Clinical Review

Assessment and management of medically unexplained symptoms

BMJ 2008; 336 doi: http://dx.doi.org/10.1136/bmj.39554.592014.BE (Published 15 May 2008) Cite this as: BMJ 2008;336:1124
  1. Simon Hatcher, senior lecturer in psychiatry1,
  2. Bruce Arroll, professor and head of department 2
  1. 1University of Auckland, Private Bag 92019, Auckland 1, New Zealand
  2. 2Department of General Practice and Primary Health Care, University of Auckland, Private Bag 92019, Auckland 1, New Zealand
  1. Correspondence to: S Hatcher s.hatcher{at}auckland.ac.nz

    Many people present with medically unexplained symptoms. For example, more than a quarter of primary care patients in England have unexplained chronic pain, irritable bowel syndrome, or chronic fatigue,1 and in secondary and tertiary care, around a third of new neurological outpatients have symptoms thought by neurologists to be “not at all” or only “somewhat” explained by disease.2 This is not a problem just in developed countries—in Bangladesh, only a third of women with abnormal vaginal discharge had evidence of infection.3 These disorders are important because they are common and they cause similar levels of disability as symptoms caused by disease.4 If not treated properly they can result in large amounts of resources being wasted5 and iatrogenic harm.

    Sources and selection criteria

    We did a Medline search over the past 10 years using the keywords “somatoform disorders”, “medically unexplained symptoms”, and “randomised controlled trials”. We consulted Clinical Evidence and the Cochrane Collaboration for relevant articles. Most of the content of this article is based on the findings of systematic reviews and randomised controlled trials. Drawing conclusions is difficult because of the various definitions of the disorders used by different authors and the wide variety of symptom severity experienced by people with the same disorder.

    This is a clinically, conceptually, and emotionally difficult area. Clinical presentations vary greatly—from people who frequently attend the general practitioner with minor symptoms to people with chronic fatigue who are bed bound. What unites them, however, is the difficulty in explaining the presenting symptoms on the basis of any known pathology. Strong feelings are common, with patients often referred to in pejorative terms as “frequent fliers,” “heart sink patients,” “thick folder patients,” or “somatisers.” Doctors may feel that their competence is challenged by their inability to explain the symptoms, and patients may feel that they …

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