS have not yet consistently shown a specific abnormality or a definite relationship with symptoms. Hormonal strategies for the treatment of PMS and PMDD have been fairly extensively studied. Positive efficacy is most impressive with selective serotonin reuptake inhibitors (SSRIs) and Gonadotropin-releasing hormone (GnRH) agonists, the former medications having the advantages of oral administration and fewer long-term health risks.
  • 6 - Interstitial Cystitis
    pp 98-126
  • View abstract

    Summary

    Interstitial cystitis (IC) is characterized by pain in the region of the bladder and pelvic musculature, and variable motor and sensory dysfunctions of the bladder. The most prevalent symptoms of IC are urinary frequency, urgency and suprapubic, perineal pain. IC can be classified into the two categories of Hunner's ulcer and nonulcer, based on cystoscopic findings. This chapter highlights research contradictions regarding IC, along with research findings relating to the therapeutic effectiveness of various treatment modalities in IC. The lack of specific pathognomonic markers for the diagnosis of IC has resulted in a host of plausible hypotheses for its etiology. To be diagnosed with IC, patients must undergo cystoscopic examination under general anesthesia with hydrodistention of the bladder and bladder biopsy. Antihistamines are critical to managing IC in people with hay fever, sinusitis or food allergies. One major breakthrough in therapy is the use of heparin-like drugs.
  • 7 - Temporomandibular Disorders
    pp 127-158
  • View abstract

    Summary

    The evolution of thinking regarding temporomandibular disorders (TMDs) has included many theories of etiology and pathogenesis, ranging from anatomical features of the temporomandibular joint (TMJ), to occlusal abnormalities, to behavioral origins such as bruxism. Many people with TMDs use over-the-counter medications to reduce their pain. The case studies in this chapter illustrate some of the variation in symptoms, duration of pain and treatment history typically seen in patients at a TMD clinic. Epidemiological research in the area of TMDs has focused primarily on estimates of prevalence rates for signs and symptoms, and descriptions of characteristics of TMD cases versus controls. Rational treatment of TMDs includes pharmacological adjuncts to optimize other treatment modalities such as splint therapy, physical therapy or biofeedback. Chronic, debilitating TMD pain that persists despite comprehensive multidisiplinary treatment may necessitate the long-term use of opiates.
  • 8 - Chest Pain Syndromes
    pp 159-174
  • View abstract

    Summary

    Sophisticated studies of the pathophysiology of chest pain in patients without serious heart disease began with Likoff's report of 15 women with recurrent chest pain, abnormal electrocardiograms (ECGs), and normal coronary angiograms. The most promising current hypothesis on the mechanism of chest pain syndromes postulates that the essential common feature in these patients is abnormal visceral pain perception. Research into the factors which contribute to chest pain syndromes has led to the development of at least four major hypotheses: esophageal spasm, esophageal irritation, smooth muscle dysfunction, and microvascular angina. An understanding of the history and the current pathogenetic mechanisms of chest pain syndromes provides a roadmap for efficiently evaluating chest pain patients. A systematic approach to each of the factors contributing to the patient's recurrent chest pain is best coordinated by a primary care physician over the course of the syndrome.
  • 9 - Repetitive Strain Injury
    pp 175-201
  • View abstract

    Summary

    Repetitive strain injury (RSI) consists in a soft tissue disorder, manifest by pain, tenderness and muscle weakness. There are no standard diagnostic tests that are consistently abnormal in this condition. The prevalence of RSI is related to the decade in which this is reported, country, type of occupation, season and age of the sufferer. Objective measure of pathological dysfunction in patients with RSI has been carried out in only a few centers. Virtually all of the well-controlled studies that have been carried out on RSI patients demonstrate that there is a higher reported frequency of depression and anxiety. The three main hypotheses to explain RSI concern the medical, psychological and sociological models of illness. The aims of clinical evaluation of patients with suspected RSI are to determine the diagnosis as far as possible and to decide on how far the disorder identified is related to work.
  • 10 - Multiple Chemical Sensitivities
    pp 202-218
  • View abstract

    Summary

    The concept of an illness with subjective wide-ranging symptoms triggered by exposure to numerous environmental chemicals, called multiple chemical sensitivities (MCS), has existed for at least 40 years, but it remains controversial. No studies to date have been carried out to assess the prevalence of patients with the diagnosis of MCS in any community. The basis for the diagnosis of MCS has been examined by a number of investigators and found to be arbitrary and predicated solely on the fact or perception by the patient that a harmful environmental exposure had occurred and was responsible for subsequent symptoms. Theories of the etiology and pathogenesis of MCS are numerous and frequently change. They encompass physical, psychological and social concepts. Psychopharmacology in MCS treatment is frequently recommended, although without specific data on results. MCS has many features in common with other controversial syndromes such as the chronic fatigue syndrome.
  • 11 - Psychopharmacology of Functional Somatic Syndromes
    pp 219-236
  • View abstract

    Summary

    This chapter describes current knowledge about two drug treatments of depression, anxiety, pain and sleep disorders as these psychiatric syndromes often accompany the functional somatic syndromes. Monoamine oxidase inhibitors (MAOIs) came from the antitubercular drug iproniazid that appeared to alleviate depression in patients with tuberculosis. Psychotic depression, i.e., major depression with delusions and/or hallucinations, responds better to a combination of an antidepressant and an antipsychotic than to either drug given separately. Short-lived anxiety suggests use of benzodiazepines with shorter half-lives, while with the longer lasting anxiety, benzodiazepines with longer half-lives could be used. Antidepressants such as tricyclic agents, selective serotonin reuptake inhibitors and trazodone have shown usefulness for patients with generalized anxiety disorder. All the benzodiazepines used for anxiety also serve as hypnotics. Carbamazepine, an anticonvulsant agent, has shown efficacy especially for neurogenic pain, at doses of 200-1200 mg/day, in divided doses.
  • 12 - Psychotherapy of Functional Somatic Syndromes
    pp 237-255
  • View abstract

    Summary

    This chapter outlines various psychotherapeutic techniques that have proved to be effective in the treatment of functional somatic syndromes. The role of psychotherapy in the treatment of bodily diseases depends on the extent to which psychological factors play a role in their etiology and course. Cognitive-behavioral therapy (CBT) is considered to be the treatment of choice for a wide range of functional somatic syndromes. Deconstructing the patient's perception of his or her condition and developing a new, shared formulation of the illness is crucial to the success of cognitive-behavioral therapy. Chronic fatigue syndrome is used to demonstrate this technique. The treatment of functional somatic syndromes requires the coordinated efforts of a variety of health professionals to minimize duplication of medical investigations. Anxiety states and depressive episodes in particular frequently require immediate relief in order to allow and encourage the patient to participate in the psychotherapeutic relationship.
  • 13 - Determination Of Disability Claimed By Patients With Functional Somatic Syndromes
    pp 256-271
  • View abstract

    Summary

    This chapter discusses the distribution of the literature publications among the nine functional somatic syndromes indicating that only the disabilities claimed by patients with fibromyalgia and chronic fatigue syndrome (CFS) have been the object of sustained scientific attention. In both CFS and fibromyalgia, the common disabling symptoms consist of cognitive deficits and exercise intolerance. The psychiatric evaluation serves the purpose of identifying and treating disabling mental disorders that are allowed to coexist with CFS. Neuropsychological disturbances, particularly poor memory and difficulty with tasks that require sustained attention and concentration, are commonly reported among the disabling symptoms of patients with CFS and fibromyalgia. An important task for the disability evaluator is to determine whether the allegedly disabling chronic pain symptom belongs to a functional somatic syndrome or is the defining complaint of a discrete chronic pain syndrome.
  • 14 - Functional Somatic Syndromes: Exploring Common Denominators
    pp 272-294
  • View abstract

    Summary

    This chapter describes major research directions in the study of each of the nine functional somatic syndromes and highlights the overlapping dimensions. The fact that a substantial proportion of chronic fatigue syndrome (CFS) patients have concurrent symptoms sufficient for a diagnosis of major depression has prompted the investigation of the serotonin function with the new method of d-fenfluramine challenge. A genetic factor responsible for the family aggregation of fibromyalgia has been demonstrated among patients attending the rheumatology clinic of the University Hospital, Beer Sheva, Israel. The presence of chronic pelvic pain in patients with irritable bowel was associated with a significantly higher likelihood of childhood sexual abuse, panic disorder and a lifetime history of somatization disorder. A prominent biological abnormality of patients with premenstrual syndrome is serotonergic deficiency. There is substantial evidence that mast cell activation plays an important role in the production of abnormalities associated with interstitial cystitis (IC).

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