Med/Psych Update

Medically unexplained physical symptoms: Evidence-based interventions

Current Psychiatry. 2011 July;10(7):17-32

References

1. Jackson JL, Kroenke K. Prevalence impact, and prognosis of multisomatoform disorder in primary care: a 5-year follow-up study. Psychosom Med. 2008;70:430-434.

2. Jackson JL, George S, Hinchey S. Medically unexplained physical symptoms. J Gen Intern Med. 2009;24:540-542.

3. Kroenke K. Efficacy of treatment for somatoform disorders: a review of randomized controlled trials. Psychosom Med. 2007;69:881-888.

4. Smith RC, Dwamena FC. Classification and diagnosis of patients with medically unexplained symptoms. J Gen Intern Med. 2007;22:685-691.

5. Nimnuan C, Hotopf M, Wessely S. Medically unexplained symptoms. An epidemiological study in seven specialties. J Psychosom Res. 2001;51:361-367.

6. Hotopf M, Mayou R, Wadsworth M, et al. Childhood risk factors for adults with medically unexplained symptoms: results from a national birth cohort study. Am J Psychiatry. 1999;156(11):1796-1800.

7. Smith RC, Gardiner JC, Lyles JS, et al. Exploration of DSM-IV criteria in primary care patients with medically unexplained symptoms. Psychosom Med. 2005;67:123-129.

8. Smith RC, Lyles JS, Gardiner JC, et al. Primary care clinicians treat patients with medically unexplained symptoms: a randomized controlled trial. J Gen Intern Med. 2006;21:671-677.

9. Henningsen P, Zimmermann T, Sattel H. Medically unexplained physical symptoms anxiety, and depression. A meta-analytic review. Psychosom Med. 2003;65:528-533.

10. Costa PT, McCrae RR. Neuroticism somatic complaints, and disease: is the bark worse than the bite? J Pers. 1987;55(2):299-315.

11. Gucht VD, Fischler B, Heiser W. Personality and affect as determinants of medically unexplained symptoms in primary care. A follow-up study. J Psychosom Res. 2004;56:279-285.

12. Smith RC, Lein C, Collins C, et al. Treating patients with medically unexplained symptoms in primary care. J Gen Intern Med. 2003;18:478-489.

13. McFarlane AC, Ellis N, Fasphm F, et al. The conundrum of medically unexplained symptoms: questions to consider. Psychosomatics. 2008;49(5):369-377.

14. Reid S, Wessely S, Crayford T, et al. Medically unexplained symptoms in frequent attenders of secondary health care: retrospective cohort study. BMJ. 2001;322:1-4.

15. Nimnuan C, Hotopf M, Wessely S. Medically unexplained symptoms: how often and why are they missed? QJM. 2000;93:21-28.

16. Salmon P, Humphris GM, Ring A, et al. Primary care consultations about medically unexplained symptoms: patient presentations and doctor responses that influence the probability of somatic intervention. Psychosom Med. 2007;69:571-577.

17. Salmon P, Ring A, Humphris GM, et al. Primary care consultations about medically unexplained symptoms: how do patients indicate what they want? J Gen Intern Med. 2009;24(4):450-456.

18. Peters S, Rogers A, Salmon P, et al. What do patients choose to tell their doctors? Qualitative analysis of potential barriers to reattributing medically unexplained symptoms. J Gen Intern Med. 2008;24(4):443-449.

19. Martin A, Rauh E, Fichter M, et al. A one-session treatment for patients suffering from medically unexplained symptoms in primary care: a randomized clinical trial. Psychosomatics. 2007;48:294-303.

20. Smith BJ, McGorn KJ, Weller D, et al. The identification in primary care of patients who have been repeatedly referred to hospital for medically unexplained symptoms: a pilot study. J Psychosom Res. 2009;67:207-211.

The estimated prevalence of somatoform disorder in patients with MUPS is approximately 4%, which is higher than in the general population (.2% to 2%).^7,8 On measures of mental and physical function, patients with MUPS who have somatoform disorders have been found to be more distressed than normal controls and patients with MUPS without somatoform disorders.⁸

Although few studies have directly examined the relationship between personality disorders and MUPS, there is evidence of an association between certain personality traits (eg, neuroticism, alexithymia, negative affect) and MUPS.^10,11

CASE CONTINUED: Rejected advice

Mrs. B has been worked up multiple times for acute coronary syndrome; been unsuccessfully treated for gastroesophageal reflux disease, lactose intolerance, and IBS; had a negative rheumatologic workup; and tried several medication regimens with no improvement in symptoms. Three years ago Mrs. B’s gastroenterologist implied her abdominal symptoms were caused by her history of sexual assault and suggested she seek psychiatric consultation. Offended, Mrs. B sought a second opinion and no longer sees her first gastroenterologist.

Barriers to treatment

Despite having high levels of psychosocial distress, health care utilization, and medical disability, patients with MUPS often are suboptimally treated. Factors that might contribute to this include:

inadequate identification
bias in diagnosis and treatment
poor follow-up on referrals
an absence of treatment guidelines.^7,12,13

Many clinicians are unaware of the high prevalence of MUPS, which often leads to repeated referral to specialty clinics, even when patients already have received an MUPS diagnosis.^12,14 Additionally, clinicians often are unaware of how individual biases influence their diagnostic thought process. A “difficult patient” may receive a MUPS diagnosis more readily than a “pleasant patient,” which could contribute to an incomplete workup. An epidemiologic study revealed that the strongest predictor of misdiagnosing MUPS is doctor dissatisfaction with the clinical encounter.¹⁵ Younger, unmarried, anxious patients receiving disability benefits are more likely to be incorrectly labeled as having MUPS, only to later receive a non-MUPS diagnosis.¹⁵

Bias in treatment and intervention also exists. Qualitative analysis of consultations suggests that physicians’ decisions to offer patients somatic treatments (eg, investigation, add/change medications, referral to specialists) are responses to patients’ extended and complex accounts of their symptoms.¹⁷ The likelihood of intervention was unrelated to patients’ request for treatment, and intervention became less likely when patients described psychosocial problems.¹⁶

Patients with MUPS and comorbid psychiatric disorders often are referred for psychosocial treatment, but 1 study found that as few as 10% of such patients follow up on a referral.¹⁷ In that study, 81% of MUPS patients were willing to receive psychosocial treatment in a primary care setting by their physician. Although there are many reasons patients with MUPS resist referral to mental health professionals, be aware that many of these individuals do not attribute their symptoms to psychosocial problems or experience their symptoms psychologically. To these patients, psychiatric referral may seem inappropriate or be perceived as belittling and minimizing their symptoms.

CASE CONTINUED: Frustration and guilt

Mrs. B’s depressive symptoms began 18 months ago with fatigue, poor sleep, and withdrawal from her children and husband. She struggles with hopelessness that her physical symptoms will not resolve and guilt because of the financial strain her medical care has placed on the family. She is extremely frustrated that her doctors are unable to find a medical diagnosis for her symptoms and fears that without a diagnosis she will be perceived as “crazy.” She is not certain if there is a medical explanation for her symptoms but vehemently believes they are not associated with her mood or psychosocial stress.

Treatment strategies

A collaborative, unbiased, integrated approach to treatment can address some of the challenges that arise when patients with MUPS confront the limitations of modern medicine. Integrated care involves ongoing communication among medical and psychiatric specialists, as well as collaboration with social workers, physical therapists, nutritionists, or pain management specialists when indicated.

Although the primary care provider often coordinates a MUPS patient’s medical treatment, a consulting psychiatrist plays an important educational, diagnostic, and therapeutic role. The therapeutic role is especially important because patients with MUPS frequently view their general practitioner as having a limited role in managing psychosocial problems.¹⁸

Because physical illness and psychosocial stress frequently coexist and compound each other, diagnostic efforts should focus on medical and psychiatric illness. Review the patient’s medical workup of the unexplained symptoms and, when indicated, request further testing. Evaluate the risks and benefits of additional testing and discuss them with the patient; additional testing carries a risk of iatrogenic harm, higher false-positive rates, and increased costs. Avoiding iatrogenic harm and unnecessary, overly aggressive testing is essential.