Chest pain, back pain, headache, muscular pains,
bowel symptoms, breathlessness, dizziness, and
fatigue often remain unexplained after medical assessment.1
Such cases may be referred to as func≠
tional syndromes of chronic fatigue, chronic pain,
fibromyalgia, and irritable bowel or as somatoform
(somatisation) disorders. In many cases the symptoms
are severe, persistent, and disabling and cause
considerable personal, social, and healthcare costs.1-3
Furthermore, the problem is large, accounting for a
quarter of general practice consultations, as many as a
half of outpatient clinic attendances, and a substantial
number of hospital admissions.2
When symptoms are found not to result from
“genuine physical illness” they are often believed to be
insignificant or attributed to mental illness. Conse-
quently when investigations prove negative, manage-
ment is commonly limited to reassurance about the
absence of disease and occasionally referral to a
general psychiatrist. In our experience such referrals
are unpopular with patients and rarely result in
effective treatment. In fact there is scant provision in
either medical or psychiatric services for the patient
with somatic complaints who has neither physical dis-
ease nor severe mental illness.4
We now know that we could do better. Evidence for
the superiority of new ways of thinking about and
managing such patients is growing. Several recently
published randomised trials show that new treatments
are both acceptable to patients and more effective than
conventional medical care.5,6 These new treatments,
often referred to as cognitive behavioural therapies,
take an explicitly integrative approach to patients'
complaints—an approach in keeping with the evidence
that the perpetuation of unexplained somatic symp-
toms is best understood in terms of an interaction
between physiological processes, psychological factors,
and social context.7
This integrative approach also provides a logical
basis for management. The first step is acknowledging
the reality of the patient's problem. The second is
systematically identifying and listing the principal
factors that perpetuate illness, including disordered
physiology, misinterpretation of associated bodily sensa-
tions, abnormalities of mood, unhelpful coping behav-
iour, and social stressors. The third step is making a
management plan that targets the most important of
these factors for each patient. For example, a patient
with chronic fatigue may benefit from information to
combat unfounded fears about the illness, guidance and
encouragement in returning to normal activity, and help
with employment and other problems.7 For selected
patients antidepressant treatment may also help.25
Implementation of this new approach will require
changes in both medical practice and the organisation
of services. Most patients will continue to be managed
in primary care, where the doctor's positive explana-
tion of the symptoms and practical advice may be aug-
mented by printed information, reinforced if necessary
during a longer session with a suitably trained nurse.
The general practitioner should be supported by a
readily available medical consultant, whose confident
assessment and statement of findings will reinforce the
general practitioner's approach. Innovative service
developments such as joint medical-psychiatric clinics
and dedicated liaison psychiatry and psychology serv-
ices will provide for patients who require more
intensive treatment. Finally, the small but conspicuous
group of patients who present with recurrent and mul-
tiple physical symptoms will be given proactive and
coordinated care aimed at limiting unnecessary medi-
cal intervention and preventing iatrogenic harm.8
If these simple and inexpensive changes in practice
and service provision could improve patient care, why
have they not been implemented? One reason is the
widespread lack of awareness that effective evidence
based treatments are available. Another is a miscon-
ception that such patients are only “worried well,”
undeserving of health service resources. But perhaps
the main obstacle to change is the remarkable persist-
ence of mind-body dualism,9 which appears to be as
prevalent among the medical profession as among the
general public. Overcoming this intellectual obstacle to
a more constructive attitude to medically unexplained
physical symptoms will require changes in doctors'
professional training and a greater dialogue with
colleagues in psychiatry and clinical psychology. There
are welcome signs of change, as evidenced by recent
joint royal college reports.2-10 But to meet the challenge
of “medically unexplained” symptoms we must do
more to lead public opinion in a positive and
non≠judgmental acceptance of the role of physical,
psychological, and social factors in most, if not all,
illness. Such an acceptance would encourage the
implementation of what we already know, as well as
opening the door to the development of innovative
treatments for these hitherto problematic illnesses.
Richard Mayou, Professor
Oxford University Department of Psychiatry, Warneford Hospital,
Oxford OX3 7JX
Michael Sharpe, Senior lecturer in psychological medicine
Edinburgh University Department of Psychiatry, Royal Edinburgh
Hospital, Edinburgh EH10 5HF
1
Kroenke K, Mangelsdorff D. Common symptoms in ambulatory care:
incidence, evaluation, therapy and outcome.
AmJMed
1989;86:262≠6.
2
Joint working party of the Royal Colleges of Physicians, Psychiatrists, and
General Practitioners.
Chronic fatigue syndrome
. London: Royal College of
Physicians, 1996.
3
Smith GR. The course of somatization and its effects on utilization of
health care resources.
Psychosomatics
1994;35:263≠7.
4
Wessely S. The rise of counselling and the return of alienism.
BMJ
1996;313:158≠60.
5
Mayou RA, Bass C, Sharpe M.
Treatment of functional somatic symptoms
.
Oxford: Oxford University Press, 1995.
6
Speckens AE, Van Hemert AM, Spinhoven P, Hawton KE, Bolk JH, Rooij≠
mans HG. Cognitive behavioural therapy for medically unexplained physi≠
cal symptoms: a randomized controlled trial.
BMJ
1995;311:1328≠32.
7
Sharpe M. The treatment of functional somatic symptoms; the example
of chronic fatigue syndrome.
Psychosomatics
1997;38:356≠62.
8
Smith GR, Monson RA, Ray DC. Psychiatric consultation in somatization
disorde
r ≠ a randomized controlled study.
N Engl J Med
1986;314:1407≠13.
9
Kirmayer LJ. Mind and body as metaphors: hidden values in
biomedicine. In: Lock M, Gordon D, eds.
Biomedicine examined
. Dordrecht:
Kluwer, 1988:57≠92.
10 Joint working party of the Royal Colleges of Physicians, Psychiatrists and
General Practitioners.
The psychological care of medical patients: recognition of
need and service provision.
London: Royal College of Physicians, 199
