BMJ  2006;333:136 (15 July), doi:10.1136/bmj.333.7559.136

Commentary

Power of the mind

¹ Maudsley Hospital, London SE5 8AZ Sabina.dosani{at}slam.nhs.uk

I hadn't heard of rumination syndrome before reading Mr Neville's story.¹ My first thought on hearing about his repeated presentation, negative findings, and distress was that this was a case of somatoform disorder.² His deterioration after a difficult meeting with a staff member supported that view.

Is rumination syndrome a distinct syndrome or is it an example of a functional somatic syndrome?³ It is unfortunate that mind-body dualism still dominates clinical discussions and management. To me, this sounds like a condition with psychogenic aetiology but physical manifestation. His symptoms are not "all in the mind," they are "all in the stomach"; understandably Mr Neville and his general practitioner sought advice from gastroenterologists.

Psychological support

Mr Neville started to feel better when he was given an explanation of his symptoms and learnt how to suppress contractions. Explanations that are tangible remove blame and involve patients in managing their illness and improve wellbeing. They are also associated with patient satisfaction.⁴ A psychoeducational approach could be helpful in explaining to Mr Neville that abdominal wall contraction is under his control and assist in reducing frequency of these contractions. Cognitive behavioural therapy is effective in patients with somatoform disorder as it gives them enhanced coping skills, reduces worries about illness, reduces the frequency of avoidant behaviour, and imparts a sense of control.⁵

This case also reminds us of the importance of working with families. Mr Neville's mother, described as "highly protective," was almost certainly anxious about her son's four year history of unexplained and upsetting symptoms. Her thoughts, feeling, and actions will have a bearing on Mr Neville's prognosis.

Psychological or pathological? Credit: ANDREZEJ DUDZINKSI/SPL

 

What will psychiatrists learn from Mr Neville's case? On the one hand, we could consider rumination syndrome as a possible differential diagnosis in children and young people presenting with weight loss or school refusal. However, I am more likely to remember Mr Neville's story, rather than his label, and what he has taught us. Child and adolescent psychiatrists in community clinics are well placed to identify and intervene before abnormal illness behaviour becomes entrenched.

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Competing interests: None declared.

References

1. Fox M, Young A, Anggiansah R, Anggiansah A, Sanderson J. A 22 year old man with persistent regurgitation and vomiting: case outcome. BMJ 2006;333: 133.[Free Full Text]
2. Craig TKJ, Boardman AP. Somatisation in primary care settings. In: Bass CM, ed. Somatisation: physical symptoms and psychological illness. Oxford: Blackwell, 1990.
3. Nimnuan C, Rabe-Hesketh S, Wessely S, Hotopf M. How many functional somatic syndromes? J Psychosom Res 2001;51: 549-57.[CrossRef][ISI][Medline]
4. Salmon P, Peters S, Stanley I. Patients' perceptions of medical explanations for somatisation disorders: qualitative analysis. BMJ 1999;318: 372-6.[Abstract/Free Full Text]
5. Kroenke K, Swindle R. Cognitive-behavioral therapy for somatization and symptom syndromes: a critical review of controlled clinical trials. Psychother Psychosom 2000;9: 205-15.

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