Elsevier

The Lancet

Volume 369, Issue 9565, 17–23 March 2007, Pages 946-955
The Lancet

Review
Management of functional somatic syndromes

https://doi.org/10.1016/S0140-6736(07)60159-7Get rights and content

Summary

Although functional somatic syndromes (FSS) show substantial overlap, treatment research is mostly confined to single syndromes, with a lack of valid and generally accepted diagnostic criteria across medical specialties. Here, we review management for the full variety of FSS, drawn from systematic reviews and meta-analyses since 2001, and give recommendations for a stepped care approach that differentiates between uncomplicated and complicated FSS. Non-pharmacological treatments involving active participation of patients, such as exercise and psychotherapy, seem to be more effective than those that involve passive physical measures, including injections and operations. Pharmacological agents with CNS action seem to be more consistently effective than drugs aiming at restoration of peripheral physiological dysfunction. A balance between biomedical, organ-oriented, and cognitive interpersonal approaches is most appropriate at this truly psychosomatic interface. In view of the iatrogenic component in the maintenance of FSS, doctor-centred interventions and close observation of the doctor–patient relationship are of particular importance.

Introduction

Functional somatic syndromes (FSS) are common worldwide and in practically all areas of medicine. FSS are a burden for sufferers, they are also often difficult to treat for doctors and costly for society.1, 2, 3 Diagnostic and therapeutic approaches to FSS vary substantially across and within medical specialties, from biomedicine to psychology. In this review, we try to improve the understanding of common factors across single FSS and hence of common therapeutic strategies across medical specialities. We give an overview of current concepts underlying the management of FSS, of results of appropriate therapeutic trials in single syndromes and diagnostic analogues, and of practical steps for management.

Section snippets

Definition, overlap, terminology, and classification

FSS are characterised by patterns of persistent bodily complaints for which adequate examination does not reveal sufficiently explanatory structural or other specified pathology. We differentiate three main types of bodily complaints in FSS: pain of different location (back, head, muscles or joints, abdomen, chest, etc); functional disturbance in different organ systems (eg, palpitation, dizziness, constipation or diarrhoea, movement, sensation); and complaints centring around fatigue and

Aetiology and pathophysiology

Management of FSS must be informed by knowledge about the diversity of predisposing, precipitating, and maintaining factors for FSS. In terms of predisposing factors, no clear pattern of genetic influences has been identified, and the heritability of FSS seems to be small.29, 30 Childhood adversities are not restricted to sexual or physical abuse.31 Childhood experience of organically unexplained symptoms, parental ill health, and increased parental illness behaviour for bodily symptoms in the

Balanced approaches to FSS

There is not one single focus in the management of FSS, and this ambiguity has to be seen as a characteristic feature of these syndromes (panel 1). Some patients (eg, those with uncomplicated irritable bowel syndrome) will benefit most from typical medical interventions that are limited to reassurance and symptomatic relief focussed on gut functioning, but diagnostic elements of the cognitive interpersonal approach have to be integrated to assure that there are no symptoms or problems beyond

Description of treatment foci and types

We could not identify trials that tested treatments of groups of patients fulfilling criteria for more than one FSS. Differentiation of the following five treatment foci and types is useful for the organisation of the evidence on the treatment of single FSS and diagnostic analogues, such as somatoform disorders (table 2),51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94,

Management of functional somatic syndromes as a whole

The effect of non-pharmacological passive treatments, be they invasive or non-invasive, seems to be weaker than the effect of non-pharmacological treatments that involve active patients' cooperation. The evidence for efficacy of the latter across different FSS, in particular graded exercise and psychotherapy, underlines the importance of common factors in FSS, as the therapeutic rationale of these treatments typically aims at overall function and not at the alleviation of specific symptoms. The

Conclusion

The evidence base for the management of FSS has grown considerably over the last years and many patients are served well with the treatments applied in different subspecialities of medicine. However, there is still a predominance of a splitting view on single FSS and a lack of diagnostic criteria and classifications that are valid and generally agreed upon. This not only leads to confusion, but also to the neglect of important therapeutic options for many patients. Stigmatisation of

Search strategy and selection criteria

We searched the Cochrane Library, MEDLINE, and PSYCINFO from 2001. We used a string of search terms previously applied in a meta-analysis on FSS and diagnostic analogues and adapted it to the terms of FSS that are indicated in table 1. We included commonly referenced and highly regarded publications from before 2001. We also searched the reference lists of articles identified by this search strategy and selected those we judged relevant. For the section on therapeutic evidence we restrict

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