Medically Unexplained Symptoms (Assessment and Management)

Clinicians can often find the management of patients with medically unexplained symptoms (MUS) frustrating.
Some prefer the term MUS, but others use Somatisation (see our dedicated record) or somatoform disorders.¹ These labels should be regarded as descriptive and do not automatically imply a psychiatric origin to the patient's distress.

General practice has a key role in the management of this clinical problem as approximately 20-30% of primary care patients have medically unexplained symptoms.²

Unfortunately many MUS patients seek care to find an organic disease they fear but do not have. Doctors then may test for and even treat (non-existent) organic disease. This produces high use of services, unnecessary laboratory testing and consultation, increased costs, and high iatrogenic complication rates e.g. ill-advised tests, drug addiction and trial treatments for presumed but absent organic diseases.

Usually the complaints involve chronic pain and problems with the digestive system, the nervous system and the reproductive system. The disorder usually begins before the age of 30 and occurs more often in women than in men.
Antisocial personality disorder is associated with a risk for somatisation disorder.³
Several studies have suggested an association between somatisation and a history of sexual or physical abuse in a significant proportion of patients.⁴

Prevalence rates for the most strict criterion diagnosis of somatisation disorder appear low in community samples (0.1%).⁵
Low community prevalence rates may be due to reporting bias.
Medical record studies suggest the rate of somatisation disorder in the community among women may be as high as 2%.

The symptoms are generally severe enough to affect work and relationships and lead the person to consult a doctor and take medication. A lifelong history of "sickliness" is often present:

• Despite thorough investigation, no specific underlying physical cause is ever identified to account for the symptoms.
• Stress often worsens the symptoms.

Some of the numerous symptoms that can occur with somatisation disorder include:

Cardiac

Shortness of breath
Palpitations
Chest pain

Gastrointestinal

Vomiting
Abdominal pain
Difficulty swallowing
Nausea
Bloating
Diarrhoea

Musculoskeletal

Pain in the legs or arms
Back pain
Joint pain

Neurological

Headaches
Dizziness
Amnesia
Vision changes
Paralysis or muscle weakness

Urogenital

Pain during urination
Low libido
Dyspareunia
Impotence
Dysmenorrhoea, irregular menstruation and menorrhagia

Diagnosis is not merely the exclusion of serious physical problems but also the combined consideration of medically unexplained symptoms and classic psychiatric disorders.²A thorough physical examination and diagnostic tests are performed to rule out physical causes - which tests are done is determined by the symptoms present.

A psychological evaluation should also be performed to rule out related disorders:
However, finding evidence of a psychiatric condition does not rule somatisation in or out. It can be a clue to the diagnosis.

There is considerable evidence that patients with common psychiatric conditions such as depression and anxiety disorders may present to primary care physicians with nonspecific somatic symptoms, including fatigue, aches and pains, palpitations, dizziness and nausea.

Somatisation is often a diagnosis of exclusion, however it is much more effective to pursue a positive diagnosis of somatisation when the patient presents with typical features:⁶

• Multiple symptoms, often occurring in different organ systems⁷
• Symptoms that are vague or that exceed objective findings
• Chronic course
• Presence of a psychiatric disorder
• History of extensive diagnostic testing
• Rejection of previous physicians

The general practitioner's emotional response to a patient can serve as an early cue to pursue a somatisation diagnosis:

• A feeling of frustration or anger at the number and complexity of symptoms and the time required to evaluate them in an apparently well person.
• A sense of being overwhelmed by a patient who has had numerous evaluations by other physicians.

These can be a signal to the clinician to consider somatisation in the differential diagnosis early in the patient's evaluation.

The first occasion that the diagnosis is discussed (after the initial investigations have failed to show any organic pathology) is a key moment in the physician-patient relationship.⁸

The challenge is to describe the condition to the patient in a manner that avoids any implication of a psychosomatic illness. One journal suggests the following:
"The results of my examination and of the tests we conducted show that you do not have a life-threatening illness. However, you do have a serious and impairing medical condition, which I see often but which is not completely understood. Although no treatment is available that can cure it completely, there are a number of interventions that can help you deal with the symptoms better than you have so far."⁹

Once other causes have been ruled out and a diagnosis of somatisation disorder is secured, the goal of treatment is to help the person learn to control the symptoms:

• There is often an underlying mood disorder which can respond to antidepressants.
• Unfortunately, persons with this disorder rarely admit that it can be caused, at least in part, by mental health problems, and may refuse psychiatric treatment.
• It is important to ask open-ended questions.

The BATHE technique provides a framework for exploration of psychosocial stressors in less than 5 minutes:¹⁰

• Background: "What is going on in your life?"
• Affect: "How do you feel about it?"
• Trouble: "What troubles you the most about that situation?"
• Handle: "What helps you handle that?"
• Empathy: "This is a tough situation to be in. Your reaction makes sense to me ..."

It is sensible to avoid setting unrealistic goals:

• In severe cases of somatoform disorder, symptoms are unlikely to resolve completely. Therefore avoid making the goal of the treatment plan to relieve the patient's illness. The physician and patient will soon become frustrated and tempted to engage in a new flurry of diagnostic tests and invasive procedures.
• Attempts to "take away the symptom" may cause the patient to substitute another symptom as a result of the need-to-be-sick phenomenon.
• A better goal is to help the patient succeed in coping with the symptoms. Treatment is successful if it keeps the patient out of the hospital.

The whole primary care health team should be aware of the diagnosis and management plan. This will make the approach to management consistent across the practice.
Interventions directed at reducing specific sources of stress are most helpful, these may include advice about dealing with marital conflict.

Some physical exercise is important as it prevents loss of fitness, enhances self-esteem and provides an opportunity for patients to take a break from oppressive duties or unpleasant situations. A minimum of three 20-minute exercise sessions per week is desirable.
The importance of pleasurable private time should be emphasised. This may include yoga classes or meditation, bowling or nature walks, which, under the general title of "stress management," can be presented as necessary medical treatments.

Some patients may request tests repeatedly, but they should be reminded that they will be followed with frequent and regular visits so that any problems will be identified early. Sometimes requesting investigations becomes a "negotiating" process designed to give the patient some control over what test is performed and to enhance the trust level between the physician and patient.

Recent qualitative research into aspects of the communication between doctors and patients has shown that doctors' usual ways of communicating with patients who have medically unexplained symptoms may need essential adjustment. Patients seem to be prepared for simultaneous biological and psychosocial approaches to evaluation of symptoms.¹¹ The methods currently used by general practitioners to reassure patients that their symptoms are part of normality are insufficient.¹² If reassurance does not address the patients' specific concerns it may exacerbate their presentation of somatic symptoms and increase the likelihood of somatic management outcomes.¹² These findings are in line with previous observations that doctors' explanations are often at odds with the patients' own thinking and result in conflict, a feeling of rejection, and undermined confidence.¹³

Approaches derived from cognitive behavioural therapy have been shown to reduce the intensity and frequency of somatic complaints and to improve functioning in many somatising patients:¹⁴

• This type of treatment starts with the mutual agreement that whatever the patient has been thinking and doing about the condition has not been successful.
• It then begins to challenge the patient's beliefs and maladaptive behaviours in a caring manner.
• Short course intervention therapy (eight to 16 sessions) specifically for treatment of somatising patients have been shown to be remarkably effective in improving function and reducing distress.¹⁵
• The sessions combine general advice such as stress management, problem solving and social skills training with specific interventions targeted at the amplification and need-to-be-sick features of somatisation.

Reattribution model

Goldberg and Gask first described the reattribution model in 1989.¹⁶ This can be used by general practitioners after brief training and is based on a cognitive oriented approach.
The key principles are:

• To make the patient feel understood.
• Then to broaden the agenda.
• Finally to negotiate a new understanding of the symptoms including psychosocial factors

The reattribution model has been shown to have positive effects on general practitioners' interviewing skills, healthcare costs and patients' health.¹⁷

There are psychiatric disorders associated with somatisation, specifically anxiety and depression. These respond well to treatment but, especially with antidepressants, it is important to start with low doses and to increase progressively to avoid side effects that may be present at the beginning of treatment and discourage the patient from continuing.

Complications may result from invasive testing and from multiple evaluations that are performed while looking for the cause of the symptoms.
A dependency on pain relievers or sedatives may develop.
A poor relationship with the health care provider seems to worsen the condition, as does evaluation by many providers.