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Medically Unexplained Illness: Gender and Biopsychosocial Implications.

Medically Unexplained Illness: Gender and Biopsychosocial Implications by Susan K. Johnson, American Psychological Association, Washington, DC, 2008. 271 pp., $36.45

DOI: 10.1037/a0023450

Medically unexplained symptoms and illness present a clinical challenge in primary, secondary, and tertiary health care because of patient suffering, often poor response to intervention and subsequent functional disability, and inordinate utilization of medical services. Studies in the United States and around the world indicate that 25-50% of primary care patients present with medically unexplained symptoms.

The author surveys a broad spectrum of patient presentations ranging from subsyndromal medically unexplained symptoms to common functional disorders, for example, Irritable Bowel Syndrome and Fibromyalgia. Medically unexplained illness (MUI) is presented in the biopsychosocial explanatory tradition but with extraordinary emphasis on the role of gender and bidirectional nature of the bio-behavioral transaction. The requisite factors defining these conditions are insufficient medical explanation, significant functional impairment, and female predominance.

The author's blending of gender into the discussion on etiologic factors, developmental course, and response to treatment addresses a long overdue foundational imperative for any survey of this literature. Empirically supported summaries and commentaries punctuate each chapter describing the confluence of physical, psychological, and sociocultural variables that explain the preponderant female prevalence across the spectrum of medically unexplained symptoms and syndromes. Factors that occur more often in women--neglect, abuse, role strain, and greater reliance on an emotion-based coping style, as contrasted with problem-focused coping strategies, were meticulously woven into a discussion on the precipitation and chronic nature of medically unexplained illness in females.

The historical perspective on medically unexplained symptoms and comorbidity are succinctly but adequately covered in the early chapters with reference to multiple labels that have appeared in the published literature that include medically unexplained symptoms, functional somatic symptoms, medically unexplained illness, chronic multisymptom illness, multisomatoform disorder, and abridged somatization. Noteworthy is work underway on the revision of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-V draft) addressing nomenclature controversy. Preliminary progress reports by the DSM-V work group suggest that the somatoform group classifications (e.g., Somatization Disorder and Hypochondriasis) may be replaced with one diagnostic label-Complex Somatic Symptom Disorder. The publication version of DSM-V is scheduled to be released in late 2012 or early 2013.

Consistent with the author's allegiance to the biopsychosocial explanatory model and specifically evidence for the biology of medically unexplained illness, she offered a detailed and useful analysis of the hypothalamic-pituitary-adrenal axis, especially for the nonmedically trained. A distinct and unambiguous case was made for the H-P-A axis--environmental stress interaction in the etiology and course of functional somatic syndromes. The illumination of a contextual perspective to account for the interaction of biological, psychological, social, and cultural factors is subsequently evident throughout each topical chapter.

Relevant to presenting an unbiased review and commentary on the literature is the absence of evidence that the author had a preexisting bias for one theory or therapy over competing therapeutic or explanatory doctrines. The summaries and commentaries were presented with respect for the complex and dynamic interaction of multiple factors and avoided reductionism or biologic primacy by focusing on the contributions of interdependent mechanisms across the physiologic, psychosocial, and cultural continua. In addition to reviewing a broad segment of this literature, the author pointed out the need for new and revised dynamic research models to better apportion the variance among the multiple factors associated with medically unexplained illness.

Strengths of this book that set it apart from comparable publications that review and analyze the published literature, in my opinion, are the emphasis on female gender and the succinct summaries and commentaries on evidence-based and meta-analytic research regarding diagnostic distinctions and treatment options on the four most currently prominent functional somatic syndromes, that is, irritable bowel syndrome; fibromyalgia; chronic fatigue syndrome; and multiple chemical sensitivity. The author skillfully unified these syndromes by surveying their unique and overlappping diagnostic criteria, prevalence, comorbidity, etiology, and syndrome course, genetic contributions, role of the neuroendocrine system, gender differences, treatment options, and prognosis using a cross-comparative style.

As with virtually all publications, this book has limitations. First, the literature survey does not extend beyond 2006. If the reader wishes to have an up-to-date and more exhaustive familiarity of this literature, a review of 2007 through 2010 publications will be required. Second, conspicuously absent is the coverage of alexithymia as a personality trait associated with somatization independent of somatic disease and confounding sociodemographic variables. Third, coverage of personality factors in general, and specifically the important construct of negative affectivity (NA) are limited to a sketchy review in the chapter on chronic fatigue syndrome. Fourth, stepped care models and the compelling clinical outcomes reported by Allen, Woolfolk, Escobar, Gara, and Hamer (2006) for cognitive-behavioral therapy and Smith et al. (2006) using a patient-centered behavioral therapy approach is not addressed. Finally, this book is not a treatment manual but does alert the reader to references and resources on the methodology and algorithms of multiple interventions.

This book is a useful and scholarly treatise on the etiology, diagnostic distinctions, and conundrums, and available medical and psychological treatments for patients with medically unexplained illness. Dr. Susan Johnson is to be commended for the evenhanded and fair perspective reflected in this survey of the literature. She aptly pointed out recent advances in understanding and treating patients with medically unexplained illness while also identifying the flaws in research design that limit the interpretability of many studies.

The book lived up to its title "medically unexplained illness" and in particular the subtitle "gender and biopsychosocial implications." This volume will be useful to the clinician-scientist in either the primary or tertiary clinic setting interested in medically unexplained phenomena but particularly beneficial to the primary care provider who typically first encounters the patient with medically unexplained illness.

References

Allen, L. A., Woolfolk, R. L., Escobar, J. I., Gara, M. A., & Hamer, R. M. (2006). Cognitive-behavioral therapy for somatization disorder: A randomized controlled trial. Archives of Internal Medicine, 166, 1512-1518.

Smith, R. C., Lyles, J. S., Gardiner, J. C., Sirbu, C., Hodges, A., Collins, C., ... Goddeeris, J. (2006). Primary care clinicians treat patients with medically unexplained symptoms: A randomized controlled trial. Journal of General Internal Medicine, 21, 671-677.

Norman H. Rasmussen, EdD, ABPP Consultant

Mayo Clinic Department of Family Medicine & Department of Psychiatry and Psychology, Assistant Professor, Mayo College of Medicine, Rochester, MN
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Author:Rasmussen, Norman H.
Publication:Families, Systems & Health
Geographic Code:1USA
Date:Jun 1, 2011
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