Treating medically unexplained symptoms

Several studies suggest ways to deal with patients who have pain and discomfort even when a treatable disease cannot be found.

By Victoria Stagg Elliott — Posted Sept. 18, 2006

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Cognitive behavioral therapy, psychotropic medications and an empathic relationship with a physician can reduce patients' medically unexplained symptoms, such as backaches, dizziness, headaches or fatigue, according to a pair of studies published this summer.

One study, published in the July 24 Archives of Internal Medicine, found that cognitive behavioral therapy performed by a mental health professional reduced the physical symptoms of patients with somatization syndrome. It also improved functioning and reduced the utilization of health care services.

The other, appearing in the July Journal of General Internal Medicine, found that patients with medically unexplained symptoms could be treated in the primary care setting.

Researchers randomized patients who had a history of high health care utilization to receive either usual care or cognitive behavioral therapy and treatment by physicians trained in patient-centered care.

"Virtually all treatment studies of medically unexplained symptoms are by mental health providers," said Robert C. Smith, MD, the lead author of that paper and professor of general internal medicine and psychiatry at Michigan State University in East Lansing. "This was the first comprehensive treatment by primary care [physicians and nurses] in a randomized controlled trial."

In this study, the focus of care was improving a patient's ability to cope rather than eliminating his or her symptoms. Many patients were prescribed antidepressants, and all were assured that they did not have a serious disease. Instead, they were told they had a problem that required attention. This intervention resulted in patients feeling better.

Multiple challenges

Experts said these studies were important because they provided evidence to back strategies for dealing with this extremely frustrating patient population. The patients in Dr. Smith's study visited a physician, on average, more than 13 times a year. Those in the Archives study had more than six symptoms that appeared to have no cause.

"This is a sick population," Dr. Smith said. "They cost an arm and a leg, and these people are actually made worse by the system."

But some of the most obvious approaches, such as physician reassurance that nothing is wrong, may have little impact. Most recently, a study in the August Public Library of Science Medicine found that patients with medically unexplained symptoms were more likely to be concerned about their health status than those in the healthy control group. They also were more likely to believe that a physician had determined an actual cause for their symptoms when he or she had not.

"The first explanation may not take," said Kurt Kroenke, MD, a research scientist at the Regenstrief Institute and a professor of internal medicine at Indiana University School of Medicine in Indianapolis. "We have to make sure the patient understands, and [we] may have to go over it once again."

Those who research this issue say these patients also can be stubborn in their search for both a physical cause and a cure for what ails them. Cognitive behavioral therapy repeatedly has been shown in studies to help those with various somatoform disorders, but physicians said they often have a hard time getting patients into this kind of treatment. This circumstance tends to be less a problem with insurance reimbursement and more one of patient willingness to deal with a physical symptom by using mental health services. For this reason, there are some efforts to have this kind of therapy provided in the primary care setting.

"The vast majority won't go for such therapy because [they believe] their symptoms are of a physical origin," said Ronald M. Epstein, MD, professor of family medicine and psychiatry at the University of Rochester in New York.

Knowing when the symptom truly does not have an organic cause and when that cause just hasn't been found yet is also a challenge.

"These people have a very noisy nervous system with a lot of static. They get a lot of false alarms," said Norman Jensen, MD, professor of general internal medicine at the University of Wisconsin, Madison. "And you wonder, have I done enough tests? Have I done enough imaging? Have I missed something?"

But experts urged physicians to continue working with these patients despite these difficulties.

"Many physicians try to avoid these folks and get rid of them," Dr. Jensen said. "I encourage physicians to hang onto them and keep them from doctor shopping."

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Addressing the unexplainable

Objective: To determine the effect of a long-term multidimensional primary care intervention for patients with medically unexplained symptoms.

Participants: Two hundred HMO patients in Lansing, Mich., who were high utilizers of medical services and had symptoms such as headaches, fatigue and back pain that seemed to have no organic cause.

Methods: Patients were randomized to receive an intervention incorporating cognitive behavioral therapy with pharmacology, or usual care. Clinicians in the intervention arm were trained to be patient-centered. They also prescribed antidepressants if appropriate, reduced controlled-substance painkillers as much as possible, recommended exercise, trained patients in relaxation and suggested physical therapy.

Results: Those who received the intervention had less disability, were less likely to use prescribed narcotics and were more likely to be satisfied with care.

Conclusion: A multidimensional intervention by primary care physicians can lead to improvements in patients with medically unexplained symptoms.

Source: Journal of General Internal Medicine, July

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External links

"Cognitive-Behavioral Therapy for Somatization Disorder," abstract, Archives of Internal Medicine, July 24 (link)

"Why Reassurance Fails in Patients with Unexplained Symptoms -- An Experimental Investigation of Remembered Probabilities," Public Library of Science Medicine, August (link)

"Primary Care Clinicians Treat Patients with Medically Unexplained Symptoms: A Randomized Controlled Trial," abstract, Journal of General Internal Medicine, July (link)

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