Assessment and management of patients with medically unexplained symptoms in primary care

Abstract 

Medically unexplained symptoms (MUS) are common in primary care and associated with high healthcare usage, impaired function or distress. They are not explainable by lasting organic pathology. Usually they have a reversible physiological explanation, they are precipitated by life stress or modern lifestyle, and sometimes they are associated with depressive and anxiety disorders. The definition is more acceptable to GPs than somatoform disorder because it does not suggest a psychiatric process and does not require lifetime symptom counts in a busy surgery. Most patients seek an alliance with their general practitioner (GP) to legitimize their distress and help understand their cause, but GPs commonly manage MUS using a biomedical model rather than manage the underlying distress. The article outlines a number of useful assessment and management approaches to MUS in primary care. Reattribution is a structured consultation used by GPs to provide patients with an explanation for their MUS in terms of life stress, lifestyle or psychiatric disorder. The use of regular appointments to manage chronic MUS associated with high consultation rates is also established. Graded exercise and antidepressants can be helpful in patients with particular types of MUS. Cognitive behavioural therapy is a helpful second line treatment but few GPs are currently willing to utilize it. Despite the high distress and cost of these patients, there are few incentives to GPs to manage MUS in health systems around the world.

Keywords:  psychological medicine , medically unexplained symptoms , somatization , primary care , symptom belief , reattribution , cognitive behavioural therapy , antidepressants , exercise , clinical communication

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