Medically unexplained physical symptoms

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See also: Somatoform disorder

Medically unexplained physical symptoms or MUPS is a term used in health care to describe a situation where an individual suffers from multiple physical symptoms for which the physician or other healthcare provider has found no physical cause.[1] Up to 30% of all primary care consultations are patients with medically unexplained symptoms.

History and usage

The term medically unexplained physical symptoms was first used in 1987 by D.I. Melville.[2]

MUPS is not synonymous with somatoform disorders such as somatization disorder where the cause or perception of symptoms is mental in origin. Instead, MUPS refers to the clinical situation where the cause of the symptoms cannot be determined, but might include somatic, physical or environmental causes.

However, several definitions of both somatization and MUPS exist, and the usage of both terms is not consistent in medical literature and practice. MUPS is sometimes used interchangeably with both somatization and functional somatic symptoms. [3]

Cause

Clustering of illnesses such as chronic fatigue syndrome, low back pain, irritable bowel syndrome, chronic tension headache, fibromyalgia, temporomandibular joint disorder, major depression, panic attacks, and posttraumatic stress disorder,[4] suggests a common, but not understood, underlying cause.

The more different symptoms are present, the more likely is underlying psychiatric illness.[5]

Environmental influences are suggested by the association between major life stresses and somatic symptoms.[6]

The associations between psychological stress and medical illnesses may be due to either subtle physiological changes induced by the stress, or may be due to the stress leading to increased seeking of medical care.[7]

Controversy

The lack of etiology diagnosis in MUPS cases can lead to conflict between patient and health-care provider over the diagnosis and treatment of MUPS. This conflict can occur in the public arena and may involve media controversy, advocacy groups, scientific and political debate and even legal proceedings [8].

Diagnosis of MUPS is seldom a satisfactory situation for the patient, as many patients feel this implies it is "all in their head." This can lead to an adversarial doctor-patient relationship[8], which can develop into an iatrogenic neurosis, thus complicating the situation.

Treatment

An empathetic approach by the doctor leading to a successful physician-patient relationship may be helpful.[9] A randomized controlled trial found improvement using multi-faceted, collaborative care.[10]

Reassurance may help according to a randomized controlled trial.[11]

Frequent visits, perhaps monthly, with their primary care physician may reduce may reduce health expenditures according to a randomized controlled trial.[12]

Consultation, in the form of a consultation letter from a psychiatrist or a joint consultation with the patient and both the psychiatrist and physician may help according to the Cochrane Collaboration. [13]

The use of diagnostic tests for reassurance is unclear with some studies reporting benefit among patients with chest pain in the emergency room[14] and no benefit among outpatients with unexplained symptoms[11].

References

  1. Kroenke K, Rosmalen JG (2006). "Symptoms, syndromes, and the value of psychiatric diagnostics in patients who have functional somatic disorders". Med. Clin. North Am. 90 (4): 603–26. DOI:10.1016/j.mcna.2006.04.003. PMID 16843765. Research Blogging.
  2. Descriptive clinical research and medically unexplained physical symptoms. Melville, D.I., Journal of Psychosomatic Research, 1987;31(3):359-65.
  3. Somatization, heartsink patients, or functional somatic symptoms? Resendal, et al, Scandinavian Journal of Primary Health Care, 2005; 23: 3-10
  4. Schur EA, Afari N, Furberg H, et al (2007). "Feeling bad in more ways than one: comorbidity patterns of medically unexplained and psychiatric conditions". Journal of general internal medicine : official journal of the Society for Research and Education in Primary Care Internal Medicine 22 (6): 818–21. DOI:10.1007/s11606-007-0140-5. PMID 17503107. Research Blogging.
  5. Kroenke K, Spitzer RL, Williams JB, Linzer M, Hahn SR, deGruy FV et al. (1994). "Physical symptoms in primary care. Predictors of psychiatric disorders and functional impairment.". Arch Fam Med 3 (9): 774-9. DOI:10.1001/archfami.1994.01850220044011. PMID 7987511. Research Blogging.
  6. Intimate partner violence and women's physical and mental health in the WHO multi-country study on women's health and domestic violence: an observational study. Lancet 2008. DOI:10.1016/S0140-6736(08)60522-X
  7. Herschbach P, Henrich G, von Rad M (1999). "Psychological factors in functional gastrointestinal disorders: characteristics of the disorder or of the illness behavior?". Psychosomatic medicine 61 (2): 148–53. PMID 10204966[e]
  8. 8.0 8.1 Caring for Medically Unexplained Physical Symptoms after Toxic Environmental Exposures: Effects of Contested Causation Engel, et al. Environmental Health Perspectives, Vol 110, Nu. S4, August 2002.
  9. Epstein; Hadee, Carroll, Meldrum, Lardner, Shields (2007-12-17). "Could his Be Something Serious?". Journal of General Internal Medicine 22 (12): 1731-1739. DOI:10.1007/s11606-007-0416-9. Retrieved on 2007-11-27. Research Blogging.
  10. Smith RC, Lyles JS, Gardiner JC, Sirbu C, Hodges A, Collins C et al. (2006). "Primary care clinicians treat patients with medically unexplained symptoms: a randomized controlled trial.". J Gen Intern Med 21 (7): 671-7. DOI:10.1111/j.1525-1497.2006.00460.x. PMID 16808764. PMC PMC1924714. Research Blogging.
  11. 11.0 11.1 van Bokhoven MA, Koch H, van der Weijden T, et al (2009). "Influence of watchful waiting on satisfaction and anxiety among patients seeking care for unexplained complaints". Ann Fam Med 7 (2): 112–20. DOI:10.1370/afm.958. PMID 19273865. Research Blogging.
  12. Smith GR, Monson RA, Ray DC (1986). "Psychiatric consultation in somatization disorder. A randomized controlled study.". N Engl J Med 314 (22): 1407-13. PMID 3084975.
  13. Hoedeman R, Blankenstein AH, van der Feltz-Cornelis CM, Krol B, Stewart R, Groothoff JW (2010). "Consultation letters for medically unexplained physical symptoms in primary care.". Cochrane Database Syst Rev 12: CD006524. DOI:10.1002/14651858.CD006524.pub2. PMID 21154369. Research Blogging.
  14. Sox H, Margulies I, Sox C (1981). "Psychologically mediated effects of diagnostic tests". Ann Intern Med 95 (6): 680-5. PMID 7305144.