Somatoform diSorderS and medically unexplained SymptomS

Symptoms: a new approachmichael Sharpe

Jane Walker

AbstractSymptoms are a major reason for patients to see doctors. modern medi-

cine and modern psychiatry both conceptualize symptoms in terms of pa-

thology. for medicine it is organic bodily pathology and for psychiatry it

is psychopathology. However, these simple pathology-based approaches

to symptoms are increasingly found to be both scientifically and clini-

cally inadequate. an alternative is to regard symptoms not simply as a

manfestation of pathology but rather as the expression of a combina-

tion of biological, psychological and social factors. this comprehensive

approach transcends the traditional division of symptoms into medical

and psychiatric, has major implication for the organization of services

and provides new opportunities for research.

Keywords concepts; dualism; formulation; pain; symptoms

Symptoms and medicine

Few would argue that the aims of medicine are to prolong life and to relieve suffering. A hundred years ago, our understand-ing of bodily pathology and treatments to cure it were extremely limited. Doctors could, therefore, do very little to prolong life. Their only option was to try to relieve suffering by focusing on reducing their patients’ symptoms.1

However, times have changed. Medicine has benefited greatly from advances in understanding of pathological mechanisms of disease and there have been corresponding advances in treat-ment. This means that much of the modern physician’s work is concerned with identifying and treating pathology. It is, there-fore, not surprising that modern doctors tend to be less interested in their patients’ symptoms. Indeed, symptoms are increasingly relegated to the status of ‘signposts’ on the road to identifying the ‘underlying’ pathology. They are no longer problems that have interest in their own right. An example of this tendency to describe patients in terms of their pathology, rather than by their symptoms or suffering, is the patient with pain and weakness

Michael Sharpe MA MD FRCP FRCPsych is Professor of Psychological

Medicine and Symptoms Research at the School of Molecular and

Clinical Medicine, University of Edinburgh, UK. Conflicts of interest:

none declared.

Jane Walker MB ChB MRCPsych is a Cancer Research UK Research Fellow and

Honorary Consultant at the School of Molecular and Clinical Medicine,

University of Edinburgh, UK. Conflicts of interest: none declared.

pSycHiatry 8:5 14

who becomes a ‘case of cancer’. But does this matter? Is this not just an indication of medical progress?

Symptoms and the limitations of pathology-based medicine

Identifying and treating pathology has clearly helped medicine to prolong patients’ lives. However it has often not been sufficient to relieve their suffering, especially for those with chronic ill-ness.2 What should we do, for example, when a patient’s symp-toms cannot be explained by organic bodily pathology?3 One commonly adopted solution is to assume that pathology is pres-ent but cannot be seen: that it is hidden. It is assumed that, if we looked long and hard enough, the pathology would be found. However attractive this idea of hidden pathology, current evi-dence does not support it. The fact is that some bodily symp-toms are not associated with identifiable bodily pathology, even after exhaustive medical investigations – they remain ‘medically unexplained’. And so-called medically unexplained symptoms are not rare; they account for the majority of consultations in primary care and a third of all consultations in hospital outpa-tient clinics.4

Even when associated disease pathology is demonstrable, the pathology often plays a much smaller part in explaining the patient’s symptoms than is commonly assumed. Recent search studies have found only a weak relationship between the severity of the associated pathology and that of the patients’ symptoms. One example is a study of patients with chronic cardiac disease (the Heart and Soul Study), which found no association between the severity of patients’ symptoms and the degree of pathology in terms of the heart’s ability to function as a pump.5

Symptoms and the limitations of psychopathology-based psychiatry

So, how do we explain bodily symptoms when the patient is found to have no bodily pathology? As symptoms tend to be regarded as manifestations of pathology, when there is no bodily pathology there is assumed to be psychopathol-ogy. Unlike bodily pathology, psychopathology is not directly demonstrable; it has to be inferred from patients’ reports of their psychological symptoms. This approach does have some utility, for example when various symptoms such as low mood and hopelessness are combined under a label of depression. However, it cannot work when the patient’s symptoms are predominantly somatic rather than psychological. In such cases, it has been proposed that the patients ‘really do’ have psychopathology, but that it is hidden. This is a hypothetical solution that is analogous to the medical hypothesis of hidden bodily pathology. It is further proposed that the psychopathol-ogy does not manifest in psychological symptoms because it has been ‘converted’ into bodily symptoms by a process called ‘somatization’ (literally making the mental somatic). As with the idea of hidden bodily pathology, this theory is attractive to many but is not supported by the evidence.6

Symptoms and the limitations of dualism

Patients are divided into two groups: those with bodily pathology and those who have psychopathology. This two-category or

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Somatoform diSorderS and medically unexplained SymptomS

‘dualistic’ approach is based on the idea that mind and body are separate entities, a view attributed to the writings of the philosopher Descartes. So-called Cartesian dualism has exerted a profound influence on Western medical thinking and still shapes our training, practice, and service provision – most obviously forming the basis of the division of services into those for physical health and those for mental health.7 Psycho-pathology defines the clinical territory of the psychiatrist, in the same way as bodily pathology defines that of the physician. We have already seen that the attempt to maintain the view that symptoms must always be explained by pathology by proposing psychopathology in cases where bodily pathology is absent is flawed. Nonetheless, it still has enormous influence in medical practice.

Symptoms and practice

Does this dualistic approach to allocating the treatment of patients to separate specialists – one for bodily pathology and one for mental pathology – actually work in practice? To explore this question, let us consider the example of a patient with chronic pain. The patient is likely to be referred to a medical clinic because the presenting symptom is considered a bodily one; however, associated disease pathology is unlikely to be found. The physician then has two options. First, the pain can be attributed to a hypothesized but unproven pathol-ogy, such as ‘fibromyalgia’. Although this approach allows both doctor and patient to achieve a medical diagnosis, it often leads to no effective treatment. Second, the doctor can refer the patient to a psychiatrist on the assumption that, as there is no bodily pathology, there must be psychopathology. In many such cases depression or anxiety will indeed be found, but in others it will not. Even when psychopathology is found, it might not adequately explain the pain and its treatment is unlikely to relieve the pain. Furthermore, the patient might protest at having their bodily symptoms regarded as evi-dence of a problem in their mind. As this example shows, the allocation of patients to specialists on the basis of a dualistic conception of their proposed pathology risks leaving doctors frustrated and the patient’s symptoms unrelieved.8 Is there an alternative?

pSycHiatry 8:5 147

A focus on symptoms

If we allow ourselves to think ‘outside the box’ (or boxes) of this current pathology based on a dualistic conceptualization of symptoms, can we do better? Perhaps we can learn from the phy-sicians of old by renewing our interest in the understanding and management of patients’ subjective experience of symptoms in their own right. Rather than rushing to assume that symptoms are merely manifestation of and signposts to either bodily pathology or psychopathology, we might also find interest in the symptoms themselves. If we did this, we could go beyond the simple patho-logical understanding of symptoms and conceive of them more broadly as having multiple causes, a way of thinking about them which can open up new approaches to treatment.

Let us return to the patient with chronic pain. The scientific evidence indicates that the symptom of chronic pain has multiple contributory causes: biological, psychological and social.9 These might, in turn, be divided into the predisposing, precipitating and perpetuating causes. Such a scheme of understanding and its implications for treatment are outlined in Table 1.

Symptom-based research

This new approach to symptoms is gaining ground. Recently, there has been increased interest in symptom research as a new scientific discipline.10 The American National Institutes of Health (NIH) have produced a useful on-line text on symp-tom research (http://symptomresearch.nih.gov/). There are now several research groups working on symptoms. A group at the MD Anderson Cancer Hospital in the USA is devoted to the study of symptoms in patients with cancer (http://www.mdanderson.org/departments/PRG/). The authors’ own research group at the University of Edinburgh focuses on symptoms in cancer and neurology patients (http://www. pmr-edinburgh.org).

Symptom-based practice

This approach to symptoms also has implications for how we think about the patients we see in our day-to-day practice. Rather than being preoccupied with deciding whether symptoms are ‘medical’

Aetiological factors to consider for chronic pain, and treatments targeted at the perpetuating factors

Predisposing Precipitating Perpetuating Targeted treatments

Social lack of support life events misinformation advice and education

Social or work stress problem-solving therapy

over-caring partner education of partner

psychological personality perceived stress depression cognitive behavioural therapy

catastrophic interpretation of pain

low self-efficacy

avoidance of activity

Biological Genetics acute disease

or injury

central nervous system changes analgesic agents

physical deconditioning Graded increases in activity

Sleep disorder Sleep hygiene

Table 1

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Somatoform diSorderS and medically unexplained SymptomS

or ‘psychiatric’ in nature, we can start thinking of them in a broader way. The multi-axial approach to diagnosis provides a systematic approach to generating a more comprehensive and potentially more useful aetiological summary. Treatment can then be targeted at the perpetuating causes using a combination of psychological and physical interventions, rather than only at pathology.

Symptom services

Who should treat symptoms? We already have a variety of spe-cialties and services that focus on symptom relief, but these tend to be organized in a fragmented, and not necessarily logi-cal or helpful, way. They include nursing, palliative medicine, pain medicine and liaison psychiatry. Allocation of patients to these services is not usually systematic. The patient with pain can be referred to any of these; if they are approaching the end of life, they can be referred to palliative medicine, which focuses largely on pain relief through pharmacological means. If the pain is especially prominent they might be referred to pain medicine, which is usually a branch of anaesthesia and uses the interven-tions of that specialty. If the patient also has psychological symp-toms, they can be sent to liaison psychiatry or health psychology, where there will be a focus on psychological symptoms and the use of psychological and psychotropic interventions. In other words, we lack a comprehensive ‘symptoms-centred’ approach.

Symptoms, the future

How might symptom relief achieve a similar status to the treat-ment of pathology? Clearly, we need a more focused and coordi-nated approach to symptom relief. First, those patients who are suffering from severe symptoms have to be identified. One way to achieve this is to screen patients routinely for symptoms. This can be achieved using technology such as touch-screen comput-ers that record patients’ symptoms and supply a report on them to the clinician in real time (Figure 1).

This can ensure that severe symptoms are not forgotten in a consultation that tends to focus only on pathology.11 Second, we need symptom management services. Protocol-based manage-ment for symptoms that makes a comprehensive assessment and then uses a variety of pharmacological and non-pharmacological interventions could be developed. An example is nurse-delivered services for symptoms in patients with cancer.12 In this way, we

figure 1 a patient being guided in the use of a touch screen computer

system which collects information on symptoms and provides a

printout to the doctor.

pSycHiatry 8:5 14

can envisage the future patient’s management moving along two parallel and interrelated tracks: one for the identification and treatment of bodily pathology, and the other for the identification and management of their symptoms. Such an approach is likely to be especially important for patients with chronic conditions such as cancer, arthritis, and multiple sclerosis, as well as for those with medically unexplained symptoms.

Conclusion

Patients consult doctors for help with their bodily symptoms and doctors traditionally use these symptoms as clues to diag-nosing pathology of the body or of the mind. They then treat the pathology with the assumption that the symptoms will be relieved. This simple model, which we were all taught in medi-cal school, is inadequate. There is, however, a new and more comprehensive way of thinking about bodily symptoms. This new approach regards symptoms not simply as expressions of pathology, but as resulting from a combination of biological, psy-chological and social factors. This new approach is not only more scientifically accurate, it also offers new opportunities to relieve patients’ symptoms, which transcends the traditional separation into medical and psychiatric. Perhaps today’s liaison psychiatrist will become tomorrow’s symptom specialist. ◆

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