See also posting:
https://meagenda.wordpress.com/2008/12/26/dr-chris-bass-pulse-somatoform-disorders-article-and-unum/
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Selected papers and articles co-authored by Dr Christopher Bass, consultant in liason psychiatry, John Radcliffe Hospital, Oxford
http://www.bmj.com/cgi/content/full/325/7359/323
BMJ 2002;325:323-326 ( 10 August )
Clinical review
ABC of psychological medicine
Chronic multiple functional somatic symptoms
Christopher Bass, Stephanie May.
Full text in html format: http://www.bmj.com/cgi/content/full/325/7359/323
PDF format: BMJ ABC Bass
The previous article in this series described the assessment and management of patients with functional somatic symptoms. Most such patients make no more than normal demands on doctors and can be helped with the approach outlined. However, a minority have more complex needs and require additional management strategies. These patients typically have a longstanding pattern of presenting with various functional symptoms, have had multiple referrals for investigation of these, and are regarded by their doctors as difficult to help…
Read full BMJ ABC Clinical review: Chronic multiple functional somatic symptoms, Bass and May in html format here
Read all Rapid Responses to Chronic multiple functional somatic symptoms, Bass and May here
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The previous article in this BMJ Clinical review: ABC of psychological medicine series, to which Bass and May refer, can also be read in full on the BMJ website. Note the inclusion by Mayou and Farmer of “Chronic fatigue (myalgic encephalomyelitis)”. Note also (as Dr Abhijit Chaudhuri highlights in his Rapid Response to the Bass and May article) that Bass and May had illustrated their article with a ‘Summary of a 15 year “segment” of the life of a patient with chronic multiple functional somatic symptoms’ in which they report this female patient as having made a “self-diagnosis of myalgic encephalomyelitis” and having joined a “self-help group”.
http://www.bmj.com/cgi/content/full/325/7358/265
BMJ 2002;325:265-268 ( 3 August )
Clinical review
ABC of psychological medicine
Functional somatic symptoms and syndromes
Richard Mayou, Andrew Farmer.
Full text in html format: http://www.bmj.com/cgi/content/full/325/7358/265
PDF format: BMJ ABC Mayou
Concern about symptoms is a major reason for patients to seek medical help. Many of the somatic symptoms that they present with such as pain, weakness, and fatigue remain unexplained by identifiable disease even after extensive medical assessment. Several general terms have been used to describe this problem – somatisation, somatoform, abnormal illness behaviour, medically unexplained symptoms, and functional symptoms. We will use the term functional symptoms, which does not assume psychogenesis but only a disturbance in bodily functioning.
Some common functional symptoms and syndromes
- Muscle and joint pain (fibromyalgia)
- Low back pain
- Tension headache
- Atypical facial pain
- Chronic fatigue (myalgic encephalomyelitis)
- Non-cardiac chest pain
- Palpitation
- Non-ulcer dyspepsia
- Irritable bowel
- Dizziness
- Insomnia
Read full BMJ ABC Clinical review: Functional somatic symptoms and syndromes, Mayou, Farmer in html format here
Read all Rapid Responses to Functional somatic symptoms and syndromes, Mayou, Farmer (to which Dr Chaudhuri also responded) here
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The Bass and May BMJ Clinical review: “Chronic multiple functional somatic symptoms” provoked some interesting Rapid Responses, including this response from Dr Abhijit Chaudhuri who, in 2002, was still based at University of Glasgow.
http://www.bmj.com/cgi/eletters/325/7359/323#24583
Through the looking glass
12 August 2002
A. Chaudhuri,
Clinical Senior Lecturer in Neurology
University of Glasgow
Send response to journal:
Re: Through the looking glass
Bass’ and May’s review of “chronic multiple functional somatic symptoms” (CMFSS) deserves a few comments. The authors have essentially proposed two diagnostic criteria for CMFSS: first, the “thickness of patients’ paper notes” and second, observations of the medical and non- medical health service staff (presumably overriding the observations made by patient’s own family members or his/her relatives). I congratulate the BMJ, the editors of this review series and, of course, the authors, for introducing a novel use of the measuring tape in clinical medicine. My only suggestion is that it would be very useful to know the numerical “cut -off” for the case note thickness for the purpose of referral to the psychiatry unit and perhaps the GPs ought to be advised to mention this at the time of referral of their presumed CMFSS patients to the specialist service, e.g. “Thank you for seeing this patient with case note thickness of little over three and three-quarter inches”.
Am I being facetious when I say this? In my practice, the thickest case notes occasionally belonged to patients who were treated in the psychiatry units for considerable length of time for what was later discovered to be a neurological disease. To me, the statement that nearly one out of every ten patients admitted to the tertiary care have CMFSS also appears rather exaggerated. Even if there are published data to support this figure (which have not been cited), I suspect that the assessment might have been prone to selection bias. More surprisingly, however, Bass and May fail to mention that follow-up studies at the academic centres of patients diagnosed to have functional disorders did reveal a staggering misdiagnosis rate of 20-40% in the past.[1] The most common errors were failure to identify diseases like systemic lupus erythematosus (SLE), paroxysmal and demyelinating neurological disorders. Staff in most tertiary care units will be able to recount the tale of a “functional” patient in the ward who became critically ill or died all too suddenly. Could the authors please provide a statistics for this initial misdiagnosis for the sake of comparison?
I have also some concerns regarding the broad stereotyping of patients (women, substance misusers and childhood abuse) in the context of applying the diagnosis of CMFSS. Epileptic seizures (with or without pseduoseizures) may arise from brain injury sustained as a result of childhood physical abuse. SLE is more common in women. Organic neurological diseases after substance abuse are too well recognised. It is also incorrect to assume that symptoms developing after a major psychological trauma is invariably due to CMFSS. For example, studies have repeatedly confirmed that there are changes in brain MRI and symptom severity in patients with central nervous system demyelination after stressful “life events”.
In this review, we have been provided with the history of a single illustrative case and the picture of a single patient (Charles Darwin). Darwin might or might not have had CMFSS and I shall not comment on this example, and leave this task to the competent medical historians. Referring to the “15 year segment” in the illustrative case history of a woman with CMFSS, there appears to be a few inconsistencies. I think it would be disingenuous to question the diagnosis of acute appendicitis made by a GP and confirmed by a surgeon in this woman and the normal outcome does not contribute materially to the diagnosis of CMFSS. The second life event, an unwanted pregnancy, is certainly stressful but in itself, does not constitute a feature of CMFSS unless it was a pseudopregnancy. Thus, the record of “medically unexplained symptoms” in this case is not 15, but of 10 years duration. Without questioning the diagnosis of CMFSS here, I would humbly suggest that the excellent response of pain to a very modest dose of amitriptyline is not something I have frequently seen in patients with somatising chronic pain who, on the contrary, are invariably resistant to such a simple measure, just as patients with pseudoseizures are refractory to common anti-epileptic drug therapy. In addition, based on the history provided here, I was unable to identify the features of recurrent depressive and/or personality disorders [2] that the authors highlight as important associations of CMFSS: indeed, 50 mg of amitriptyline is a grossly subtherapeutic dose for depression. I am sure that there are far more compelling examples of somatoform disorder in everyone’s experience and I wonder if the authors and the editors wanted to be deliberately provocative with this example merely because the patient had made a self-diagnosis of myalgic encephalomyelitis and had joined a self-help group to seek assistance. In any case, I would be equally interested to know the follow up in the second 15 year segment of this patient’s life (1986-2000) because surely her response is important in evaluating the efficacy of psychiatric input in CMFSS.
This commentary is already long enough and I would like to conclude with one final point. The authors have introduced an inconveniently long term and yet another new acronym (CMFSS) to describe what would be otherwise diagnosed as somatoform disorders in current clinical practice. [2] After all, the purpose of any diagnostic classification and terminology is to increase understanding of the condition for the purposes of treatment. Just as most medical and psychiatric syndromes have both organic and psychosocial aetiologies, so will most of the therapies applied. [3] I am uncertain from reading this review if the introduction of “CMFSS” offers an advancement in our current understanding or management of the somatoform disorders.
Which do you think it was? [4]
References:
1. Chaudhuri A. The role of neurodiagnostics in functional disorders. In: Zasler ND, Martelli MF(eds). Physical Medicine and Rehabilitation: State of the Art Reviews ,vol 16, No.1 (Functional Disorders). Philadelphia, Hanley & Belfus Inc. 2002; pp 63-75.
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (4th ed). Washington DC: APA, 1994.
3. Miller L. What is the true spectrum of functional disorders in rehabilitation? In: Zasler ND, Martelli MF(eds). Physical Medicine and Rehabilitation: State of the Art Reviews ,vol 16, No.1 (Functional Disorders). Philadelphia, Hanley & Belfus Inc. 2002; pp 1-20.
4. Carroll L. Through the looking glass, and what Alice found there. London: McMillan & Co., 1872.
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Free: http://apt.rcpsych.org/cgi/reprint/3/1/9.pdf
Advances in Psychiatric Treatment (1997), vol. 3, pp. 9-16
Somatoform and dissociative disorders: assessment and treatment
David Gill and Christopher Bass
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http://apt.rcpsych.org/cgi/content/full/13/3/169
Advances in Psychiatric Treatment (2007) 13: 169-177. doi: 10.1192/apt.bp.105.001982
Fabrication and induction of illness in children: the psychopathology of abuse
Christopher Bass and Gwen Adshead
Christopher Bass is a consultant in liaison psychiatry at the John Radcliffe Hospital (Headley Way, Headington, Oxford OX3 9DU, UK. Email: christopher.bass@oxmhc-tr.nhs.uk). His main areas of research and clinical interest include patients with persistent medically unexplained physical symptoms and patients with fabricated illnesses. Gwen Adshead is a forensic psychiatrist and consultant forensic psychotherapist at Broadmoor Hospital, Crowthorne, UK. Her research interests include maltreating parents, moral reasoning in antisocial personality disorder and ethics in psychiatry. She is currently Chair of the Royal College of Psychiatrists’ Ethics Committee.
Abstract:
Fabricating or inducing illness in children (previously called Munchhausen syndrome by proxy) is a form of child abuse in which a caregiver falsifies illness in a child by fabricating or producing symptoms and presenting the child for medical care disclaiming knowledge of the cause of the problem. The behaviour has attracted considerable interest and controversy, and some have questioned its existence. In this article, we assess the prevalence of the behaviour, describing behaviours that have been reported and identified, and discuss its psychopathology. We consider the role of psychiatric expertise in the investigation of such behaviour and in the assessment of those who carry it out, based on what is known to date about their psychopathology. We also outline an approach to management with special reference to the characteristics in the mother that may allow for reunification with the child after the abuse has been established…
Full paper available in PDF and html format here: http://apt.rcpsych.org/cgi/content/full/13/3/169
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http://jrsm.rsmjournals.com/cgi/content/abstract/100/2/81
J R Soc Med. 2007 Feb;100(2):81-4. Review.
Illness related deception: social or psychiatric problem?
Christopher Bass 1 Peter W Halligan 2
1 Department of Psychological Medicine, John Radcliffe Hospital, Oxford OX3 9DU, UK E-mail: christopher.bass@obmh-tr.nhs.uk
2 School of Psychology, Cardiff University, UK
SUMMARY
In this paper we question the validity of factitious disorder as a meaningful psychiatric diagnosis. When the diagnosis is used there is often the assumption that the person engaging in the ‘deception’ is not lying in the traditional sense of being deliberately misleading. Moreover, little is known about the aetiology or psychopathology underlying factitious disorder, and the legitimacy of deception as a mental disorder has been questioned. It is argued that while illness deception may be more common that hitherto assumed, factitious disorder as a distinct type of psychiatric disorder is conceptually flawed, diagnostically impractical and clinically unhelpful and should be dropped from existing nosologies…
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