Cognitive behaviour therapy has role in treatment of medically unexplained physical symptoms

BMJ 1998; 316 doi: http://dx.doi.org/10.1136/bmj.316.7125.147a (Published 10 January 1998) Cite this as: BMJ 1998;316:147
  1. Steve Williams, General practitionera
  1. a The Garth Surgery, Westgate, Guisborough, Cleveland TS14 6AT

    Editor—As a general practitioner and cognitive behavioural therapist, I was encouraged by the message in Mayou and Sharpe's editorial on treating medically unexplained physical symptoms.1 Training doctors to extend themselves beyond the classical medical model and to think simultaneously in physical, psychological, and social terms has been central to vocational training in general practice from its inception. Identifying physical problems is the main part of our job; most doctors are sensitive to the importance of social factors, while social interventions, when appropriate, consist largely of delegation to other professionals. Intervening at a psychological level, however, has been far more problematic, largely because the theoretical models and techniques available have simply not been adequate in terms of time, efficiency, and effectiveness.

    Cognitive behavioural approaches are proved not only in the management of unexplained physical symptoms but in many other clinically relevant areas.2 In addition, many developments in consultation technique already contain a cognitive element.3 4 Perhaps most importantly, cognitive behavioural interventions can fit within the time frame of a “normal” consultation in general practice.5

    As Mayou and Sharpe describe, an essential strength of the cognitive behavioural model is its integrative approach, constructing an overall meaning from the patient's distress simultaneously in physiological, behavioural, affective, and cognitive terms, all within a social context. This contrasts with the traditional approach, in which both doctors and patients have been driven to seek isolated causes, framed in dualistic terms and 19th century concepts, derived from the success of the germ theory of disease.

    The authors make suggestions for the implementation of this approach and outline the obstacles. These obstacles should not be underestimated for they represent a major paradigm shift in our thinking and attitudes. However, the potential benefits that may be derived from introducing and integrating a cognitive approach into our clinical practice—in terms of reduced distress for the patient and the doctor, reduced costs, and prevention of iatrogenic damage—are enormous. I look forward to the consequences.


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