Letter to the Editor of the Lancet:

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Dear Dr. Horton,

We found it hard to take the article on functional somatic syndromes seriously (September 4 p 936¹). Are Wessely et al really suggesting that we’d be better off classifying chronic fatigue syndrome with tension headaches, and pre-menstrual syndrome alongside non-cardiac chest pain? Do they honestly believe that the differences between these conditions are of no clinical significance?

Medicine is a science and science demands precision. Lumping patients together because "they have much in common" or because we don’t yet understand the aetiology of the conditions is what we expect from ill-informed laymen and complementary practitioners, not well-trained medical specialists.

The basic suggestion is that acceptance of these disorders as "distinct syndromes" is of limited value. Keeping them separate apparently adds a "spurious complexity", and undermines both understanding and management. If we focus instead on shared characteristics, we can reject the "sub-specialist" with their "idiosyncratic approach", in favour of a broad-based programme, including cognitive behaviour therapy (CBT) and anti-depressants.

Let’s analyse the main argument in more detail. We are asked to consider a more uniform approach to the listed disorders because:

• some definitions list the same (ubiquitous) symptoms;
• patients with one syndrome frequently meet the criteria for another;
• patients often share non-symptom characteristics (e.g. many belong to the same gender, report emotional distress and aren’t entirely happy with their doctors);
• all the syndromes are associated with altered functioning of the central nervous system, and, apparently, CBT is superior to minimal care for "most of these syndromes".

If we apply the same reasoning, it could be argued that we should also stop differentiating between breast, pancreatic, liver, prostate and colon cancer. For instance, they all have at least one thing in common (malignancy), those with one form of the disease may develop another, and most respond to the same treatments (surgery/radiotherapy/chemotherapy; remember, we don’t need to consider differences). Focusing on shared non-symptom characteristics, we might note that most of those affected are aged above 20 and that a significant proportion experience some degree of emotional distress. As for dissatisfaction with their doctors, there are plenty of references on the anger caused by misdiagnosis or insensitive comments.

Consider now how we should be treating ‘adult cancer syndromes’. Would we prescribe the same regime for every patient? Of course not. We don’t even treat all breast cancers in the same way. In fact, we don’t gloss over the differences and rely on general physicians. We study any anomalies and value the expertise of the sub-specialists. Even if the similarities outnumber the differences, that’s no reason to ignore them.

In our view, Wessely et al’s article represents the ‘dumbing-down’ of psychiatry. Perhaps the listed syndromes should be reclassified, but not because most patients report fatigue and headaches or because many respond positively to practical advice and a listening ear. Nor should we base such decisions on the observation that the majority of patients are women, let alone the fact that some don’t always agree with everything their doctor says!

Yours sincerely,
Dr. Ellen Goudsmit Chartered Health Psychologist	Dr. Charles Shepherd Medical Director, ME Association

1. Wessely S, Nimnuan C and Sharpe, M. Functional somatic syndromes: one or many? Lancet 1999; 354: 936-939.