Managing Medically Unexplained Symptoms in Primary Care

Abstract

Medically unexplained symptoms (MUS) are persistent physical symptoms in the absence of identifiable disease. MUS present a major challenge for primary care providers (PCPs) because complex symptom presentations, strained patient-physician relationships, and treatment-resistant symptoms can challenge a PCP’s sense of competency. This review is intended to help PCPs understand the burden and theoretical context of MUS and to provide concise recommendations for managing MUS within primary care settings. Based on a narrative review of the literature, these recommendations emphasize in particular the importance of co-creating plausible explanations for MUS, understanding the pitfalls of consultations involving MUS, and developing multimodal treatment plans.

‘Part of the challenge in managing MUS lies in identifying appropriate language for conceptualizing these somatic presentations and communicating effectively with patients and colleagues.’

Persistent physical symptoms in the absence of identifiable disease present a major challenge for patients and physicians alike. Symptoms are classified as medically unexplained when adequate investigation rules out known physical causes for their occurrence or for the associated level of impairment.¹ Medically unexplained symptoms (MUS) must also cause significant functional disability or distress and cannot be solely attributable to anxiety, depression, health anxiety, or psychosis. Common examples of MUS include pain, fatigue, dizziness, headaches, changes in gut motility, and visual and auditory disturbances. Medically unexplained symptoms can also refer to functional syndromes (eg, fibromyalgia or irritable bowel syndromes) and to symptoms of an identified disease that are more frequent, intense, or enduring compared with reports of patients with the same diagnosis and same stage of disease. That said, the suffering of patients with MUS is very real, even though their symptoms are likely not the result of disease processes sufficiently elucidated by medical science. Despite extensive medical evaluations and interventions, treatment is typically ineffective. This can lead to frustration for both patients and physicians, iatrogenesis via unnecessary medical assessment and procedures (eg, computerized axial tomography scans and surgery complications), and high health care costs. A hypothetical case with typical features of patients with MUS is presented in Figure 1.

Figure 1.

Case example of a patient with medically unexplained symptoms.

This review briefly summarizes the terminology, identification, burden, and theoretical context of MUS and provides concise recommendations for primary care providers (PCPs) who treat patients with MUS.

Terminology

Functional Syndromes

Part of the challenge in managing MUS lies in identifying appropriate language for conceptualizing these somatic presentations and communicating effectively with patients and colleagues. There are several diagnoses in the International Classification of Diseases, Tenth Revision (ICD-10) manual² and the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)³ that may be appropriate for patients with MUS. Medically unexplained symptoms are commonly diagnosed as functional syndromes (ie, fibromyalgia, irritable bowel syndrome, chronic fatigue syndrome, etc) by medical providers who rely primarily on the ICD-10 and as somatic symptoms and related disorders by mental health professionals who rely primarily on the DSM-5. Despite considerable overlap between symptoms of functional syndromes, diagnosing patients with functional syndromes often depends less on patients’ symptom profiles and more on location of care of the diagnosing physician.⁴ For example, rheumatologists often diagnose patients with fibromyalgia, whereas gastroenterologists often diagnose the same patients with irritable bowel syndrome. Although basic science is clarifying the pathological processes underlying functional syndromes, many physicians still consider these syndromes to be unexplained medically.

Psychological Disorders

In specialty mental health settings, the most common diagnosis for patients with MUS is a somatic symptom disorder diagnosis (formally called somatization disorder). The DSM-5 criteria for this disorder include the presence of 1 or more somatic symptoms that are persistent, are functionally impairing, and co-occur with maladaptive thoughts, feelings, or behaviors.³ Other related DSM-5 diagnoses one may see include illness anxiety disorder (formerly hypochondriasis), functional neurological disorder (formerly conversion disorder), and psychological factors affecting other medical conditions (see Table 1).

Table 1.

Somatic Symptom and Related Disorders in the Fifth Edition of Diagnostic and Statistical Manual of Mental Disorders.

Somatic Symptoms and Related Disorders	Definition
Somatic symptoms disorder (can include “predominant pain” as a specifier)	One or more persistent and impairing somatic symptoms plus maladaptive thoughts, feelings, and behaviors related to the symptom(s)
Illness anxiety disorder (formerly hypochondriasis)	Continuous worrisome preoccupation about having a serious medical condition (in the absence of severe symptoms) for at least 6 months plus excessive behavior related to health
Functional neurological disorder (formerly conversion disorder)	Altered voluntary motor or sensory function plus negative neurological findings
Psychological factors affecting other medical conditions	Psychological or behavioral factors that adversely affect a medical symptom or condition.

It is important that PCPs have familiarity with DSM-5 terms, since they may see them. Somatic symptoms disorder, as described in the new diagnostic category of the DSM-5, is a plausible candidate for an overarching term for MUS; however, somatic symptoms disorder is too inclusive and does not adequately capture the functional syndromes, which many physicians recognize and diagnose more frequently. Therefore, in the context of primary care, we recommend using the term MUS, as is consistent with guidelines published in Up-to-Date⁵:

The term “medically unexplained symptoms” is useful, over and above somatization, because it represents a broader concept, includes the full spectrum of severity, and is consistent with the presence of concurrent general medical and psychiatric illness causing these symptoms.

Identification

There are several approaches to identifying patients with MUS. The most convenient and face-valid approach is based on PCPs’ opinions regarding whether patients’ symptoms are medically unexplained.⁶ A second option is to rely on DSM-5 diagnostic criteria or ICD-10 diagnoses of functional disorders. However, experts in MUS caution against a sole reliance on ICD-10 and DSM-5 diagnostic criteria given that existing taxonomies for patients with MUS are too restrictive to be optimally useful for PCPs who encounter a range of clinical presentations that vary considerably in terms of symptom severity, duration, and comorbidity.⁷ Finally, a third option that has been used in research is more intensive chart ratings methods, which can reliably identify patients with MUS.⁸ Such chart review approaches can specify symptom duration, symptom severity, and comorbidity for each patient with more precision than methods reliant on PCP opinion; however, the 40 hours of training and 15 to 20 minutes required to rate a single chart is burdensome and likely not feasible in the context of routine clinical practice.⁸ For these reasons, at this time, careful workups and physician judgment appear the most optimal methods for identifying patients with MUS.

In the context of this approach, identifying subgroups of patients with MUS can help PCPs assess nuances in patient presentations and tailor treatment accordingly. For example, Dwamena and colleagues⁹ identified 3 subgroups using qualitative interviews with 19 patients with MUS:

1. Coping high utilizers (n = 4) demonstrate considerable psychological insight into their symptoms, continue to function highly in the face of their MUS, and primarily seek explanations and self-management recommendations from PCPs.

2. Classic high utilizers (n = 9) demonstrate less psychological insight, experience a high degree of functional impairment, feel authorized to absolve themselves from professional and social duties, primarily seek legitimization from PCPs, and usually do not accept interpretations attempting to reattribute somatic symptoms to psychological distress.

3. Worried high utilizers (n = 6) present primarily with persistent concerns and anxiety about serious illness, express dissatisfaction with health care services despite using many resources, and primarily benefit from strategies that address the source of health anxiety and explanations that incorporate relevant psychosocial factors. (It is important to note that not all patients with MUS are “high utilizers,” as the titles of these subgroups may imply. This review does focus, however, on patients of significant relevance to routine practice in primary care—namely, those who are high utilizing.)

Burden

The epidemiology of MUS in primary care settings is difficult to pinpoint because researchers use different approaches to identify and classify MUS. It is estimated that on average, 80% of the general population will report experiencing a symptom in any given month, yet only 25% seek medical care.¹⁰ For primary care patients, estimates of MUS based on PCPs’ opinions suggest a prevalence rate of 19%.⁶ When more restrictive criteria are imposed on physicians in judging whether patients’ symptoms are medically unexplained (eg, a 95% certainty criterion), prevalence rates can drop to under 10%.¹¹

Of patients presenting to primary care with a somatic complaint, it is estimated that less than 5% have an acutely serious symptom, 70% to 75% have minor or self-limited symptoms, and 20% to 25% have persistent MUS.¹² Despite the widely varying prevalence estimates, it is generally accepted that between 15% and 30% of patients present to primary care with a chief complaint of MUS at some point across the life span.

Patients with MUS endure great personal burden and also strain the health care system with disproportionate use of scarce resources. Compared with patients without MUS, those with MUS demonstrate poor health care outcomes, especially in 3 key domains outlined by Berwick and colleagues’ Triple Aim framework¹³: patient experience of care, population health, and health care costs. Indeed, patients with MUS consistently report poor experiences with health care services,¹⁴ have poor quality of life¹⁵ and benefit less from treatment,¹⁶ and incur greater cost estimated to exceed $250 billion a year nationally.¹⁷ With complex symptom profiles often complicated by mental health comorbidity, these patients receive extensive physical health assessment and intervention, often unnecessarily so.¹²

Many PCPs also experience patients with MUS as burdensome. A survey among physicians in family practice and internal medicine suggested that only 25% reported “very good or excellent ability to manage these patients,” and only 14% reported excellent or very good satisfaction in managing these patients.¹⁸ Unfortunately, many patients with MUS have acquired the label of “heartsink” patients,¹⁹ and despite recognition that PCPs feel responsible for treating these patients,²⁰ many PCPs devalue their own skill in managing MUS and decline training to more effectively treat patients with MUS.²¹

Theoretical Models

For centuries, clinicians and scholars have developed theories about the phenomenon of MUS and have advanced a variety of theories in an attempt to explain how patients can experience significant physical symptoms that defy medical explanation. Adherents to the psychoanalytical tradition advanced the first comprehensive theory of MUS and hypothesized that neural energies exceeding the coping capacity of defense mechanisms expressed themselves as somatic symptoms.²² These conceptualizations dominated the field for nearly a century before more contemporary biopsychosocial, dyadic, and cultural models gained more favorable reputations.

Biopsychosocial Models of MUS—Integrating Multiple Factors

Contemporary researchers have outlined the purported physiological, behavioral, cognitive, and emotional mechanisms to explain why some individuals experience more somatic symptoms or are more distressed by somatic symptoms than are others. Two predominant, integrative biopsychosocial models of MUS have generated more research and have been cited more often than other existing models. First, Brown¹ drew heavily on cognitive research to describe how the ways in which people pay attention give rise to everyday experience and guide thought and action. Accordingly, MUS can arise when chronic activation of memories of symptom experiences competes with current perceptual stimuli to influence moment-to-moment experience. The undue influence of memories, at the expense of contemporary perception, can cause people to experience somatic symptoms that are subjectively valid despite having tenuous connections to perceptual stimulation. Brown’s integrative model is thus noteworthy because it offers a mechanistic explanation for how patients with MUS experience substantial discomfort and impairment in the absence of known physical causes. Put another way, MUS may result more from dysregulated cognitive processes than from physiologic anomalies. Several recent studies using a variety of modern experimental paradigms provide further empirical support to substantiate this model.^23-28

In addition, Rief and Broadbent²⁹ proposed a “filter model” in which bodily signals (ie, sensations/symptoms) pass through a nonconscious filter system before they are consciously perceived. Increases in strength of bodily signals can arise under conditions of high distress, chronic hypothalamic-pituitary-adrenal (HPA) axis activation, physical deconditioning, sensitization of the filter system, and the influence of other people. Similarly, the hypothesized filter can become compromised due to selective attention, infections, health anxiety, depressive mood, lack of distraction, and the influence of other people. And finally, cortical perception of bodily signals can be enhanced as a result of factors such as expectation, trauma, and neuronal plasticity. As a result, strengthened somatic afferents, faulty filtering, and enhanced cortical perception can allow more of the somatic sensations to rise to conscious awareness and generate somatic symptom experiences.

From an empirical standpoint, it is important to acknowledge that although these 2 integrative models share many similarities, important differences lead to very different empirical predictions (eg, primary difficulty for patients with MUS lies in disengaging from bodily-focused attention vs impairments in the filter system). From a clinical standpoint, patients likely benefit less from understanding nuanced differences between theoretical models of MUS and more from how their idiosyncratic experiences align with plausible mechanistic explanations. Given the heterogeneity of possible causes of MUS for patients, providers can discuss with patients the ways in which one or a combination of theoretical explanations may account for potential origins of their unique presentation of MUS (see Table 2 for a summary of explanatory models of MUS³⁰).

Table 2.

Explanations of Medically Unexplained Symptoms (MUS).

Theory	Description
Abnormal proprioception	More exact and sensitive perception of even small changes in muscle tension lead to enhanced feelings of abnormality and pain.
Autonomic nervous system dysfunction	Chronic activation of the autonomic nervous system results in long-lasting increased heart rate and stress burden.
Endocrine dysregulation	Prolonged activation of the hypothalamic-pituitary-adrenal (HPA) axis leads to “burnout” and downregulation of the HPA axis.
Immune system sensitization	The cytokine system becomes overly sensitive in response to activation during early stages of development, repetitive stimulation, or prior exposure to immunological stimuli.
Illness behavior	A cycle of maladaptive behavior and symptoms characterized by social and emotional avoidance and a sedentary lifestyle increase and maintain symptoms.
Sensitivity	Negative affect and neuroticism predispose people toward MUS.
Cognitive-behavioral	Multifactorial model that integrates perpetuating factors as well as predisposing and precipitating factors at the biological, psychological, and social levels.
Signal filter	“Faulty filtering” leads to an inability to distinguish physiological and pathophysiological processes.
Somatosensory amplification	Benign physical sensations are strengthened through repeated attentional focus and maladaptive attributions.

Dyadic Models of MUS—“Somatizing” Effects of Clinical Consultations

Especially pertinent for PCPs and their interactions with patients with MUS, Salmon and colleagues³¹ have advanced a model of MUS that describes interpersonal processes between patients and physicians that can give rise to and maintain MUS in the context of medical consultations.

This dyadic model begins with challenging the commonly held belief that patients with MUS implicitly deny potential psychosocial contributors of their idiopathic symptoms and demand medical explanation and interventions.^32,33 There is, however, little empirical evidence to support the assumption that patients with MUS disavow psychosocial contributions to MUS; rather, there is empirical evidence that they do acknowledge psychosocial contributions when asked.³⁴ In fact, physicians are actually more likely to suggest medical intervention than are patients.³⁵

Why then do PCPs propose medical interventions for patients with MUS when medical interventions may not be indicated and patients are not demanding them? There are many possible reasons. Primary care providers may feel pressured to offer intervention in response to graphic and emotionally charged symptom descriptions and persistent reports of ineffectual treatment.^36,37 Consequently, chronically symptomatic patients who consistently do not respond to treatment challenge PCPs’ sense of medical competency³⁸ with difficult to explain symptom profiles that then often leads to less assessment and more intervention.³⁹ For example, in analyzing transcripts between patients with MUS and PCPs, Salmon and colleagues³⁹ found that PCPs do not appear to offer medical interventions because their patients request them; rather, PCPs may actively disregard patients’ psychological cues. Salmon and colleagues suggest that PCPs may offer medical interventions as a way of decreasing negative emotion on the part of both the doctor and the patient, as well as returning the consultation back to an area (ie, medical interventions) where the PCPs feel more competent and have more authority.³⁸

Unfortunately, failing to adequately assess psychosocial factors, attributing symptoms solely to emotional problems, or providing simple reassurances can oftentimes have unintended consequences. In an effort to persuade physicians to take their legitimate symptoms seriously, patients may then amplify their physical symptom presentations,³⁸ which can render PCPs even more likely to propose medical interventions when exploration of psychosocial cues is largely absent.³⁹ Ironically, patients with MUS repeatedly find themselves in a position of having to convince their physicians of their (very real) suffering, which is of course antithetical to recovery.³⁶ Through the process of repeated medical assessments and interventions, suggested more often than not by PCPs, patients are in effect “somatized” by the consultation process.

Cultural Models of MUS—Illness Without Disease

Finally, several researchers emphasize how personal and cultural meanings of illness shape patients’ illness experiences. For example, Kirmayer et al⁴⁰ argued that whereas it is difficult to provide a definitive pathophysiology for most MUS, there is sufficient research to identify plausible physiological mechanisms that may be more proximal to the manifest physical symptoms than are the psychological factors that contribute to somatic symptoms. This formulation is consistent with the notion that physiological explanations for illness may be more consistent with patients’ experience of being physically ill and may therefore appeal more to patients. Such explanations do not preclude discussion of the role that psychological and emotional factors play in MUS; rather, culturally sensitive approaches to treating MUS emphasize the importance of helping patients create cohesive “illness narratives” that link patients’ experiences, symptoms, and cultural beliefs.⁴¹ Developing cohesive narratives is important given that patients with MUS often present with chaotic narratives characterized by confusion, an absence of definable and treatable problems, worry about stigmatizations that their symptoms are “all in their head,” and feeling like “medical orphans” being passed around from one specialist to the next like a “hot potato.”⁴² Indeed, it is generally unacceptable in Western society to be ill without a disease—the distress of which is compounded by the absence of a coherent explanation of symptoms.⁴³

Summary

The theoretical models outlined above emerged from different fields and reflect the variety of ways in which researchers approach MUS. Primary care providers who have long-term relationships with patients, as well as often possess a more comprehensive understanding of the biopsychosocial factors that contribute to and maintain a given patient’s illness experience, are uniquely positioned to facilitate appropriate care for patients with MUS.

Management in Primary Care

No single primary care intervention for patients with MUS is acceptable to patients, feasible to implement, and broadly efficacious in reducing symptoms. Given that patients with MUS constitute a heterogeneous group with varying needs, experts agree that patients with MUS require careful assessment and multimodal treatment. For example, in 2002, the Veterans Affairs and Institute of Medicine published guidelines for managing patients with MUS using a detailed algorithm with assessment and treatment recommendations.⁴⁴ Using a similar and more concise algorithmic approach, the treatment recommendations provided here are based on Kroenke’s stepped-care approach¹² for managing somatic complaints in primary care settings, a synthesis of the literature on evidence-based interventions for MUS and functional syndromes, and guidelines for interacting with patients with MUS derived from the dyadic and cultural models described above (see Figure 2 for a treatment plan developed for the hypothetical patient depicted in Figure 1).

Figure 2.

Assessment and plan for hypothetical patient with medically unexplained symptoms.

Stepped Care for MUS

Kroenke’s stepped-care approach¹² in Figure 3 involves determining initial severity, assessing and treating comorbid mental health symptoms and functional syndromes, and developing multimodal treatment plans for patients with persistent MUS.

Figure 3.

Kroenke’s (2006) modified stepped care approach.¹² MUS, medically unexplained symptoms.

Step 1: Determine Severity

The stepped-care approach begins with determining MUS severity, duration, and impairment and categorizing MUS into 1 of 3 groups:

1. Acutely serious (<5% of patients)

2. Minor and self-limited (70%-75% of patients)

3. Persistent, chronic/recurrent, and impairing (20%-25% of patients)

Acutely serious symptoms (ie, chest pain, sudden changes in consciousness, labored breathing) require expedited diagnostic evaluation (step 1.A.i in Figure 3), whereas common MUS such as muscle pain, fatigue, and stomach upset are seldom life-threatening, typically respond to symptom-specific therapies, and often resolve at a follow-up visits (step 1.B.ii). When MUS persist after treatment and follow-up (step 1.C), PCPs move to step 2.

Step 2: Assess and Treat Psychiatric Symptoms and Functional Syndromes

Even though psychiatric symptoms are not necessarily the underlying cause of MUS, it is important to assess for psychiatric symptoms given the high rate of comorbidity with MUS. Primary care providers can use the Patient Health Questionnaire⁴⁵ to screen for depressive and anxiety disorders given that approximately 50% to 75% of patients with MUS experience a depressive disorder, and 40% to 50% experience an anxiety disorder.⁴⁶ A range of efficacious psychotherapies and pharmacotherapies can help patients cope with symptoms of depression and anxiety,^47,48 which, in turn, can help alleviate impairment associated with physical symptoms. When recommending mental health treatment or making a referral to a mental health specialist, care must be exercised in providing a rationale for why such a course of treatment will help patients with their MUS, without implying that MUS are purely psychogenic (see guidelines below for interacting with patients with MUS for more details). Instead, physicians might recommend patients consider treatment to help them deal with the legitimate stress of coping with their symptoms.

It is also recommend that PCPs assess for functional syndromes that are consistent with patients’ symptom presentations. While several researchers have called for the unification of functional syndromes under a single construct such as “bodily distress syndrome,”⁴⁹ current guidelines retain distinctions between the various functional syndromes and specify assessment procedures and treatment recommendations specific to each individual functional syndrome.^50,51

Step 3: Develop Plan for Managing MUS

If patients do not respond to treatments specified in steps 1 and 2, PCPs are advised to collaborate with their patients in further developing a personalized treatment plan. By definition, personalized treatment plans will vary from patient to patient; however, the following common elements can help PCPs develop a framework for structuring individual consultations and long-term treatment planning for patients with MUS⁵²:

1. Help patients to feel understood—elicit histories of physical and psychological symptoms, assess beliefs about illness and prior treatment, conduct indicated physical examinations, and focus on understanding the patient’s perspective and finding parts of patients’ experiences that physicians can agree with and validate.

2. Negotiate an agenda—acknowledge distress and never communicate to patients that their symptoms are “all in their head,” provide feedback about assessments, and clarify patient reactions to feedback and treatment preferences;

3. Take action—co-create explanations with the patient, negotiate specific requests for medical investigations and interventions, continue monitoring physical symptoms and psychiatric symptoms as appropriate, and make specific plans for coping with stress, self-management, lifestyle changes, or watchful waiting.

4. Terminate consultation—determine follow-up appointment if any, emphasize commitment to continued collaboration, and agree to reconsider plan if symptoms worsen or new symptoms arise.

Guidelines for Interpersonal Interactions With Patients With MUS

The dyadic model described above highlights several principles to guide interactions with patients with MUS, including the following.

First, key to effectively treating patients with MUS is validating the legitimacy of patients’ experience of their symptoms. Reassuring patients that their symptoms are real can diffuse the emotional charge of the clinical consultation, help patients feel understood, and serve as a primer for co-creating plausible explanations to account for MUS in ways that are consistent with patients’ cultural beliefs. Nonjudgmentally accepting patients’ experience allows patients to relinquish tendencies to convince providers of the validity of their symptoms and sets the stage for collaborative treatment planning.

Second, it is clear that patients with MUS seek engagement and support from their PCPs.³⁶ One of the most powerful ways PCPs can demonstrate their commitment to patients with MUS is by facilitating the development of cohesive illness narratives that link somatic and psychiatric symptoms with past experiences, medical science, and patients’ cultural beliefs.⁴⁰ Given the complexity of patients’ medical and psychosocial presentations, it is important for PCPs to help patients understand how all the “pieces fit together,” especially when patients are referred to specialists. Such careful explanations, which combine patients’ experiences with scientific medical knowledge, can empower patients to embrace self-management strategies such as lifestyle changes, relaxation, or stress management, as well as promote acceptance and tolerance of symptoms.

One semistructured approach to helping patients with MUS develop cohesive narratives is the McGill Illness Narrative Interview,⁵³ which helps patients elaborate on 3 key themes:

1. Chain complexes that link past experiences and current symptoms chronologically yet do not require causal attributions (eg, “My abusive father died when I was a teenager and I started getting these terrible pains in my stomach”).

2. Prototypes that influence patients’ symptoms based on their own past experiences or others’ similar experiences. These prototypes provide foundational episodes on which patients can elaborate (eg, “My mom was tired all the time too, but her pain didn’t radiate all throughout her body like mine does”).

3. Explanatory models that organize patients’ causal attributions for their symptoms (eg, “I get these terrible headaches in the morning because I clench my jaw in my sleep when I’m stressed out about something”).

Using this framework, PCPs can help patients clarify the various psychological, social, and biological factors they believe contribute to their illness experience and how these perceived contributors interact with physiological and psychological processes elucidated by medical and social science.⁵⁴ Co-creating illness narratives that are tailored to patients’ specific symptoms and culturally based beliefs helps to align patients and providers in a unified collaboration and alleviate the distress associated with having no explanation for persistent MUS.

Third, recommend medical assessment and intervention only when clearly indicated. The complex and emotionally charged stories told by patients with MUS can also predispose PCPs to recommended medical assessment or interventions that may not be indicated or may even be iatrogenic. In the face of high complexity and highly emotional consultations, it is understandable that any provider would feel uncomfortable, and proposing medical assessment or intervention can be viewed as a compassionate attempt to offer something to suffering patients.³⁴ Put another way, PCPs treating patients with MUS are susceptible to “action biases” fueled by a perceived need to do something that outweighs the perceived need to recommend watchful waiting.⁵⁵ Nonetheless, it is critical for PCPs to renew their commitment to patient-centered care while retaining professional standards that maintain high thresholds for proposing medical assessment or intervention only when clearly indicated. To help any potential feelings of guilt associated with sending patients home empty handed, PCPs can openly discuss with patients the dilemma of a genuine desire to offer something to alleviate their suffering with their professional judgment that medical assessment or intervention is not indicated. In addition, PCPs can further alleviate any potential guilt by helping patients develop personalized behavioral plans to minimize discomfort and increase functioning in the face of MUS.

Role of Psychotherapy in Treating MUS

Not all patients with MUS will be interested in psychotherapy, nor will all interested patients benefit from psychotherapy. However, several variants of psychotherapy and delivery formats are efficacious treatments for MUS. Interventions based on the principles of cognitive-behavioral therapy have the most robust evidence (see Deary et al⁵⁶ for a review). These interventions help patients reduce overall distress as well as preoccupation with MUS by teaching patients relaxation techniques, activity regulation strategies, somatic and emotional awareness, increasing adaptive interpretations of the self and world, and interpersonal communication strategies.⁵⁷ Relaxation techniques frequently involve the use of exercises in diaphragmatic breathing, progressive muscle relaxation, and visualization, while activity regulation strategies involve replacing maladaptive behavioral responses to life stressors (ie, withdrawal and avoidance) with adaptive behavioral responses (ie, approach and problem solving). In cognitive-behavioral therapies, techniques such as self-monitoring and mindfulness help patients increase somatic and emotional awareness, and patients also learn to replace distorted interpretations of the self and world (ie, all-or-nothing attributions and catastrophizing) with more objective interpretations. Finally, patients in cognitive-behavioral therapy also learn communication strategies such as prioritizing interpersonal goals and assertiveness training.

On the basis of a systematic review of treatments for somatic symptom and related disorders, 11 of 13 studies demonstrated statistically significant advantages of cognitive-behavioral therapy compared with a control condition.¹⁶ Brief psychodynamic therapies,⁵⁸ mindfulness training,⁵⁹ and group therapy⁶⁰ also show promise, but data supporting these approaches are limited to a small handful of studies. Reattribution therapy, which teaches PCPs to coach patients to endorse psychogenic origins of MUS, has not been shown to be effective⁵² and therefore is not recommended.

Patients with MUS are often willing to acknowledge the contribution of psychosocial factors to their illness experience when given the opportunity and especially when they trust that PCPs will not assume psychosocial factors are the sole source of their symptoms.^61,62 Still, when recommending psychotherapy, PCPs are encouraged to exercise care in communicating that psychotherapy referrals do not indicate that MUS are “in their head” or that the provider is “dumping” the patient onto a different provider. Rather, effective psychotherapy referrals include affirmations that the PCP will remain in charge of patients’ physical health and a specific rationale that links how psychotherapy can teach coping strategies for MUS or co-occurring psychiatric symptoms that are associated with but not necessarily the cause of MUS.

Conclusion

Conceptualizing complex presentations, mending strained relationships with patients, persisting in the face of treatment-resistant symptoms, and practicing without well-established treatment guidelines are aspects of treating patients with MUS that can challenge a PCP’s sense of competency. Indeed, effective treatment for patients with MUS often looks very different from patterns of effective treatment for other patient subgroups. Effective treatment for patients with MUS requires high levels of collaboration and engagement as opposed to directive and intermittent treatment, jointly created explanations for symptoms as opposed to straightforward diagnoses, coordination of multimodal treatment delivered by 1 or more specialists as opposed to monotherapy delivered by a single provider, and treatment goals of modest symptom reduction and increased functioning as opposed to complete symptom remission. As many MUS experts admit, implementing these elements of treatment oftentimes represents a shift from treatment as usual. Such adjustments, however, not only have the potential to improve the care for patients with MUS, but embracing principles of effective MUS treatment—patient-centeredness, openly addressing complexity, and coordinating collaborative care—can enhance satisfaction, outcomes, and cost-effectiveness for all patients who seek our care.