Tricky ten minutes - They say there is nothing wrong but …

Numbers vary across studies in the UK and elsewhere but it seems that 20-30% of primary care consultations will be with people who are experiencing disturbing physical symptoms with no clear diagnosis. It is likely you will be seeing at least one or two patients a day who have attended repeatedly with similar problems. Lots of time and money can be spent with these patients with the process proving frustrating for the clinician and stressful or unhelpful for the patient.^1,3,12

Assessment

It is important not to pre-judge someone with a history of unexplained symptoms as a ‘heart-sink’ patient. There are lots of understandable reasons why this happens, but there are at least two good reasons why it’s unhelpful:

On this visit they might be presenting with a disease that can be identified
It has been shown to be a factor in perpetuating a cycle of unproductive visits and investigations.^1,2,4

Invite the patient to explain what brings them to the surgery for this visit and what is their main concern rather than asking ‘How can I help?’. Give them a chance to talk and encourage them to describe their experience e.g. ‘what does it feel like’. This is a useful opportunity to listen and to identify:

new and changing physical symptoms
emotional responses
their thoughts or worries surrounding their symptoms
precipitating/exacerbating and relieving factors
psychosocial/family/employment factors

There is evidence that what might lead patients with medically unexplained symptoms to ‘over-explain’ or ‘talk up’ symptoms or their impact is feeling like they are not being listened to or the clinician missing psychosocial cues.⁴ So, although this process may take some time it is likely to pay off in the long-run.

If you haven’t seen them before, or for a while, check what has been suggested to them to manage symptoms and how that has worked. Also, check the records for and discuss any ‘overall management or investigation’ plan that is in place and how this visit fits into that.

Focus examination on any presenting physical symptoms. Explain and show you are taking them seriously. Detailed examination will highlight any evidence for further investigation or treatment but also give you a chance to feedback what you find if there are no concerns. This is particularly helpful in addressing any specific worries patients have expressed. The ABC of Medically Unexplained Symptoms provides useful chapters on what to consider when examining for organic diseases and ‘red flags’ to check for in these cases.¹

Look out for symptoms of anxiety or depression. These are common in patients with medically unexplained symptoms and vice versa. Patients can be worried about raising them for fear of being diagnosed as having a ‘psychological condition’ and not have their somatic problems investigated. The Hospital Anxiety and Depression Scale can be useful in highlighting this where you have some evidence from the discussion. If a patient is experiencing significant emotional distress it is important to check for suicidal thoughts or behaviour.

Considerations

It seems physical tests or interventions are proposed more often by GPs in these cases than requested or wanted by patients. This is often due to GPs believing they don’t have the skills or information to provide a convincing alternative explanation or to offer emotional support, which the evidence suggests is what patients value more.⁴

A recent meta-study found that diagnostic tests for symptoms with a low risk of serious illness do little to reassure patients, decrease their anxiety, or resolve their symptoms, although it might lead to a small reduction in visits.⁵

A simple reattribution from physical symptoms to a psychological cause has been shown to have limited long-term efficacy and can close off the potential for re-examining the diagnosis as things develop. Individual medically unexplained symptoms are not necessarily stable over time and around 10% of these patients do go on to have explained symptoms related to the original difficulties. Organic diseases and psychosocial difficulties are not necessarily explanatory on their own but are often co-morbid and interacting.⁶

Management

Where there is no obvious or likely explanation for the functional somatic problems a patient is experiencing, it is important to explain how you have come to that conclusion. Where further investigation or treatment is indicated again, it is important to explain your rationale and to set realistic expectations about what they might expect as a result.

One useful way of getting over the problem of giving the impression ‘it’s all in your mind’, or to explain why further investigation might be premature, is to explain how thoughts, emotional states and physiology interact. We now know much more about the functional symptoms caused by hyper- and hypo-arousal of the autonomic nervous system (ANS) and how this is affected by external and internal factors.^7,8 Many of these symptoms are associated with the cluster of syndromes often grouped together as medically unexplained symptoms.

The ANS affects and is affected by most of the major systems and organs in the body. The balance of activation between the sympathetic and parasympathetic systems affects the ability of other systems to do their ‘everyday’ job. We have found that a useful analogy is the ANS being like a person balancing on a tightrope, with all of the other major systems being like people trying to do their work while sitting on a beam balanced on his shoulders. The better the person balances the easier it is for the others to do their work. This can lead onto a discussion of how the ANS can be helped to re-balance through changes in lifestyle and social support, reductions in stress, medication or forms of therapy or relaxation techniques.⁹ It can be a useful way of helping a patient to understand how they can participate in reducing their symptoms and make it easier to identify symptoms that persist and possibly need more investigation.

It can be better to present medically unexplained symptoms as a working hypothesis rather than a firm and fixed diagnosis. This can progress into a joint conversation about how to maintain a ‘vigilant and watchful waiting’ management approach to their situation. Embarking on such an approach requires continuity of care and an ongoing plan. Ideally, this means seeing one doctor consistently across appointments and planning the next appointment as a scheduled, maybe monthly, arrangement. This minimises the chances of these patients feeling anonymous, so reducing anxiety and unscheduled visits to either the surgery or A&E. It also allows you to reduce the chances of missing something, challenge them if they stray from the plan and to make a gradual, joint decision towards longer-term psychological therapy or support if necessary.^10,11

Barry Smale is a psychotherapist, with a special interest in somatoform disorders, MUS and complex trauma, working in London at the Capio Nightingale Hospital and in private practice.

Dr Frankie Connell is a consultant psychiatrist at the Royal London Hospital, Barts Health NHS Trust, and at Capio Nightingale Hospital

References

Burton C [Ed]. (2013) ABC of Medically Unexplained Symptoms. John Wiley & Sons Ltd, West Sussex
Hatcher S, Arroll B. (2008) Assessment and management of medically unexplained symptoms. BMJ, 336(7653): 1124–1128.
Medically unexplained symptoms – special issue. (2007) Clinical Psychology Review, 27 (7):769-872
Ring A, Dowrick C, Humphris GM et al. (2005) The somatising effect of clinical consultation: What patients and doctors say and do not say when patients present medically unexplained physical symptoms. Social Science and Medicine, 67 (7): 1505-1515.
Rolfe A and Burton C. (2013) Reassurance after diagnostic testing with a low pretest probability of serious disease: systematic review and meta-analysis. JAMA Internal Medicine, 173 (6): 407-416
Gask L, Dowrick C, Salmon P et al. (2011) Reattribution reconsidered: Narrative review and reflections on an educational intervention for medically unexplained symptoms in primary care settings. Journal of Psychosomatic Research, 71 (5): 325-334
Schore A. (2012) The science of the art of psychotherapy. W.W. Norton & Co, New York.
Porges S. (2011) The Polyvagel theory: neuropsychological foundations of emotions, attachment, communication and self-regulation. W.W. Norton &Co, New York
McEwen B and Gianaros P. (2011) Stress and allostasis-induced brain plasticity. Annual Review of Medicine, 62: 431-445
Improving Access to Psychological Therapies (IAPT). (2008) Medically unexplained symptoms positive practice guide. London: Department of Health
CSL Mental Health Project Team. (2010) Medically Unexplained Symptoms (MUS): A whole systems approach. London: Commissioning Support for London
Shattock L, Willaimson H, Caldwell K et al. (2013) ‘They’ve just got symptoms without science’: Medical trainees’ acquisition of negative attitudes towards patients with medically unexplained symptoms. Patient Education and Counselling, 91 (2): 249-254.