Delighted to see the response from Sarah Evans.1 Adverse childhood experience and relational trauma in particular are now recognised to be potent and widespread causes of MUS. As the effects are registered and maintained sub-cortically, in the limbic brain and in the lower, reptilian, brain, it should be no surprise that CBT is of limited benefit. Neuroscience has met psychotherapy in recent years and trauma-focused therapies such as Somatic Experiencing (Dr Peter Levine, https://www.seauk.org.uk, as referenced by Sarah), Sensorimotor Psychotherapy (Dr Pat Ogden, https://www.sensorimotorpsychotherapy.org), and Internal Family Systems (IFS, Dr Richard Schwartz, https://www.internalfamilysystemstraining.co.uk) are all proving to be much more effective in addressing the somatic expressions of post-psychic trauma and adversity than psychodynamic, CBT, psychoanalysis, or indeed many of the other traditional relational/attachment-oriented therapies. The body is increasingly being recognised as a seat of the unconscious and presentations are as many and varied as the body is complex. Dr Gabor Maté, GP and trauma and addiction specialist, has much useful to say on this also (https://drgabormate.com).
NHS provision of trauma assessment and management is patchy but improving. Complex PTSD has only just made it into ICD11 and is undoubtedly at the root of many MUS, but relevant services are some years down the line yet.
I would encourage all GPs to carry out a short trauma assessment interview for all their regular attenders, MUS, and heartsinks. You will be surprised at what is lurking in the past experiences of these patients, and, now that we have effective therapies, equally surprised at how quickly they respond to these new tailored interventions.
To get quickly up to speed with developments in this area I would highly recommend reading The Body Keeps the Score by Professor Bessel van der Kolk. (Penguin, 2015, ISBN 978-0141978611).
- © British Journal of General Practice 2019
