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

Andy

Retired committee member
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
 
Current evidence on the development of persistent physical symptoms is best represented by biopsychosocial vulnerability–stress models, which distinguish between predisposing, triggering, and maintaining or aggravating factors
"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:
Evidence increasingly suggests that symptoms are imprecise representations of body states. This inaccuracy can lead to overestimation or underestimation of the activity of disease processes. Central to a contemporary neuroscientific account of symptoms is the process of predictive coding
Ah, poor things are suffering from "imprecise representations of body states". Must be hard and distressing.
Placebo and nocebo effects (ie, positive or negative treatment effects that cannot be attributed to the active treatment components
87) can also be explained by predictive coding processes
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.
A 2023 meta-analysis concluded that psychological interventions have a small, statistically significant effect on reducing somatic symptoms
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:
Encouragingly, the results of a recent randomised clinical trial suggest that the statistically significant positive effect of CBT on fatigue in multiple sclerosis was sustained over 12 months.
It's been over a century, including decades of implementation, and still it's just potential, "imagine a world where...":
A biopsychosocial understanding of persistent physical symptoms has great potential to provide a patient-centred focus on subjectively distressing somatic symptoms
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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Basic care consists of addressing underlying pathophysiology and using person-centred communication techniques with validation, appropriate reassurance, and biopsychosocial explanation.

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?
 
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.
 
abstract said:
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.
Well, sure, if you really need an umbrella term for the pain and functional restriction of arthritis, the loss of physical capacity of multiple sclerosis, the tremors of Parkinsons, the pain of migraines, the numbness of leprosy, the weight loss of cancer, and so much more....
But, the title of the paper seems extremely ambitious - to explain 'the diagnosis, genesis and management' of all of the physical symptoms lasting several months or more from all the possible causes.

abstract said:
These symptoms are associated with substantial disability and represent a major burden for patients, health-care professionals, and society.
Sure

abstract said:
Persistent physical symptoms can follow infections, injuries, medical diseases, stressful life events, or arise de novo.
Starting to veer into speculation here. Where's the evidence for physical symptoms lasting months that are directly caused by a stressful life event? Or perhaps they aren't suggesting causation, and 'can follow' is just noting a temporal association, much like 'the onset of PPS can follow September'.
'Arise de novo'? Now it becomes clear why 'genesis' is used in the title rather than etiology or aetiology. The symptoms have miraculously appeared from nothing, the paper is about a creation story.

As symptoms persist, their link to clearly identifiable pathophysiology often weakens, making diagnosis and treatment challenging.
Amazing. So, after a few months, all those symptoms I mentioned in the first paragraph are just a problem of perception with no link to pathophysiology? Cancer is just a short term problem! Unless of course, the authors don't actually mean 'Persistent physical symptoms' when they write 'Persistent physical symptoms'? Or maybe they do, because we've seen them think they can fix symptoms of multiple sclerosis and cancer. And their definition says 'regardless of cause'.

Basic care consists of addressing underlying pathophysiology
Well, yes, that's always good if you can, but then
and using person-centred communication techniques with validation, appropriate reassurance, and biopsychosocial explanation.


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.
'Mechanism' based' treatment? When you stop using words in a way that relates to their actual meaning, I guess truth need not constrain you.

It's hard to understand why everyone isn't laughing at these people.
 
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It's hard to understand why everyone isn't laughing at these people.
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.
 
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.
 
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)

A critique of this study was published by Paul Garner, Alan Carson and others

Interesting how Garner and Carson can deliver robust critiques of biologically based studies, but seem blind to the serious flaws in their own studies and claims.
 
There is clearly something about health that turns most of this reasoning off.
Doctors are not trained as scientists, though they flatter themselves that they are. They are trained as technicians, which they often forget.

Engineering has a similar problem.
Health is the last discipline where myths, superstitions and odd beliefs continue to dominate in some places.
Medicine is still trying to shake of its deeply embedded eminence based model, with limited success thus far.

In fairness, having worked in a hospital, including in wards seeing doctors and nurses in action at the coalface, there is a need for a fair degree of seniority based on experience. So called corporate memory is a thing, and can be a very good thing, that helps anchor and stabilise functioning of a system. I would not want to throw out the seniority system completely. Just make sure they are not treated as gods who cannot be questioned.
 
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. :(
 
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.
It's sort of neither one meaning nor the other, but can be both at the same time, depending on what suits the author's purpose. If challenged, the authors would probably say, as they sort of do in this abstract, that 'somatic' is a synonym for 'physical'. And yet, 'somatic' tends to only be used when there is some implication of psychosomaticism.
 
It's sort of neither one meaning nor the other, but can be both at the same time, depending on what suits the author's purpose. If challenged, the authors would probably say, as they sort of do in this abstract, that 'somatic' is a synonym for 'physical'. And yet, 'somatic' tends to only be used when there is some implication of psychosomaticism.
Schrödinger’s Somatic symptom
 
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.
I am very firmly of the view that it is deliberate. They know what they are doing. It is entirely arse covering for their very serious sins during the 20 year reign of the current editor in chief, Horton, and will not change while he remains in the position.
 
I'm actually quite shocked that The Lancet is allowing it to happen
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:
The investigation of these risk factors also serves to develop a biopsychosocial explanatory model for the persistent physical symptoms, which itself often has beneficial therapeutic effects
So a biopsychosocial explanatory model, regardless of whether it is true or not has beneficial therapeutic effects. No reference needed.

Or take this one:
Although biomedical factors are usually, but not always, central to the development of short-term symptoms, psychological factors (such as the patient’s beliefs or expectations) and social factors appear to be more important for the longterm persistence of somatic symptoms
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:
Current evidence on the development of persistent physical symptoms is best represented by biopsychosocial vulnerability–stress models, which distinguish between predisposing, triggering, and maintaining or aggravating factors
Is this really the best approach though? Again there is no evidence, they only reference earlier reviews written by themselves.

Placebo and nocebo responses provide a good example of the importance of patients’ beliefs and expectations in the perception and management of their symptoms.
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.
 
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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.


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SUMMARY AND COMMENT

Can a Symptom Clinic Help Patients Without Detectable Physical Disease?
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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.
 
I've just found this one online when looking at the SSD developments and did a search to check this was on here already.

Just placing a note regarding this seeming relevant in chronology potentially after I've noted attempts to get the SSD (somatic symptom disorder) that is in the DSM V into ICD 10 and then ICD 11 (which seems to be from 2021)

and how potentially 'similar' the end principles are for this, albeit with slightly different storytelling in the middle and a few more diagrams, but also it seems some very defined pathways being suggested as working.

I also note the following in 'description and symptom patterns' section - so there seems to be something of a focus on BDD (and maybe it 'subsuming' SSD being a plan?):

This timeframe takes into account that different time limits—usually between 3 and 6 months—are used to distinguish between non-persistent and persistent symptoms in different medical conditions, and is consistent with both the timeframe used in the International Classification of Diseases, 11th Revision (ICD-11) to distinguish between acute and chronic pain and the definition of persistent in the context of bodily distress disorder.27 Persistent physical symptoms are evaluated by repeated assessments of the patient's subjective somatic symptom severity.

and the following in this paper: Somatic symptom disorder: a scoping review on the empirical evidence of a new diagnosis | Psychological Medicine | Cambridge Core

Thus far, it remains unclear how often the diagnoses of SSD or the respective ICD-11 diagnosis of BDD are actually used in different fields of medicine and countries (Kohlmann, Löwe, & Shedden-Mora, Reference Kohlmann, Löwe and Shedden-Mora2018).

This suggests that it is important to consider the diagnosis of SSD in patients with somatic diseases in order to adequately treat them. Although no suitable reference could be identified, it should be mentioned that excessive somatic focus is a feature of both body dysmorphic disorder and SSD, but in the former, the patient is concerned with appearance, while in SSD the worry is about being ill.

In the 11th edition of the International Classification of Diseases, ICD-11 (World Health Organization, 2021), which will take effect in January 2022, the former category of somatoform disorders has also been intensively revised and designated with the term “bodily distress disorder” (BDD). BDD is in large parts similar to SSD; in this respect, it is to be expected that some strengths and weaknesses of SSD will also apply to BDD, for which empirical studies are still missing.
 
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