Assessment and immediate management of patients with medically unexplained symptoms in primary care

Medically unexplained symptoms (MUS) are physical symptoms that doctors cannot explain by organic pathology, which distress or impair the functioning of the patient. Patients with MUS account for around 50% more visits to primary care doctors, one-third more secondary care contacts than patients without MUS. MUS are often precipitated or exacerbated by psychosocial stress, depression and anxiety. Primary care consultations can take the form of a contest between the patient with MUS and the doctors: the doctor tries to reassure the patient, the patient provides more evidence of their distress or information that challenges the authority of the doctor, and the consultation often ends in collusion with an investigation, prescription, or referral that neither patient nor doctor is content with. Patients with MUS seek doctors who take their concerns seriously and legitimize their complaints. They do not necessarily expect a cure, but they seek an alliance to help them understand their health problems. Provision of emotional support, modification of symptom beliefs, explanations linking physical problems to psychosocial issues when they are relevant, antidepressants, and graded exercise for some types of MUS seem to be worth trying by doctors for patients with MUS. A four-stage model to help doctors manage MUS is provided. Some patients with chronic MUS and high consultation behaviour will require regular consultations with a single doctor who restricts the use of investigations, prescriptions, and referrals. Cognitive behavioural therapy may be helpful for patients with MUS who are willing to seek further psychological help.