Review Persistent physical symptoms: definition, genesis, and management 2024 Löwe, Rosmalen, Burton et al

Summary

Persistent physical symptoms (synonymous with persistent somatic symptoms) is an umbrella term for distressing somatic complaints that last several months or more, regardless of their cause. These symptoms are associated with substantial disability and represent a major burden for patients, health-care professionals, and society. Persistent physical symptoms can follow infections, injuries, medical diseases, stressful life events, or arise de novo. As symptoms persist, their link to clearly identifiable pathophysiology often weakens, making diagnosis and treatment challenging. Multiple biological and psychosocial risk factors and mechanisms contribute to the persistence of somatic symptoms, including persistent inflammation; epigenetic profiles; immune, metabolic and microbiome dysregulation; early adverse life experiences; depression; illness-related anxiety; dysfunctional symptom expectations; symptom focusing; symptom learning; and avoidance behaviours, with many factors being common across symptoms and diagnoses.

Basic care consists of addressing underlying pathophysiology and using person-centred communication techniques with validation, appropriate reassurance, and biopsychosocial explanation. If basic care is insufficient, targeted psychological and pharmacological interventions can be beneficial. A better understanding of the multifactorial persistence of somatic symptoms should lead to more specific, personalised, and mechanism-based treatment, and a reduction in the stigma patients commonly face.

Open access, https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(24)00623-8/fulltext

 

"Best represented". I don't know what kind of standard that is. Not much different from "I like this model".

Looks like the current fashionable thing is predictive coding, or whatever:

Ah, poor things are suffering from "imprecise representations of body states". Must be hard and distressing.

That would be somewhat convincing if those mythical *cebo effects had any consistency. But they don't. If this were true, we'd never hear the words "this wasn't as bad as I feared". Lots of waffling about beliefs, this is basically a generic version of the FINE/PACE behavioral "false illness beliefs" nonsense. There is no attempt at being coherent or providing evidence that isn't itself just opinions that echo other opinions.

Who needs clinical significance? Barely meeting statistical significance some of the time is where it's at!

Like I said, when you can't meet a standard, lower it:

It's been over a century, including decades of implementation, and still it's just potential, "imagine a world where...":

So just the same old arguments presented as novel and full of potential, but not a single bit of useful actionable anything. The old model of pre-science "here's my opinion, presented in dozens of slightly different ways, which other self-important people agree with".

I have no idea why papers like this ever get funded. They provide nothing of value, they are basically a theological seminar, people gathering and echoing each other, the same things generations before them have chanted and hymned.

 

seems like the usual papermill copy paste garbage we have seen so many times before . They are still recreating the same false evidence base simply to give themselves more useless busywork. Easy job if you leave out any ability to think critically.
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I always find formulations like this very suspicious. How do you provide a biospsychosocial explanation—or any other explanation, for that matter—for a condition of unknown aetiology and pathogenesis?

 

Exactly how is it possible to state "addressing underlying pathophysiology...." as a first step in pt care when no one knows what that is?

Or does that refer to correcting things like anaemia etc which could cause symptoms?

Not read the paper, just the abstract. Will try and read later.

 

It's even harder to understand why MDs and professional skeptics swallow this whole and ask for more.

People in general? Sure, whatever. Ask the right leading questions and you could find that most people believe that weird folk rituals are the best thing to do ward off this or that. Belief in astrology is pretty strong and all religions have sketchy stuff that defy scientific knowledge.

But this, this is the stuff that professionals are supposed to mock mercilessly, that skeptics are supposed to point out all the flaws and how this is mostly indistinguishable from young earth creationism and other ideologies that they mercilessly debunk.

There is clearly something about health that turns most of this reasoning off. You could build an AI model trained only on weeding out logical fallacies and nothing else, and it would be absolutely brutal on pretty much all biopsychosocial nonsense. That's all it takes, just point out how it's based on completely fallacious rhetoric. Nothing genuine or scientific would have a false positive here. But this stuff would light up as strongly as any flat earth or astrology-based nonsense. Possibly even more so considering how much it borrows the language of science without featuring any of its substance. This is the absolute peak of pseudoscience, likely for all time.

Health is the last discipline where myths, superstitions and odd beliefs continue to dominate in some places. And really, not just exist, but actually dominate, overrule a huge amount of evidence about as absurdly as taking clear video evidence of a crime, freezing on a single frame where nothing is happening and arguing that it fully exonerates. It makes absolutely no sense.

 

It’s truly about only being sceptical when you want to be. So many medical professionals are extremely sceptical of any physical illness they can’t immediately see or diagnose with a blood test. But will swallow any mental explantions with conflations of correlation and causation that should be obviously problematic to anyone who has taken an introductory BSc course.

 

Eg on "Acute blood biomarker profiles predict cognitive deficits 6 and 12 months after COVID-19 hospitalization" (2024)

 

One of the things that really annoys me about papers like this (and this entire area) is the rewriting of biology and biological language that is going on.

I'm actually quite shocked that The Lancet is allowing it to happen. They used to be absolute sticklers for making sure that if a word was used, it meant one thing and one thing only. We had our own dictionary of accepted terms, and as editors we enforced it rigorously.

Here we see the word "somatic" being used not in its usual sense - "pertaining to the body (soma)" - but to mean psychosomatic, *as if* somatic, not really somatic, feels like somatic but isn't, perceived as somatic but generated by the psyche.

This rewriting of language is designed to confuse, and to make people say things they don't mean, and to make people misunderstand what is said to them. It is deceitful, and in my opinion The Lancet should be playing no part in this nonsense. That they are, and seemed to have devoted so much of an entire weekly issue to it, is dreadful.

 

Schrödinger’s Somatic symptom

 

Me too. Very frustrating. So many claims in this article that aren't based on scientific evidence. I suspect some of the Lancet editors and peer reviewers are really biased towards this view otherwise this would never have passed.

Take for example statements like these:

So a biopsychosocial explanatory model, regardless of whether it is true or not has beneficial therapeutic effects. No reference needed.

Or take this one:

So they are claiming that long term somatic symptoms are the result of beliefs or expectations rather than biomedical factors. An extraordinary claim requires extraordinary evidence but only 1 reference is given. A 2005 paper where 'fear of movement' showed a stronger correlation with pain in those who had been ill longer...

Another one:

Is this really the best approach though? Again there is no evidence, they only reference earlier reviews written by themselves.

No reference is given. Placebo responses are not solely about patients' beliefs and expectations (could for example just be response bias) and the effects are usually small and only visible on subjective measures. Here's what the cochrane review said about it: "We did not find that placebo interventions have important clinical effects in general. However, in certain settings placebo interventions can influence patient-reported outcomes, especially pain and nausea, though it is difficult to distinguish patient-reported effects of placebo
from biased reporting."
https://www.cochrane.org/CD003974/COMMUN_placebo-interventions-for-all-clinical-conditions#:~:text=We studied the effect of,by patients, such as pain.

The review on psychotherapy seem to be focused on unblinded studies with subjective outcomes and it found only a modest effect with an SMD of 0.38. The review on short-term psychodynamic psychotherapy found a really big effect of 0.9. The fact that they don't make any recommendations (e.g. that this therapy is highly effective and should be preferred over other psychotherapy), probably indicates that they themselves don't take it very seriously. For pharmacological interventions only antidepressants are discussed.

 

It is also nearly impossible to discuss this in a rational way because the category is so broad: all long-term somatic symptoms, regardless if they are explained or not. If they claim that 'catastrophising interpretations' or 'somatosensory amplification' are important they can simply point to some paper in one illness and claim that it applies to all somatic symptoms. Apparently that is allowed.

It is such an absurd situation. They clearly want to claim that symptoms physicians fail to explain are caused by psychosocial factors and should be treated with psychotherapy. But they don't dare to say that out loud so instead use all these terminology that hides their simplistic view. So they use the biopsychosocial model (even though bio is not discussed), it's no longer medically unexplained symptoms, but persistent symptoms (even though they ignore those that are explained), they want to discuss pharmacological and non-pharmacological interventions (but obviously there aren't any drug interventions so they only mention antidepressants).

 

Unfortunately it has come up in this bulletin. It's behind a pay wall.

SUMMARY AND COMMENT

Can a Symptom Clinic Help Patients Without Detectable Physical Disease?

Bruce Soloway, MD, reviewing Burton C et al. Lancet 2024 Jun 15

Four or fewer sessions with specially trained generalist physicians reduced symptom intensity 1 year later.