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Persistent Physical Complaints Without Medical Cause, Features and Care
Abnormal Psychology · Chapter 14: Somatic Symptom and Related DisordersSection 14.2 · lesson 52 of 9716 min · free with a free account
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In this lesson
What happens to people in services - and what good care looks like.
- Describe persistent functional somatic presentations and their impact
- Explain the factors that maintain them
- Describe good care, and the documented harms of poor care
- Explain when fresh medical assessment is warranted
Transcript
Everything said in the video, section by section (2,081 words). Read along, or search it.
Somatic Symptom and Related Disorders
Persistent Physical Complaints Without Medical Cause
Some people live for years with physical symptoms that disable them, where investigation never finds a structural cause. This section is less about diagnostic categories, which the last section covered, and more about what happens to these people in services. We look at what maintains these presentations, and at two very different care pathways from the same starting point. And we look at when a working explanation should be reopened.
Read This First
Real, Disabling - and Not Yet Explained
Three things come first. The symptoms described here are real and disabling. They are not imagined, not exaggerated, and not sought after. People in this group are frequently among the most disabled that services see, and the disability is genuine. Second, no cause found is not the same as no cause exists. Some people in this group are later found to have a medical condition. Remaining open to that is a clinical duty, not a courtesy. New, changing, or worsening symptoms need fresh medical assessment, whatever diagnosis a person already carries. And this material is educational. It is not a basis for changing any medical care you are receiving.
The Territory
A Large Group, Not an Unusual One
This section concerns persistent bodily symptoms that cause real disability, where investigation has not identified a structural explanation. It is a large group, not an unusual one. A substantial share of consultations in primary care, and in several hospital specialties, involve symptoms like these. Most of these people are seen in general services, not specialist psychological ones. The terminology is unstable, and that instability is itself informative. Medically unexplained symptoms, persistent physical symptoms, functional symptoms, bodily distress. Each replaced something worse, and each was criticized in turn. Medically unexplained foregrounds an absence. Functional is heard by many people as a euphemism. And somatic is opaque outside the professions. The deeper problem is that a name for symptoms without an identified cause tends to absorb the stigma, rather than remove it. Presentations take three broad shapes. A single persistent symptom. Multiple symptoms across different body systems. Or clusters that form recognized functional syndromes.
Contested Syndromes
Real Disability, Unresolved Mechanisms
Those recognized syndromes are contested, and this course is careful about how it teaches them. It does not assert that any of them is psychological in origin. Their classification and mechanisms are genuinely disputed. And patient communities' objections to psychological framing are presented as a reasoned position, not as a misunderstanding to correct. Chronic fatigue conditions, including myalgic encephalomyelitis, are classified internationally as conditions of the nervous system, with active biomedical research. The evidence for some behavioral approaches in this condition faced sustained methodological criticism and formal re-evaluation. Guidance in several countries changed as a result. Fibromyalgia is classified as a chronic pain condition. The mechanism most often invoked is central sensitization, an amplified processing in the nervous system. Irritable bowel presentations involve disturbed communication between the gut and the nervous system, and are among the better characterized mechanistically. And persistent post-concussion and post-infectious presentations continue well beyond expected recovery, with mechanisms still unsettled. What all four share is real and often severe disability, active research, unresolved disagreement about mechanism, and a history of people being disbelieved.
The Patient Perspective
The Experience of Not Being Believed
The dominant theme in what people in this group report about their care, is the experience of not being believed. Being told again and again that tests are normal, while still unable to work, produces a distress that is distinct from the symptoms themselves. And it is frequently the more damaging of the two. The search for a diagnosis follows from that. A diagnosis gives an explanation, access to services, and evidence that the person is not making it up. Seen that way, persistent pursuit of a diagnosis is a reasonable response to being disbelieved, not a symptom of anything. Patient communities' resistance to psychological framing is not an objection to psychology as such. It responds to a documented history. Psychological framing has been used to withdraw services and funding. It has closed off further investigation. It has arrived instead of biomedical investigation, rather than alongside it. And some specific treatment evidence was challenged, and guidance changed. So the resistance was partly vindicated. So when someone reacts badly to a psychological formulation, they may be responding to that history, not to this particular clinician.
Dismissive Language
Labels That Do Clinical Harm
Some clinical shorthand does real damage. These terms are named here in order to be criticized. Heartsink locates the difficulty in the person, rather than in the mismatch between what they need and what the service offers. It turns a clinician's discomfort into the patient's attribute. Frequent flyer reframes repeated presentation as misuse. But repeated presentation is what someone does when nothing has helped. Difficult patient attributes to a person what is usually a property of a situation. And once written down, it follows them through the record, and shapes how the next clinician reads them. The consequences are not only about feelings. Labeled patients receive less thorough assessment, and are less likely to be investigated when something new appears. And they disengage from care, which makes everything harder for everyone.
Maintaining Factors
What Keeps It Going - the Treatment Targets
As in the last section, contributing factors divide into those that made the presentation more likely, those that set it off, and those that keep it going. The onset is often datable, after an infection, an injury, surgery, or a period of high demand. That describes something that happened to the person, not a lifelong pattern. The maintaining factors are the treatment targets. Symptom focusing increases a sensation's detected intensity, and is addressed by explaining that mechanism. Illness beliefs, what the person takes the symptom to mean, shape attention and behavior, and respond to a positive explanation. Activity cycling, overexertion on good days followed by prolonged rest, is addressed by clinician-led pacing at a sustainable level. Sleep disruption amplifies pain and fatigue, and is amplified by them. It deserves treatment in its own right. Iatrogenic factors come from the service itself. Repeated investigation signals that something serious remains to be found. That one is most directly within a clinician's control, through agreed limits with criteria for reassessing. And others' responses, well-meaning solicitude, or systems demanding proof of incapacity, can inadvertently sustain disability.
Attention and Perception
Amplifying Is Not Imagining
Attention deserves a closer look, because it is so easily misunderstood. Two ordinary properties of perception are involved. Attending to a sensation increases its detected intensity. And expectation shapes what we perceive. These apply to everyone, including people with unambiguous structural disease. They form a loop. Attention to a real sensation amplifies it, which draws more attention. The loop amplifies what is already there. It does not create it. Here is the sentence most likely to be lost. That attention amplifies a sensation is not evidence the sensation is imagined. It is simply how perception works. It is why a mild ache is noticeable in a quiet room, and unnoticed during absorbing work. Explaining this to a person requires care. It explains why symptoms fluctuate, and why attention is a treatment target. It says nothing about whether they are real.
Figure 14.2.2
Same Person, Same Symptom, 2 Pathways
This figure follows the same person, with the same real symptom, down two different pathways. Both start by investigating. The difference is in what the service does next. On the escalating pathway, investigation is followed by referral onward, then conflicting explanations from different clinicians. Then escalating investigation, with invasive procedures and incidental findings, and finally a breakdown in the relationship. The outcome is more disability, more risk, and still no explanation. On the coordinated pathway, investigation comes with limits agreed in advance. One clinician coordinates. The person receives a positive explanation. Goals are set in terms of function, and contact is scheduled rather than crisis-driven. The outcome is better function, retained trust, and an open door. The care pathway itself is the intervention.
The Pathway That Works
5 Deliberate Components
The pathway that works has five components, and each one is deliberate. First, a single coordinated clinician, who holds the history, the explanation, and the plan, so the person is not restarting with every new professional. Second, an explanation the person can accept. Positive, mechanistic, and explicit that the symptoms are real. Third, agreed limits on investigation, with clear criteria for re-investigating. Limits without criteria are abandonment. Limits with criteria are a plan. Fourth, realistic goals based on function, rather than eliminating the symptom. That makes progress possible while symptoms continue. Fifth, regular scheduled contact rather than crisis-driven contact. It is the component most often left out, and among the most effective. When contact is crisis-driven, being worse is the ticket of entry. Nobody chose that arrangement, but everybody maintains it. Scheduled contact removes that contingency. And a clinician who sees someone regularly has a baseline, which makes a genuinely new symptom visible.
Diagnostic Humility
When to Reassess - Agreed in Advance
A functional formulation is a working explanation, not a closed file. That is the principle of diagnostic humility. But openness has a cost too. Investigating every symptom afresh reproduces the escalating pathway and its harms. The resolution is to specify in advance what would warrant reassessment. That turns a judgment made under pressure into a rule agreed while calm. A genuinely new symptom qualifies, because the formulation was built on the established pattern. So does a change in a symptom's character, since maintaining factors explain intensity, not character. And so do new objective findings on examination. Steady deterioration in a specific function is a different pattern from the fluctuation typical of functional symptoms. Symptoms that wake a person from sleep are not readily explained by attentional factors, which operate in waking life. And a formulation that predicted improvement, and did not get it, has produced evidence against itself. Treating that as the person's failure to engage is one of the commoner errors in this area.
Language
Same Information, Different Outcome
Language here is clinical content, not etiquette. The same information can leave a person with something, or with nothing. Instead of there's nothing wrong, try this. The tests haven't shown structural damage, and I can explain what I think is happening. Instead of it's all in your head, the single most damaging sentence in this area, try this. This is a problem with how the system is functioning. The symptom is real. Instead of the good news is everything is normal, try this. The results rule out some serious things. They don't explain your symptom, and that is the next question. And instead of we've done everything we can, which reads as discharge, try this. More tests of this kind won't help. Here is what we will do instead, and here is what would make me reconsider. Notice that none of these replacements involves pretending to have found something.
Treatment and Systems
Principles - and a Stated Controversy
Treatment is described here at the level of principle only. Cognitive-behavioral approaches target symptom focus, illness beliefs, and activity patterns. Their effects are real, generally modest, and better when the relationship is good. Graded rehabilitation is clinician-led. And its contested status has to be stated clearly. In chronic fatigue conditions, the evidence for graded activity faced sustained criticism, and patient reports of harm were substantial. Guidance in several countries changed. Unsupervised activity escalation is not recommended here for any condition. Nothing in this section is an instruction to increase activity. Treating co-occurring anxiety or depression is frequently among the most effective steps available. At work, a graded return with adjustments is better than a binary fit-or-unfit judgment, which forces people to demonstrate incapacity in order to be believed. Families can be included in the explanation, which helps with both over-solicitude and skepticism. And outcomes are consistently better where the person feels believed. In this area, the relationship is close to being the treatment itself.
1 Presentation, 2 Pathways
George, 47 - Dizziness After a Viral Illness
One composite case, followed down both pathways, shows the difference. It describes no real person. George, forty-seven, developed persistent dizziness and fatigue after a viral illness. On the escalating pathway, his normal results were called good news, leaving him with a symptom and nothing else. He was referred to one specialty, then another that offered a different account. He had an invasive test with a minor complication, and an incidental finding led to more tests. By eighteen months, a note in his record called him a frequent attender, and he no longer trusted the practice. Each decision was defensible. The pathway was not. On the coordinated pathway, the same tests came with a plan stated in advance, and a positive explanation followed in month two. One named clinician held the plan. Limits came with written criteria for reassessment. He was seen every six weeks, however he was. A co-occurring depression was treated. At twelve months the dizziness persists, but less, and he is working three days a week. Notice that the coordinated pathway never required anyone to decide the symptom was psychological.
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