Letter to the Editor

Dear Sir/Madam,

We are writing in response to Dr Lachmansingh’s letter dated the 22nd of September regarding ‘breast implant illness’. As liaison psychiatrists who see patients presenting with functional disorders across a broad range of medical and surgical settings, we welcome this correspondence. Our colleagues in General Adult Psychiatry tend to have less familiarity with, and exposure to, this presentation of mental disorder which is common in the acute hospital setting. When these patients are seen in the community psychiatry setting, it is usually as a result of the associated distress and to access treatment for co-morbid psychiatric illness. Such patients are understandably sceptical of referral to psychiatry, inferring from it the message that their symptoms are ‘all in the mind’.

The role of the psychiatrist in cases of functional disorders should not just be the identification and treatment of co-morbidities but also to assist in diagnostic clarification. Where this diagnosis is made, a collaborative and integrative approach is required. While patients with this disorder vary in terms of their clinical presentation, there is a common underlying mechanism at play, that is, chronic overactivity of the autonomic nervous system. The wide ranging symptoms provoked by this ‘fight or flight’ state give rise to the patient’s experiences as outlined by Dr Lachmansingh, that is, brain fog, chest pain, headaches, etc. It is very helpful for patients to have an understanding of the pathophysiology of their experiences, for example, stress/anxiety leads to an increase in the respiratory rate which in turn leads to hypocapnia. Hypocapnia is associated with a tingling sensation in the limbs and around the mouth (paresthesia). Similarly, when the fight or flight response is activated, it leads to an increase in heart rate and muscle tension resulting in palpitations and chest pain for the patient. Psychoeducation as to the functional (i.e., software) rather than structural (i.e., hardware) origin of their symptoms is an important part of management. The neurosymptoms.org website, which was developed by a consultant neurologist, is an excellent resource not just for functional neurological disorders, but across the whole range of ‘mind-body’ presentations.

In terms of management of these patients, the overarching aim is to support the patient in their healthcare journey, to reduce the risk of iatrogenic harm, to improve functioning and reduce symptom burden and distress. Patients with somatoform disorders benefit from psychotropic medication, whether or not co-morbid with a major mood disorder. Indeed, somatoform or functional disorders can be understood as the somatic expression of the same psychological distress which underlies major mood disorders and the treatment approach is much the same. There is good evidence that medications such as Selective Serotonin Reuptake Inhibitors (SSRIs) and Amitriptyline are of benefit in the treatment of functional disorders such as irritable bowel syndrome whether or not they are co-morbid with a depressive episode (Jackson et al. 2000). Antidepressants reduce the activity of the Autonomic Nervous System (ANS), thereby reducing symptom burden. Psychological input is key; the emphasis is on the meaning of the symptoms for the patient and a move toward recovery. A joint educational session with the medical specialist, the psychiatrist, the patient and a family/other member can be transformative in moving away from further investigations and the risk of iatrogenic harm.

The central focus of our General Adult Psychiatry services is often determined by resource constraints with psychotic disorders and severe mood disorders 'seen as the primary targets for intervention. Psychiatric disorders which lie outside this remit can fall between the stools of the acute hospital and mental health services. We cannot provide a comprehensive mental health service on the 6% of the health budget allocated to mental health services. As psychiatrists, we have an important role in the education of our medical colleagues about the excellent treatments available for the one-third of their patients who have functional disorders, and the encouragement of investment from acute hospital funding to ensure the availability and sustainability of these evidence-based treatment approaches.