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Functional Somatic Syndromes
- Arthur J. Barsky, MD; and
- Jonathan F. Borus, MD
- Brigham and Women's Hospital; Boston, MA 02115 (Barsky) Brigham and Women's Hospital; Boston, MA 02115 (Borus)
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IN RESPONSE:
The correspondents make many different points, but several common themes emerge. The first is that our review failed to include evidence of demonstrable medical causes for some of the functional somatic syndromes. A review of such evidence was tangential to the main point of our report, which was that psychosocial factors and symptom amplifiers compound, perpetuate, and intensify symptoms that result from a variety of causes and that they make symptom relief more difficult to attain. We specifically did not assert that these psychosocial factors initiate the symptoms or are necessarily their primary cause. As we suggested in our article, patients with functional somatic symptoms experience symptoms that may be the result of “self-limited ailments, chronic medical conditions, psychosocial stress, psychiatric disorders, and … previously unknown or unrecognized medical conditions.” Thus, patients with each functional somatic syndrome constitute a heterogeneous group, with varying sources for their presenting symptoms. However, once patients are symptomatic, then beliefs, expectations, the sick role, and psychological distress become important in amplifying, maintaining, and perpetuating these symptoms and in heightening the disability they engender. Indeed, these same psychosocial factors are operative in illnesses that have a clearly demonstrable medical basis, such as ischemic heart disease. We certainly agree that the absence of a well-established medical cause for a syndrome does not mean that one does not exist, and there could well be a subgroup of patients within each functional somatic syndrome who have a medical condition that is not yet adequately understood or diagnosable by using current techniques.
Several correspondents assert that our argument trivializes these illnesses, implying that the illness and the patients' suffering are not real or that patients do not wish to overcome their illness. Nothing of course could be further from the truth: The suffering of patients with functional somatic syndromes is equally real and legitimate, regardless of its cause; these patients are not malingering or feigning illness, nor do they wish to be ill or prefer to remain so. Quite to the contrary, the entire thrust of our paper is to take their suffering seriously, to describe the factors that intensify and amplify it, and to suggest ways in which to ameliorate it.
Finally, the intense response our article has generated speaks to the unfortunate persistence of an “either/or” view that psychosocial and medical factors are mutually exclusive, along with a tendency to consider the former somehow less real, less important, and stigmatizing. Several correspondents suggest that our report will cause patients with functional somatic syndromes to be dismissed without adequate medical attention or therapy. On the contrary, we argue that their suffering and distress cannot be adequately treated without taking their beliefs, expectations, illness behaviors, and emotional distress, as well as their physiology, into account. We do not agree that psychological factors play no role in such syndromes; the objective of our review was to organize and present some of the evidence to the contrary.
- Copyright ©2004 by the American College of Physicians
