Symptomiatry: Interdisciplinary scope and implications

To the Editor

A large proportion of patients presenting to primary care (Jackson and Passamonti, 2005) and specialty outpatient clinics (Reid et al., 2001) have physical symptoms that are not accounted for by a physically identifiable pathological process. It has long been a challenge to find terminology to describe these presentations and the discipline concerned with their study and treatment. The adjectives ‘psychosomatic’ and ‘psychogenic’ have met with criticism related to the potential for reinforcing mind–body dualism and social stigma (Lipowski, 1984). Controversy also surrounds the term ‘psychosomatic medicine’ which has not been universally accepted as indicating an interdisciplinary approach that can be applied within any specialty but is often considered to refer only to psychiatric subspecialty (Fava et al., 2010). Along with uncertain terminology, there has been a deficiency in clinical research and evidence-based practice guidelines, not to mention a paucity of dedicated clinical services and training pathways.

Towards addressing the above, the author draws on experience with such presentations in a neuropsychiatric liaison role within a comprehensive epilepsy programme as well as postgraduate studies in applied linguistics. In order to refer to clinical approaches to such presentations within any specialty and also to refer to a potential clinical and academic specialty concerned with the treatment and study thereof, the author proposes a term that attempts to avoid assumptions beyond what is readily observable. One cannot help but acknowledge the defining feature of these presentations which is the presence of symptoms unaccounted for by physically definable disease. There is no disagreement that the patient genuinely experiences physical symptoms that cause suffering and disability – and the alleviation of physical distress lies within the responsibility of the medical profession. Hence, there is a need for a symptom- oriented approach, for which the author proposes the term ‘symptomiatry’.

A focus on symptoms should not be misinterpreted as an attempt to treat symptoms rather than to treat their underlying causes. The suffix –iatry emphasises the need for the involvement of a medical practitioner so as to adopt an integrated biopsychosocial approach where the interplay of a wide range of potential contributors (e.g. autonomic, endocrine, pharmacodynamic, psychodynamic) to symptoms is not dismissed. As advances in research continue to uncover pathogenetic mechanisms for hitherto unexplained presentations, some presentations will be expected to move from the domain of symptom-oriented medicine to the domain of disease-oriented medicine. However, as there is no basis to assume that our knowledge of pathological processes will necessarily ever be definitive, familiarity with both disease-oriented and symptom-oriented approaches to management in the various specialties appears warranted.

The term ‘symptomiatry’ is neither linguistically nor conceptually evocative of mind–body dualism – which would hopefully be expected to dissociate these presentations from at least some of the currently attached social stigma. Also, whilst one cannot overlook the importance of some level of psychiatric training to the clinical practice of symptomiatry, the term is not linguistically related to any particular specialty and thus is less alienating to generalists and specialists from other disciplines. One would hope that this would be conducive to the incorporation of this holistic approach into clinical care within a broad range of specialties as well as general practice. The contribution of psychiatrists would be essential in providing clinical training modules in this field, in providing secondary consultation, and in direct clinical care within specialised tertiary clinics dedicated to these presentations. In this latter setting, psychiatrists with active interest in general medicine would be in an ideal position to conduct clinical research to further the evidence base in this area.