Treating medically unexplained physical symptoms

Effective interventions are available

Chest pain, back pain, headache, muscular pains, bowel symptoms, breathlessness, dizziness, and fatigue often remain unexplained after medical assessment. 1 Such cases may be referred to as functional syndromes of chronic fatigue, chronic pain, fibromyalgia, and irritable bowel or as somatoform (somatisation) disorders. In many cases the symptoms are severe, persistent, and disabling and cause considerable personal, social, and healthcare costs.1 2 3 Furthermore, the problem is large, accounting for a quarter of general practice consultations, as many as a half of outpatient clinic attendances, and a substantial number of hospital admissions.2

When symptoms are found not to result from “genuine physical illness” they are often believed to be insignificant or attributed to mental illness. Consequently when investigations prove negative, management is commonly limited to reassurance about the absence of disease and occasionally referral to a general psychiatrist. In our experience such referrals are unpopular with patients and rarely result in effective treatment. In fact there is scant provision in either medical or psychiatric services for the patient with somatic complaints who has neither physical disease nor severe mental illness.4

We now know that we could do better. Evidence for the superiority of new ways of thinking about and managing such patients is growing. Several recently published randomised trials show that new treatments are both acceptable to patients and more effective than conventional medical care.5 6 These new treatments, often referred to as cognitive behavioural therapies, take an explicitly integrative approach to patients' complaints—an approach in keeping with the evidence that the perpetuation of unexplained somatic symptoms is best understood in terms of an interaction between physiological processes, psychological factors, and social context.7

This integrative approach also provides a logical basis for management. The first step is acknowledging the reality of the patient's problem. The second is systematically identifying and listing the principal factors that perpetuate illness, including disordered physiology, misinterpretation of associated bodily sensations, abnormalities of mood, unhelpful coping behaviour, and social stressors. The third step is making a management plan that targets the most important of these factors for each patient. For example, a patient with chronic fatigue may benefit from information to combat unfounded fears about the illness, guidance and encouragement in returning to normal activity, and help with employment and other problems.7 For selected patients antidepressant treatment may also help.2 5

Implementation of this new approach will require changes in both medical practice and the organisation of services. Most patients will continue to be managed in primary care, where the doctor's positive explanation of the symptoms and practical advice may be augmented by printed information, reinforced if necessary during a longer session with a suitably trained nurse. The general practitioner should be supported by a readily available medical consultant, whose confident assessment and statement of findings will reinforce the general practitioner's approach. Innovative service developments such as joint medical-psychiatric clinics and dedicated liaison psychiatry and psychology services will provide for patients who require more intensive treatment. Finally, the small but conspicuous group of patients who present with recurrent and multiple physical symptoms will be given proactive and coordinated care aimed at limiting unnecessary medical intervention and preventing iatrogenic harm.8

If these simple and inexpensive changes in practice and service provision could improve patient care, why have they not been implemented? One reason is the widespread lack of awareness that effective evidence based treatments are available. Another is a misconception that such patients are only “worried well,” undeserving of health service resources. But perhaps the main obstacle to change is the remarkable persistence of mind-body dualism,9 which appears to be as prevalent among the medical profession as among the general public. Overcoming this intellectual obstacle to a more constructive attitude to medically unexplained physical symptoms will require changes in doctors' professional training and a greater dialogue with colleagues in psychiatry and clinical psychology. There are welcome signs of change, as evidenced by recent joint royal college reports.2 10 But to meet the challenge of “medically unexplained” symptoms we must do more to lead public opinion in a positive and non-judgmental acceptance of the role of physical, psychological, and social factors in most, if not all, illness. Such an acceptance would encourage the implementation of what we already know, as well as opening the door to the development of innovative treatments for these hitherto problematic illnesses.