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Medically unexplained symptoms: assessment and management

Mujtaba Husain and Trudie Chalder
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DOI: https://doi.org/10.7861/clinmed.2020-0947
Clin Med January 2021
Mujtaba Husain
ASouth London and Maudsley NHS Foundation Trust (SLaM), London, UK
Roles: consultant liaison psychiatrist
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  • For correspondence: mujtaba.husain@slam.nhs.uk
Trudie Chalder
BKing's College London, London, UK and South London and Maudsley NHS Foundation Trust (SLaM), London, UK
Roles: professor of cognitive behavioural psychotherapy
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ABSTRACT

Medically unexplained symptoms or persistent physical symptoms are common, real and are associated with significant distress, loss of functioning and high healthcare costs. History, examination and appropriate investigations are essential to make a diagnosis. Once the diagnosis has been made, exploring the impact of the symptoms helps us to tailor our advice to patients. This paper sets out a practical approach to taking a history, assessment and stepwise management principles.

KEYWORDS:
  • cognitive behavioural therapy
  • medically unexplained symptoms
  • persistent physical symptoms

Introduction

Medically unexplained symptoms (MUS) or persistent physical symptoms (PPS) are very common. They account for up to one in five presentations in primary care.1,2 This can be even higher in some secondary care clinics.3 Hence assessing and supporting people with unexplained symptoms is a significant part of the everyday work of most clinicians.

PPS are often associated with significant distress, impaired functioning, loss of role and high use of healthcare and welfare.4 Patients often report feeling that their concerns are not taken seriously by their healthcare professionals.5 Doctors also report feeling unprepared for helping people with PPS.6 PPS are also estimated to account for approximately 10% of total NHS expenditure for the working-age population in England.7

Much of this delivers limited value to the patient and can be counterproductive or even harmful (for example, multiple or repeat investigations).8

The longer the duration of untreated symptoms the poorer the prognosis.9,10 Evidence-based treatment is available.9,11 Yet, it is common for diagnosing, explaining the diagnosis to the patient and offering treatment to be delayed.5

Definitions and classification: one syndrome or many?

The language we use to describe PPS can be complex and confusing. Adjectives such as functional, somatic, unexplained and dissociative are commonly used. And there are specialty-specific diagnoses like irritable bowel syndrome, fibromyalgia and functional neurological disorder. Almost every medical specialty has an equivalent diagnostic category.

It has been proposed that PPS can be considered as one syndrome rather than many.12 There is significant overlap in the risk factors and symptoms seen in specific diagnoses.13 PPS frequently present with multiple symptoms that cut across specialty boundaries (which can result in multiple referrals). A number of symptoms (such as fatigue, pain and disrupted sleep) are common across diagnoses. Indeed, many of the challenges of helping people with PPS stem from a fragmented approach to management where the symptoms cut across medical silos and divides (primary and secondary care; physical and mental health; and different medical specialties).

The Diagnostic and Statistical Manual of Mental Disorders, 5th edn (DSM-5) now defines somatic symptom disorder.14 Under DSM-IV, symptoms had to be unexplained but the new definition removes this requirement and focuses on distress and disruption of daily life. International Classification of Diseases, 11th revision (ICD-11) proposes the similar bodily distress disorder.

The term PPS has also been shown to rank highly in surveys of patient preference.15,16 MUS and PPS describe similar symptoms but are not quite the same thing. Describing symptoms as medically unexplained can be seen by patients as dismissive.17 It has been suggested PPS should occupy a neutral space with neither a somatic disease aetiology, nor a mental disorder to reflect their complex nature (analogous to pain disorders in ICD-11).18,19

Physical and mental health

Having a physical health diagnosis increases the risk of experiencing unexplained symptoms. For example, around a fifth of those diagnosed with non-epileptic seizures also have epilepsy, non- cardiac chest pain is common after myocardial infarction and dysfunctional breathing is frequently seen in those with asthma.20–22 Hence, the divide between explained and unexplained symptoms is not quite as clear cut as the terms imply.

Mental health comorbidity is also common. Around 50% of individuals with PPS suffer from associated anxiety or depression, which is more than that seen in other long-term conditions.3,23 This may be due to the impact of living with persistent symptoms and the distress and impairment they cause, it may reflect a common aetiology, or it may be a combination of the two.

Associated physical and mental health problems stress the need for a thorough assessment to ensure the treatment approach offered addresses comorbidity.

Aetiology

The most convincing models for how PPS develop take a multifactorial approach. Deary, Chalder and Sharpe have described a cognitive behavioural model of persistent physical symptoms and how they develop9.

Some factors which increase the risk of developing PPS are non- modifiable. These include parental ill health during childhood; illness during childhood; childhood adversity and abuse; personality traits; and having a long-term condition and a family history of someone with a long-term condition.

There can often be a ‘trigger’ (but this is not always the case). This could be an infection, a physical illness or trauma. It may be a psychosocial stressor or repeated stressors. Often both physical and psychosocial stressors precede the onset of PPS.

Then there are maintaining factors which keep the symptoms going. These can be divided into four groups.

  • Physiological: autonomic dysregulation, central sensitisation, hypothalamic–pituitary–adrenal (HPA) axis dysfunction and sleep disruption.

  • Social: loss of role and medical uncertainty.

  • Cognitive: catastrophic misappraisal of symptoms, symptom focusing and intolerance of uncertainty.

  • Behavioural: avoidance behaviour, ‘all or nothing’ behaviours and poor sleep hygiene.

Treatment focuses on addressing modifiable maintaining factors, particularly cognitive and behavioural factors.

Another model describes the brain as actively making predictions or inferences rather than passively waiting for sensory input from the body. It proposes PPS are due to ‘failures of inference’ in which expectations, cognition and emotion play a part in symptom perception.24

It is now recognised that a variety of physiological processes are involved in PPS. There is increasing evidence that autonomic nervous system dysregulation plays a role. For example, a recent meta-analysis found differences in heart rate variability comparing patients with PPS to healthy controls.25 Central sensitisation has also been proposed as a common physiological basis for PPS.26 Other hypotheses include immune dysfunction and metabolic abnormalities.18

Assessment

As ever in medicine, assessment of PPS starts with a thorough history. Active listening with empathy is important to help the patient feel heard and understood. Table 1 outlines a suggested approach and key questions as you do this.

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Table 1.

Taking a history

Physical examination (cardiovascular, respiratory, abdominal and neurological examinations) is essential to look for signs of other physical health problems. In some functional neurological disorders, there are also positive signs that can be elicited.27

Baseline physical observations (heart rate, blood pressure and temperature) are required.

The following investigations should be undertaken as a minimum:

  • urinalysis for protein, blood and glucose

  • full blood count

  • urea and electrolytes

  • liver function

  • thyroid function

  • erythrocyte sedimentation rate and C-reactive protein

  • random blood glucose

  • serum creatinine

  • tissue transglutaminase antibodies (tTG–IgA) for coeliac disease

  • serum calcium

  • creatine kinase.

Further investigations may be indicated. For example, for persistent unexplained gastrointestinal symptoms in women, particularly for those aged over 50 years, CA125 should be measured.28

Common diagnoses which are sometimes missed include diabetes, coeliac disease, thyroid problems and inflammatory conditions.

While diagnoses of persistent physical symptoms should be made carefully only after a full assessment, evidence now suggests that when a diagnosis is made, they are stable diagnoses with low misdiagnosis rates.29 Doctors are more likely to under-diagnose than over-diagnose unexplained symptoms.30

Management

Treatment takes a stepwise approach.

Positive diagnosis and explanation

The first and most important step is a positive diagnosis and explanation of what the diagnosis means. This must be a two-way conversation and should be tailored to the individual's concerns and experiences. Ask what they think may be the cause and what they are worried about. Answer their questions and engage in a dialogue. It is crucial that every clinician, whether in primary care, the emergency department or secondary care sees this as part of their role. Table 2 sets out a guide and suggested phrases.

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Table 2.

Explaining the diagnosis

Guided self-help

For those presenting for the first time, particularly with a shorter duration of symptoms and less functional impairment, a guided self-help approach is the next step.

Direct them to useful resources like www.nhs.uk/conditions/medically-unexplained-symptoms and www.rcpsych.ac.uk/mental-health/problems-disorders/medically-unexplained-symptoms.

There is more specific information and support available for some presentations, for example from https://fndhope.org for functional neurological symptoms.

Approaches at this stage include:

  • advice on managing activity (Table 3)

  • advice on stress management

  • improving sleep hygiene particularly:

    • a consistent bedtime and wake up time

    • if they have difficulty falling asleep, getting up for 30 minutes to do something to distract themselves out of the bedroom environment

    • reducing daytime naps

  • tailored advice on general health, diet and exercise

  • treating associated depression or anxiety, considering medication if appropriate.

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Table 3.

Managing activity

We should not fall into the trap of referring patients for therapy or specialist care while skipping the first essential steps of making a positive diagnosis, giving a positive explanation and guiding patients through self-help. Many patients will not need further referral when these steps are taken.

Cognitive behavioural therapy

If things are not improving after 4–8 weeks the next step is offering cognitive behavioural therapy (CBT). CBT is the treatment with the best evidence base for persistent physical symptoms, both for general symptoms and more specific syndromes, and overall there is evidence for a moderate beneficial effect.9,11,32 CBT is available through local IAPT (Improving Access to Psychological Therapy) services where patients can also self-refer.

When offering CBT, it can be helpful to say that it has been shown to help people with physical symptoms in long-term physical health conditions like multiple sclerosis; CBT is a treatment which has the potential to help whatever the cause of PPS.33

Specialist referral

Where first-line CBT has not helped, specialist referral should be considered. In practice, what is available can vary depending on where you are based and the symptoms the individual has. However, a multidisciplinary approach is best. Good communication and consistency between healthcare professionals around the explanations given and the plan is essential. Research suggests psychological treatments are helpful in terms of improving symptoms and alleviating their impact, and so this message can be delivered with some confidence.

Specialist referral should be considered earlier if employment or education is at risk; there is physical or mental health comorbidity; particularly frequent attendance to emergency departments; or multiple specialists are already involved.

In some cases, harm minimisation is also important. Repeat investigations and interventions can lead to direct and indirect iatrogenic harm. Involving all healthcare professionals and/or departments the patient attends and discussing a plan to limit or stop harmful interventions with the patient is essential. For example, this might be a multidisciplinary plan on what happens in the emergency department or regarding invasive investigations.

Funding

Trudie Chalder is part-funded by the National Institute for Health Research (NIHR) Biomedical Research Centre at South London and Maudsley NHS Foundation Trust, and King's College London at King's College Hospital NHS Foundation Trust.

  • © Royal College of Physicians 2021. All rights reserved.

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Medically unexplained symptoms: assessment and management
Mujtaba Husain, Trudie Chalder
Clinical Medicine Jan 2021, 21 (1) 13-18; DOI: 10.7861/clinmed.2020-0947

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Medically unexplained symptoms: assessment and management
Mujtaba Husain, Trudie Chalder
Clinical Medicine Jan 2021, 21 (1) 13-18; DOI: 10.7861/clinmed.2020-0947
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