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are defined as “ those symptoms having little or no basis in underlying organic disease , [ and ] when organic disease exists , the symptoms are inconsistent with it or out of proportion to it ”. 1 These symptoms are often combined with psychological symptoms , but the cause – effect relationship may not be clear .

Patients with mixed emotional and physical symptoms , but no biomedical diagnosis , have been described for centuries , but the way in which their distress is understood , expressed and classified has changed significantly . 2-5 Prevalence statistics are almost meaningless as they depend on a variety of definitions that do not always align . 6 Nevertheless , we know that patients commonly present in primary care with symptoms we are unable to explain . 6

Medically unexplained symptoms are more common in women , are associated

abuse or trauma and are frequently seen in patients who also have anxiety or depression . 7-11 These symptoms can cause significant morbidity . 9 , 12-15 Not all medically unexplained symptoms are the same , and there can be significant diversity in the cohort . This heterogeneity makes it problematic to use a standardised approach .

The term ‘ medically unexplained symptoms ’ is not a diagnosis ; it really represents a series of dilemmas that are difficult to address .

This How to Treat describes some of the challenges of working with patients with medically unexplained symptoms and aims to ensure the GP can use safe clinical reasoning strategies , effective interpersonal skills and harm minimisation approaches to maximise the outcomes for patients .

THE POWER OF A

DIAGNOSIS

A DIAGNOSIS has biomedical value , in that it can guide therapy . Even if defini-

organises illness . It implies prognosis , treatment and explanation .

However , a diagnosis also has psychosocial value , in that it gives “ permission to be ill ”. 16 Patients with medically unexplained symptoms experience loneliness , isolation , marginalisation and invalidation ( see figure 1 ). 17 Without a diagnosis , they have difficulty accessing financial supports through organisations like the National Disability Insurance Scheme or care through public health services , especially if there are other barriers like

18 , 19 poverty or low health literacy .

A 2002 US study looked at the attitude of medical students to patients , which demonstrated patients with medically unexplained symptoms were held in the lowest regard of all diagnoses , including addictions and other psychiatric disorders . 20 Nobody wants an anonymous illness . 21

It is therefore understandable that people with medically unexplained symptoms seek diagnoses . But this

over-investigation , overdiagnosis and overtreatment is considerable — both inside and outside the conventional medical system . 22

When the medical system is unable to supply a useful diagnosis , patients may seek validation from other individuals and communities , including virtual communities . 23-25 These communities may provide support , validation and appropriate ways of managing symptoms , but they may also lead to disengagement with the health system

26 , 27 that can provide safe care .

THE MIND – BODY

PROBLEM

THERE is a long history of medically unexplained symptoms being attributed to psychological illness , particularly in women . While some patients have symptoms that have psychological triggers , others do not . 28 Despite this , medically unexplained symptoms have been classified in psychiatric taxonomies for centuries . The

14 July 2023

with a history of childhood

tive therapy is not possible , a diagnosis

can be risky . Iatrogenic harm from

various psychiatric diagnoses

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