Definitions

Other names such as somatisation and somatoform disorder are also in use and, although the two concepts overlap, they are not synonymous:^[1]

• 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.

Aetiology

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.

Epidemiology

Studies have shown that 15-20% of primary care consultations involve a physical symptom without likely organic disease.^[2][3]

Presenting features

'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.^[2][3]

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.

General advice

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.

Management

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.^[4]

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.

Psychotherapy

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:^[5]

• 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.^[6]
• 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.^[7] 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.^[8]

Communication

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.^[9] 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.^[10]

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.^[11]

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

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.