Is Cognitive Change Necessary to Alleviate Symptoms in Patients With Functional Somatic Syndrome?

Abstract

What has been included under the umbrella term “Functional somatic syndromes” (FSS) has varied over the years. Diagnoses such as “somatoform” and “somatic symptom disorders,” as well as “medically unexplained symptoms,” have been included in FSS (1). Although there is no complete consensus, FSS usually comprise of conditions such as fibromyalgia, irritable bowel syndrome (IBS), and chronic fatigue syndrome (CFS) (2). A characteristic of FSS is persistent physical symptoms that lead to impairment or disability and that disrupt the capacity to take part in daily life. Although FSS are believed to be caused by a complex interaction of biological and psychosocial factors (3), the conditions are not medically explained in terms of well-Understood or established pathophysiological mechanisms. Cognitive behavioral therapy (CBT) has become the gold standard psychological treatment for FSS. Several meta-analyses have shown a small to moderate effect in patients with FSS (4–7). Even though the small to moderate effect is robust, in the sense that results have been replicated both within and across conditions, there is limited research on treatment mechanisms (8). That is, CBT has an effect, but why the effect takes place is not firmly established. Traditional CBT rests on the idea that changing cognitions and behaviors in FSS will decrease somatic symptoms (9). Specifically, changing so-called dysfunctional illness beliefs “are of paramount importance for treatment (success)” (10). According to a review of Windgassen et al. (11), there is a “clear indication” that “cognitive change is important for reducing symptom severity.” Put simply, a patient who, for example, believes that “something is wrong with my body” or claims a physical attribution such as “I have a chronic infection, that is why I feel fatigued,” will not easily get well. There are some merits to this position. In a review of CBT for IBS, four out of five studies found cognitions to mediate the effect of treatment on symptom severity (11). In another review of CBT for CFS, three different types of illness perceptions (fatigue as something aversive, activity as potentially dangerous to health, and a symptom preoccupation with fatigue) were found to potentially perpetuate CFS symptoms (12). Although there is a value in the position that changing cognition is of “paramount importance” to reduce symptoms in FSS, we argue that this idea is a simplification and leaves several questions unanswered. In the following, we provide two major arguments against this position. Counterargument 1: Patients With FSS Hold Complex Illness Beliefs or Attributions Patients with FSS have been assumed to hold strong beliefs that the cause of their symptoms is a physical disease (10). It has been suggested that they inflexibly hold assumptions like “something is wrong with my body” or “there is nothing I can do except waiting for a medical cure.” While it might be true that there is a tendency among certain patients with FSS to hold such beliefs (13, 14), some research speaks to the fact that patients with FSS either do not hold clear causal attributions or have a plethora of quite complex illness attributions. For example, in a study of 104 patients with fibromyalgia, over two-thirds of the patients endorsed the statement that “I cannot understand at all the cause of my pain (the reason I have pain)” (15). In these patients, there simply are no dysfunctional illness beliefs to change, as they do not understand the reason for why they have pain. In a study of 66 patients with chronic fatigue syndrome, half of the sample believed that stress had played a role in the development of their illness (16). In another qualitative study based on nine adolescents with CFS, three out of nine participants had a multi-causal understanding of their illness, believing that the illness had both physical and psychological origins (17). It is not clear how a patient who holds a psychological attribution fits with the idea of changing dysfunctional illness beliefs about the illness as a pervasive and uncontrollable physical disease.