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Medically unexplained symptoms 1
Medically unexplained Symptoms
(MUS, Somatoform Disorders)
H.Afshar
Psychosomatic
research center
IUMS
ASIA LINK VN009
Importance for the Health System
(Western countries)
Medically unexplained Symptoms 
High prevalence in primary care (30 %) and
secondary care (20 %)
Diagnosis
High use of medical service
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Treatment costs up to 9 times higher (Work
disability time due to sick leave and retirement)
Ineffective therapeutic measures in ca. half of the
patients; e.g. non-indicated surgical procedures
are performed in 20 % of hospitalized
„somatisers‘
Frequent change of doctors, emergency
admission to hospital and dissatisfaction with
treatment
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Overview
Medically unexplained Symptoms 
1.
Definition
2.
Classification
3.
Etiology
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Definition and Terminology
Medically unexplained Symptoms 
Medically unexplained symptoms (MUS)
General term, very broad
Functional syndroms
Disturbance of bodily function rather than structure
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Somatization
A psychological problem or emotional disorder is
expressed somatically
Somatoform disorders
Diagnostic category in the psychiatric classification of
DSM and ICD
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Overlapping of MUS, Functional Syndroms,
Somatization and Somatoform Disorders
Medically unexplained Symptoms 
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Definition of somatoform disorders
Medically unexplained Symptoms 
Definition
Repeated presentation of physical symptoms
Stubborn demand for medical examination despite
negative organic findings (dysfunctional illness
behavior).
Emotional problems denied, although there is close
relationship with psychosocial life events or conflicts
(somatic fixation).
Symptoms are not feigned or aggravated
Disappointing doctor-patient relationship (interpersonal
disorder)
Disruption of the Doctor-Patient Relationship
Doctor retreats or
refers to Specialist or
the patient breaks off contact;
doctor shopping
Patient feels misunderstood
and demands further
diagnostic measures
The doctor is irritated
Doctor looks for psychosocial
stress; Patient denies and
becomes enraged
Patient experiences physical
symptoms and seeks help
The doctor focuses on
organically-caused symptoms and
prescribes organ-medical diagnostic tests
prescribes medications
Patient sees no improvement;
the findings are negative;
Patient doesn´t know where to turn
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Medically unexplained Symptoms 
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Overview
Medically unexplained Symptoms 
1.
Definition
2.
Classification
3.
Etiology
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ICD – 10 classification
Medically unexplained Symptoms 
Classification
F 45.0 Somatization disorders
F 45.2 Hypochondrial disorders
F 45.3 Somatoform autonomic
dysfunction
F 45.4 Persistent somatoform pain
disorders
F 44 Dissociative (conversion) disorders
F 48.0 Neurasthenia
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Subgroups of somatization
Medically unexplained Symptoms 
Classification
Initial somatizers
Part somatizers
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Facultativ somatizers
True somatizers
Functional somatizers
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Common Symptoms
Medically unexplained Symptoms 
Classification
Symptoms of pain
backache
headache
bellyache
(73%)
(67%)
(56%)
Symptoms in the gastrointestinal tract
feeling of pressure
(54%)
flatulence
(56%)
Symptoms in the cardiovascular tract
heart palpitation
(55%)
sweating
(62%)
Rief et al. 1997
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Medically unexplained Symptoms 
Classification
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Depressive
disorder
Anxiety disorder
Somatisation
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Physical symptoms in anxiety disorders
Medically unexplained Symptoms 
Affected Organ (system)
Symptoms
1. Heart
Irregular beat, chest pain
2. Vessels
Pallor or flush
3. Musculature
Trembling, weak knees, tension
4. Respiratory tract
Feeling of constriction, suffocation
5. Gastrointestinal tract
Lump in the throat, vomiting,
stomach pain, diarrhea
6. Vegetative nervous
Sweating, urinary urge
system
7. Central nervous system Dizziness and feeling of
helplessness,
Classification
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Overview
Medically unexplained Symptoms 
1.
Definition
2.
Classification
3.
Etiology
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Vicious circle of somatoform symptoms
Medically unexplained Symptoms 
Etiology
Elicitor e.g.
Minor injury
Psychosocial stress
Sudden cardiac death of a
close person
Maintain Factors
„Checking the body“
Excessive worries about
health
„Doctor shopping“ – many
medical examinations
Taking medications
Protective behaviour
Somatic concept of illness
(Based on Rief 2000)
Physical Changes
Physical reactions
Malaise
Symptoms
Symptom potentiation
Increased attention to
one’s own body
Physiological arousal
Anxiety, depressive
symptoms
Perception
Misinterpretation
as asign of threatening disease
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Body related
l idioms
Medically unexplained Symptoms 
My hair stood on end
Get cold feet
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Have butterflies in the stomach
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What can the medical doctor do?
Medically unexplained Symptoms 
Avoid insults, recognize the illness as an
attempt at solution, legitimization of the
symptoms
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Take the physical symptoms seriously
Pay attention to difficulties in the doctorpatient relationship (e.g. Negative
feelings)
Avoid premature coupling of the symptoms
to psychosocial stress
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Approach to patients:
disease or illness oriented
Medically unexplained Symptoms 
Cognition: content, styles
Emotion
Function
Expectation
Concerns: questions
The reattribution model
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- how to talk to somatizating patients and how to deal Medically unexplained Symptoms 
Stage 1: Feeling understood
1. Take a full history of the symptoms
2. Explore emotional cues
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3. Explore social and family factors
4. Explore health beliefs
5. Brief focused physical examination
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The reattribution model
Medically unexplained Symptoms 
Stage 2: broadening the agenda
1. Feed back the results of the examination
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2. Acknowledge the reality of the symptoms
3. Reframe the complaints: link physical,
psychological, and life events
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The reattribution model
Medically unexplained Symptoms 
Stage 3: making the link
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1. Simple explanation
Three-stage explanation for anxiety
How depression lowers the pain threshold
2. Demonstration
Practical
Link to life events
„Here and Now“
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Three Stage explanation for “Anxiety
and physical complaints”
Medically unexplained Symptoms 
Emotions
Anxiety
Excitation
Inner
restlessness
Tension
Physical Reactions
Symptoms
Blood pressure
increase
Heart rate
increase
Rapid breathing
Tensed muscles
Extra systoles
Palpitations
Shortness of breath
Tingling
Muscle pains, esp.
shoulder and neck
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Three Stage explanation for
“Depression“
Medically unexplained Symptoms 
Emotions
Physical Reactions
Symptoms
Feeling blue
Lack of energy
Lack of interest
Withdrawal
Reduced pain
threshold
Increased
sinsitivity to
physical
discomfort
Weakened
immune system
Headache
Aching joints
Stomache
Back pain
Susceptibility to
infections
Neglect of preventive
health measures
Viscious circle model of anxiety and
panic attacks (Margraf & Schneider, 1990)
Vicious circle model of anxiety and panic attacks
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Medically unexplained Symptoms 
Physical Stimuli
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Physical
Sensations
Perception
Physiological
Changes
Thoughts
(„Danger“)
Anxiety
Visible Behaviour
Symptom Diary
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Record of thoughts and feelings during physical complaints
Medically unexplained Symptoms 
Date
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Example:
14.09.98
Symptom
(Severity 0-10)
0 = not at all
10 = very strong
How did you feel?
(Intensity 0 – 10)
0 = not at all
10 = very much
What did you think Problem
about?
solving
(Intensity of these strategies
thoughts from 0-10)
0 = not at all
Situation (what you e.g. anxious, very 10 = very strongly
are doing now or tense,
sad,
what occupies your nervous, annoyed,
thoughts.)
happy, restless
Pains in the chest Anxiety (6)
(8) working in the
garden
20.09.98 K Shortness of breath ( Anxiety (6)
rapid heart beat (6)
I’m having a heart I relaxed,
attack (9)
breathed
deeply
Something’s
wrong
with my heart (7)
I took a rest
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Medically unexplained Symptoms 
Potentially acutely serious? (< 5 %)
Yes
Expedited diagnostic evaluation
No
Likely minor and self-limited (70-75 %)
Yes
No
1. Adress patient expectations
2. Symptom-specific therapy
3. Follow-up in 2-6 weeks
Persistent unexplained
somatic symptoms (20-25 %)
Yes
Yes
Antidepressant and /
or cognitive- behavioral therapy
Depressive or anxiety disorder?
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Ineffective
No
Functional somatic syndrome?
No
Kroenke 2003
Yes
Syndrom-specific therapy
if evidence-based
•Regular time-limited clinic visits
•Psychological assesment (e.g. somatoform disorders, personality
disorders, history of trauma/abuse)
•Individual or group chronic symptom management programs
•Complementary medicine treatments when evidence-based
•Rehabiltative rather than disability approach