Functional Somatic Syndrome: Assessment and Management

Abstract

Functional somatic syndrome (FSS) occurs in as many as 30% of patients in general medical practice, but it is infrequently a topic of formal instruction. Many physicians feel uncomfortable with medically unexplained symptoms and are unfamiliar with how to assess or manage them. Traditional medical approaches can be ineffective and can contribute to iatrogenic or adverse physiologic effects in patients. Physicians treating patients with FSS should not only consider standard medical tests, but they should also try to gain a deeper behavioral understanding of the mind-body connections that underlie the presenting symptoms. Osteopathic physicians, with their emphasis on holistic patient care, are in a key position to treat patients with FSS. This review provides a brief recapitulation of the literature and illustrates key factors in the assessment and management of FSS.

Full text

Functional Somatic Syndrome: Assessment and
Management
Christopher J. Graver, PhD
Financial Disclosures:
None reported.
Support: None reported.
Disclaimer: The views
expressed herein are those of
the authors and do not
necessarily reflect the official
policy or position of the
Department of the Army,
Department of Defense, or the
US Government.
Address correspondence to
Christopher J. Graver, PhD,
Neuropsychology, MCHJ-
CLU-CP, 9040 Jackson Ave,
Tacoma, WA 98431-1100.
E-mail:
christopher.j.graver.civ@
mail.mil
Submitted
March 02, 2017;
revision received
May 12, 2017;
accepted
June 14, 2017.
Functional somatic syndrome (FSS) occurs in as many as 30% of patients in
general medical practice, but it is infrequently a topic of formal instruction.
Many physicians feel uncomfortable with medically unexplained symptoms
and are unfamiliar with how to assess or manage them. Traditional medical
approaches can be ineffective and can contribute to iatrogenic or adverse
physiologic effects in patients. Physicians treating patients with FSS should
not only consider standard medical tests, but they should also try to gain a
deeper behavioral understanding of the mind-body connections that underlie
the presenting symptoms. Osteopathic physicians, with their emphasis on
holistic patient care, are in a key position to treat patients with FSS. This
review provides a brief recapitulation of the literature and illustrates key
factors in the assessment and management of FSS.
J Am Osteopath Assoc. 2017;117(8):511-519
doi:10.7556/jaoa.2017.101
Keywords: functional somatic syndrome, medical unexplained symptoms, somatic symptoms
Functional somatic syndrome (FSS) has been around for thousands of years.
1
Various terminology has been used to describe FSS throughout the years, includ-
ing hysteria,somatoform disorders,medically unexplained symptoms, and fash-
ionable illnesses.
1
Current terminology in the Diagnostic and Statistical Manual of
Mental Disorders, fifth edition,
2
includes somatic symptom disorder,conversion dis-
order, and illness anxiety disorder. However, for the purposes of the present review, the
term functional somatic syndrome will be used to describe a combination of symptoms
that cannot be fully explained by pathologic conditions or diseases and that cause func-
tional impairment or disruption of everyday activities, without evidence of the patient
intentionally feigning their symptoms. Functional somatic syndrome is a term that
patients find minimally offensive when describing their condition, but it is not suggested
as formal diagnostic terminology.
2
The aim of this review is to impart a framework for
successful assessment and treatment of patients with FSS.
Functional somatic syndrome is commonly encountered in the general and specialty
health care settings.
3
A review on the prevalence of somatoform disorders and medically
unexplained symptoms in primary care found that at least 1 medically unexplained
symptom was observed in 40% to 49% of all primary care patients.
4
In a neurologic prac-
tice, approximately one-third of new patients were found to have symptoms not fully
explained by neurologic causes.
5
Nevertheless, physicians fail to consider FSS in the dif-
ferential diagnosis as much as 90% of the time when presented with nonspecific symp-
toms that are unexplained by medical tests or known diseases.
6
Additionally, physicians
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are more likely to seek to medically explain symptoms
regardless of the available evidence.
7
In the present
article, I review the literature on FSS and describe
assessment and management techniques for this
condition.
Assessment and Diagnosis
Appropriate diagnosis of FSS is just as important as
that of medically explained illnesses, and the rate of
misdiagnosis in patients presenting with FSS is only
about 4%.
8
Failing to consider FSS can result in detri-
mental outcomes from both the clinical and economic
perspective. Patients with FSS present with nonspecific
symptoms that typically include myalgia, joint pain,
back pain, headache, fatigue, feeling faint or dizzy,
chest pain, heart palpitations, trembling, diarrhea and
constipation, insomnia, and cognitive issues (eg, lack
of attention, loss of memory). These symptoms are
often within the realm of normal human experience.
9
Clusters of nonspecific symptoms have been labeled as
chronic fatigue syndrome, Lyme disease, fibromyalgia,
irritable bowel syndrome, and atypical chest pain.
10
Henningsen et al
11
described nearly 30 different labels
for conditions in which patients present with FSS.
Nevertheless, several studies have found that symptoms
do not cluster into easily defined, distinct syndromes
and should not be presumed to be independent.
12,13
When symptoms are clustered into groups, managing
subsets of those symptoms as unique conditions can
lead to misdiagnosis, ineffective treatment, and failure
to recognize and manage the underlying cause of the
individual symptoms.
Patients with FSS have been shown to have more
than twice the use and costs of health care services
than a patient with a medically-confirmed illnesses.
14,15
For example, Sicras-Mainar et al
16
found that compared
with a reference population, patients with fibromyalgia
had €5010 more in health care costs, had more
comorbidities, had an average of 6 more outpatient
visits annually, missed more days of work, and used
more pain-relieving medication. Also, patients with
fibromyalgia were more likely to undergo surgical pro-
cedures compared with patients with a rheumatic dis-
order.
16
From a clinical perspective, as many as 55%
of patients with FSS whose symptoms are managed
with standard medical approaches will experience
adverse effects because the underlying cause of the
symptoms is not addressed.
17
Functional somatic syndrome has a strong correlation
to psychological conditions, such as depression and
anxiety, as well as a history of trauma or abuse.
Depressive episodes, negative life events, the number
of medically unexplained symptoms at baseline, attri-
butional style, autonomic sensations, and catastrophic
cognitions should be considered when a patient pre-
sents with FSS.
18
Studies found that 80% of people
with FSS had a history of an anxiety or depressive dis-
order, per standard diagnostic criteria,
15
and people
with a history of anxiety or depressive disorders were
nearly 3 times more likely to have FSS.
19
In another
study,
18
investigators examined a sample of patients in
Health Maintenance Organization plans and found that
half of the patients in the top 10% of ambulatory care
users had anxiety, depression, or somatization.
Functional somatic syndrome has also been asso-
ciated with a history of childhood abuse or neglect.
20
Bonvanie et al
21
discovered that stressful life events in
adolescence were associated with FSS, even when
adjusting for levels of functional somatic symptoms,
anxiety and depression symptoms, and socioeconomic
status before the stressful life event. In an epidemiolo-
gic study of more than 1200 women, Walker et al
22
concluded that the number of symptoms without clear
medical explanation that a patient presented with dir-
ectly correlated to the number of reported adverse
childhood experiences. In addition, FSS can develop
as a result of natural life stressors. For example, after
the San Francisco Bay Area earthquake of 1989, a
sample of residents reported significantly greater
numbers and frequency of dissociative symptoms,
including derealization and depersonalization; distor-
tions of time; and alterations in cognition, memory,
and somatic sensations up to 4 months after the
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earthquake compared with their baseline symptoms 1
week before the earthquake.
23
These nonspecific cogni-
tive and somatic symptoms represent a subjective index
of affective distress with low correlations to objective
testing.
24,25
Although patients with FSS report more symptoms
and higher degrees of disability than those with trad-
itionally defined medical or psychological conditions,
physicians may perceive symptom severity and disabil-
ity as less severe when the symptoms are not medically
supported.
7
Apex clinical care is always a goal, but
many physicians are not trained in how to assess or
manage symptoms of FSS. A survey of medical stu-
dents in the United Kingdom showed that no specific
course covered the topic of FSS, and, if the topic was
covered, it was inconsistent and disparate across
medical schools.
26
In my experience, this lack of train-
ing regarding FSS and discrete medical profiles can
lead to physicians feeling mild discomfort or anxiety
and resentment when patients present with FSS. These
feelings can also stem from limited exposure and train-
ing in enhanced care, which includes a treatment model
that draws on explanations for symptoms in broad biop-
sychosocial terms, in general practice settings.
27
Osteopathic physicians, with their holistic approach to
patient care, are in a unique and advantageous position
to offer enhanced care to patients with FSS.
Unreported stressors may be the most damaging to
physical and mental health, whereas disclosure of stres-
sors can result in improved measures of cellular
immune system function and fewer health care visits.
28
Stressors may go unreported because it may be more
comfortable for patients with FSS to focus on physical
symptoms rather than exploring mental stressors.
29
It
is critical to investigate FSS symptoms in the context
of ongoing stress, but patients may experience this
assessment as hostile and adversarial. If an adversarial
mindset dominates the encounter, then exploring psy-
chosocial factors becomes difficult. Page and Wessely
7
proposed that such encounters can be viewed by
patients as rejecting, colluding, or empowering.
Patients who feel rejected will continue to seek other
opinions and resources (eg, outpatient visits, emer-
gency department visits, medical tests and procedures,
medication).
7
Physicians who collude with patients
can encourage iatrogenic illness and overuse of
medical tests, often with adverse effects.
7
Collaborating with patients and empowering them to
be a part of controlling their symptoms is the most
beneficial approach for the patient, the physician, the
patient’s family, and the health care system because
these patients are less likely to feel rejected, can work
with the physician on proposed treatments, and are
less likely to seek unnecessary resources.
7
Patients with FSS must be approached differently
than other patients. The physician must keep in mind
that, despite research
28,29
showing a strong association
with psychological factors, patients with FSS
often present with only physical symptoms.
30
Well-documented stressors, medical history, and behav-
ioral health conditions are imperfectly recalled and
make the prospect of illusory mental health likely to
be unintentional.
31
For example, as many as 40% of
people who had documented abuse in childhood fail to
report it, even if they are directly questioned about it.
32
Patients with FSS also tend be biased in their recall of
symptoms before an onset marker (the start of the first
symptoms identified by the patient to cause a change
in their health) and may minimize past symptoms.
33
Furthermore, they are more likely to incorrectly report
previous medical diagnoses or test findings and over-
pathologize their medical history than patients with a
confirmed disease.
34
On the one hand, directly con-
fronting the lack of evidence for a confirmed medical
cause of a patient’s symptoms is likely to put them on
the defensive and leave them feeling rejected. On the
other hand, accepting subjective reports without skepti-
cism or objective evidence can lead to collusion.
Contrary to many patients, those with FSS become
more anxious when more tests are run, even if the
results are negative.
17
These patients tend to catastro-
phize their illness as being rare and serious if it cannot
be detected by standard tests and even minor or
irrelevant abnormalities in the results become
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hypothesis-generating, which then increases their
anxiety.
7
The Figure illustrates this cycle.
Physicians can take certain actions to aid in a posi-
tive patient-physician relationship, including listening
openly, documenting a detailed medical history, and
documenting the exhaustive list of symptoms.
35
This
approach includes asking about the onset and course
of the symptoms and, specifically, how patients are
functionally limited by the symptoms. Part of this
initial encounter includes gently probing for life stres-
sors, particularly in a manner that allows the patient to
begin to externalize the source of stress.
35
It is also
helpful to ask similar questions in multiple different
ways to ensure consistency and limit corroboration.
Often, the particular end-state behavioral manifestation
of FSS relates to modeling, which highlights the
importance of asking whether the patient knows
anyone with a similar condition.
35
If patients have
been evaluated or treated for FSS before, it is important
to ask about their previous experiences to ensure that
negative experiences are not repeated and expectations
can be accurately managed. Then, a routine physical
examination and basic tests (eg, complete blood cell
count, comprehensive metabolic panel, thyroid-
stimulating hormone test) can be ordered, per the physi-
cian’s judgment. Once an organic cause has been
excluded, further examination and investigation should
only be initiated if new symptoms develop.
7
Given the
complex nature of the symptoms and history presented
by patients with FSS, it can be beneficial to both the
patient and the physician to develop visual aids, as sug-
gested by Stone et al,
35
that document patients’symp-
toms, stress level, and duration of symptoms.
Stone et al
36
reported that more than 90% of patients
with FSS found it offensive to be told that their symp-
toms were all in the mind, and as many as 50% of
patients with FSS considered it offensive to be told
their condition was psychosomatic or medically unex-
plained.
36
Fewer patients with FSS (<15%) took
offensetoatermlikefunctional somatic to describe
their symptoms. Patients with FSS respond in a more
positive way when they are offered reassurance (eg, “I
have looked carefully, and there seems to be nothing
of serious or life-threatening concern”) and a functional
approach to management (eg, “Your body is not
working as well as it should,”“Perhaps your body is
trying to tell you something,”“Everyone copes with
stress in different ways”) than being told overtly there
is no medical explanation for their symptoms or trying
to convince them of an isolated psychological cause.
37
Because psychological symptoms frequently remain
unrecognized or untreated in patients with FSS, these
patients will often express dismay, trepidation, or even
rejection of suggestions to see a behavioral health
Figure.
The presentation and assessment cycle of a patient with functional somatic syndrome.
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514 The Journal of the American Osteopathic Association August 2017 |Vol 117 |No. 8

professional.
38
They may feel as though the physician
is rejecting their claim to legitimate medical symptoms
and abandoning them. Physicians can have more
success with patients by standing with them and
helping them to understand the results of medical tests
completed in terms of a broad umbrella of factors
influencing their condition.
Management
There are 3 common ways that patients with FSS react
to their symptoms.
39
Patients who sought to understand
the psychological and physical interplays of their symp-
toms had better success in life; patients who sought
symptom relief and legitimization from physicians
were less able to carry out independent activities of
dailylivingandfeltentitledtobeexcusedfrom
normal social obligations; and patients who expressed
worry about missed diagnoses sought excessive
medical help, protested when their demands for investi-
gations or treatments were resisted, and were not reas-
sured by negative test results or their physician’s
benign assessment.
39
Although patients with FSS can have positive medical
test results that indicate an underlying physiological
issue, the resulting symptoms and disabilities are not
entirely explained by or are more severe than expected
by the organic syndrome alone.
40
An FSS can have
physiologic examination findings associated with it,
because it is causing real symptoms, but one must be
cognizant that it is also significantly overrepresented in
terms of comorbid psychological conditions.
27
Functional somatic syndrome with physiologic examin-
ation findings associated with them share more similar-
ities than differences with other symptoms of FSS in
terms of management; thus, behavioral health treatment
remains an integral part of optimal management.
41,42
Positive functional restoration outcomes (the ability to
engage in independent activities of daily living) are more
likely when physicians take a collaborative approach with
patients.
43
Collaborating with patients includes changing
their attitudes about their symptoms, helping them to
understand that their symptoms are not life-threatening
or disabling, and alleviating dysfunctional thoughts that
create anxiety regarding their health.
37
A qualitative
review of different ways to manage symptoms of FSS
suggests that a combination of the following 3 factors is
most effective: (1) create a nonthreatening, therapeutic
environment; (2) provide interventions that do not
require specialized training in behavioral health (eg,
motivational interviewing, tangible explanations, reassur-
ance, regularly scheduled appointments); and (3) recom-
mend specific interventions with behavioral health
specialists and psychotropic medication.
44
Researchers
have suggested different approaches to the treatment of
patients with FSS: an organ-oriented approach (ie, symp-
tomatic treatment), acognitive interpersonal approach (ie,
cognitive processing of health-related anxiety), or a con-
textual approach (cultural beliefs, workplace character-
istics, incentives).
11
Regarding the latter approach, the
family system should be kept in mind as well. An associ-
ation has been found between FSS behaviors and
attention-seeking or withdrawal behaviors of significant
others.
45
It has also been found that dependency on a sig-
nificant other predicted greater long-term health care use
(>90 days), and yet, a literature search revealed no studies
of families of patients with FSS.
45
Patient-physician
visits that include a brief physical examination instead
of ordering tests based on subjective reports of symptoms
translates to decreased health care use and better physical
functioning in patients with FSS, even though this
approach may run counter to most medical training.
46
The most consistent finding in randomized controlled
trials (RCTs) has been the benefit of cognitive behavioral
therapy in patients with FSS. A study
44
concluded that
cognitive behavioral therapy is an evidence-based treat-
ment for FSS. Several reviews also found evidence sup-
porting the use of cognitive behavioral therapy in the
management of FSS.
41,42
In a review of RCTs, 85% of
the included studies showed that the use of cognitive
behavioral therapy significantly benefited patients with
FSS.
47
In a meta-analysis of 27 studies, cognitive behav-
ioral therapy had a small to moderate positive effect in
patients with FSS.
48
A study that examined patients in
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secondary care clinics with chronic fatigue syndrome
showed that 3 to 14 sessions of cognitive behavioral
therapy resulted in reduced fatigue and increased phys-
ical function.
49
In another study, patients with FSS who
completed an average of 7 cognitive behavioral therapy
sessions reported fewer days spent in the hospital and
fewer visits to the emergency department, suggesting
that the sessions helped patients avoid catastrophizing
physiologic experiences that can lead to emergent,
costly care.
50
In a small pilot study examining the use
of cognitive behavioral therapy in a primary care
setting, a 1-hour initial session and three 20-minute ses-
sions had an effect size of 0.5 for physical symptom
reduction, and 72% of patients with FSS reported that
the intervention helped them to effectively cope with
their symptoms.
51
In a meta-analysis of 13 RCTs exam-
ining mindfulness-based stress reduction and cognitive
therapies, a small to moderate positive effect was found
on pain, symptom severity, depression, anxiety, and
quality of life in patients with FSS that underwent these
therapy sessions.
In addition to positive patient outcomes, cognitive
behavioral therapy is also a cost-effective way to manage
FSS.
52
When comparing the effect of mindfulness
therapy with medical care from a specialist, Fjorback
et al
53
showed that after 15 months of treatment, about
half as many patients in the mindfulness therapy group
were receiving disability, and their total direct health
care costs were an average of $1754 less, including the
cost of therapy, than those in the specialist care group.
A Cochrane review that analyzed the use of medica-
tion to manage symptoms in patients with FSS found
that there was no evidence supporting the efficacy of tri-
cyclic antidepressants over a placebo, and there was low-
quality evidence of benefit from new-generation antide-
pressants and natural products, such as St. John’s
wort.
54
Data have shown that escitalopram is more
effective than placebo in managing FSS at 6 and 12
weeks, but long-term term follow-up information is not
available.
55
The benefit of antidepressants is conflicting,
though, as a study found that symptoms in patients with
FSS in the otolaryngologic region could be successfully
managed with selective serotonin reuptake inhibitors.
56
Systematic reviews examining FSS have indicated that
antidepressants can be beneficial even if overt evidence
of depression is not present,
57
but Stone et al
37
sug-
gested that patients should be informed that their symp-
toms can improve without medication, and this option
is merely to explore all avenues of treatment.
Physical treatments (ie, exercise, autogenic training,
progressive muscle relaxation) for patients with FSS
have shown promise in a number of studies. A
Cochrane review showed that exercise has positive
effects on sleep habits, fatigue, physical functioning,
and self-perceived health in patients with FSS,
similar to the effects of cognitive behavioral therapy,
with no documented adverse effects.
58
Graded exer-
cise therapy is the most frequent physical treatment
recommended, with programs emphasizing the role
of physiologic dysregulation to manage fatigue. An
RCT that compared the effects of graded exercise
therapy with that of conventional medical care in
patients with chronic fatigue syndrome showed that
the exercise group had greater improvement in symp-
toms and less fatigue than the standard medical care
group.
59
In another study examining patients with
chronic fatigue syndrome, 69% attained adequate
physical functioning on the SF-36 physical function-
ing subscale
60
after participating in a graded exercise
therapy program vs 6% of control patients.
61
In add-
ition, cognitive behavioral therapy combined with
graded exercise therapy has led to clinically signifi-
cant benefit for multiple conditions, including
chronic fatigue syndrome and fibromyalgia.
62,63
Additionally, a 10-week RCT
64
was conducted to
compare psychophysiologic management strategies
(eg, stress education, heart rate variability training,
progressive muscle relaxation with electromyography
feedback, autogenic training) with visits with a psychi-
atric physician for care while waiting for psychophysio-
logic treatment. The psychophysiologic treatment–only
group showed a decrease in depressive and physical
symptoms and an increase in functional abilities by the
end of the treatment.
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Many other options have been suggested for the man-
agement of symptoms of FSS, including standard
medical treatments (eg, medication, surgical procedures),
reattribution therapy, psychodynamic therapy, hypnosis,
and herbal remedies, but these either do not have support
in the empirical literature or the support they have is based
on anecdotal evidence, case studies, or small case series
without appropriate comparison groups, including sham
or placebo procedures, and without appropriate blinding
to the treatment groups, raising their risk of bias.
Conclusion
Patients with FSS present a unique challenge to physi-
cians, as these patients do not have confirmatory
medical findings to explain their symptoms, and trad-
itional approaches to management of symptoms, such
as medication, are unlikely to be beneficial in isolation.
Although they can be complex, perplexing, and enig-
matic, the symptoms of FSS are no less real or debilitat-
ing than those caused by medically explained illnesses,
and these patients are no less deserving of medical
attention. Symptoms of FSS can be successfully
managed if physicians take a collaborative and inclusive
approach to care. Positive outcomes do not depend on
convincing patients of the psychological nature of their
symptoms. Instead, physicians can best care for these
patients by helping them recognize the multitude of
factors that may be affecting their lives and working to
restore them to healthy functioning. Osteopathic
physicians are in a prime position to provide this
comprehensive biopsychosocial approach to care that
can lead to optimal outcomes in patients with FSS.
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