How should we manage adults with persistent unexplained physical symptoms?

Den Boeft et al‘s review (1) of persistent unexplained physical symptoms is valuable in the context of recent proposals of Right Place Right Time (2). Whilst the symptoms may be “unexplained” to the patient, understanding has evolved enough that they should not be a mystery to the doctor in the way that might be portrayed. Indeed often a positive diagnosis could be made based upon the presentation & absence of robust clinical findings in the face of a multiplicity “symptoms” & their non-specific nature, without investigations as a somatoform disorder.

Although adverse events are experienced by many, the link between abuse & experience of somatoform phenomena is well recorded (3). Indeed the importance of this association has lead to a position statement from The American Academy of Neurology (AAN) calling on neurologists to begin screening their patients for abusive or violent treatment by family, caretakers or others (4). Scrutinising 4 years of my own unselected clinics 64 cases of abuse were identified: 45 were deemed “relevant”, 18 incidental. This compared to 19 new MND/ALS diagnoses & 19 new/established cases of Myasthenia. It should be obvious that the practice advised by the AAN should extend to all medical practioners, although this cannot be achieved in 15 minutes, let alone 10, and probably not even in a ½ hour,.

Considering the likely diagnosis is the start but I agree that greater access to trauma-focused cognitive-behavioural therapy might better manage this tranche of patients.

(1) Practice Uncertainties: How should we manage adults with persistent unexplained physical symptoms? February 2017): BMJ 2017;356:j268 Madelon den Boeft, Nikki Claassen-van Dessel,Johannes C van der Wouden.
(2) NHS Providers report 'Right place, right time: better transfers of care - a call to action' Foundation Trust Network 2015
(3) JAMA. 2009 Aug 5;302(5):550-61. doi: 10.1001/jama.2009.1091. Sexual abuse and lifetime diagnosis of somatic disorders: a systematic review and meta-analysis. Paras ML1, Murad MH, Chen LP, Goranson EN, Sattler AL, Colbenson KM, Elamin MB, Seime RJ, Prokop LJ, Zirakzadeh A.
(4) The American Academy of Neurology position statement on abuse and violence Elliott A. Schulman, MD, FAAN and Anna De Pold Hohler, MD, FAAN Neurology February 7, 2012 vol. 78 no. 6 433-435