assessment and management of patients with medically unexplained symptoms in primary care

8/13/2019 Assessment and Management of Patients With Medically Unexplained Symptoms in Primary Care

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DISORDERS WITH SOMATIC PRESENTATION

2006 Elsevier Ltd65PSYCHIATRY 5:2

ASSESSMENT AND MANAGEMENT

What are medically unexplained symptoms?

Medically unexplained symptoms (MUS) are physical symptoms

that doctors cannot explain by organic pathology, which distress

or impair the functioning of the patient. MUS include distress or

impairment of function that is disproportionate to the underlying

physical pathology. While MUS are not explainable by lasting

organic pathology they do have a physiological explanation that

is usually reversible and temporary, although they may last forsome considerable time. The definition is similar to the DSM-IV

diagnostic category of undifferentiated somatoform disorder, except

that it includes patients with mood disorder, anxiety disorder and

other somatoform disorders, including functional disorders such

as chronic fatigue syndrome or fibromyalgia.

Advantages of the term medically unexplained symptoms

General practitioners (GPs) prefer the term MUS because it makes

no underlying assumptions about the presence of mental disorder

or psychosocial problems, and it is more practical in busy surgeries

than some definitions of somatoform disorder that require lifetime

symptom counts. Primary care works on the basis of probabilities.

The definition of MUS allows the GP to make decisions on thebasis that the symptoms have been precipitated or exacerbated by a

psychosocial problem or have a physiological explanation, without

entirely ruling out an organic pathological basis to the problem.

Often patients identified by GPs as having problems with MUS

regularly attend surgery on some occasions with MUS, but also

attend with one or more ongoing chronic medical problems.

Relationship of MUS to depression and anxiety disorders

Patients with MUS often have mood or anxiety disorders but there

are also many MUS patients without mood or anxiety disorders.

Assessment andmanagement of patientswith medically unexplained

symptoms in primary careRichard Morriss

Linda Gask

Richard Morriss is Professor of Psychiatry at the University of Liverpool

and Honorary Consultant Psychiatrist at Mersey Care NHS Trust. His

research interests include bipolar affective disorder, somatization, mood

disorder, suicidality, chronic fatigue syndrome, primary care psychiatry,

psychological treatment and service delivery of effective treatments.

Linda Gask is Professor of Primary Care Psychiatry at the University of

Manchester and Honorary Consultant Psychiatrist at Bolton, Salford and

Trafford Mental Health Partnership Trust. Her research interests include

provision of training in mental health skills, mental health problems in

primary care, and mental health policy.


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The MUS and mood or anxiety disorder may have started at the

same time, or the mood or anxiety disorder may have preceded

or followed the MUS. The MUS may be the first symptom of the

depression or anxiety disorder but sometimes the depression or

anxiety disorder seems to arise as the consequence of the impaired

loss of function or role brought on by MUS. More commonly, MUS

are associated with life stress or lifestyle such as time pressure,

or periods of inactivity followed by frantic efforts to catch up onduties that were neglected during the period of inactivity.

The extent of the problem

The point prevalence of MUS lasting all the time or on a regularly

recurrent basis for six months in the general population is around

20%.1Patients with MUS account for around 50% more visits to

primary care doctors, one-third more outpatient costs and one-third

more hospitalizations than patients without MUS. Patients with

MUS for six months or more are usually distressed or functionally

impaired by the same or other MUS 12 months later.

GPs perception of MUS:patients with MUS are rated by their GPs

as being four times more difficult to manage than other patients.A large part of a GPs workload consists of patients with MUS

who are too numerous to refer to other health professionals or

services. Furthermore, patients with MUS are unwilling to see other

healthcare professionals because they seek the GPs diagnostic

skills and the legitimacy that the GP can bring to their perceived

physical health problem. However, GPs express lower satisfaction

with care for patients with MUS than patients with psychological

problems or physical health problems. Surveys suggest GPs receive

little formal training in the assessment and management of MUS

but many GPs would like to receive such training.

Assessment and management of MUS by GPs

Obstacles

Any approach to the assessment and management of MUS must

be compatible with the patient-centred communication, the full

range of physical and psychosocial health problems, and relatively

short duration of consultations typical of primary care.

Patient-centred communication has five features, it:

explores the patients main reason for the visit, concerns and

need for information

seeks an integrated understanding of the patients world, i.e.

their whole person, emotional needs and life issues

finds common ground on what the problem is and mutually

agrees on management

enhances prevention and health promotion enhances the continuing relationship between the patient and

doctor.

Patient-centred communication is not effective unless the patients

main health concerns are adequately explored and addressed.

Patientdoctor communication agendas there are some

significant obstacles to delivering fully patient-centred care for

patients with MUS. Patients agendas are complex and it is probably

impossible to establish all of the patients agenda in one primary

care consultation. Furthermore, the patients past experience of

illness and treatment by health professionals or other authority

figures will shape the patients current agenda as will age, gender,

culture and family experience of illness. Doctors are not passive

communicators, so doctorpatient communication is inevitably a

product of the agendas of both patient and doctor.

Organization of care increasingly, UK primary care has become

more concerned about access to care and meeting specific targets

within the new GP contract, so that patients often do not see the

same doctor on a regular basis. Patients with MUS and GPs are

most satisfied with the care provided for MUS when it has been

consistently applied by the same GP or primary care team over anumber of years. Patients with MUS are least satisfied with GPs who

seem concerned only about ruling out physical health problems

and failing to address psychosocial issues when they are present.

Healthcare systems worldwide do not provide incentives for manag-

ing patients with MUS effectively. Arguably, patients with MUS are

the most needing of the diagnostic and management skills of GPs

since most chronic medical care can be provided by primary care

nurses working to protocols under the supervision of GPs.

Routine care

GPs usually talk to patients with MUS about their symptoms in

an unstructured way, investigate, provide reassurance, sanction

time off work, prescribe symptomatic relief, exercise, psycho-tropic drugs (usually antidepressants, sedatives and hypnotics),

and refer to physiotherapy, community nursing and counselling

services, and hospital medical and surgical care. There is little

short-term evidence of improved symptoms or function with such

an approach.

Care sought by patients with MUS: patients with MUS are

often perceived to put pressure on GPs for investigations, drug

prescriptions and referrals. Frequently patients with MUS do not

ask for these interventions but put pressure on GPs (Figure 1) to

convey the reality of their suffering to the GP.2Patients with MUS

are seeking:

recognition from their GP of their distress

Patients with medically unexplained symptoms seekrecognition of their distress Use of graphic and emotional language to describe symptoms,

e.g. nightmare

Effects of symptoms on patients daily living, e.g. cant sleep

so cant work

Patient gives biomedical explanation for symptoms to discuss

with GP, e.g. wind, arthritis

Emotional distress caused by symptoms, e.g. worry, being

scared

External authority other people, usually family, vouch for

severity of symptoms

Invalidating doctors explanations by giving additional

symptoms or complexity of problems

Invalidating doctors explanations by giving patients own

alternative explanation for symptoms

Invalidating doctors explanations by emphasizing the

ineffectiveness of previous treatments

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to form an alliance with the GP to understand their health

problems through discussion and appropriate examination or

investigation

to feel that their problems are considered legitimate concerns

by the GP rather than to be blamed for their problems or con-

sidered wasteful of the GPs time.3

Communication by GPs: poor communication by their GP doesnot meet the patients needs (Figure 2). Patients with MUS accept

explanations from GPs that provide mechanisms for symptoms that

are grounded in the patients concerns, including linking physical

and psychosocial factors when relevant. Most consultations with

patients with MUS provide opportunities to discuss psychosocial

issues. Sometimes GPs respond to these patient cues but with-

out explaining how psychosocial issues relate to physical health

problems so the patient with MUS thinks they have two unrelated

health problems, one unexplained physical problem and a separate

psychological problem.4

Enhanced care

Symptom beliefs:patients with MUS in primary care often havebeliefs about symptoms that are discrepant with medical knowl-

edge, but carefully reasoned and firmly held, after prolonged

reflection and information-gathering from many sources such as

family, media, complementary medicine and other doctors such

as hospital specialists.5The patients symptom beliefs reflect both

individual experiences and cultural themes such as invasion of

the body, wearing-out of body parts, faulty wiring or plumbing,

or the body is out of balance physically, chemically or spiritually.

GPs who do not seem knowledgeable or interested in the patients

symptoms or their symptom beliefs will have little influence on

the symptom beliefs of the patient. Patients are likely to reject

explanations that contradict their own sensory knowledge of their

symptoms and do not take seriously their own explanations forthese symptoms when they are well formed.

Poor communication responses from GPs

GP withholds important information from physical examination

or investigations (including normal)

GP denies the reality of the patients concerns (its all in the

head)

GP passively accepts the patients own explanation for

symptoms without discussion GP gives a double message that there is no reason for concern

while giving the patient medication or precautionary advice

e.g. there is nothing wrong with your heart but next time you

get chest pain slip this tablet under your tongue

GP gives rudimentary reassurance without explanation

(reduces distress for less than 24 hours)

GP gives reassurance with ineffective explanation unrelated to

patients expressed concerns

GP ignores patients attempts to discuss emotional or social

issues by reasserting a physical health agenda

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Effects of symptom beliefs on patient outcome the MUS

patients perception that the GP has understood their problems pre-

dicts less distress from symptoms at one month, and the patients

perception that they have received an adequate explanation from

the GP predicts less distress at three months.6Symptom beliefs

predict distress, function and healthcare consumption over the

following 12 months (Figure 3). Ideally the GP would know the

symptom beliefs of a patient with MUS before providing an expla-nation for the symptoms to the patient. Provision of an explanation

that fits with the patients sensory experience of their symptoms

and addresses or modifies the patients symptom beliefs through

explanation seems to improve patient satisfaction with GP care

and improve function for three months or more.

Reattribution was devised by Goldberg and Gask to provide

GPs with a structured approach to a consultation with a patient

presenting with a physical health complaint but with an underly-

ing depression or anxiety disorder (somatized mental disorder or

SMD).7Reattribution starts off in the same way as any GP consulta-

tion, provides patient-centred communication, addresses symptom

beliefs, and seeks to provide an explanation of physical symptomsthat links to psychosocial issues when they are present. Reattribu-

tion does not require specialist mental health skills to implement

but GPs need to be skilled in patient-centred communication, be

able to accurately detect emotional distress, and know how to sup-

port and provide routine management of depressive and anxiety

disorders. Reattribution may require a single consultation or may

be delivered over a series of consultations.

Outcomes of reattribution in one before and after study of

215 patients and 8 GPs, patients with SMD showed improvements

in symptom beliefs, patient satisfaction, mental disorder, function

and health costs outside primary care over three months.8In the

light of comments from GPs and research on GPpatient commu-

nication, reattribution has been modified by Morriss and Gask sothat it can now be applied to all MUS patients (not just those with

SMD), and requires 6 hours of training given by trained health

educators on site to GP practices (Figure 4). Other groups from the

Netherlands, Germany and Denmark have conducted randomized

Important properties of symptom beliefs

Nature physical, psychological, normalizing (part of everyday

experience)

Cause e.g. germ, body part worn out

Severe trivial, potentially catastrophic or catastrophic

consequences

Timeline short-lasting or long-lasting

Controllability by patient, by others including health

professionals, out of control

Exacerbating factors e.g. harmful effects of exercise on

fatigue or body pain

Relieving factors e.g. benefits of complete rest on fatigue or

body pain

Fixity of beliefs certainty of above symptom beliefs held by

patients

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controlled trials (RCTs) of extended versions of reattribution. All

of these studies show at least some benefits compared to usual

care of the GP in terms of function, symptoms, healthcare and

benefit use over 24 months, and on function compared to training

delivered to GPs on patient-centred care for depression and anxiety

over six months. There are concerns whether GPs would use reat-

tribution consistently in busy routine practice outside of research

conditions, partly because reattribution may require longer thana single ten-minute consultation to implement successfully.Other approaches to the management of MUS in primary care

Meta-analysis of RCTs shows that antidepressants have efficacy in

painful and gastrointestinal MUS for two months but no efficacy for

chronic fatigue.9Graded aerobic exercise shows short-term efficacy

for chronic fatigue, chronic back pain or chronic widespread pain

for three months but probably not for other MUS. However, the

effects of graded exercise are weak unless accompanied by modi-

fication of symptom beliefs, or careful patient selection removing

Reattribution

Stage 1: feeling understood

GP takes history of presenting physical symptoms, other

associated physical symptoms, emotional symptoms and

psychosocial factors, symptom beliefs, past similar symptoms

and management, brief focused physical examination

Stage 2: broadening the agenda

GP feeds back results of physical examination and any

investigations (including no or minor abnormalities), explains

implications of findings (i.e. lack of serious underlying

pathology), acknowledgement of patients presenting

symptoms with associated distress and impairment of function,

explores possibility that physical symptoms might be linked to

psychosocial factors

Stage 3: making the link

GP links the physical symptom to an underlying psychosocial

or lifestyle issue using a normalizing physiological, temporal or

social link. Examples: stress at home causes muscles in your

body such as your back to tense and muscles held tight for long

periods ache, backache occurs each time you row with your

partner, talking about your problems now have brought on your

back pain, frustration about not working leads to depression

and depression lowers the pain threshold and makes you tired,

when your parents rowed at home your mother went to bed

complaining of a headache and now each time you have a row you

get a headache

Stage 4: negotiating further treatment

No further follow-up or treatment required, further review of

symptoms and psychosocial factors over time to test or refine GPs

explanation, symptomatic treatment or treatment of underlying

psychosocial or lifestyle issues

patients with significant psychosocial problems or difficulties with

the sleep cycle. Disclosure of underlying psychological problems

without relating them to physical complaints is ineffective for

patients with MUS in primary care. Cognitivebehavioural therapy

(CBT) appears to be effective for MUS in primary care but it is an

approach that many GPs believe to be beyond their competence.

Approaches for chronic MUS involving frequent attendance

regular appointments by GPs to listen supportively and carry outbrief physical examination but no investigation or referral without

evidence of possible disease from physical examination has improved

physical function and reduced healthcare use among patients with

chronic MUS with frequent healthcare consultation. However,

there have not been consistent improvements in the patients own

subjective health, psychological distress or social function with this

approach. The approach remains important for patients with MUS

with fixed symptom beliefs and high healthcare use. The GP may

need to plan to see the patient on a weekly or twice-weekly basis

to stop emergency call-outs and then gradually wean the frequency

of consultation to monthly or even less often.10

Conclusion

MUS patients seek GPs who take their concerns seriously and

legitimize their complaints. They do not necessarily expect a cure

but they seek an alliance to help them understand their health

problems. Modification of symptom beliefs, explanations linking

physical problems to psychosocial issues when they are relevant,

antidepressants and graded exercise for some types of MUS seem

to be worth trying by GPs in patients with MUS. Reattribution

provides all of these strategies in a structured consultation. GPs

should expect patients with MUS to require these approaches to

be given each time they present with MUS until the patient learns

to recognize and manage the MUS themselves. Some patients

with chronic MUS and high consultation behaviour will requireregular consultations with a single GP who restricts the use of

investigations, prescriptions and referrals. CBT seems an effective

second-line treatment for patients with MUS who are unresponsive

to first-line treatment and willing to seek further help. However, at

present primary care is largely left to manage patients with MUS

on their own except in a few centres where liaison psychiatry

or clinical psychology services extend their services outside the

general hospital to general practice.

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