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Explanatory and Pragmatic Perspectives Regarding Idiopathic Physical Symptoms and Related Syndromes

Published online by Cambridge University Press:  07 November 2014

Charles C. Engel
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Abstract

In recent years, research-methods literature mainly addressing controlled clinical trials has arisen regarding explanatory and pragmatic treatment trials. Explanatory trials tend to examine causal mechanisms and questions of efficacy and value internal validity (creating optimal study conditions) over generalizability (using study results to understand treatment effects in real-life patient populations). In contrast, pragmatictrials value “external relevance” (generalizability) of study results over “internal elegance” so that clinicians and health policymakers can better understand how treatments might impact their patients and policies.This review draws inspiration from these contrasting explanatory and pragmatic perspectives and develops them for clinical and research pertaining to idiopathic physical symptoms and related syndromes (eg, somatization disorder, chronic fatigue syndrome, multiple chemical sensitivities, irritable bowel syndrome). Explanatory and pragmatic perspectives are used to examine these idiopathies with regard to causation, case definition, labels, and treatment. It is concluded that idiopathic symptom syndromes are fundamentally pragmatic clinical and research challenges. For epidemiologic and methodologic reasons, the complex explanations for these syndromes remain largely elusive. Even so, scientific and clinical pragmatism offers the opportunity to reduce disagreement between competing medical disciplines and between clinicians and affected patients with regard to irreconcilable etiologic questions and to remain evidence-based in the care of patients.

Type
Review Articles
Information
CNS Spectrums , Volume 11 , Issue 3 , March 2006 , pp. 225 - 232
Copyright
Copyright © Cambridge University Press 2006

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References

REFERENCES

1.Godwin, M, Ruhland, L, Casson, I, et al.Pragmatic controlled clinical trials in primary care: the struggle between external and internal validity. BMC Med Res Methodol. 2003;3:28.CrossRefGoogle ScholarPubMed
2.Starfield, B. Quality-of-care research: internal elegance and external relevance. JAMA. 1998;280:1006–1008.Google Scholar
3.Mayou, R, Kirmayer, LJ, Simon, G, Somatoform disorders: time for a new approach in DSM-V. Am J Psychiatry. 2005;162:847–855.Google Scholar
4.Sharpe, M, Mayou, R. Somatoform disorders: a help or hindrance to good patient care? Br J Psychiatry. 2004;184:465–467.CrossRefGoogle ScholarPubMed
5.Wilson, A. Hickie, I, Hadzi-Pavlovic, D, et al.What is chronic fatigue syndrome? Heterogeneity within an international multicentre study. Aust N Z J Psychiatry. 2001;35:520–527.CrossRefGoogle ScholarPubMed
6.Schweickhardt, A, Larisch, A, Fritzsche, K. Differentiation of somatizing patients in primary care: why the effects of treatment are always moderate. J Nerv Ment Dis. 2005;193:813–819.Google Scholar
7.Turk, DC, Okifuji, A. Pain in patients with fibromyalgia syndrome. Curr Rheumatol Rep. 2000;2:109–115.Google Scholar
8.Kroenke, K. Patients presenting with somatic complaints: epidemiology, psychiatric comorbidity and management. Int J Methods Psychiatr Res. 2003;12:34–43.Google Scholar
9.Walker, EA, Katon, WJ, Keegan, D, Gardner, G, Sullivan, M. Predictors of physician frustration in the care of patients with rheumatological complaints. Gen Hosp Psychiatry. 1997;19:315–323.CrossRefGoogle ScholarPubMed
10.American Heritage Dictionary of the English Language. 4th ed. Boston, Mass: Houghton Mifflin Company; 2000.Google Scholar
11.Jensen, MC, Brant-Zawadzki, MN, Obuchowski, N, Modic, MT, Malkasian, D, Ross, JS. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med. 1994;331:69–73.Google Scholar
12.Bennett, R. Fibromyalgia: present to future. Curr Rheumatol Rep. 2005;7:371–376.CrossRefGoogle ScholarPubMed
13.Hyams, KC. Developing case definitions for symptom-based conditions: the problem of specificity. Epidemiol Rev. 1998;20:148–156.Google Scholar
14.Wessely, S, Hotopf, M, Sharpe, M. Chronic Fatigue and its Syndromes. New York, NY: Oxford University Press; 1998.Google Scholar
15.Mayou, R, Bass, C, Sharpe, M. Overview of epidemiology classification and aetiology. In: Treatment of Functional Somatic Symptoms. Mayou, R, Bass, C, Sharpe, M, eds. London, England: Oxford University Press; 1995:42–65.CrossRefGoogle Scholar
16.Vollestad, NK, Mengshoel, AM. Relationships between neuromuscular functioning, disability and pain in fibromyalgia. Disabil Rehabil. 2005;27:661–673.CrossRefGoogle ScholarPubMed
17.Dadabhoy, D, Clauw, DJ. Fibromyalgia: progress in diagnosis and treatment. Curr Pain Headache Rep. 2005;9:399–404.Google Scholar
18.Inanici, F, Yunus, MB. History of fibromyalgia: past to present. Curr Pain Headache Rep. 2004;8:369–378.CrossRefGoogle ScholarPubMed
19.Engel, CC. Unexplained physical symptoms: medicine's “dirty little secret” and the need for prospective studies that start in childhood. Psychiatry. 2000;63:153–159.Google Scholar
20.Smith, GR Jr.The course of somatization and its effects on utilization of health care resources. Psychosomatics. 1994;35:263–267.Google Scholar
21.Smith, GR Jr, Monson, RA, Ray, DC. Patients with multiple unexplained symptoms. Their characteristics, functional health, and health care utilization. Arch Intern Med. 1986;146:69–72.Google Scholar
22.Wessely, S, Nimnuan, C, Sharpe, M. Functional somatic syndromes: one or many? Lancet. 1999;354:936–939.Google Scholar
23.Aaron, LA, Buchwald, D. A review of the evidence for overlap among unexplained clinical conditions. Ann Intern Med. 2001;134(9 pt 2):868–881.Google Scholar
24.VA/DoD Clinical Practice Guideline Working Group. Medically Unexplained Symptoms: Chronic Fatigue and Pain. Washington, DC. Veterans Health Administration, Department of Veterans Affairs, and Health Affairs, Department of Defense. Office of Quality and Performance publication 10Q-CPG/CF&P-01; August, 2002. Available at: http://www.oqp.med.va.gov/cpg/cpgn/mus/MUS_Gol.htm. Accessed on December 22, 2005.Google Scholar
25.Hamilton, WT, Gallagher, AM, Thomas, JM, White, PD. The prognosis of different fatigue diagnostic labels: a longitudinal survey. FamPract. 2005;22:383–388.Google Scholar
26.Escobar, JL, Interian, A, Díaz-Martínez, Gara M. Idiopathic physical symptoms: a common manifestation of psychiatric disorders in primary care. CNS Spectr. 2006;11:201–210.CrossRefGoogle ScholarPubMed
27.Salmon, P. The potentially somatizing effect of clinical consultation. CNS Spectr. 2006;11:190–200.CrossRefGoogle ScholarPubMed
28.Jackson, JL, O'Malley, PG, Kroenke, K. Antidepressants and cognitive-behavioral therapy for symptom syndromes. CNS Spectr. 2006;11:212–222.CrossRefGoogle ScholarPubMed
29.Wendler, D, Miller, FG. Deception in the pursuit of science. Arch Intern Med. 2004;164:597–600.Google Scholar
30.Aaron, LA, Buchwald, D. Chronic diffuse musculoskeletal pain, fibromyalgia and co-morbid unexplained clinical conditions. Best Pract Res Clin Rheumatol. 2003;17:563–574.CrossRefGoogle ScholarPubMed
31.Wessely, S. To tell or not to tell: the problem of medically unexplained symptoms. In: Zeman, A, Emanuel, L, eds. Ethical Dilemmas in Neurology. London, UK: Saunders; 1999:41–53.Google Scholar