CPD: Understanding medically unexplained symptoms – initial management

In the first of a two-part CPD series, GP partner and trainer Dr Ed Pooley explains current understanding of medically unexplained symptoms and advises on how to support patients presenting with physical symptoms that have no clear underlying pathology. Read the full article on Pulse365 today

Learning objectives:

• How medically unexplained symptoms are defined and the distinction between transient and persistent symptoms
• Current understanding of the epidemiology of MUS and risk factors
• General prognosis and common underlying pathologies – and how this should influence your approach
• Rational approach to investigation and referral, including in those patients who are polysymptomatic
• Strategies to avoid over-investigation while maintaining support and follow-up

What are medically unexplained symptoms?

The term medically unexplained symptoms (MUS) is an umbrella term that covers:

1. Medical conditions which have diagnostic criteria but for which we lack full understanding of their pathological basis. Common examples could include IBS and fibromyalgia.
2. Broad-based symptoms for which we have no biological or anatomical explanation. Examples include dizziness or fatigue not attributable to specific diseases.
3. Manifestations of psychological processes, for example hypochondriasis, somatisation, and factitious disorders. Examples include preoccupations with physical sensations and conditions such as Munchausen disorder.

Alternative classifications of MUS sometimes group symptom clusters, for example functional somatic symptoms (clusters of symptoms such as headache, bloating, fatigue, and musculoskeletal pain) which often co-occur.

This two-part series on MUS will firstly explore common patterns of MUS presentation in clinic and how to approach management. The second part will provide communication approaches to engaging and building rapport with patients experiencing these often distressing symptoms.

Prevalence and impact of MUS in general practice

MUS accounts for around 45% of GP consultations and around 20% of new presentations in primary care.¹ MUS are not usually labelled as such at first presentation. Clinicians tend to use the label only after the symptoms persist over time and following extensive investigations, or when they result in functional impairment, since many symptoms will often resolve (whether medically unexplained or not).

MUS can lead to challenging conversations, particularly around diagnostic clarification, testing, management, prognosis, and containment of uncertainty for both physician and patient (and often by extension, their families or carers). Given the uncertainty when faced with symptoms that have no ready explanation, it is not uncommon for GPs to be unable to make a definitive diagnosis at the first consultation.

Risk factors for the development of MUS include but are not limited to: being female; having low educational attainment; experiencing adverse childhood events, eg, abuse; and having co-morbid disease. It should be noted that these observations may be influenced by bias within studies and how symptoms are recorded/attributed, and interactional effects (for example, adverse childhood events impact on educational attainment).

Consequently, many GPs struggle with a consistent approach to managing MUS and often bias, avoidance, dependency, frustration and over-investigation or over-medicalisation can result as there is a pressure to ease the discomfort of uncertainty, and fear of diagnostic error – particularly where the doctor is ‘encouraged’ to do something by a patient who is understandably fearful. In fact, only around 10% of persistent MUS eventually leads to an alternative, specific diagnosis,² meaning that most MUS does not warrant repeated attempts to reduce uncertainty. That said, it’s important to have a clear plan that recognises that a change in the patient’s symptoms, or new information from the history or examination, would justify further exploration.

To tackle these specific pressures, many clinicians working with patients exhibiting MUS will have standardised approaches to MUS.

Dr Edward Pooley is a GP in Nottingham

References

1. Jadhakhan F, Romeu D, Lindner O et al. Prevalence of medically unexplained symptoms in adults who are high users of healthcare services and magnitude of associated costs: a systematic review. BMJ Open 2022;12:e059971
2. Morriss R and Gask L. Assessment and immediate management of patients with medically unexplained symptoms in primary care and general hospital settings. Foundation Years 2008;4:59-63