Functional Somatic Syndromes (FSS) are the latest medical fashion to hit Western psychiatry. The term describes disorders like CFS, fibromyalgia, pre-menstrual syndrome (PMS), multiple chemical sensitivities (MCS), temporomandibular disorders and interstitial cystitis. These conditions can apparently be lumped together because they share "multiple somatic symptoms", they lack "defining structural defects or laboratory abnormalities", there’s a "frequent association with psychiatric disorders", an "absence of proven pathophysiological mechanisms" and "a paucity of effective therapeutic interventions". Since I’m not an expert on every disorder described in the book, I can’t judge the accuracy and reliability of all the chapters. However, I do have specialist knowledge of PMS and CFS, so in this review, I’ll focus on these conditions, as well as the information on definition, aetiology, disability and treatments.
The first thing I noticed about the chapter on PMS is that it fails to differentiate between the clinical entity and a research diagnosis known as pre-menstrual dysphoric disorder (PMDD). These are essentially cyclical mood disorders. Some ‘physical’ conditions can also manifest themselves solely during the pre-menstrual phase, e.g. migraine and epilepsy.
PMS is different. Common symptoms include breast tenderness, bloating, cramps, as well as tension, irritability or depression. These do not represent an pre-menstrual exacerbation of a chronic disorder (stress, food sensitivities etc.) nor the cyclical occurrence of conditions like depression, acne etc.
Although author Teri Pearlstein acknowledges the heterogeneity of the populations described, she completely ignores this fact when interpreting the research. In my view, such an approach is confusing and misleading. For instance, studies have shown that antidepressants and cognitive therapy help many women with PMDD. However, it doesn’t follow that antidepressants should therefore be the "first line treatment for PMS", especially where the main symptom isn’t tension or depression but breast pain, dizziness, fainting or headache1. Laymen may generalise from one subgroup to the population as a whole but scientists shouldn’t.
In short, this account of PMS is neither balanced nor particularly authoritative2. Pearlstein doesn’t acknowledge the mass of evidence linking PMS and hormones, nor does she mention the studies which found no psychological abnormalities in women with PMS. There’s also a lack of critical analysis, and no respect for the political influences which have motivated some writers on the subject. For example, Pearlstein cites my former professor, who couldn’t tell the difference between normal cyclical changes and PMS. The fact that my professor was a cognitive psychologist who aligned himself with radical feminists, refused to believe anyone else, had no clinical experience with PMS and did not, as far as I can recall, actually study women with PMS, is neither here nor there. The point is, his views are noted but those of experts like Professor Backstrom, a gynaecologist/endocrinologist who has published a mass of studies on PMS, are not.
The chapter on CFS is even more selective, biased and unfair. Here’s just one example of the way author Peter Manu cleverly manipulates and misleads his readers. On page 22, there’s a short section describing two studies on magnetic resonance imaging (MRI). Manu rightly concludes that findings from these types of brain scans tend to be non-specific and thus unhelpful. However, he doesn’t mention the much more significant information which has been obtained using SPECT. Did Manu not know about that research? Yes, he did! How can I be sure? Well, one of the two studies he described in relation to MRI was actually a comparison of the two techniques (Schwartz et al). In fact, that study revealed abnormalities in 81% of the SPECT scans, and found that "the number of . . . abnormalities appeared to correlate with clinical status". Manu also ignored another paper on SPECT, written by the same authors and published in the very same issue. It provided further support for the theory that CFS is linked to infection, as did Costa et al etc. Yet Manu doesn’t even allude to this work.
As for the rest, there’s virtually nothing on the endocrinological data (which show the difference between CFS and depression), and of course, no mention of McGarry et al’s autopsy report (which provides more evidence of a viral link). There’s no distinction made between studies on CFS and general fatigue (probably because there’s a closer association between the latter and depression) and no acknowledgement that if a study on CFS includes people with psychiatric illnesses, there’s a fair chance one might find a statistical relationship between CFS and psychiatric illnesses.
Of course, this state of affairs makes a mockery of the editor’s claim that the book is based on "the best available publications" and "the principles of evidence-based medicine". No, the chapters I’ve read suggest that much of the analysis is based on the contributors’ personal views and prejudices. Take for example Manu’s summary of the research by Friedberg and Krupp. They assessed the effectiveness of cognitive-behaviour therapy and found "a trend toward reduced depression-symptom scores" but "no significant changes in stress-related symptoms or fatigue severity". This is what Manu makes of the same study. "Significant improvement was noted not only for measures of depression but also for fatigue severity and the cognitive and emotional reaction to fatigue". He acknowledges that his comments relate to the patients with CFS and depression. However, he forgot to mention that they represented a subgroup and that the results he cited did not apply to the group as a whole. That’s not objective, dispassionate, evidence-based medicine: that’s a personal selection of the data which supports the theory he’s trying to plug!
Manu concludes that research has "confirmed that the majority of patients with CFS are white middle-aged women with a high prevalence of current major depression and somatisation disorder and abnormal personality traits". Is this a fair representation of the literature? I admit that the research in the US and Europe tends to select white women but so what? This does not mean that one can ignore patients who are older, younger, from a different ethnic background, and men. Do the same characteristics apply to them? What of the methodological issues which could explain the high rates of somatisation (cf. Johnson et al), or the broad criteria which do not differentiate ‘pure’ post-infectious CFS from clinical depression (cf. Jason et al)? That’s overlooked. What of the research which found low rates of psychiatric disorders (e.g. Yeomans and Conway) and the studies which suggest that many psychological abnormalities are a reaction to physical disease (e.g. Stricklin). They’re simply not mentioned. Why not? Psychiatrists all have a medical training. Can they not cope with complicated issues?
A quick dip into the other chapters supports my view that this book is biased and out-of-date, The fairest chapter is the one on assessing disability, which surprised me since the author (Manu) works for an insurance company. Still, his contribution shows once again that the CDC guidelines are not specific enough, and that CFS actually covers a multitude of ills. The most interesting chapter is the survey of common denominators, because it really shows just how different the various disorders are. Most out-of-date section must be the account of Gulf War Syndrome which lists symptoms as fatigue, rash, headache, arthralgias, sleep disturbance, gastrointestinal complaints and cough. As the rest of us know, some veterans have since died.
I’ve done my best to consider all the arguments presented in the book. However, I remain unconvinced that FSS is a useful concept. If grey is the new black in fashion, then perhaps FSS is the new psychosomatic disorders in medicine. To misquote one well known psychiatrist, isn’t it a case of new wines in old bottles? An attempt to avoid well-rehearsed criticisms and draw our attention back to an old though slightly tarnished favourite. Let’s face it, psychosomatic medicine is not what it used to be. We’ve lost stomach ulcers courtesy of H. Pylori, and we know that headaches are often due to factors other than stress. The subject could do with a bit of rebranding! All I can say is, Reader’s Digest obviously haven’t written recently about cluster headaches, otherwise they would have been in there too!
The book also illustrates the increasing dumbing-down of modern psychiatry. On the one hand, these men and women of science claim to be open-minded and evidence-based, but in reality, they are rigidly reductionistic and far from subtle in showing their preferences. The following is a basic summary of the book.
We’ve spent a few thousand pounds on research, selected a mixed group of patients, this surprisingly failed to unearth a single, shared abnormality in everyone with CFS, we’ve ignored pretty much all the other evidence of pathology and concluded that there’s no "consistent" abnormality. It could be said that we’re dealing with a hybrid, but this is too complicated, so we’ve listed a whole group of articles which found high rates of major depression and above average rates of somatisation, we’ve ignored their flaws (as you do) and completed our account with a mixture off insinuation, speculation, generalisation and conjecture. Never mind the quality, feel the width!
The reasoning is what one might have expected of a second year undergraduate. Thus in relation to PMS and CFS, no one noted that when you study mixed populations, there are likely to be several subgroups, each with a different underlying mechanism. More objective observers might argue that while some subgroups may be types of FSS (e.g. TATT), others are not (e.g. ME). As for psychotherapy, if you take any group of patients who’ve endured years of verbal abuse and insults, shouldn’t we expect them to show a positive response to therapists who are kind to them, who acknowledge their suffering and who provide practical advice and handy-hints? Call it CBT, call it psychoanalysis, call it what you like. It doesn’t prove that most or all cases of CFS or PMS are functional somatic syndromes!
The book is well-written and eminently readable. However, as a mental health professional, I found it deeply depressing. There are many people who need our help but how can we persuade them that we are well-informed professionals whose clinical judgements are based on a balanced assessment of the evidence, when we basically ignore what we don’t like and write so unsympathetically about the individuals concerned?
I share the sentiments expressed by Bell and Lapp in relation to the review of FSS in Annals of Internal Medicine (AACFS, Newsletter, 1999, Aug-Sep). They noted that "unfounded opinions can lead to cutbacks in research funding, erect obstacles to published research, and increase the difficulties of patients who seek compassionate medical care. In such a case, the authors would be committing gross malfeasance, harming both the medical community and the patients to whom they are dedicated to serve". Sadly, much the same can be said about this book.
Doctors should be free to express themselves, but where do we draw the line? Should they be permitted to be so biased in their accounts of illness and disability? Is that compatible with their occupation? If you too are fed up with ‘opinion-based medicine’, write to the appropriate authorities. After all, if psychiatrists are forgetting the rules of science, isn’t it up to their colleagues to remind them?
EMG
1. There is some evidence that fluoxetine alleviates breast pain, headaches and bloating in women with PMDD (e.g. Steiner et al, Biological Psychiatry, 1999, 45, 73S, no. 236: Romano et al, Clinical Therapeutics, 1999, 21, 615-633) and. in mixed populations (e.g. Sue et al, Neuropsychopharmacology, 1997, 16, 5, 346-356.). However, in heterogeneous samples, findings supporting the use of SSRI antidepressants have been inconsistent (e.g. Venninga et al, Psychopharmacology, 1990, 102, 414-416) and there’s still little evidence of a beneficial effect in cases of PMS, where anxiety and depression do not predominate.
2. Read the section on confirmations, paragraph two, linking PMS/PMMD with abnormal serotonin function. Then read van Leusden, Lancet, 1995, 346, 1443.
Copyright EM. Goudsmit 1999.
©
Psychologist/Archivist, London.
All rights reserved. See the full
copyright
notice.
Be sure to see the many other
valuable articles at our Main
M.E. Home Page
