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

Contents......Page 6
Preface......Page 7
Contributors......Page 8
Prevalence of medically unexplained symptoms in secondary care......Page 10
Prevalence of medically unexplained symptoms in primary care......Page 12
Outcome of medically unexplained symptoms......Page 13
Somatoform disorders......Page 14
Prevalence of somatoform disorders in primary and secondary care......Page 15
Functional somatic syndromes......Page 19
Prevalence of functional somatic syndromes in primary and secondary care......Page 21
Prevalence of functional somatic syndromes in population-based samples......Page 22
Relationship between functional somatic syndromes and somatisation......Page 23
Correlates of medically unexplained symptoms and somatoform disorders......Page 24
Predictors of persistence of medically unexplained symptoms or somatoform disorders......Page 25
Predictors of onset and persistence of functional somatic syndromes......Page 26
Impairment of health status increases with number or severity of medically unexplained symptoms......Page 27
Primary care......Page 28
Impairment of function when somatoform disorder occurs with concurrent anxiety and depression......Page 29
Impairment in functional somatic syndromes......Page 30
Costs associated with medically unexplained symptoms and somatoform disorders......Page 31
Fibromyalgia (chronic widespread pain)......Page 34
Irritable bowel syndrome......Page 35
Chronic fatigue syndrome......Page 36
Disability benefit/early retirement pension......Page 38
Conclusion......Page 39
References......Page 40
Medically unexplained symptoms......Page 52
Ten criteria to evaluate terminology......Page 53
Somatoform disorders......Page 55
Functional somatic syndromes......Page 56
History of current classification......Page 57
Self-focused attention, bodily self-observation......Page 58
Self-concept of bodily weakness......Page 59
Abnormal illness behaviour......Page 60
Interpersonal problems......Page 61
Complex somatic symptom disorder......Page 62
Bodily distress syndrome......Page 63
Nosology and the value of a classification......Page 69
Classification and pathopsychophysiology......Page 71
Conclusion......Page 73
References......Page 74
The different settings of primary and secondary care......Page 78
Overview of the evidence for effective treatments......Page 79
Recent studies of reattribution......Page 81
Conclusions from studies of interventions of medically unexplained symptoms and somatisation......Page 82
Interventions for health anxiety (hypochondriasis) reassurance......Page 83
CBT for functional somatic syndromes......Page 84
Updated systematic review of both CBT and antidepressants......Page 85
Preliminary evidence for short-term psychodynamic psychotherapy......Page 86
Rationale for psychological and exercise-based treatments of functional somatic syndromes......Page 87
Rationale for the use of antidepressants in functional somatic syndromes......Page 88
Chronic fatigue syndrome......Page 89
Irritable bowel syndrome......Page 90
NICE review......Page 91
British Society of Gastroenterology review......Page 92
Antidepressants......Page 93
Effectiveness and cost-effectiveness trials in functional somatic syndromes......Page 94
General ingredients of treatment and a stepped-care model......Page 95
Conclusions......Page 97
References......Page 98
Do current models of care provide a satisfactory service? Unmet needs......Page 106
Secondary care – outpatients......Page 107
Evidence of continuing symptoms with accompanying disability/high healthcare use......Page 109
Patient-centred approaches to unmet need......Page 110
Current models of care......Page 112
Primary care......Page 113
Consultation-liaison psychiatry/psychosomatics approach......Page 115
Syndrome-specific specialised clinics (Model B, Figure 4.3)......Page 116
Specialised units for bodily distress syndromes (Model C, Figure 4.4)......Page 117
Expert centres for chronic fatigue syndrome and pain clinics......Page 118
Local initiatives......Page 119
Level 1: Management of bodily distress by GPs – psychosomatic basic care......Page 120
Level 3: Specialised psychosomatic/psychotherapeutic treatment of patients with bodily distress syndromes......Page 121
Assumptions (and challenges)......Page 126
Location of a specialist clinic......Page 127
Conclusion......Page 128
References......Page 129
Problems in terminology and understanding......Page 133
Problems in policy, planning and service organisation......Page 134
The individual doctor–patient encounter......Page 135
The doctor’s role in the problem......Page 136
The doctor–patient relationship......Page 137
Conclusion......Page 138
References......Page 139
Epidemiology......Page 141
Body schemes, symptom attribution and illness beliefs......Page 142
Personality, emotion, coping styles, and gendered roles......Page 143
Stress and trauma......Page 144
Patient–doctor relationships and gendered communication......Page 145
Conclusions......Page 146
Epidemiology of somatic symptoms in older people......Page 147
Bodily distress and factors associated with general perception of health......Page 149
Management of bodily distress syndromes in the elderly......Page 150
‘Culture-bound’ syndromes......Page 151
Universality of ‘medically unexplained’ symptoms......Page 152
Medically unexplained symptoms in different ethnic groups......Page 154
Bodily distress syndromes in single ethnic groups......Page 156
Treatment seeking......Page 157
Treatment seeking in low- and middle-income countries......Page 158
References......Page 159
Introduction......Page 167
Classifications, definitions and current diagnostic categories......Page 168
Normal development and age-appropriate coping mechanisms......Page 170
Systemic considerations (family)......Page 171
Genetics and biological factors......Page 173
Summary and formulation......Page 174
Initial engagement and assessment......Page 175
Specific psychosocial interventions......Page 177
Cognitive behavioural therapy and pain syndromes......Page 178
Dynamic psychotherapy and systemic psychotherapies......Page 179
Relationship to adult disorders......Page 180
References......Page 181
Aims of the assessment......Page 184
A disease management approach to assessment......Page 185
High risk......Page 186
Assessment in primary and secondary medical care settings......Page 187
Sources of information......Page 188
Assess the presenting symptom......Page 189
Personal, developmental and past history of illness and mental state, including abuse and prior severe life events......Page 190
Impact of the diagnostic label......Page 192
Interpretation and communicative aspects of diagnostic tests......Page 193
Based on risk management as used in the Dutch Multidisciplinary Guideline for MUS and Somatoform Disorder [8]......Page 195
Third step......Page 196
Vignette......Page 197
Complicated or uncomplicated functional somatic syndromes – review by Henningsen and colleagues [58]......Page 199
Step 3......Page 200
Four important tasks......Page 201
Activation treatments for chronic fatigue syndrome......Page 202
Getting CBT treatment started......Page 204
The process of change......Page 205
General comments......Page 206
Intervention......Page 207
Modifications of CBT for hypochondriasis (health anxiety)......Page 208
Symptom diary......Page 209
Psychodynamic interpersonal therapy......Page 210
Vignette......Page 211
Psychopharmacotherapy......Page 212
Functional somatic syndromes......Page 215
About bodily distress syndrome......Page 216
How do we treat BDS?......Page 217
References......Page 218
Teaching primary care physicians and other non-psychiatrists to diagnose and manage bodily distress syndromes......Page 226
Educational models......Page 227
Evaluation of effectiveness......Page 230
Training of general non-psychiatric specialists......Page 231
Training of the specialist in psychosomatics and consultation-liaison psychiatry......Page 234
Education of specialists in bodily distress syndromes......Page 235
Education of non-healthcare professionals, e.g. social workers......Page 236
Training in Psychosomatic Basic Care......Page 237
Improving the psychosomatic competence in diagnosing and treating bodily distress syndromes......Page 238
Advanced training in psychotherapy and psychosomatics for physicians with any specialisation......Page 240
Outlook......Page 241
References......Page 242
Introduction......Page 245
Universal factors......Page 246
Local healthcare planning arrangements......Page 247
Components of a service to improve management of bodily distress syndromes......Page 248
Training of medical specialists......Page 249
A systems approach to ‘medically unexplained’ symptoms in Plymouth, UK......Page 250
Plymouth healthcare system......Page 251
Patient involvement......Page 253
Proposed next steps for NHS Plymouth......Page 255
Conclusions......Page 256
The model to be developed......Page 257
Suggested ways of meeting the need......Page 258
Leeds and West Yorkshire Chronic Fatigue Syndrome/Myalgic Encephalopathy Service......Page 259
References......Page 260
Index......Page 262