Occupational Medicine 2015;65:92–94 doi:10.1093/occmed/kqv004
Editorial
Medically unexplained symptoms employees with severe MUS were diagnosed with a psychiatric disorder by the specialist occupational health physician (OHP). Around 66% of employees attributed their symptoms to psychological or both psychological and physical factors. The prevalence of severe MUS was higher in employees on long-term sickness absence. Use of validated depression and anxiety screening questionnaires should therefore be a routine part of occupational health consultation for MUS. MUS are also associated with longer duration of sickness absence and higher risk of dismissal [8]. The median sickness absence was 78 days longer than for other conditions and prevalence of long-term disability was higher after 2 years in employees with severe MUS and significant depression. High levels of physical symptom severity were associated with longer sickness absence, long-term disability and job loss. Relationship breakdown with the employer was a common cause of dismissal although it is not clear whether this was due to conduct or capability. In a review of studies on the association between MUS and sickness absence [9] the authors found an association between sickness absence, psychiatric co-morbidity and severity of symptoms. The treating doctor’s knowledge of the patient, sympathy and higher levels of trust were associated with increased levels of sickness absence. None of the educational interventions aimed at improving doctors’ management of MUS reduced sickness absence although the validity and effectiveness of those interventions was unclear. The authors did not identify any studies on the impact of work factors on sickness absence due to MUS. Hoedeman et al. [10] found that OHPs are confident in assessing fitness for work in patients with MUS and that they do not represent a burdensome part of the workload. Although they did not relate confidence to outcomes such as return to work and decisions on return to work may be blocked by the treating physician if the diagnosis remains unclear. They concluded that OHPs need good psychiatric knowledge and good communication skills to identify and break down barriers to work in these patients. A narrative study invited patients with MUS who were off sick to share stories about their experiences of the process leading up to sickness absence [11]. Using theories of marginalization and coping, the authors looked at how patients’ personal resources and coping strategies could be used to counteract marginalization and reduce absence. Invisible symptoms and lack of objective clinical findings were perceived as an additional burden. Supportive social networks, good personal coping
© The Author 2015. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: [email protected]
Downloaded from http://occmed.oxfordjournals.org/ at University of Western Ontario on April 12, 2015
Medically unexplained symptoms (MUS) may be defined as physical symptoms with no identified organic cause, lasting for at least 3 months and leading to a loss of function. They are common, accounting for up to 20% of primary care consultations [1]. MUS are a cause of frequent healthcare usage and are associated with a 20–50% increase in outpatient costs and a 30% increase in admission rates (S. Bermingham, A. Cohen, J. Hague et al., personal communication; [2]). In the UK annual healthcare costs alone for MUS are around £3 billion with total costs exceeding £18 billion. Around 50% of secondary care patients meet the criteria for MUS [3]. Medical investigation of MUS is costly and causes significant harm to patients. MUS may present as a recognizable syndrome such as fibromyalgia, irritable bowel syndrome or chronic fatigue syndrome, or as symptoms with no clear organic cause. Typical presentations include pain, fatigue and functional changes in organ systems. Fibromyalgia is characterized by clinically unexplained widespread chronic pain, allodynia (pain produced by innocuous stimulus) and fatigue lasting for at least 3 months. Irritable bowel syndrome is characterized by chronic abdominal pain, altered bowel habit and bloating with no known organic cause. Chronic fatigue syndrome is characterized by new onset persistent fatigue not relieved by rest which lasts for 6 months or more and results in a substantial reduction in personal, social, occupational or educational function. It is often associated with impairment of memory and concentration, headaches, joint pains, sore throat and tender lymph nodes. All three conditions are associated with disability and adverse effects on work ability. After 12 months of investigation in outpatient clinics the prevalence of MUS has been reported as: gynaecology 66%, neurology 62%, gastroenterology 58%, rheumatology 45% and cardiology 53% [4]. In one systematic review of neurology patients diagnosed with MUS, only 4% were later found to have an organic cause [5]. MUS affect all ages but are more common in women. There is an association with childhood abuse and personality disorder. Other risk factors include current psychiatric illness and lower socio-economic status [6]. MUS are associated with increased sickness absence rates. One study showed a MUS prevalence of 15% in employees on long-term sick leave with an association with functional impairment and psychiatric co-morbidity [7]. Prevalence of depression and anxiety was 4–6 times higher than the general population and they were significantly more impaired. Female sex and high PHQ-9 scores were associated with severe MUS. Most
Editorial 93
Table 1. Guidance for health professionals on MUS: making sense of symptoms, managing professional uncertainty, building on patient’s strengths • Focus on symptoms and function rather than diagnosis • Talk about function and symptom management rather than finding a physical cause • Match your explanation using the patient’s own words rather than medicalizing and normalizing the symptoms • Share your uncertainty, avoid over-investigating • Discuss therapeutic trials and side effects rather than automatically treating with drugs • Listen to the patient and share decisions rather than assume you know what the patient wants • Acknowledge the importance of the patient’s views and do not attribute blame • Sensitively acknowledge psychological cues and let the patient expand on them • Allow time and encourage the patient to make those connections rather than enforcing psycho-social explanations • Be open about your uncertainty while reassuring that a serious cause is unlikely, but stress that you will keep an open mind RCPsych January 2011 (version 2).
underlying health conditions and considering medication side effects as a cause are important in the management of MUS. These chronic medical conditions are also associated with depression. Cognitive behavioural therapy (CBT) has been shown to be effective in the treatment of MUS [15]. The effectiveness of CBT in frequent attenders with MUS in primary care has been studied. At 6-month follow-up there was a significant improvement in physical and psychological symptoms in >50% of patients and a reduction in consultation rates. Reattribution has also been used for managing MUS [16]. This is a CBT-based technique that validates the patient’s feelings about their symptoms while negotiating more constructive ways of understanding and managing them. The three stages are: feeling understood, changing the agenda and negotiating a new understanding of the symptoms. Reattribution increases doctors’ confidence in managing uncertainty, although the effect on patient outcomes is unclear and it is very resource intensive. In conclusion, MUS are a common problem associated with significant healthcare costs, high levels of disability, increased levels of sickness absence and job loss. It is more prevalent in women and has a strong association with mental health problems including depression and anxiety and these should be screened for using a validated tool. Occupational health practitioners should be mindful of the link between MUS and chronic diseases such as COPD and the need to optimize management of other underlying health problems. CBT has been shown to be effective in managing MUS. However, good communication skills and consultation style are key to helping the patient to develop a new understanding of their symptoms and develop coping strategies to manage them effectively. Doctors should not assume that patients are
Downloaded from http://occmed.oxfordjournals.org/ at University of Western Ontario on April 12, 2015
strategies, physical activity, and positive attention and confidence from healthcare professionals were found to reduce marginalization. The management of MUS is often complicated by the patient’s health beliefs. Salmon [12] concluded that there is often a ‘contest’ between doctor and patient as a result of them occupying different conceptual ‘ground’. The doctor needs to find a model that the patient can understand and relate to in order to facilitate discussion of the symptoms. Collusion with the patient’s health beliefs can damage therapeutic relationships and lead to worse clinical outcomes. There is commonly a mismatch between the patient’s help-seeking behaviour and the doctor’s approach to care [13]. The doctor seeks to diagnose and normalize the symptoms and treat them clinically to reduce severity whereas the patient may be seeking explanations and emotional support. Healthcare professionals may assume that patients want more than they do leading to unnecessary tests and referrals. Past experience may drive some patients to minimize some symptoms and over emphasize others to nudge the doctor in a particular direction. Most patients with MUS just want explanations and reassurance. Effective communication and consultation style are vital to the doctor–patient interaction and are particularly important in managing these potential conflicts. Managing complexity and uncertainty using a nonjudgemental, patient-centred approach are key to the effective consultation. This includes use of open questions, non-verbal communication to encourage the patient to talk and good listening skills, allowing the patient to speak uninterrupted. In his seminal book The Inner Consultation, Neighbour [14] described a five-stage consultation model: ‘Connecting’ with the patient to develop a rapport; ‘Summarising’ with the patient their reasons for attending by addressing ideas, concerns and expectations; ‘Handing back’ control to the patient with an agreed management plan; ‘Safety netting’ to deal with serious pathology; ‘Housekeeping’ to ensure that the clinician is ready to deal with the next patient. Understanding the patient’s reasons for attending, addressing their ideas, concerns and expectations and handing back control to the patient are important tools for managing patients with MUS. It is important to explore the patient’s health beliefs and previous health experiences as well as the impact of symptoms, using empathy to acknowledge and validate the patient’s sense of suffering. The Royal College of Psychiatry leaflet ‘Guidance for health professionals on medically unexplained symptoms’ summarizes the elements of an effective MUS consultation (Table 1). MUS may be associated with acute or chronic medical conditions such as diabetes, chronic obstructive pulmonary disease (COPD), ischaemic heart disease and chronic pain. Achieving optimal management of
94 OCCupational medicine
looking for tests or referral as many are only seeking explanations and reassurance. While the effect of MUS on sickness absence and job loss is well understood, the effect of work factors on MUS is unknown and this should be a topic for future research.
Conflicts of interest None declared.
References 1. Simon GE, VonKorff M. Somatization and psychiatric disorder in the NIMH Epidemiologic Catchment Area study. Am J Psychiatry 1991;148:1494–1500. 2. Bermingham S, Cohen A, Hague J, Parsonage M. The cost of somatisation among the working-age population in England for the year 2008–2009. Ment Health Fam Med 2010;7:71–84. 3. Kouyanou K, Pither CE, Wessely S. Iatrogenic factors and chronic pain. Psychosom Med 1997;59:597–604. 4. Byng R. A whole systems approach to MUS in Plymouth; NHS Plymouth, personal communication, September 2009. 5. Stone J, Smyth R, Carson A et al. Systematic review of misdiagnosis of conversion symptoms and ‘hysteria’. BMJ 2005;331:989. 6. Smith GR, Jr, Monson RA, Ray DC. Patients with multiple unexplained symptoms. Their characteristics, functional health, and health care utilization. Arch Intern Med 1986;146:69–72.
Downloaded from http://occmed.oxfordjournals.org/ at University of Western Ontario on April 12, 2015
Steven B. Nimmo Department of Occupational Medicine, Plymouth Hospitals NHS Trust, Derriford Hospital, Plymouth PL6 8BG, UK e-mail: [email protected]
7. Hoedeman R, Krol B, Blankenstein N, Koopmans PC, Groothoff JW. Severe MUPS in a sick-listed population: a cross-sectional study on prevalence, recognition, psychiatric co-morbidity and impairment. BMC Public Health 2009;9:440. 8. Hoedeman R, Blankenstein AH, Krol B, Koopmans PC, Groothoff JW. The contribution of high levels of somatic symptom severity to sickness absence duration, disability and discharge. J Occup Rehabil 2010;20:264–273. 9. Aamland A, Malterud K, Werner EL. Phenomena associated with sick leave among primary care patients with medically unexplained physical symptoms: a systematic review. Scand J Prim Health Care 2012;30:147–155. 10. Hoedeman R, Krol B, Blankenstein AH, Koopmans PC, Groothoff JW. Sick-listed employees with severe medically unexplained physical symptoms: burden or routine for the occupational health physician? A cross sectional study. BMC Health Serv Res 2010;10:305. 11. Aamland A, Werner EL, Malterud K. Sickness absence, marginality, and medically unexplained physical symptoms: a focus-group study of patients’ experiences. Scand J Prim Health Care 2013;31:95–100. 12. Salmon P. Conflict, collusion or collaboration in consultations about medically unexplained symptoms: the need for a curriculum of medical explanation. Patient Educ Couns 2007;67:246–254. 13. Dowrick CF, Ring A, Humphris GM, Salmon P. Normalisation of unexplained symptoms by general practitioners: a functional typology. Br J Gen Pract 2004;54:165–170. 14. Neighbour R. The Inner Consultation (2nd revised edn, October 2004). Radcliffe Publishing Ltd, 1987. 15. Escobar JI, Gara MA, Diaz-Martinez AM et al. Effectiveness of a time-limited cognitive behavior therapy type intervention among primary care patients with medically unexplained symptoms. Ann Fam Med 2007;5:328–335. 16. Goldberg D, Gask L, O’Dowd T. The treatment of somatization: teaching techniques of reattribution. J Psychosom Res 1989;33:689–695.
Editorial
Medically unexplained symptoms employees with severe MUS were diagnosed with a psychiatric disorder by the specialist occupational health physician (OHP). Around 66% of employees attributed their symptoms to psychological or both psychological and physical factors. The prevalence of severe MUS was higher in employees on long-term sickness absence. Use of validated depression and anxiety screening questionnaires should therefore be a routine part of occupational health consultation for MUS. MUS are also associated with longer duration of sickness absence and higher risk of dismissal [8]. The median sickness absence was 78 days longer than for other conditions and prevalence of long-term disability was higher after 2 years in employees with severe MUS and significant depression. High levels of physical symptom severity were associated with longer sickness absence, long-term disability and job loss. Relationship breakdown with the employer was a common cause of dismissal although it is not clear whether this was due to conduct or capability. In a review of studies on the association between MUS and sickness absence [9] the authors found an association between sickness absence, psychiatric co-morbidity and severity of symptoms. The treating doctor’s knowledge of the patient, sympathy and higher levels of trust were associated with increased levels of sickness absence. None of the educational interventions aimed at improving doctors’ management of MUS reduced sickness absence although the validity and effectiveness of those interventions was unclear. The authors did not identify any studies on the impact of work factors on sickness absence due to MUS. Hoedeman et al. [10] found that OHPs are confident in assessing fitness for work in patients with MUS and that they do not represent a burdensome part of the workload. Although they did not relate confidence to outcomes such as return to work and decisions on return to work may be blocked by the treating physician if the diagnosis remains unclear. They concluded that OHPs need good psychiatric knowledge and good communication skills to identify and break down barriers to work in these patients. A narrative study invited patients with MUS who were off sick to share stories about their experiences of the process leading up to sickness absence [11]. Using theories of marginalization and coping, the authors looked at how patients’ personal resources and coping strategies could be used to counteract marginalization and reduce absence. Invisible symptoms and lack of objective clinical findings were perceived as an additional burden. Supportive social networks, good personal coping
© The Author 2015. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: [email protected]
Downloaded from http://occmed.oxfordjournals.org/ at University of Western Ontario on April 12, 2015
Medically unexplained symptoms (MUS) may be defined as physical symptoms with no identified organic cause, lasting for at least 3 months and leading to a loss of function. They are common, accounting for up to 20% of primary care consultations [1]. MUS are a cause of frequent healthcare usage and are associated with a 20–50% increase in outpatient costs and a 30% increase in admission rates (S. Bermingham, A. Cohen, J. Hague et al., personal communication; [2]). In the UK annual healthcare costs alone for MUS are around £3 billion with total costs exceeding £18 billion. Around 50% of secondary care patients meet the criteria for MUS [3]. Medical investigation of MUS is costly and causes significant harm to patients. MUS may present as a recognizable syndrome such as fibromyalgia, irritable bowel syndrome or chronic fatigue syndrome, or as symptoms with no clear organic cause. Typical presentations include pain, fatigue and functional changes in organ systems. Fibromyalgia is characterized by clinically unexplained widespread chronic pain, allodynia (pain produced by innocuous stimulus) and fatigue lasting for at least 3 months. Irritable bowel syndrome is characterized by chronic abdominal pain, altered bowel habit and bloating with no known organic cause. Chronic fatigue syndrome is characterized by new onset persistent fatigue not relieved by rest which lasts for 6 months or more and results in a substantial reduction in personal, social, occupational or educational function. It is often associated with impairment of memory and concentration, headaches, joint pains, sore throat and tender lymph nodes. All three conditions are associated with disability and adverse effects on work ability. After 12 months of investigation in outpatient clinics the prevalence of MUS has been reported as: gynaecology 66%, neurology 62%, gastroenterology 58%, rheumatology 45% and cardiology 53% [4]. In one systematic review of neurology patients diagnosed with MUS, only 4% were later found to have an organic cause [5]. MUS affect all ages but are more common in women. There is an association with childhood abuse and personality disorder. Other risk factors include current psychiatric illness and lower socio-economic status [6]. MUS are associated with increased sickness absence rates. One study showed a MUS prevalence of 15% in employees on long-term sick leave with an association with functional impairment and psychiatric co-morbidity [7]. Prevalence of depression and anxiety was 4–6 times higher than the general population and they were significantly more impaired. Female sex and high PHQ-9 scores were associated with severe MUS. Most
Editorial 93
Table 1. Guidance for health professionals on MUS: making sense of symptoms, managing professional uncertainty, building on patient’s strengths • Focus on symptoms and function rather than diagnosis • Talk about function and symptom management rather than finding a physical cause • Match your explanation using the patient’s own words rather than medicalizing and normalizing the symptoms • Share your uncertainty, avoid over-investigating • Discuss therapeutic trials and side effects rather than automatically treating with drugs • Listen to the patient and share decisions rather than assume you know what the patient wants • Acknowledge the importance of the patient’s views and do not attribute blame • Sensitively acknowledge psychological cues and let the patient expand on them • Allow time and encourage the patient to make those connections rather than enforcing psycho-social explanations • Be open about your uncertainty while reassuring that a serious cause is unlikely, but stress that you will keep an open mind RCPsych January 2011 (version 2).
underlying health conditions and considering medication side effects as a cause are important in the management of MUS. These chronic medical conditions are also associated with depression. Cognitive behavioural therapy (CBT) has been shown to be effective in the treatment of MUS [15]. The effectiveness of CBT in frequent attenders with MUS in primary care has been studied. At 6-month follow-up there was a significant improvement in physical and psychological symptoms in >50% of patients and a reduction in consultation rates. Reattribution has also been used for managing MUS [16]. This is a CBT-based technique that validates the patient’s feelings about their symptoms while negotiating more constructive ways of understanding and managing them. The three stages are: feeling understood, changing the agenda and negotiating a new understanding of the symptoms. Reattribution increases doctors’ confidence in managing uncertainty, although the effect on patient outcomes is unclear and it is very resource intensive. In conclusion, MUS are a common problem associated with significant healthcare costs, high levels of disability, increased levels of sickness absence and job loss. It is more prevalent in women and has a strong association with mental health problems including depression and anxiety and these should be screened for using a validated tool. Occupational health practitioners should be mindful of the link between MUS and chronic diseases such as COPD and the need to optimize management of other underlying health problems. CBT has been shown to be effective in managing MUS. However, good communication skills and consultation style are key to helping the patient to develop a new understanding of their symptoms and develop coping strategies to manage them effectively. Doctors should not assume that patients are
Downloaded from http://occmed.oxfordjournals.org/ at University of Western Ontario on April 12, 2015
strategies, physical activity, and positive attention and confidence from healthcare professionals were found to reduce marginalization. The management of MUS is often complicated by the patient’s health beliefs. Salmon [12] concluded that there is often a ‘contest’ between doctor and patient as a result of them occupying different conceptual ‘ground’. The doctor needs to find a model that the patient can understand and relate to in order to facilitate discussion of the symptoms. Collusion with the patient’s health beliefs can damage therapeutic relationships and lead to worse clinical outcomes. There is commonly a mismatch between the patient’s help-seeking behaviour and the doctor’s approach to care [13]. The doctor seeks to diagnose and normalize the symptoms and treat them clinically to reduce severity whereas the patient may be seeking explanations and emotional support. Healthcare professionals may assume that patients want more than they do leading to unnecessary tests and referrals. Past experience may drive some patients to minimize some symptoms and over emphasize others to nudge the doctor in a particular direction. Most patients with MUS just want explanations and reassurance. Effective communication and consultation style are vital to the doctor–patient interaction and are particularly important in managing these potential conflicts. Managing complexity and uncertainty using a nonjudgemental, patient-centred approach are key to the effective consultation. This includes use of open questions, non-verbal communication to encourage the patient to talk and good listening skills, allowing the patient to speak uninterrupted. In his seminal book The Inner Consultation, Neighbour [14] described a five-stage consultation model: ‘Connecting’ with the patient to develop a rapport; ‘Summarising’ with the patient their reasons for attending by addressing ideas, concerns and expectations; ‘Handing back’ control to the patient with an agreed management plan; ‘Safety netting’ to deal with serious pathology; ‘Housekeeping’ to ensure that the clinician is ready to deal with the next patient. Understanding the patient’s reasons for attending, addressing their ideas, concerns and expectations and handing back control to the patient are important tools for managing patients with MUS. It is important to explore the patient’s health beliefs and previous health experiences as well as the impact of symptoms, using empathy to acknowledge and validate the patient’s sense of suffering. The Royal College of Psychiatry leaflet ‘Guidance for health professionals on medically unexplained symptoms’ summarizes the elements of an effective MUS consultation (Table 1). MUS may be associated with acute or chronic medical conditions such as diabetes, chronic obstructive pulmonary disease (COPD), ischaemic heart disease and chronic pain. Achieving optimal management of
94 OCCupational medicine
looking for tests or referral as many are only seeking explanations and reassurance. While the effect of MUS on sickness absence and job loss is well understood, the effect of work factors on MUS is unknown and this should be a topic for future research.
Conflicts of interest None declared.
References 1. Simon GE, VonKorff M. Somatization and psychiatric disorder in the NIMH Epidemiologic Catchment Area study. Am J Psychiatry 1991;148:1494–1500. 2. Bermingham S, Cohen A, Hague J, Parsonage M. The cost of somatisation among the working-age population in England for the year 2008–2009. Ment Health Fam Med 2010;7:71–84. 3. Kouyanou K, Pither CE, Wessely S. Iatrogenic factors and chronic pain. Psychosom Med 1997;59:597–604. 4. Byng R. A whole systems approach to MUS in Plymouth; NHS Plymouth, personal communication, September 2009. 5. Stone J, Smyth R, Carson A et al. Systematic review of misdiagnosis of conversion symptoms and ‘hysteria’. BMJ 2005;331:989. 6. Smith GR, Jr, Monson RA, Ray DC. Patients with multiple unexplained symptoms. Their characteristics, functional health, and health care utilization. Arch Intern Med 1986;146:69–72.
Downloaded from http://occmed.oxfordjournals.org/ at University of Western Ontario on April 12, 2015
Steven B. Nimmo Department of Occupational Medicine, Plymouth Hospitals NHS Trust, Derriford Hospital, Plymouth PL6 8BG, UK e-mail: [email protected]
7. Hoedeman R, Krol B, Blankenstein N, Koopmans PC, Groothoff JW. Severe MUPS in a sick-listed population: a cross-sectional study on prevalence, recognition, psychiatric co-morbidity and impairment. BMC Public Health 2009;9:440. 8. Hoedeman R, Blankenstein AH, Krol B, Koopmans PC, Groothoff JW. The contribution of high levels of somatic symptom severity to sickness absence duration, disability and discharge. J Occup Rehabil 2010;20:264–273. 9. Aamland A, Malterud K, Werner EL. Phenomena associated with sick leave among primary care patients with medically unexplained physical symptoms: a systematic review. Scand J Prim Health Care 2012;30:147–155. 10. Hoedeman R, Krol B, Blankenstein AH, Koopmans PC, Groothoff JW. Sick-listed employees with severe medically unexplained physical symptoms: burden or routine for the occupational health physician? A cross sectional study. BMC Health Serv Res 2010;10:305. 11. Aamland A, Werner EL, Malterud K. Sickness absence, marginality, and medically unexplained physical symptoms: a focus-group study of patients’ experiences. Scand J Prim Health Care 2013;31:95–100. 12. Salmon P. Conflict, collusion or collaboration in consultations about medically unexplained symptoms: the need for a curriculum of medical explanation. Patient Educ Couns 2007;67:246–254. 13. Dowrick CF, Ring A, Humphris GM, Salmon P. Normalisation of unexplained symptoms by general practitioners: a functional typology. Br J Gen Pract 2004;54:165–170. 14. Neighbour R. The Inner Consultation (2nd revised edn, October 2004). Radcliffe Publishing Ltd, 1987. 15. Escobar JI, Gara MA, Diaz-Martinez AM et al. Effectiveness of a time-limited cognitive behavior therapy type intervention among primary care patients with medically unexplained symptoms. Ann Fam Med 2007;5:328–335. 16. Goldberg D, Gask L, O’Dowd T. The treatment of somatization: teaching techniques of reattribution. J Psychosom Res 1989;33:689–695.
