This month we spoke to Consultant Neuropsychiatrist, Dr Rupesh Adimulam (MBBS, MRCPsych), about medically unexplained symptoms. With such extensive healthcare cost implications in the UK, we discuss the importance of making the link between the physical and psychological.
Medically unexplained symptoms are persistent bodily complaints for which adequate examination does not reveal sufficient structural, or other specified, pathology. This is a cause of concern for many doctors across the world and it can affect their confidence as well as the trust patients have in them.
Medically unexplained symptoms account for up to 20% of GP consultations and are associated with up to 50% more outpatient costs, and 30% more hospitalisation, than some other more widely known presentations. Moreover, annual healthcare costs of medically unexplained symptoms in the UK exceed £3.1 billion, with total costs estimated to be £18 billion.
Why should a GP consider medically unexplained symptoms?
Are you left wondering what could be causing certain symptoms? Do you worry you might be missing something more serious? Do your patients feel dissatisfied and unsupported?
Such questions can often lead to extensive yet unproductive investigations and the possibility of medically unexplained symptoms is always worth considering.
Interesting statistics about medically unexplained symptoms
- 75% remain unexplained at 12 months
- 25% will persist for over 12 months
What are the presenting signs and symptoms?
Medically unexplained symptoms, sometimes known as somatoform disorders, are not uniform in presentation. Some examples of symptoms that you can look out for in a patient include:
- Functional weakness
- Non-epileptic seizures
- Irritable bowel syndrome
- Chronic abdominal pain
- Chronic pelvic pain
- Premenstrual syndrome
- Functional dysphonia
- Atypical chest pain
- Unexplained palpitations
- Chronic fatigue syndrome
- Multiple chemical sensitivity syndrome
Although no test is available to identify patients who are presenting with medically unexplained symptoms, here are some more signs to look out for:
- Patients give a vague description of the symptoms
- There is a frequent repetition of the symptoms
- Patient tends to give a long list of the symptoms
- Previous history can provide some clues
What are the causes?
A widely accepted theory is that distress and mental ill health that cannot be expressed in words are subsequently shown in bodily symptoms. Different cultural responses to mental health, certain personality traits, and existing beliefs about illness and diseases, also play a role in shaping these symptoms.
What does help?
GPs are the gate keepers in healthcare and play a crucial role in early detection and treatment of mental health conditions, in order to ensure patients are given the correct treatment for their presentation.
A key component in making a diagnosis is the ‘doctor-patient relationship’. Some patients may have had previous bad experiences, or hold no faith that a doctor would take them seriously. Anxiety can be generated from their beliefs about the symptoms they experience and this demands a serious, thorough and reassuring response from their doctor.
Adapting general rules is an important start to supporting these patients. Such rules include:
- Thoroughly explaining what ‘medically unexplained symptoms’ means
- Normalising the symptoms to help empower the patient
- Listening with empathy
The Reattribution Model
The Reattribution Model has been widely accepted in primary care to manage these illnesses. The key components of this model are:
- Allowing patients to understand psychosocial circumstances and the impact of the symptoms on their life
- Offering advice on activities that help improve mood
- Reassure, explain and build trust
Changing the agenda
- Summarise the physical findings in a neutral and reassuring way
- Acknowledge the reality of the patient's pain or other symptoms
- Reframe the patient's complaint in a language that they understand
- Be open about uncertainty of these symptoms
Making the link
It is important to make a link to psychological distress, and the first two steps offered in the model need to be successfully crossed in order to discuss the possible links to mental health.
Preferable questions to explore could include:
- “What do you think could be causing the stress in your life?
- “What differences do you see in your physical symptoms when your mood gets better?”
Once the patient is comfortable to consider an alternative approach, it is worth seeking the help of a mental health specialist. Cognitive behavioural therapy (CBT) plays a vital role in achieving control and stability. Considering a referral to a psychiatrist may be appropriate at this stage for a positive outcome.
GPs need to be open to re-explore symptoms if the nature of them changes, or if the symptoms become more intense in their quality.