Medically unexplained physical symptoms

Medically unexplained physical symptoms (MUPS) or medically unexplained symptoms (MUS) are patient symptoms for which the treating physician, other healthcare providers, and research scientists have found no medical cause. The term does not necessarily imply that a physical cause does not exist, but rather notes that cause(s) for given symptoms are uncertain, unknown or disputed—there is no scientific consensus. A task force of the US National Institutes of Health states, "Medically unexplained syndromes (MUS) present the most common problems in medicine."^[1]

Estimates of primary care consultations with medically unexplained symptoms range from 15%^[2] to a high of 66% in specialty settings.^[3] Psychiatric co-morbidity is common,^[2][4][5] but symptoms may not be due exclusively to psychiatric factors^[2][3][5][6] and there may be a strong association between psychiatric morbidity and physical symptoms irrespective of whether they have a medical explanation or not.^[7] Association with depressive and anxiety disorders increases with the number of unexplained symptoms reported,^[8][9] but medically unexplained symptoms "as a whole" are not necessarily associated with depression and anxiety.^[10]

Physical symptoms have been associated with adverse psychosocial and functional outcome across different cultures, irrespective of etiology (either explained or unexplained).^[11] One use of the term MUS is in reference to the overlapping symptoms present in a variety of conditions such as chronic fatigue syndrome, fibromyalgia, multiple chemical sensitivity, somatoform disorder, and Gulf War Illness, which also share a significant overlap in treatment.^[12][13]

History and usage

MUPS may be synonymous with somatization disorder^[14] or psychosomatic illness, where the cause or perception of symptoms is mental in origin, or may overlap these terms or be a "lower threshold variant" of them.^[15] Because several definitions of both somatization and MUPS exist, and the usage of both terms is inconsistent in medical literature and practice, MUPS is sometimes used interchangeably with somatization and functional somatic symptoms,^[16] although "somatised mental distress" and "somatisation disorders" (based on symptom counts) may not adequately account for most patients seen with MUPS.^[12]

A study of terms related to MUPS found that patients often object to the phrase "medically unexplained." The study revealed differences between patients' and doctors' opinions. For example, patients preferred terms using the word "functional" although doctors felt this word was potentially offensive.^[17]

When a cause for MUS is found, the symptom(s) are no longer medically unexplained. Some cases of ulcers and dyspepsia were considered MUS until bacterial infections were found to be their cause.^[18]

Contested causation

The lack of known etiology in MUPS cases can lead to conflict between patient and health-care provider over the diagnosis and treatment of MUPS. This conflict can occur in the public arena and may involve media controversy, advocacy groups, scientific and political debate and even legal proceedings.^[19]

Diagnosis of MUPS is seldom a satisfactory situation for the patient, as many patients feel this implies it is "all in their head." This can lead to an adversarial doctor-patient relationship,^[19] which can develop into an iatrogenic neurosis,^{[citation needed]} thus complicating the situation. A 2008 review in the British Medical Journal stated that a doctor must be careful not to tell a patient that nothing is wrong, "as clearly this is not the case." The symptoms that brought the patient to the doctor are real, even when the cause is not known. The doctor should try to explain the symptoms, avoid blaming the patient for them, and work with the patient to develop a symptom management plan.^[20]

According to psychiatrist Simon Wessely, "Various names have been given to medically unexplained symptoms. These include somatisation, somatoform disorders and functional somatic symptoms."^[14] He writes that "a substantial overlap exists between the individual syndromes and that the similarities between them outweigh the differences." In reply, the psychiatrist Peter White has stated that "the concept of a general functional somatic syndrome is unhelpful in understanding illness, aetiology, treatment and outcome".^[21] In another publication, Wessely states that providing a label for a set of symptoms "is not a neutral act, since specific labels are associated with specific beliefs and attitudes," and "even when organic illness is certain, the illness label can result in adverse behaviour changes.", while there is conflicting evidence on whether such labelling is helpful.^[22]

Luxembourg et al^[23] write that a substantial portion of MUPS and associated somatoform disorders have a clearly-identified cause: repeated psychological traumas, particularly during childhood. Evidence indicates that repeated abuse or other traumas often leads to disturbed lymphatic system functioning, under-production of cortisol and overproduction of endogenous opioids, all of which can contribute to MUPS. Those who were seriously traumatized on three or more occasions during childhood were substantially more likely than a control group to develop such difficult-to-treat MUPS as chronic headaches, pelvic pain, and seizures. Trauma researcher Bessel van der Kolk^[24] has noted that chronically abused persons sometimes report a baffling array of MUPS while simultaneously reporting none of the expected psychological distress related to their abuse; he further suggests that, due to severe dissociation, chronic physical symptoms are these people's only means of expressing what would otherwise be overwhelming emotional pain.

Treatment

The most effective current treatment for some medically unexplained symptoms is a combination of therapeutic approaches tailored to the individual patient. Most MUS patients are in need of psychotherapy, relaxation therapy and physiotherapy under medical supervision. A Combined therapeutic approach which is at least twice as effective as other therapeutic modalities published to date is described in Steele RE et al. "A novel and effective treatment modality for medically unexplained symptoms" ^[25] The next best documented approach is cognitive behavioral therapy (CBT), with evidence from multiple randomized controlled trials.^[15][26] Antidepressants may also help, but the evidence is "not yet conclusive."^[15] The effectiveness of CBT and antidepressants has not been studied for all medically unexplained symptoms, however. Evidence for a positive effect of CBT has been found in trials for fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, unexplained headaches, unexplained back pain, tinnitus, and non-cardiac chest pain.^[27] As of 2006, CBT had not been tested for menopausal syndrome, chronic facial pain, interstitial cystitis, or chronic pelvic pain.^[27]

For antidepressants, both tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) have been tested for some medically unexplained symptoms. TCAs have effects on IBS, fibromyalgia, back pain, headaches, and possibly tinnitus, and single studies show a possible effect in chronic facial pain, non-cardiac chest pain, and interstitial cystitis. SSRIs are usually not effective or have only a weak effect. One exception is menopausal syndrome, where SSRIs are "possibly effective" as well as a third class of antidepressants, the serotonin-norepinephrine reuptake inhibitors (SNRIs).^[27]

A randomized controlled trial of multi-faceted, collaborative care found some improvement in the mental health of people with forms of MUS involving somatoform disorders and psychological distress.^[28]

See also

• Culture-bound syndrome
• Somatoform disorders

References

1. ^ Hellhammer, Dirk H. Stress: The Brain-Body Connection. ISBN 3805582951. 
2. ^ ^{a b c} Explaining Medically Unexplained Symptoms Laurence J Kirmayer, MD, The Canadian Journal of Psychiatry, October 2004
3. ^ ^{a b} Nimnuan C, Hotopf M, Wessely S (2001). "Medically unexplained symptoms: an epidemiological study in seven specialities". J Psychosom Res 51 (1): 361–7. doi:10.1016/S0022-3999(01)00223-9. PMID 11448704. 
4. ^ Li, C. T.; Chou, Y. H.; Yang, K. C.; Yang, C. H.; Lee, Y. C.; Su, T. P. (2009). "Medically Unexplained Symptoms and Somatoform Disorders: Diagnostic Challenges to Psychiatrists". Journal of the Chinese Medical Association 72 (5): 251–256. doi:10.1016/S1726-4901(09)70065-6. PMID 19467948.  edit
5. ^ ^{a b} Henningsen, P.; Zimmermann, T.; Sattel, H. (Jul 2003). "Medically unexplained physical symptoms, anxiety, and depression: a meta-analytic review" (Free full text). Psychosomatic medicine 65 (4): 528–533. doi:10.1097/01.PSY.0000075977.90337.E7. ISSN 0033-3174. PMID 12883101. http://www.psychosomaticmedicine.org/cgi/pmidlookup?view=long&pmid=12883101.  edit
6. ^ Binder, M.; Campbell, A. (May 2004). "Medically unexplained symptoms and neuropsychological assessment". Journal of clinical and experimental neuropsychology 26 (3): 369–392. doi:10.1080/13803390490510095. ISSN 1380-3395. PMID 15512927.  edit
7. ^ Kisely S, Goldberg D, Simon G (September 1997). "A comparison between somatic symptoms with and without clear organic cause: results of an international study.". Psychol Med 27 (5): 1011–9. doi:10.1017/S0033291797005485. PMID 9300507. 
8. ^ Kroenke, K. (2003). "Patients presenting with somatic complaints: epidemiology, psychiatric comorbidity and management". International journal of methods in psychiatric research 12 (1): 34–43. doi:10.1002/mpr.140. ISSN 1049-8931. PMID 12830308.  edit
9. ^ Kroenke, K.; Rosmalen, G. (Jul 2006). "Symptoms, syndromes, and the value of psychiatric diagnostics in patients who have functional somatic disorders". The Medical clinics of North America 90 (4): 603–626. doi:10.1016/j.mcna.2006.04.003. ISSN 0025-7125. PMID 16843765.  edit
10. ^ Creed F (October 2006). "Should general psychiatry ignore somatization and hypochondriasis?". World Psychiatry 5 (3): 146–50. PMC 1636127. PMID 17139341. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1636127. 
11. ^ Kisely S, Simon G (February 2006). "An international study comparing the effect of medically explained and unexplained somatic symptoms on psychosocial outcome.". J Psychosom Res 60 (2): 125–30. doi:10.1016/j.jpsychores.2005.06.064. PMID 16439264. 
12. ^ ^{a b} Burton C (March 2003). "Beyond somatisation: a review of the understanding and treatment of medically unexplained physical symptoms (MUPS).". Br J Gen Pract 53 (488): 231–9. PMC 1314551. PMID 14694702. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1314551. 
13. ^ Richardson RD, Engel CC Jr. "Evaluation and management of medically unexplained physical symptoms." Neurologist 2004 Jan;10(1):18-30. PMID 14720312
14. ^ ^{a b} Wessely S, Nimnuan C, Sharpe M (1999). "Functional somatic syndromes: one or many?". Lancet 354 (9182): 936–9. doi:10.1016/S0140-6736(98)08320-2. PMID 10489969. 
15. ^ ^{a b c} Kroenke K (2007). "Efficacy of treatment for somatoform disorders: a review of randomized controlled trials". Psychosom Med 69 (9): 881–8. doi:10.1097/PSY.0b013e31815b00c4. PMID 18040099. 
16. ^ Rosendal M, Fink P, Bro F, Olesen F (2005). "Somatization, heartsink patients, or functional somatic symptoms? Towards a clinical useful classification in primary health care". Scandinavian Journal of Primary Health Care 21 (1): 3–10. PMID 16025867. 
17. ^ Stone, J.; Wojcik, W.; Durrance, D.; Carson, A.; Lewis, S.; MacKenzie, L.; Warlow, C. P.; Sharpe, M. (Dec 2002). "What should we say to patients with symptoms unexplained by disease? The "number needed to offend"". BMJ (Clinical research ed.) 325 (7378): 1449–1450. doi:10.1136/bmj.325.7378.1449. ISSN 0959-8138. PMC 139034. PMID 12493661. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=139034.  edit
18. ^ Jones, E. W. (Jan 2005). "War Syndromes: The Impact of Culture on Medically Unexplained Symptoms". Medical history 49 (1): 55–78. ISSN 0025-7273. PMC 1088250. PMID 15730130. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1088250.  edit
19. ^ ^{a b} Caring for Medically Unexplained Physical Symptoms after Toxic Environmental Exposures: Effects of Contested Causation Engel, et al. Environmental Health Perspectives, Vol 110, Nu. S4, August 2002.
20. ^ Hatcher, S.; Arroll, B. (May 2008). "Assessment and management of medically unexplained symptoms". BMJ (Clinical research ed.) 336 (7653): 1124–1128. doi:10.1136/bmj.39554.592014.BE. ISSN 0959-8138. PMC 2386650. PMID 18483055. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=2386650.  edit
21. ^ Wessely S, White PD. There is only one functional somatic syndrome. Br J Psychiatry. 2004 Aug;185:95-6. PMID: 15286058 [1]
22. ^ Page LA, Wessely S (May 2003). "Medically unexplained symptoms: exacerbating factors in the doctor-patient encounter.". J R Soc Med 96 (5): 223–7. doi:10.1258/jrsm.96.5.223. PMC 539474. PMID 12724431. http://jrsm.rsmjournals.com/cgi/content/full/96/5/223. 
23. ^ Toni Luxenberg, PsyD, Joseph Spinazzola, PhD, Jose Hidalgo, MD, Cheryl Hunt, PsyD, and Bessel A. van der Kolk, MD. (2001). "Complex Trauma and Disorders of Extreme Stress (DESNOS) Diagnosis, Part One: Assessment"Directions in Psychiatry, Vol 21.
24. ^ van der Kolk BA. The complexity of adaptation to trauma: Self-regulation, stimulus discrimination, and characterological development. In: van der Kolk BA, McFarlane A, Weisaeth L, eds. Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. New York: Guilford Press; 1996; 182–213.
25. ^ Steele RE, de Leeuw E, Carpenter D. "A novel and effective treatment modality for medically unexplained symptoms" J Pain Management 2009 1(4):201-212.
26. ^ Woolfolk RL, Allen LA, Tiu JE, "New directions in the treatment of somatization" Psychiatr Clin North Am. 2007 Dec;30(4):621-44
27. ^ ^{a b c} Jackson JL, O'Malley PG, Kroenke K (March 2006). "Antidepressants and cognitive-behavioral therapy for symptom syndromes". CNS Spectr 11 (3): 212–22. PMID 16575378. http://www.cnsspectrums.com/aspx/articledetail.aspx?articleid=417. 
28. ^ Smith RC, Lyles JS, Gardiner JC, et al. (2006). "Primary care clinicians treat patients with medically unexplained symptoms: a randomized controlled trial". Journal of general internal medicine : official journal of the Society for Research and Education in Primary Care Internal Medicine 21 (7): 671–7. doi:10.1111/j.1525-1497.2006.00460.x. PMC 1924714. PMID 16808764. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1924714. 

External links

• Medically Unexplained Physical Symptoms DHCC/DOD Pamphlet.
• Medically unexplained physical symptoms R. Mayou, British Medical Journal, 1991 September 7: 534–535.