Clinicians can often find the management of patients with medically unexplained symptoms (MUS) frustrating. In all parts of our healthcare system we meet patients presenting with physical symptoms that lack an obvious organic basis. The terms used to describe such symptoms - medically unexplained symptoms or functional somatic symptoms - are purely descriptive and do not imply psychogenesis.
Many of the affected patients do not receive a correct diagnosis and undergo numerous fruitless investigations and attempts at treatment. The narrow focus on the somatic aspects of a complex problem may reinforce their concerns about having a physical disease, make them less satisfied with the healthcare system, contribute to the development of chronic disablement and cause healthcare costs to become excessive.
Medically unexplained symptoms therefore represent a clinical problem that must be taken seriously.
- One is the expression of psychological illness through physical symptoms - as in the term 'somatised depression' or somatisation. See separate article Somatisation Disorder.
- The other is repeated medical help-seeking for multiple medical symptoms without organic disease - physical symptoms for which no clear or consistent organic pathology can be demonstrated. These use a variety of criteria, but all include patient self-ratings of the presence of symptoms.
- Add notes to any clinical page and create a reflective diary
- Automatically track and log every page you have viewed
- Print and export a summary to use in your appraisal
The causative factors for medically unexplained symptoms (MUS) are similar to those for anxiety and depression:
- Stress at home or work, history of childhood or family illness and high deprivation index may all play a part.
- A history of past or recent abuse is often associated - particularly in the case of chronic pelvic pain, in which around a third of patients will have some history of abuse.
'Medically unexplained symptoms' (MUS) comprises a wide spectrum of complaints ranging from mild transitory illness to chronic disorders with severe disability.
In UK studies, MUS are more likely if there is a past or current history of depression or anxiety. 10% of presenting patients have been found to have a mood disorder but present with physical symptoms. 30% have presented with multiple somatic symptoms, but only one-third of these patients have also had a psychiatric disorder.
There seem to be clusters of typical presenting complaints; for example, many patients with irritable bowel syndrome also meet the diagnostic criteria for chronic pelvic pain or fibromyalgia, and vice versa. Patients with MUS do not fit into the existing framework of a biomedical model that tends to focus on the exclusion of physical disease. However, the exclusion of relevant physical disease may not in itself cure the patient. He or she may still feel ill and seek medical care.
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.
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.
Medical care of medically unexplained symptoms (MUS) should include improvements in three interrelated elements; diagnosis, specific treatment strategies and communication.
Making a diagnosis
Diagnosis is not merely the exclusion of serious physical problems but also the combined consideration of medically unexplained symptoms and classic psychiatric disorders.
A 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.
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 (nonexistent) organic disease. This produces high use of services, unnecessary laboratory testing and consultation, increased costs, and high iatrogenic complication rates, eg ill-advised tests, drug addiction and trial treatments for presumed but absent organic diseases.
- 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 (8 to 16 sessions) specifically for treatment of somatising patients have been shown to be remarkably effective in improving function and reducing distress.
- 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.
Goldberg and Gask first described the reattribution model in 1989. This can be used by general practitioners after brief training and is based on a cognitive-orientated 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.
In 2000 Fink et al modified the model to the extended reattribution and management model in order to include a broader spectrum of disorders.
The reattribution model has been shown to have positive effects on general practitioners' interviewing skills, healthcare costs and patients' health.
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 (MUS) may need essential adjustment.
The methods currently used by general practitioners to reassure patients that their symptoms are part of normality, are inadequate. 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. Effective explanations provide real mechanisms for understanding, based on patients' concerns, often linking physical and psychological factors. These explanations were accepted by patients; those linking physical and psychological factors contributed to management outcomes.
These findings are in line with previous observations that doctors' explanations are often at odds with patients' own thinking and result in conflict, a feeling of rejection, and undermined confidence.
Such communication issues have been integrated into the specific management models of reattribution. Improved and evidence-based communication strategies are essential in any comprehensive management strategy. However, they cannot stand alone but must be incorporated in the specific treatment programmes.
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 healthcare provider seems to worsen the condition, as does evaluation by many providers.
Further reading & references
- Burton C; Beyond somatisation: a review of the understanding and treatment of medically Br J Gen Pract. 2003 Mar;53(488):231-9.
- Mumford DB, Devereux TA, Maddy PJ, et al; Factors leading to the reporting of 'functional' somatic symptoms by general Br J Gen Pract. 1991 Nov;41(352):454-8.
- Peveler R, Kilkenny L, Kinmonth AL; Medically unexplained physical symptoms in primary care: a comparison of J Psychosom Res. 1997 Mar;42(3):245-52.
- Rosendal M, Olesen F, Fink P; Management of medically unexplained symptoms. BMJ. 2005 Jan 1;330(7481):4-5.
- Speckens AE, van Hemert AM, Spinhoven P, et al; Cognitive behavioural therapy for medically unexplained physical symptoms: a randomised controlled trial. BMJ. 1995 Nov 18;311(7016):1328-32.
- Kashner TM, Rost K, Cohen B, et al; Enhancing the health of somatization disorder patients. Effectiveness of short-term group therapy. Psychosomatics. 1995 Sep-Oct;36(5):462-70.
- Goldberg D, Gask L, O'Dowd T; Goldberg D, Gask L, O'Dowd T; The treatment of somatization: teaching techniques of reattribution. J Psychosom Res. 1989;33(6):689-95.
- Morriss RK, Gask L, Ronalds C, et al; Clinical and patient satisfaction outcomes of a new treatment for somatized mental disorder taught to general practitioners. Br J Gen Pract. 1999 Apr;49(441):263-7.
- Salmon P, Peters S, Stanley I. Patients' perceptions of medical explanations for somatisation disorders: qualitative analysis. BMJ. February 1999
- Dowrick CF, Ring A, Humphris GM, et al; Normalisation of unexplained symptoms by general practitioners: a functional typology. Br J Gen Pract. 2004 Mar;54(500):165-70.
- Salmon P, Dowrick CF, Ring A, et al; Voiced but unheard agendas: qualitative analysis of the psychosocial cues that patients with unexplained symptoms present to general practitioners. Br J Gen Pract. 2004 Mar;54(500):171-6.
|Original Author: Dr Hayley Willacy||Current Version: Dr Hayley Willacy|
|Last Checked: 16/07/2010||Document ID: 9076 Version: 2||© EMIS|
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.