BMJ  2008;336:1124-1128 (17 May), doi:10.1136/bmj.39554.592014.BE

Clinical Review

Assessment and management of medically unexplained symptoms

¹ University of Auckland, Private Bag 92019, Auckland 1, New Zealand, ² Department of General Practice and Primary Health Care, University of Auckland, Private Bag 92019, Auckland 1, New Zealand

The first 150 words of the full text of this article appear below.

Many people present with medically unexplained symptoms. For example, more than a quarter of primary care patients in England have unexplained chronic pain, irritable bowel syndrome, or chronic fatigue,¹ and in secondary and tertiary care, around a third of new neurological outpatients have symptoms thought by neurologists to be "not at all" or only "somewhat" explained by disease.² This is not a problem just in developed countries—in Bangladesh, only a third of women with abnormal vaginal discharge had evidence of infection.³ These disorders are important because they are common and they cause similar levels of disability as symptoms caused by disease.⁴ If not treated properly they can result in large amounts of resources being wasted⁵ and iatrogenic harm.

Sources and selection criteria We did a Medline search over the past 10 years using the keywords "somatoform disorders", "medically unexplained symptoms", and "randomised controlled trials". We consulted Clinical Evidence and the Cochrane Collaboration for relevant . . . [Full text of this article]

Summary points

Medically unexplained symptoms or somatoform disorders?

Who gets medically unexplained symptoms?

How should I assess patients who present with medically unexplained symptoms?

Taking a history and setting the agenda
Box 1 Assessment in non-psychiatric settings
Why now and what’s the agenda? Questions for the patient
Assess the presentation
Is there associated pathology?
Does the patient have an anxiety or depressive disorder?
Is this some other emotional distress presenting as physical distress?
Could there be any associated pathology?
Explanation and reassurance
Box 2 Reassurance, explanation, and the use of investigations
Reassurance
Explanation
Use of investigations
What is the evidence for using diagnostic tests for reassurance?
Box 3 Signs and investigations for unexplained weakness and non-epileptic seizures
Unexplained weakness
Non-epileptic seizures
The risks of iatrogenic damage
Does the person have an anxiety or depressive disorder?
Is this some other emotional distress presenting as physical distress?

Management in non-psychiatric settings

Psychiatric management

How do I discuss making a referral to a psychiatrist?

What is the prognosis?

Additional educational resources
Information resources for healthcare professionals
Information resources for patients

Ongoing research priorities

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