Studying ICD-11 Primary Health Care bodily stress syndrome in Brazil: do many functional disorders represent just one syndrome? 2018, Fortes et al

[Trish]

Studying ICD-11 Primary Health Care bodily stress syndrome in Brazil: do many functional disorders represent just one syndrome?

Brazilian Journal of Psychiatry, Epub October 11, 2018. Fortes, Sandra, Ziebold, Carolina, Reed, Geoffrey M., Robles-Garcia, Rebeca, Campos, Monica R., Reisdorfer, Emilene, Prado, Ricardo, Goldberg, David, Gask, Linda, & Mari, Jair J (2018).
https://dx.doi.org/10.1590/1516-4446-2018-0003

Abstract:

Objective:

Disorders characterized by “distressing unexplained somatic symptoms” are challenging. In the ICD-11 Primary Health Care (PHC) Guidelines for Diagnosis and Management of Mental Disorders (ICD-11 PHC), a new category, bodily stress syndrome (BSS), was included to diagnose patients presenting unexplained somatic symptoms. The present study investigated the association of BSS with anxiety, depression, and four subgroups of physical symptoms in a Brazilian primary health care (PHC) sample.

Methodology:

As part of the international ICD-11 PHC study, 338 patients were evaluated by their primary care physicians, followed by testing with Clinical Interview Schedule (CIS-R) and World Health Organization Disability Assessment Schedule, Version 2.0 (WHODAS 2.0). BSS was diagnosed in the presence of at least three somatic symptoms associated with incapacity. The association between anxiety, depression, and four subgroups of physical symptoms with being a BSS case was analyzed.

Results:

The number of somatic symptoms was high in the overall sample of 338 patients (mean = 8.4), but even higher in the 131 BSS patients (10.2; p < 0.001). Most BSS patients (57.3%) had at least three symptoms from two, three, or four subgroups, and these were associated with anxiety and depression in 80.9% of these patients. The symptom subgroup most strongly associated with “being a BSS” case was the non-specific group (OR = 6.51; 95%CI 1.65-24.34), followed by musculoskeletal (OR = 2,31; 95%CI 1.19-4.72).

Conclusion:

Somatic symptoms were frequent in a sample of PHC patients in Brazil. In the present sample, one third were BSS cases and met the criteria for at least two symptom subgroups, supporting the hypothesis that different functional symptoms are related to each other.

 

[Hoopoe]

They should do this study with controls that have similar number of symptoms and symptom burden but recognized pathology. That would tell you whether BSS represents distinct entity or is just a nonspecific description of illness.

 

[chrisb]

Interesting to see Goldberg, David amongst the authors, given his apparent role in the redrawing of ME, and his emphasis on anxiety and depression at that time.

 

[Peter T]

They should do this study with controls that have similar number of symptoms and symptom burden but recognized pathology. That would tell you whether BSS represents distinct entity or is just a nonspecific description of illness.

I agree it is a major flaw in any interpretation that there is no attempt at establishing any form of control for this group.

Also there is no clear indication how they evaluated whether there had been reliable elimination of all biomedical conditions potentially causing these symptoms. Given the only way to diagnose these supposed conditions is by physician belief, the circumstances in which they establish that belief and the views of the diagnosing physician are likely to lead to enormous variation in how reliable such a diagnosis is to be considered.

Further, that the authors unquestioningly include ME/CFS, Fibromilagia and IBS as examples of functional or somatoform disorders when there is significant evidence of biomedical abnormalities in these conditions, which, as we are only too well aware, raises very large questions about potential researcher bias. [This means that the authors are effectively saying not only is the failure to find evidence for a biomedical condition (an absence of evidence) sufficient for their presumed psychiatric diagnosis, they are further assuming that the presence of biomedical abnormalities can be disregarded in the absence of an accepted theory of causation.]

 

[Peter T]

PCPs initiated 347 somatic symptom screenings. Of these, information was missing in six. Three patients refused to participate because they lacked time or did not feel well enough. Thus, 338 patients were screened. Of these, only 131 fulfilled BSS criteria (Figure 1). They were mostly women (n=113; 86%), with mean age of 47.7±13.7 years; 34% (n=45) worked full time, 18% (n=24) worked part time, 16% (n=21) were retired, 22% (n=29) were housemakers, and 4% (n=5) were unemployed due to illness.

Again this is a study that excludes the more severely incapacitated with 52% still in work, a figure which rises to 74% if you include home makers.

Though they indicate that 91 (26%? over a quarter) of participants were subsequently excluded because the presented a 'know physical pathology', they still do not raise any questions over the entire diagnostic proceedure or the dangers of misdiagnosis preventing appropriate medical treatment.

Also they missed an opportunity here in that they could have used these intially misdiagnosed patients as a control group. Is this study potentially telling us that there is a group of patients, predominantly middle aged women with concerning symptoms likely to make life difficult, but not severe enough to incapacitate, that physicians are likely (at least 1 in 4 times) to misdiagnose initially as having a psychiatric condition.

When the psychiatrists and psychologists are also saying that once a functional or somatoform diagnosis is suspected further medical investigation should be discontinued because it would reinforce false beliefs the risks of this unacceptablely high level of initial misdiagnosis persisting become much greater. Combine this with the considerable anecdotal evidence in at least the ME community of people given one of these unevidenced psychiatric diagnosis withdrawing from health provision the risks of preventable deterioration or death surely become very significant.

 

[Peter T]

A further bizarre feature of this whole process is they posit a psychiatric condition, that does not coexist with a 'physical pathology'. This must be the only psychiatric condition that by definition would be cured by acquiring a biomedical condition.

My working life as a speech and language therapist would have been made much easier if a stroke would have cured schizophrenia or cancer of the tongue cured manic depression.

Does this mean, as I have probably had one or more TIAs, my ME has been cured? Though presumably not as I was not well enough to attend outpatients for the appropriate scans, so no firm diagnosis has been made. What a fool I was, if I had pushed for an ambulance to take me to outpatients or hired one myself, I might have been cured of my ME. (Also I seem to have misunderstood my own condition, as refusing a medical assessment in the belief that it would, on the basis of a single fully resolved neurological event, be unlikely to have any implications for management, but would result in a major ME crash, I missed the chance to reinforce my own false beliefs. Though a dedicated BPSer would have argued that I refused the appointment because I was afraid of having my false beliefs exposed, as false. Damned if you do, damned if you don't.)

Obviously there is a difference between research definitions and clinical definitions, but given the inadequate discussion of diagnosis in this paper and in general this not at all clear.