Editorials

Medically unexplained symptoms in secondary care

Consider the possibility of anxiety or depressionor simply distress

Papers p 767

The efficient use of medical resources is important, so the findings of Reid et al in this issue (p 767)¹ are timely, highlighting the previously undocumented number of frequent attenders at secondary care consultations with medically unexplained symptoms. However, this study raises concerns other than economic ones: there appear to be large numbers of patients whose frequent attendance suggests distress that is neither appropriately identified or addressed.

The reasons for frequent attendance by such patients are undoubtedly complex. At least for the first consultation, attendance may reflect the referral patterns of general practitioners. Medically unexplained symptoms are very common in primary care,² but primary care physicians seem to have considerable discomfort in managing these patients.³ Any patient whose symptoms cannot be explained raises the concern, "What am I missing?" Compounding this unease is the expectation or demand of the patient for a specialist opinion, against a background of increasing litigation.

To clarify the nature of these patients' problems it is necessary to adopt a more critical analysis of each patient's health. A recent study showed that the way in which patients describe their symptoms influences detection of anxiety or depression.⁴ This is useful to bear in mind in light of the fact that patients with anxiety disorders are high users of medical care from specialists.⁵ International studies describe that half of patients with depression report multiple unexplained somatic symptoms, 11% denying psychological symptoms on direct questioning,⁶ and that recognition and diagnosis of depression in primary care is associated with significantly greater short term improvement.⁷

If anxiety and depression are easy to miss, what of the more ill defined area of somatisation? A recent study of 50 people without organic disease who were frequent attenders at a gastroenterology clinic showed that 45 had at least one current psychiatric diagnosis and 24 at least two, with somatoform disorders being the most common.⁸ Although rare in the general population, patients who somatise seem to represent a sizable population in general medical clinics, and they probably overuse and overtax the healthcare system.⁹

The common feature of the somatoform disorders is the presence of physical symptoms that suggest a general medical illness but are not fully explained by such an illness, the direct effects of a drug, or another mental disorder.¹⁰ It is crucial to recognise that somatisation variously may represent the expression of the bodily aspect of emotion (for example, sweating and dry mouth associated with anxious arousal), an attribution (for example, the anxious patient who attributes his rapid heart rate to heart disease), or, at a more basic level, distress.¹¹

Before we collectively sigh and refer these difficult patients to the psychiatric service it is worth pondering our own contribution to the problem. The tendency to conceptualise medical problems in biological terms is powerful, and medical practitioners are often reluctant to explore the non-biological aspects of a patient's case. In part this may reflect concerns about inadequate training, fear of being unable to help, or the conviction that no psychological interventions would help anyway. Patients respond to the cues offered by health professionals and are themselves part of a culture that continues to stigmatise mentally ill people and those with emotional problems. Hence for a distressed patient it is far more acceptable to present with somatic symptoms.

The need to investigate has the effect of reinforcing concerns about the physical nature of the problem, and this is compounded if the patient sees a new doctor at a subsequent consultation and the tests are repeated "just to be sure." It becomes clear there are major costs to the healthcare system and the patient.

The challenge by Reid et al to focus on this group of patients is timely,¹ as their levels of disability appear high. One wonders to what extent they contribute to physician exhaustion and stress, given that it is frustrating and annoying to be confronted with patients one cannot help or understand.³ The fact that a patient returns many times despite being told there is no medical explanation for his or her symptoms reflects continuing distress and concern. Faced with such behaviour health professionals must consider the possibility of depression or anxiety.

In addition they need to pay careful attention to the consultation itself. Patients with somatisation disorders often feel that medical explanations reject the reality of their symptoms, yet those who receive information without blame and are provided with strategies for coping feel empowered.¹² In attempting to help this group of patients we should reflect on our own training, skills, and prejudices as well as broadening our approach to clinical assessment.

Jane Turner, senior lecturer in psychiatry. 

Royal Brisbane Hospital, Herston, Queensland 4029, Australia (j.turner{at}psychiatry.uq.edu.au)