Intended for healthcare professionals

Clinical Review ABC of psychological medicine

Chronic multiple functional somatic symptoms

BMJ 2002; 325 doi: (Published 10 August 2002) Cite this as: BMJ 2002;325:323
  1. Christopher Bass,
  2. Stephanie May

    The previous article in this series described the assessment and management of patients with functional somatic symptoms. Most such patients make no more than normal demands on doctors and can be helped with the approach outlined. However, a minority have more complex needs and require additional management strategies. These patients typically have a longstanding pattern of presenting with various functional symptoms, have had multiple referrals for investigation of these, and are regarded by their doctors as difficult to help.

    Charles Darwin (1809-82) suffered from chronic anxiety and varied physical symptoms that began shortly after his voyage in the Beagle to South America (1831-6). Despite many suggested medical explanations, these symptoms, which disabled him for the rest of his life and largely confined him to his home, remain medically unexplained


    Because such patients may evoke despair, anger, and frustration in doctors, they may be referred to as “heartsink patients,” “difficult patients,” “fat folder patients,” and “chronic complainers.” The use of these terms is inadvisable. If patients read such descriptions in their medical notes they are likely to be offended and lose faith in their doctor and may make a complaint. In psychiatric diagnostic classifications these patients are often referred to as having somatisation disorder. We prefer the term “chronic multiple functional symptoms” (CMFS).

    Epidemiology and detection

    Over 4% of the general population and 9% of patients admitted to tertiary care have CMFS. Each primary care doctor will have on average 10-15 such patients.

    Most patients with CMFS are women. They often have recurrent depressive disorder and a longstanding difficulty with personal relationships and may misuse substances. There is an association with an emotionally deprived childhood and childhood physical and sexual abuse. Some patients will clearly have general disturbances of personality.

    The risk of iatrogenic harm from over-investigation and over-prescribing for somatic complaints makes it …

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