Management of medically unexplained symptoms
BMJ 2004; 330 doi: https://doi.org/10.1136/bmj.330.7481.4 (Published 30 December 2004) Cite this as: BMJ 2004;330:4All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Thank you for the many responses to our editorial. In reply, we would like to make some general comments and clarifications. Evidence about medically unexplained symptoms is growing in these years and we find it important to rely on this evidence instead of trusting in opinions and experiences.
‘Medically unexplained symptoms’ (MUS) is a purely descriptive term and does not imply a psychological or any other genesis of the patients’ symptoms. Often patients have multiple problems when presenting physical symptoms and it is important to be able to take biological, psychological and social approaches simultaneously, especially when the patients’ symptoms are medically unexplained. Furthermore, research point to the importance of acknowledging the patients’ symptoms and not blaming the patient for them.
‘MUS’ is not a real diagnosis but it is a useful construct. We need such a construct, just like we need diagnoses, in order to conduct rigorous research and to make appropriate management decisions and predict prognosis with regard to the large number of patients presenting with MUS or functional somatic symptoms.
The question about long-term follow-up is often asked. At present studies have shown, that MUS often remain medically unexplained, that is, no physical cause is found (ref 1-4) but of course further follow-up studies would be of great interest.
Concerning management, we must be aware that the actions we take also have costs. If we are focussing on physical disease only we also lock the patient on this approach and they may run the risk of iatrogenic harm.
Furthermore, the patient is restrained from relevant and effective treatment as for example cognitive behavioural therapy. We agree that all patients may profit from better communication and better consultations skills. However, these general skills are not sufficient in the treatment of MUS. Specific treatment strategies are also necessary. We agree that stepwise care would be a very constructive solution. We cannot expect general practitioners to become specialists in cognitive behavioural therapy and we need specialist treatment for the most severe cases of patients with MUS. On the other hand MUS is so frequent in primary health care that specialist treatment will never be available for all of them and general practitioners must be able to manage the majority of these patients.
1. Kroenke K,.Mangelsdorff AD. Common symptoms in ambulatory care: incidence, evaluation, therapy, and outcome. Am.J.Med. 1989;86:262-6.
2. Wilson A, Hickie I, Lloyd A, Hadzi-Pavlovic D, Boughton C, Dwyer J et al. Longitudinal study of outcome of chronic fatigue syndrome. BMJ 1994;308:756-9.
3. Crimlisk HL, Bhatia K, Cope H, David A, Marsden CD, Ron MA. Slater revisited: 6 year follow up study of patients with medically unexplained motor symptoms. BMJ 1998;316:582-6.
4. Gureje O,.Simon GE. The natural history of somatization in primary care. Psychol.Med 1999;29:669-76.
Competing interests: None declared
Competing interests: No competing interests
I have read with great interest the editorial of Rosendal et al (1). However, I have just published on the official Journal of the FADOI (The Italian Society of Internal Medicine Hospitalists) a paper entitled “A new approach of scientific evidences in clinical practice: the uncommon clinical pictures” (2). The Journal is not indexed in MEDLINE even though more than 3000 internists, spread over Italy, read it. That could represent a publication bias for international readers. So, it could be useful for your readers to know a different point of view on this topic.
Unexplained signs or symptoms, when they have clinical relevance, can be better defined as “uncommon clinical pictures”, and I proposed a structured method to possibly resolve them. I report the experience, lasting for approximately a decade, about the use of bibliographic databases (MEDLINE, etc.) as diagnostic/therapeutic decision-making support. A method has been developed that is based firstly on anamnestic/clinical data analysis. Then, a search method is used to construct a search string to seek out and retrieve bibliographic citations. After a systematic review of all retrieved citations and their findings, related to the specific clinical picture, a decision should be taken by a clinical audit. After all, by this paper, I propose a work hypothesis for the scientific community in order to rehabilitate and effectively make use of a type of scientific literature, until now, considered a low level of evidence(case-report, case-series etc.)In my opinion, this work hypothesis both completes Rosendal’s considerations and proposes a new management strategy of uncommon clinical pictures for quality of care improvement and related health-care expenditure control.
1)Rosendal M, Olesen F, Fink P. Management of medically unexplained symptoms BMJ 2005;330:4-5
2)Corrao. S. Un nuovo approccio all’implementazione delle evidenze scientifiche nella pratica clinica: i casi clinici non comuni. GIMI 2004; 3: 108-111.
Competing interests: None declared
Competing interests: No competing interests
EDITOR- The editorial by Rosendal et al. sounds surprising indeed. 'At least 20-30% of primary care patients have medically unexaplained symptoms' and all our application should be nothing more that adding psycho-social supplements to the accustomed clinical explanations? Are there alternative meanings of 'to broaden the agenda ... including psychosocial factors'(1)?
Passing over the unlikely GPs' competence or substantiality about the management of problems beyond their traditional biological education, symptoms which recur so numerous and frequent and 'do not fit into the existing framework' perhaps deserve theoretical researches with regards to a different model of construction(2).
We think the critical point is that of a less elusive system to make sense to those patients' specific concerns which lack a convincing clinical understanding; the crux of the matter really is the reference frame. But persisting into the actual body-mind dichotomy(3), even if half -hidden through bio-psycho-social patchwork, we'll not take any steps to get a more reliable professional equipment.
References:
1. Rosendal M., Olesen F., Fink P. Management of medically unexaplained symptoms. BMJ 2005; 330:4-5. (1 January.)
2. Damasio AR. Descartes' Error: Emotion, Reason and the Human Brain. New York : Grosset/Putnam, 1994.
3. Damasio AR. The Feeling of What Happens: Body and Emotion in the Making of Consciousness. New York: Harcourt Brace, 1999.
Competing interests: None declared
Competing interests: No competing interests
Medically unexplained symptoms includes a body of doctors who are dealing with something that perhaps they have not come across before, or are unable to think about the actual diagnosis “i.e. not thinking of the bigger picture”. Susanne Macabe rightly asks about case studies for long-term follow up of these patients that is if, of course, that they are actually followed up rather than ignored and what their eventual diagnosis is. Perhaps, then doctors would learn from this experience.
There are many people with chronic fatigue, ME/MS autoimmune type disease such as lupus, lyme disease, thyroid disorders, depressive type illnesses that do take a considerably long time to diagnose often years because the symptoms are so vague.
There are other such illnesses which are diagnosed initially as “a virus” turn out to be completely different and are, in fact, serious illness. An example of this, is my own son who later was diagnosed with sub-actuate bacterial endocarditis, no blood cultures were taken on initial consultation, developed complications and died despite his symptoms consistent with a potential diagnosis. He was a patient with severe multiple congenital heart disease at birth.
To me, medically unexplained symptoms are those doctors who are completely out of their depth, incompetent and have no time for the patient or the mother.
Perhaps proper note taking, obtaining a family history, communication not just with the patient but with other colleagues who are more experienced, undertake investigations and subsequently review them?
Staying away from such non-sense diagnosis as Munchausen syndrome by Proxy, exaggeration, fabrication, somatization etc etc. Then you might be able to come to some conclusion pretty quickly.
Competing interests: None declared
Competing interests: No competing interests
I and others have reviewed families' medical records where a parent has been accused of Munchausen's Syndrome by Proxy (MSBP) and found that a clinician's inability to diagnose a genuine illness in a child turns to suspecting MSBP, without having sought an opinion from an appropriate specialist. It's a wonderful short cut, especially when the parents complain about the management of the case, as has happened.
How often have symptoms caused by medications inappropriately prescribed (unlicensed for paediatric use - cisapride for example) been blamed on the mother? When the child is removed from parental care the medication is discontinued so of course the symptoms ceased. QED MSBP.
How often when illnesses spontaneously go into remission after separation (as some do but just ignore the occasional repeat of milder symptoms which still occur in foster care or on the ward, as has happened) does this confirm MSBP.
Where exactly should MSBP stand now in the differential diagnosis when a child's illness is (so far) medically unexplained, given concerns that have arisen about MSBP's architect and his chief supporters?
Competing interests: None declared
Competing interests: No competing interests
Medically Unexplained Symptoms: Different Diagnosises Needing Different Interventions
Management of medically unexplained symptoms has been discussed by Rosendal M et al.(1). However, it seems some points remain.
The term illness behavior describes patients' reactions to the experience of being sick. Illness behavior and the sick role are affected by people's previous experiences with illness and by their cultural beliefs about disease. The influence of culture on reporting and manifestation of symptoms must be evaluated. For some disorders this varies little among cultures, whereas for others the way a person deals with the disorder may strongly shape the way the condition presents itself.(2) Concerning patients consulting a physician, after doing appropriate evaluations, if there are medically unexplained symptoms, it doesn't necessarily mean the demonstration of mental disorder. Some mental disorders which may be related to presenting physical symptoms are depressive disorders (at least half of persons with major depressive disorder somatize, especially with fatigue, headache, and abnormal pain)(3), anxiety disorders such as panic disorder, somatoform disorders, some psychotic disorders (e.g., patients with somatic delusions), factitious disorder, malingering, and etc, each of each needs meeting specific criteria (and not merely ruling out general medical conditions) as well as specific interventions. Patients with medically unexplained symptoms are the best paradigm for the benefits of a team approach by mental health and primary care. It is important to differentiate "psychological factors affecting medical condition" from psychosocial factors causing them. It must be kept in mind that "all patients" not just ones with medically unexplained symptoms, need physicians' biopsychosocial point of view in evaluation and treatment of symptoms.
And as the last point, the class so-called "unclassified", "idiopathic", "not otherwise specified", and the like in classification of diseases and clinical manifestations in medicine-which physicians generally don't like using it as a diagnosis- shouldn't be neglected in patients presenting with physical symptoms medically unexplained.
1. Rosendal M, Olesen F, Fink P. Management of medically unexplained symptoms. BMJ, Jan 2005; 330: 4-5.
2. Contributing editors. The Doctor_Patient Relationship and Interviewing Techniques. In: Sadock BJ, Sadock VA. Kaplan & Sadock's Synopsis of Psychiatry. 9th ed. Philadelphia: Lippincott Williams & Wilkins; 2003: 2.
3. Lipkin MJR. Primary Care and Psychiatry. In: Sadock BJ, Sadock VA. Kaplan & Sadock's Comprehensive Textbook of Psychiatry. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2000: 1931.
Competing interests: None declared
Competing interests: No competing interests
Can you kindly give some references to studies you mention re long term follow up of people with unexplained symptoms. Thanks
Competing interests: None declared
Competing interests: No competing interests
Dear Sir
I find myself very much agreeing with Dr David Derauf when he says that "our approach to caring for patients with medically unexplained symptoms should begin with a careful appraisal and assessment of our approach to caring for ALL patients". MUS and multiple morbidities are our chance to upraise the evidence for our intraconnectdness.
However,thanks to Descartes, we are still examining (and teaching people to examine), people, in an order: conventionally, the physical first, followed by the mental (if we have time). It is extraordinary that so many clinicians and services continue to re-iterate time-expired and non evidence-based paradigms and the mind-brain can be so excluded from our overall assessment of a person. Every week, the BMJ alone iterates further evidence of the way in which we are all "wired for health". Even in the absence of caseness, people are usually in predicaments before they acquire a diagnosis (it can often be better to avoid one when putting people in touch with themselves and helping them to make sense of their physical symptoms in relation to life circumstance, whether as cause, effect, or both).
The new GP UK contract also perpetuates a mindless approach through considering the management of "mental health" (let alone "mental illness) as reducing to two tasks: namely, the production of a 'register' of people with "severe and enduring" mental illness (a variously interpreted non- diagnosis, but usually interpreted as schizophrenia and bipolar disorder) and a register of people taking lithium. Apparently, these are the only two areas of primary care clinical practice where there is enough evidence to support intervention. Furthermore, depression (and not even anxiety) are now kicked into the long grass of indifference through the provision of 'enhanced' services (basically, 'non-core' services that are provided if PCTs can find enough money to provide them, or feel are worth bothering about).
As for medically unexplained symptoms (I like "not yet diagnosed", even if it does rather play into the potential trap of endless medical investigation), you could expect that, unless the modern GP can find evidence of diabetes, IHD or cancer, you might as well pack your bags and prepare for a long wait for more enlightened times.
How is the mighty primary care profession fallen in the UK. That the mind-brain and its associated complexity and 'wiring' should be reduced down to the level of hen-pecking simplicity oft makes me want to weep. It is truly remarkable that it could only be the future GPs with a 'special interest' who will have the naus and nerve to tackle emotions and feelings. It is unthinkable that we would train doctors NOT to be able to deal with diabetes or IHD as core elements of their day-to-day practice. A so-called, and self-appointed, 'first-world country' has every right to be downgraded if its doctors do not have the skills and capabilities necessary to deal with people in a wholistic way and address the 'mental' issues. That is how we work and the caring professions should reflect that reality.
Helping people to understand their connectedness (at times when they often feel the opposite)is also one of the best ways to defuse the self- stigmatising notions that attach to such statements as "so you think it's all in my mind, doctor?". Why should anyone be ashamed of that? If we all bothered to understand the latest evidence relating to mind/brain-body connectedness anyway, we would remain in awe, and not feel we are being reduced down to the sum of our parts, because there are billions of them anyway.
We need to help people to understand that our mind and its mentality are part of what the brain "does" (Steven Pinker) and are delivered and governed by the same physical laws and processes, as deliver all the physical processes and attributes of every other physical organ in the body. We do not have to go to the planet Zog for special understanding or carry on thinking that brains and bodies operate in different cosmologies.
One would have thought that matters of the mind-brain would, by now, be in the mainstream of clinical care. Sadly, this is not the case and the stigma and discrimination that surround the word 'mental' will continue to blight our lives and services, until we finally "Dump Descartes" and deliver a physical understanding of the term and its reality.
Furthermore, whether we are seeing people with explainable, unexplained, or even inexplicable, symptoms, a highest common factor approach based on the latest evidence and interventions, would surely benefit ALL consultations with conscious human beings...and if unconscious, would still ensure dignity and respect.
Yours Faithfully
Dr Chris Manning www.primhe.org
Competing interests: None declared
Competing interests: No competing interests
We were very pleased to read the editorial by Rosendal,Olesen and Fink. Inappropriate medical treatments and referrals are not only bad medicine but are costly bad medicine.Whether patients presenting with medically unexplained symptoms are the victims of poor diagnostic skills by their doctors, or show poor self reflection by the patients themselves is largely irrelevant- as the evidence shows that treatable organic disease is rarely found on long term follow up of these patients. The doctor remains confused, irritable, blaming and hostile(or gives yet another useless prescription) and the patient leaves feeling ignored,unheard, blamed and still with the symptoms.
Simple reattribution techniques are commonly used already by most GPs - explaining tension headaches or panic attacks for example. Thus it is likely that increased use of such techniques can fit in with the current acceptability of a joint biological and psychosocial model of illness and help patients with more minor or acute symptoms. However we wonder whether such an approach will help patients with longstanding and complex complaints who are likely to return to primary care repeatedly after secondary referrals fail to lead to any diagnosis. Such patients are a substantial part of many GPs workload and it may be more constructive in such cases to offer joint appointments with the GP and a psychotherapist.In this way patients can feel listened to, the GP can feel supported and the therapist can offer some insights into the consultation process.Such consultations can help free a "stuck" pattern and improve the relationship between doctor and patient.We feel that primary care mental health provision should try new ways of working which offer help to patients and doctors alike.We can then hopefully move away from considering medically unexplained symptoms as either physical or psychological in origin, towards thinking of them as starting points for the doctor, therapist and patient to explore together.
Competing interests: None declared
Competing interests: No competing interests
Re: Authors’ reply to the rapid responses concerning the editorial ‘Management of medically unexplained symptoms’
Sorry to be 'picky' but the language used to refer to people with medical conditions is important as it can convey an underlying attitude which may be inappropriate.
eg., in this case....re '..General Practitioners must be able to MANAGE the majority of patients' People are not managed by healthworkers. They may help the person manage or treat a condition or they may even 'Care' for people - but the introduction of 'managementspeak'does not properly reflect the relationship between individuals and healthworkers.
Competing interests: None declared
Competing interests: No competing interests