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DISORDERS WITH SOMATIC PRESENTATION
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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
2
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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