Introduction to the special issue on medically unexplained symptoms: Background and future directions

doi:10.1016/j.cpr.2007.07.003

Clinical Psychology Review

Volume 27, Issue 7, October 2007, Pages 769-780

https://doi.org/10.1016/j.cpr.2007.07.003 Get rights and content

Abstract

This special issue is devoted to the topic of medically unexplained symptoms (MUS), a heterogeneous group of conditions characterized by persistent physical symptoms that cannot be explained by medical illness or injury. Although psychological factors have long been regarded as central to these problems, patients with MUS have typically been managed within medical settings and referrals to mental health services have been relatively rare. In recent years, however, interest in the psychological nature and treatment of MUS has expanded, culminating in the development of tailored psychological interventions for these conditions. This, coupled with the increasing willingness of practitioners to diagnose conditions such as chronic fatigue syndrome, fibromyalgia and irritable bowel syndrome, has led to an increase in the number of patients who are referred for psychological treatment. At present, however, many psychological therapists are unfamiliar with the literature on MUS. With this in mind, this special issue presents a series of papers that provide an overview of what is known about the nature, aetiology and treatment of medically unexplained illness. This introductory paper provides general information about the clinical presentation, diagnosis, classification, terminology and epidemiology of MUS in adults, and concludes with an examination of important areas for future development in the field. Subsequent papers address the psychological mechanisms [Deary, V., Chalder, T., & Sharpe, M. (2007-this issue). The cognitive behavioural model of medically unexplained symptoms: A theoretical and empirical review. Clinical Psychology Review; Iverson, A., Chalder, T., & Wessely, S. (2007-this issue). Gulf war illness: Lessons from medically unexplained illness. Clinical Psychology Review; Rief, W., & Broadbent, E. (2007-this issue). Explaining medically unexplained symptoms: Models and mechanisms. Clinical Psychology Review; Roelofs, K., & Spinhoven, P. (2007-this issue). Trauma and medically unexplained symptoms: Towards an integration of cognitive and neuro-biological accounts. Clinical Psychology Review] and management [Deary, V., Chalder, T., & Sharpe, M. (2007-this issue). The cognitive behavioural model of medically unexplained symptoms: A theoretical and empirical review. Clinical Psychology Review] of these conditions. A separate overview of the literature on MUS in children and adolescents is provided by Eminson [Eminson, J. (2007-this issue). Medically unexplained symptoms in children and adolescents. Clinical Psychology Review].

Section snippets

Clinical presentation

MUS can be related to any bodily system and most medical specialties have their own unexplained symptom syndromes (Table 1). Common symptoms in adult¹ primary care include fatigue, pain, dizziness and general “malaise”, although

Future directions

Although recent years have seen important advances in our understanding of MUS, research in this area is still in its infancy. Even apparently basic issues concerning definition, classification and terminology are unresolved, research studies often lack methodological rigour, and fundamental questions concerning the mechanisms of MUS remain unanswered. Until these shortcomings are addressed, the effectiveness of our treatments for these conditions will remain limited. The following represent

References (56)

CreedF. et al.
A systematic review of the epidemiology of somatisation disorder and hypochondriasis
Journal of Psychosomatic Research
(2004)
DearyV. et al.
The cognitive behavioural model of medically unexplained symptoms: A theoretical and empirical review
Clinical Psychology Review
(2007)
GaraM.A. et al.
A hierarchical classes analysis (HICLAS) of primary care patients with medically unexplained somatic symptoms
Psychiatry Research
(1998)
GuthrieE. et al.
A controlled trial of psychological treatment for irritable bowel syndrome
Gastroenterology
(1991)
HalliganP.W. et al.
Imaging hypnotic paralysis: Implications for conversion hysteria
The Lancet
(2000)
HamiltonJ. et al.
Randomized controlled trial of psychotherapy in patients with chronic functional dyspepsia
Gastroenterology
(2000)
HillerW.
Don't change a winning horse
Journal of Psychosomatic Research
(2006)
KroenkeK. et al.
Common symptoms in ambulatory care: Incidence, evaluation, therapy, and outcome
American Journal of Medicine
(1989)
KroenkeK. et al.
Revising the classification of somatoform disorders: Key questions and preliminary recommendations
Psychosomatics
(2007)
LevensonJ.L.
A rose by any other name is still a rose
Journal of Psychosomatic Research
(2006)

NimnuanC. et al.

Medically unexplained symptoms. An epidemiological study in seven specialities

Journal of Psychosomatic Research

(2001)

RiefW. et al.

Psychobiological perspectives on somatoform disorders

Psychoneuroendocrinology

(2005)

RiefW. et al.

Toward empirically based criteria for the classification of multiple somatoform symptoms

Journal of Psychosomatic Research

(1999)

RoelofsK. et al.

Trauma and medically unexplained symptoms: Towards an integration of cognitive and neuro-biological accounts

Clinical Psychology Review

(2007)

WesselyS. et al.

Functional somatic syndromes: One or many?

Lancet

(1999)

AaronL.A. et al.

A review of the evidence for overlap among unexplained clinical conditions

Annals of Internal Medicine

(2001)

AllenL. et al.

Psychosocial treatments for multiple unexplained physical symptoms: A review of the literature

Psychosomatic Medicine

(2002)

American Psychiatric Association

Diagnostic and statistical manual of mental disorders

(1994)

BassC. et al.

Somatoform disorders: Severe psychiatric illnesses neglected by psychiatrists

British Journal of Psychiatry

(2001)

Breuer, J., & Freud, S. (1893–1895/1955). Studies on hysteria. In J. Strachey & A. Strachey (Eds.), The standard...

BrownR.J.

Psychological mechanisms of medically unexplained symptoms: An integrative conceptual model

Psychological Bulletin

(2004)

BrownR.J.

Dissociation and conversion in psychogenic illness

Brown, R. J., Cardeña, E., Nijenhuis, E., Sar, V., & van der Hart, O. (in press). Should conversion disorder be...

CrimliskH.L. et al.

Slater revisited: 6 year follow up study of patients with medically unexplained motor symptoms

British Medical Journal

(1998)

EminsonJ.

Medically unexplained symptoms in children and adolescents

Clinical Psychology Review

(2007)

GuthrieE. et al.

Cluster analysis of symptoms and health seeking behaviour differentiates subgroups of patients with severe irritable bowel syndrome

Gut

(2003)

InterianA. et al.

The value of pseudoneurological symptoms for assessing psychopathology in primary care

Psychosomatic Medicine

(2004)

IversonA. et al.

Gulf war illness: Lessons from medically unexplained illness

Clinical Psychology Review

(2007)

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Citation Excerpt :
The data are based on focus group and follow-up interviews with GPs in Norway about their work with the large, heterogeneous group of patients suffering from medically unexplained symptoms (MUS). MUS are thought to differ from other subjective complaints (e.g. ‘headache’ or ‘loss of appetite’) in being persistent, debilitating and often widely contested conditions for which medical science has no explanation (Barker, 2010; Brown, 2007). ( In some studies, however, MUS is not differentiated but equated to subjective complaints, cf. Reid et al., 2003; see Rasmussen, 2020 for details).
This article explores general practitioners' (GPs) persuasive efforts in cases where biomedical evidence is absent but expected. Health insurance in Western countries is based on the biomedical ideal that legitimate complaints should have objective causes detectable by medical examination. For GPs responsible for assessing sickness and incapacity for work, the demand for objective evidence can be problematic: what if they as experts deem that a patient is in fact sick and eligible for benefits, but are unable to provide objective evidence to that fact? How can they convince bureaucrats in the insurance system to accept their judgment? Taking ‘medically unexplained symptoms’ as my case, I draw on focus group and follow-up interviews with GPs in Norway to explore how GPs attempt to persuade bureaucrats to accept their professional judgment. Proposing the concept of ‘rhetorical work’, I reconstruct a typology of such work that doctors engage in to influence bureaucratic decision-making and provide long-term health benefits for patients. I then discuss the potential societal implications of GPs' rhetorical practices and the applications of the concept of rhetorical work in future research.
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To examine the effectiveness of a cognitive behavioural intervention delivered by mental health nurse practitioners (MHNPs) to patients with undifferentiated somatoform disorder (USD), compared to usual care.
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EditorialIntroduction to the special issue on medically unexplained symptoms: Background and future directions

Abstract

Section snippets

Clinical presentation

Future directions

Journal of Psychosomatic Research

Clinical Psychology Review

Psychiatry Research

Gastroenterology

The Lancet

Gastroenterology

Journal of Psychosomatic Research

American Journal of Medicine

Psychosomatics

Journal of Psychosomatic Research

Journal of Psychosomatic Research

Psychoneuroendocrinology

Journal of Psychosomatic Research

Clinical Psychology Review

Lancet

A review of the evidence for overlap among unexplained clinical conditions

Annals of Internal Medicine

Psychosocial treatments for multiple unexplained physical symptoms: A review of the literature

Psychosomatic Medicine

Diagnostic and statistical manual of mental disorders

Somatoform disorders: Severe psychiatric illnesses neglected by psychiatrists

British Journal of Psychiatry

Psychological mechanisms of medically unexplained symptoms: An integrative conceptual model

Psychological Bulletin

Dissociation and conversion in psychogenic illness

Slater revisited: 6 year follow up study of patients with medically unexplained motor symptoms

British Medical Journal

Medically unexplained symptoms in children and adolescents

Clinical Psychology Review

Cluster analysis of symptoms and health seeking behaviour differentiates subgroups of patients with severe irritable bowel syndrome

Gut

The value of pseudoneurological symptoms for assessing psychopathology in primary care

Psychosomatic Medicine

Gulf war illness: Lessons from medically unexplained illness

Clinical Psychology Review

Editorial
Introduction to the special issue on medically unexplained symptoms: Background and future directions