Abstract
As a medical resident in the early 1960s, I worked for 6 months with an eminent internist in the United Kingdom. Many of his patients suffered from what are now called somatoform disorders. After a multitude of investigations, all negative, I would watch him give his final verdict to the patient: “There is nothing wrong with you,” he said. The words were pronounced in a serious and confident tone, with the expectation that the patient would leave his office happily, relieved that he or she had been given a “clean” bill of health. Even then, despite my naivety and inexperience, I knew that his diagnostic appraisal was insufficient and unhelpful to the patient, although my internist chief was quite unaware of this. For all of my working career since then, I have marvelled at the somatoform group of disorders.
For centuries, these conditions have alternately puzzled and perplexed, fascinated and frustrated clinicians. Many studies have shown that they are also a huge drain on the health care budget and on the country’s economy.
Scamvougeras and Howard have written an excellent and up-to-date book on this controversial topic. As neuropsychiatrists at the University of British Columbia, they are well qualified to take on this task. Under chapter titles of Introduction, Referral, Assessment, Formulation, Management, Future Directions, and Summary Points, the authors cover all the bases on this complex condition. The book is well referenced and evidence based, but the authors do not hesitate to provide their own opinions and guidelines regarding understanding or management, based on their extensive clinical experience, even when research data are minimal or absent. The paucity of evidence-based data does not obviate the need for decision making in the practical clinical situation. Brief clinical vignettes are scattered through the text that give examples of these conditions and how they are managed and respond to treatment.
In a series of 6 appendices, the authors discuss additional aspects of the somatoform disorders, including classification, misdiagnosis, pathophysiology, and management. They also make available a Patient Education Brochure they use and display a letter sent to the DSM-5 Working Group with their critique of its recommendations.
Diagnosticians can often be categorized roughly into “lumpers” and “splitters.” Scamvougeras and Howard definitely fit into the former category. They state, “We would suggest the collapse of all somatoform syndromes (including conversion-type syndromes) into a single Somatoform Disorder entity” (p. 155). Furthermore, somatoform disorder “is present if apparent physical symptoms and signs are judged, after thorough assessment, to be the result of underlying emotional distress, rather than primary physical disease.” They go on to provide a diagnostic template that includes both psychiatric and psychological factors that contribute to the illness. They strongly criticize, and rightly so in my opinion, the concept of making the diagnosis simply on the negative criterion of ruling out organic disease, or finding “medically unexplained symptoms,” to use current jargon. In fact, I believe the authors do not go far enough in their description of psychological factors that may contribute to conversion and somatoform symptoms. Personally, I believe the psychological concepts of modelling and primary, secondary, and even tertiary gain play a larger part in the psychopathogenesis of this condition than is suggested by the authors.
The book rightly emphasizes that somatoform disorder is a treatable condition, particularly if diagnosed early. “Missing” its diagnosis is as serious a clinical issue as missing a diagnosis of an organic disease and may condemn the patient to a lifetime of ill health, with its accompaniment of extensive doctor and hospital shopping.
The authors write excellent chapters on the treatment of the condition, emphasizing the need for a “step-wise, flexible” plan, individualized according to the patient’s needs. Both psychotherapeutic and pharmacological therapies are recommended where appropriate, including particularly the importance of continuity of longitudinal care. They emphasize also the need to provide emotional support without encouraging dependence, promoting insight, autonomy, and motivation while minimizing drug dependency by using habit-forming medication minimally, if at all. If used, such drugs need to be given on a regular, time-based schedule, not “p.r.n.”
Scamvougeras and Howard have written a fine book on somatoform disorders. It can be highly recommended not only to psychiatrists (especially liaison psychiatrists) but also to family doctors, neurologists, gastroenterologists, and rheumatologists—in other words, to all those who encounter this misunderstood condition in its countless manifestations.