Medically unexplained symptoms: are we making progress?

A substantial proportion of patients in general practice consult for subjective symptoms, such as pain or fatigue, without corresponding objective findings.1–4 Some of these patients present trivial symptoms that do not indicate disease; others recover after long-lasting symptoms and disability. Here, we shall refer to conditions with long-lasting and disabling symptoms, not trivial or passing symptoms. Such conditions are called medically unexplained symptoms (MUS). Syndromes with specific diagnostic criteria, such as fibromyalgia, chronic fatigue syndrome, or irritable bowel syndrome, are often included among MUS conditions.2 Although management of patients with MUS presents several challenges, GPs accept the responsibility for investigation, diagnosis, treatment, and follow-up.5 Biopsychosocial approaches are commonly applied in medical practice, whether the aim is full recovery or coping with symptoms and disability,1 and psychologically based interventions (especially different cognitive behavioural therapies [CBT]) have been developed for coping and symptom relief. Yet, such approaches do not substantiate MUS as a mental disorder. Lamahewa et al found, for example, that comorbidity with depression and generalised anxiety disorder occurred in only one-third of these patients.2 Studies have evaluated effects of CBT on different outcome measures, such as pain, function, work ability, or healthcare use, often presenting limited or no significant effects based on weak evidence.4 MUS is not a clinical diagnosis but an analytical concept, unifying a diverse group of health problems where no joint cause or biomarker have been identified. Together MUS conditions dispute the idea that objective findings are needed to confirm subjective symptoms as disease. The biomedical disease model has imposed an unfortunate body–mind duality, with illness categorised as psychological when no objective findings are identified.2,4 Conceptualising MUS …