Medically unexplained symptoms and bodily distress

• Medically unexplained symptoms


  Physical symptoms without an obvious physical cause
• Medically unexplained symptoms are common - up to 1 in 5 presentations in primary care (may be up to 1/3 in neurology clinics)
• Medically unexplained symptoms are real symptoms
• Lots of people will have medically unexplained symptoms which are transient and do not present to health services
• Medically unexplained symptoms


  • Associated with significant distress, loss of functioning and high healthcare usage and costs
• Medically unexplained symptoms are estimated to account for approximately 10% of total NHS expenditure for working age population in England
• There is often overlap of multiple unexplained symptoms leading to multiple referrals to different specialties, which can lead to a fragmented approach to management and multiple investigations
• Multiple investigations for medically unexplained symptoms are costly
• Medically unexplained symptoms


  • Risk of iatrogenic harm
  • Diagnosis and treatment is often delayed
  • The longer the duration of symptoms, the poorer the prognosis
• Common medically unexplained symptoms

  • Pain – muscular/joint, back pain
  • Headaches
  • Fatigue
  • Dizziness
  • Chest pain
  • Palpitations
  • GI symptoms
  • Cognitive symptoms – eg 'brain fog'
  • Plus many other possible symptoms
• Diagnosis of medically unexplained symptoms

  1. Thorough history

  2. Physical examination

  3. Appropriate investigations dependent on symptoms

  4. Both in order to diagnose a physical disorder if it exists, and also means that patient is more likely to feel that symptoms have been taken seriously, and more likely to accept diagnosis
• Diagnosis for medically unexplained symptoms

  Can be given when there is a particular pattern (eg IBS, non-epileptic attack disorder) or when there is evidence of a similar cause (eg bodily distress disorder, health anxiety/hypochondriasis; body dysmorphic disorder)
• Different specialties use different terms for medically unexplained symptoms, which can be confusing
• Terms used for medically unexplained symptoms

  • 'Medically unexplained symptoms'
  • 'Persistent physical symptoms'
  • 'Functional'
  • 'Dissociative'
  • 'Bodily distress disorder'
  • 'Somatic'
  • 'Somatoform disorder'
  • 'Conversion syndrome'
  • Specialty specific diagnoses such as IBS, fibromyalgia, chronic pain syndrome, functional neurological disorder
• Predisposing risk factors for medically unexplained symptoms

  • Parental ill health during childhood
  • Illness during childhood
  • Childhood adversity or abuse
  • Personality traits
  • Having a long-term condition
  • Family history of a long-term condition
• Precipitating triggers for medically unexplained symptoms

  • Physical stressors
  • Infection
  • Physical illness
  • Trauma
  • Psychosocial stressors
  • Lack of sleep
• Perpetuating factors for medically unexplained symptoms

  • Physiological – e.g. sleep disruption, central sensitisation (CNS modulation)
  • Social – e.g loss of role
  • Cognitive – e.g. catastrophising symptoms, focusing on symptoms
  • Behavioural – e.g. avoidance behaviour, poor sleep hygiene
• Up to 50% of people with persistent physical symptoms have associated anxiety or depression (higher than other long term conditions)
• Having a physical health diagnosis increases the risk of experiencing unexplained symptoms
• Examples of physical health diagnoses that increase risk of unexplained symptoms

  • Non cardiac chest pain – common after MI
  • Dysfunctional breathing – frequently seen in those with asthma
  • 1/5 of those with non epileptic seizures also have epilepsy
• Treatments for medically unexplained symptoms

  • Sleep hygiene
  • Treat co-existing psychiatric disorders
  • Managing activity – graded return to normal activity, but avoid 'boom and bust'
  • Stress management and address social factors
  • General health/diet/exercise advice
  • Relaxation and grounding techniques
  • Antidepressants
  • Psychological therapy – best evidence for CBT
• How to explain medically unexplained symptoms

  1. Give a positive diagnosis

  2. Explain that people can and do get better with time, there are treatments that can help

  3. Tell them that their symptoms are real

  4. Be honest about what we don't know - often a combination of many causes

  5. Explain mind-body interactions

  6. Use a biopsychosocial model for explanation
• If you were a computer, medically unexplained symptoms are like having a software problem rather than a hardware problem
• ICD 11 classification of disorders related to medically unexplained symptoms


  • Disorders of bodily distress or bodily experience
  • Dissociative disorders
  • Obsessive-compulsive or related disorders
  • Factitious disorder
• Bodily distress disorder


  Characterised by distressing and persistent bodily symptoms, with excessive attention directed toward the symptoms, may manifest by repeated contact with health care providers, appropriate clinical investigation and reassurance doesn't help, usually involves multiple bodily symptoms that may vary over time, with some effect on functioning
• Bodily distress disorder is a new term - previously known as somatoform or somatization disorder
• Bodily integrity disorder


  Intense, persistent desire to become physically disabled in a significant way (e.g. major limb amputation), with harmful consequences
• Dissociative neurological symptom disorder

  Motor, sensory or cognitive symptoms with an involuntary disconnect in the normal integration of functions, lasting at least several hours, not consistent with a recognised disease or other condition, with functional impairment
• Examples of dissociative neurological symptoms


  • Visual disturbance
  • Vertigo/dizziness
  • Non epileptic seizures (AKA non epileptic attack disorder)
  • Paresis or weakness
  • Movement disturbance (eg chorea, tremor, spasm, dystonia)
  • Cognitive symptoms (eg impaired memory, language)
  • Sensory eg numbness
• Transient changes in sensory or cognitive functions can accompany intense activity or emotionally intense states, which are normal experiences
• Prognostic factors for dissociative neurological symptom disorder


  • Good: Younger age, acute onset after a clear stressor, early diagnosis and initiation of treatment, acceptance of psychological nature of disorder
  • Poorer: non-transient symptoms, lots of symptoms, comorbid medical or psychiatric illnesses
• Hypochondriasis


  Persistent preoccupation or fear about the possibility of having one or more serious, progressive or life-threatening illness, accompanied by repetitive, excessive health-related behaviours or maladaptive avoidance behaviour, with distress or significant functional impairment
• Body dysmorphic disorder


  Persistent, inappropriate concern about the appearance of the body (eg size/shape of nose) despite reassurance, may demand cosmetic plastic surgery
• Factitious disorder


  Intentionally feigning, falsifying, inducing or aggravating symptoms, medical or psychological, in oneself or another person (usually a child dependent), associated with identified deception, not solely motivated by obvious external rewards
• Factitious disorder imposed on another (FDIA) is a serious form of child abuse, with a high mortality rate
• Red flags in factitious disorder related to the perpetrator

  • Observations/investigations inconsistent with carer's report
  • Vague and inconsistent details about child's medical history
  • Invasive procedures accepted without concern
  • Shows medical knowledge
  • Requests made for further interventions
  • Attention and approval of medical staff sought
  • Missed medical appointments
  • Previous history of psychiatric disorder
  • Isolated, lack of relationships, family and marital problems
• Red flags in factitious disorder related to the victim

  • Atypical presentation of the disorder
  • Tests and observations are normal
  • Medical problems don't respond to treatment
  • Symptoms/signs only occur in the presence of the carer and disappear in their absence
  • History of multiple hospital admissions and procedures
  • Presence of multiple medical illnesses
  • Occurrence of new pathology or complications when findings are negative
• Malingering


  Feigned, intentional production or significant exaggeration of physical or psychological symptoms, motivated by external incentives
• Malingering is diagnosed after thorough investigation