DIES tea cenns {siebhoe of known pystea! Sissies constie high: per, af medical ea jDepeding won te pea sfcintyspecialist con disease: i isease category, ss exertion, intolerance: disease," which ‘yndronie.” Allies contigs ‘pin, and, i the fn a’ iiologist, be found tobe free of thing wn diseases. by.a, neufolofist. After 7 :" problems; they 4 rtantly, ‘the aed for beter a ranaeiment of the con- : : Nove, ; this condition | Authorship: The’ autor ix. soll é tinues.to b¢ included: within the categories of psychiatric _ : disorders. In the latest Diagnostic and Statistical Manual > nate maar Stik, af Mental Disorders, 5" edition’ -handbook,.it has. been > $600 Elders Ra, Nobiesvtl IN 46062! renamed somatic symptom disorder. Previous labels such : as somatization disorder, hypochondriasis, and widespread Tavel, M. E. (2015). Somatie symptom disorders without known physical causes: One disease with many names?. The American Journal Of Medicine, 128(10), 1054-1058. doi:10.1016f.amjmed.2015.04.041Tavel Somatic Symptom Disorders 1055 pain disorder have been removed in favor of this more inclusive term, “somatic symptom disorder.” This new classification recognizes that mind and body cannot be separated. Thought to be purely psychiatric, the previous diagnosis of somatoform disorder required multiple pains of differing types and locations in the absence of identifiable physical diseases. By contrast, the somatic symptom disorder criteria, no longer have such a requirement; however, the somatic symptoms must be significantly disruptive to daily life and accompanied by excessive thoughts, feclings, or behaviors. The new criteria now acknowledge that medically un- explained symptoms are not ne- cessary for a somatic symptom disorder diagnosis and that they may or may not be associated with an identifiable physical condition, Also, the fact that a physical basis is unexplained does not automatically categorize such patients into a purely psychiassic category, Moreover, this classification accepts the reality of subjective symptoms such as pain and fatigue, but it also acknowledges that the underlying mechanisms of the symptoms are, in most cases, unknown, Because many of the symptoms usually are accompanied by excessive emotional reactions, a psychiatric component is usually apparent, often establishing the need for treatment within this realm, The new narrative for somatic symptom disorder also notes that some patients with physical conditions such as heart disease or cancer may experience disproportionate and excessive thoughts, feelings, and behaviors related to their illness, and these individuals may also qualify for a diagnosis of somatic symptom disorder. In all instances of somatization, the clinician must carefully seek associated signs that can allow for identifi- cation of superimposed and disproportionally intense emotional reactions. These latter complications may be purely emotional in origin, such as feelings of anxiety and depression, which, in themselves, are amenable to treatment. Anxiety itself, however, may produce additional physical manifestations secondary to the commonly associated hy- perventilation,? which often occurs in the context of “panic attacks.” These episodes consist of various combinations of extreme fear, diaphoresis, breathlessness, dry mouth, hot or cold feelings, light-headed sensations (often called dizzi ness), numbness and tingling of the extremities, chest pains, weakness, exhaustion, and even syncope. Occasionally, the peripheral sensations of numbness and tingling appear mainly on one side of the body,’ causing confusion with a neurological disorder. The hyperventilation—triggered by fear or anxiety—alters the acid/base balance and reduces ‘carbon dioxide levels in the blood, which accounts for many of these various symptoms. Although often abrupt and dramatic, symptoms may be chronic and quite subtle. Pa- tients are often unaware of rapid breathing, frequently proper identification presented. CLINICAL SIGNIFICANCE Nomenclature, recog) agement of the various acterized by widespread p are challenging, but suggestions for complaining that they often cannot get a “deep enough breath,” and they may sigh repeatedly while being inter- viewed. This part of the disorder is confirmed easily by reproducing the primary symptoms by instructing the patient to breathe rapidly and deeply for at least 2 or 3 minutes. ‘Once recognized, prevention and control of at least this part of the disorder are usually suc- cessful through explanation of symptom causation, combined, if necessary. with cither breath holding or rebreathing into a paper bag. By allowing patients to un- derstand the mechanism of pro- duction, these maneuvers not only relieve the symptoms, but help to allay the underlying anxiety that initially triggered the attack. This combination of anxiety with the physical consequences of hyperventilation is quite common, but the physical sensations of the latter are often overlooked ‘components of “panic attacks,” and the combined disorder ‘may account for as much as 5%-10% or more of individuals seen in general medical clinies.** FIBROMYALGIA As noted, the diagnosis of fibromyalgia suggests a physical origin, and this often leads to the referral of such patients— rightly or wrongly—to a rheumatologist. Although the major complaint in these patients is centered on pains, multiple additional symptoms are included in this disorder, and they seem to place the origin in the brain or central nervous system, with the suggested term of “central sensitization. "7 In the case of fibromyalgia, we were first provided with the “objective” means to establish the diagnosis in the form of a series of “trigger points” that denote increased sensitivity in various parts of the body that presumably confirmed a “physical” nature. This criterion was reached by consensus from the American Rheumatism Association® in 1990 and then modified in 2010” by no longer requiring the tender- point examination. Diagnosis is said to be difficult because symptoms are vague and generalized, Nevertheless, almost every patient complains of pain, fatigue, and sleep distur- bance.'” The pain is typically diffuse, multifocal, deep, gnawing, or burning, often fluctuating and migratory. Additional symptoms may include weight fluctuations, morning stiffness, imtable bowel disease, cognitive distur- bance, headaches, heat and cold intolerance, irritable bladder syndrome, and restless legs.'' But diagnosis by any of these means is problematic, for it depends on analysis of subjective ‘complaints, and this creates a condition thut could fall under the heading of somatic symptom disorder, as described above. As a result, much of the medieal profession is highly skeptical that the disease fibromyalgia—at least in purely physical terms—actually exists, ‘Another factor casting doubt on a purely physical ongin of fibromyalgia is ts regular association with severe1056 ‘The American Journal of Medicine, Vol 128, No 10, October 2015 depression, which is more frequently associated with fibromyalgia than with other musculoskeletal diseases.'* Depression also worsens fibromyalgic symptoms and vice versa, and antidepressants are comerstones of fibromyalgia therapy. Although patients usually dismiss the depression as the result of their widespread pains, this explanation again is questionable, for we frequently find less or absent depression in patients with severe pain from major diseases such as cancer or end-stage heart failure. Moreover, depression alone—with or without anxiety—is capable of causing multiple somatic complaints.'? The prevalence of psychiatric conditions among patients afficted with fibro- myalgia is higher than among subjects complaining of typical rheumatic diseases." In addition to depression, the most common disorders associated with fibromyalgia are anxiety, somatization, panic disorders, and posttraumatic stress disorder.'* Unfortunately, many of these patients seem to cling to a “physical” disease label, for they likely fear that, if their subjective symptoms are attributable to psychological ori- gins alone, they might be considered “crazy” or at least that all their symptoms are not real, but “all in their head.” This latter concept is likely often fostered by seemingly insen- sitive remarks by attending physicians, who appear dismissive of such complaints. In this setting, the idea of referring such individuals for psychiatric evaluation or treatment is clearly inimical and often evokes resentment from most patients. Additional support for the necessity of having a “phys- ical” disease label is often provided by well-meaning family and friends, who, through much attention and physical assistance, provide them with so-called “secondary gain” from their illness. Additional incentives for retaining a labeled physical disease are provided by potential disability compensation from industrial or governmental sources. Most of these apparent advantages would be threatened if the symptoms were thought to be produced by mental—rather than physical—maladies. CHRONIC FATIGUE SYNDROME One of the commonest complaints we hear as physicians is that of fatigue, which is quite prevalent in the general population. From surveys involving patients visiting family physicians, 28% reported fatigue.'® This symptom may signify a serious underlying organic disease, but it is far more often the result of psychological factors such as anx- iety, depression, overwork, lack of adequate sleep, or simply boredom, stresses that may be caused by an unhappy mar riage, work frustrations, or a myriad of others. They can also be magnified by the effect of deconditioning in an in- dividual who avoids any physical activities. After various physical causes for fatigue are eliminated, underlying psychological factors must be sought. But even if profound depression or anxiety is uncovered, patients frequently resist any suggestion that their fatigue is caused by anything but a “physical” disease. If depression is obvious, they often declare that this mood disorder is a result of the fatigue, rather than its cause, Complicating ‘matters even more, gauging the severity of a subjective symptom such as fatigue is virtwally impossible. But now we are confronted by another disease label, “systemic exertion intolerance disease,"'? which again suggests a physical disease. Formerly named chronic fatigue syndrome, it depends on the following 4 criteria for diagnosi 1, Substantial reduction or impairment in the ability to engage in pre-illness levels of occupational, educational, social, or personal activities, that persists for more than 6 months and is accompanied by fatigue, which is often profound, is of new or definite onset (not lifelong), is not the result of ongoing excessive exertion, and is not substantially alleviated by rest 2. Postexertional malaise 3. Unrefreshing sleep 4, Cognitive impairment; orthostatic intolerance (symptoms when standing upright that are relieved when sitting down again); or both. These characteristics are, at best, nonspecific and overlap considerably with the somatic disorders noted above. This raises the possibility that the underlying culprit in most cases diagnosed with this syndrome could be primarily depression, with or without anxiety. A study with a mult national primary care sample from 14 countries suggested that over 80% of patients with chronic fatigue syndrome-like illness had a lifetime psychiatric disorder such as depression or generalized anxiety disorder.'*"” If the majority of these individuals actually harbor a primary diagnosis of depres- sion, we are then likely providing a disservice by applying ‘an organic disease label. The disadvantages of such a label would include the omission of detailed analysis and therapy for depression or anxiety. This classification might also qualify one as being physically disabled, implying the inability to perform even basic physical chores. But some would argue that, under most conditions, depression is the result—rather than the cause—of the chronic fatigue. If this were the case, however, one would expect a similarly high, or higher, prevalence of depression in serious life- threatening disorders such as cancer. Although cancer may produce depression, a meta-analysis”? disclosed that the pooled prevalence of major depression in palliative care settings was equal to approximately 16.5%, far below the prevalence reported in chronic fatigue syndrome. This alone raises a red flag that challenges the thesis that fatigue alone may account for such frequent and profound depression. In each individual case, the clinician must determine whether the degree of fatigue is commensurate with—or represents an exaggerated response—to the severity of depression, CONCLUSIONS Because of the similarity and tremendous overlap of symp- toms among the various somatic conditions noted above,Tavel Somatic Symptom Disorders they all might best be categorized under one label, possibl somatic symptom disorder, or, alternatively, central sensiti- zation disorder. Until we discover objective chemical or biopsy proof, little purpose is served by applying various labels that suggest differing underlying mechanisms, which often results in the referral of patients to fragmented spe- cialty groups. ‘These patients may be best cared for by physician gen- eralists that are well grounded in psychiatric disorders. In addition, the frequent concomitant and often overlooked hyperventilation syndrome, which is often inextricably associated with the panic’ disorder but can also produce chronic and fluctuating symptoms, demands proper recog- n and treatment, Treatment options”? for these disorders are usually sub- optimal, but might best employ a multidisciplinary app- roach that includes drugs (in particular, antidepressants and neuromodulating antiepileptics such as pregabalin), and nonpharmacological treatment such as aerobic and strength-training exercises, aquatic exercises, and cognitive- behavioral therapy. Because of limitations of all these, however, additional avenues of treatment require explora- tion. Interestingly, the process of acupuncture has shown some promise in management, for when compared with controls, most studies demonstrate its efficacy in pain relief in these disorders. In general, however, they demonstrate even more profound symptom improvement when both active and sham acupuncture are compared with stardard medical teatment.2?"? This suggests that these subjects respond not only to the acupuncture itself, but most pro- foundly to the associated placebo effect, sometimes referred to as the “non-specific effect.”** This effect is enhanced by any procedures that include detailed explanations, physical contact, and expectations of success.”* These features usu- ally surround the procedure of acupuncture. OF special interest is a study from the UK?® performed on a group of frequent attendees to general clinics with “medically unexplained symptoms.” Indistinguishable from the groups described above, these are people who have persistent physical symptoms that cannot be explained by current medical knowledge, that is, “medically unexplained physical symptoms (MUPS).” These individuals comprise 11%-19% of UK general medical consultations, and up to 50% of new referrals to outpatient clinics. These “frequent attenders” to primary care are described as not only costly to the overall health system, but are often recipienis of long-term sick leave. In that study, the commonest com- plaints were chronic musculoskeletal pain, fatigue, and headache. They found that, when compared with usual care, the addition of 12 sessions of acupuncture carried out over a 6-month period resulted in considerable improvement of health status and well-being that was sustained for 12 months, When compared with usual care, other stu also have demonstrated the superiority of acupuncture in the treatment of fibromyalgia.” Although questiomble, this management likely accomplishes its results prirvarily through the placebo effect. This raises the intriguing 1057 question of whether placebo effects should be purposely utilized in managing these patients. Interestingly, actual surveys of conventional practitioners confirm the general widespread use of placebos: in one study," 60% of physi- cians and nurses used placebos, usuatly as often as once a month or more, and in most cases the patients were told they were receiving “real” medication. Of this latter group, 94% reported they found placebos generally effective. Another survey among academic physicians in the US* disclosed that 45% had used placebos in clinical practice, most commonly to reduce anxiety and as supplemental treatment for physical problems. As many as 96% of these physicians believed placebos can have therapeutic effects, and 40% reported placebos could even benefit patients’ physical problems. ‘Although acupuncture probably functions primarily as a placebo, it provides a bona fide rationale for expecting improvement, and therefore, may add an important adjunct to treatment. In the last analysis, however, we should pro- vide our patients with what we believe are the best chances of maximum benefit—whether with a placebo, some type of “real” treatment, or merely being a sympathetic listener. Whether or not the conditions of somatic symptom dis- order, exertion intolerance disease, and fibromyalgia are found ultimately to have an underlying physical basis, there is no reason to believe that the symptoms of fatigue and pain are not really perceived as such. In the management of these disorders, the least desirable method would be to simply provide powerful analgesies or to refer these individuals to pain clinics without careful assessment of all possible underlying environmental stresses, intemal psychodynamics, and multiple treatment options. ACKNOWLEDGMENT The author indebted to Edward R. Gabovitch, MD, rheumatologist, for providing valuable personal observa- tions and insight concerning this important and challenging problem. References 1. American Psychiatic Associaton. Diagnostie and Statistical Manual of Mental Disorders. 5® ed. Arlington, VA: American Psychiatric Association; 2013. +2. Meuret AE, Ritz T. 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