1. Describe the nature and prevalence of medically unexplained symptoms
   1. Nature of unexplained symptoms
      1. symptoms presented
         1. chest pain
         2. fatigue
         3. dizziness
         4. headache
         5. oedema
         6. back pain
         7. dyspnoea
         8. insomnia
         9. abdominal pain
         10. numbness
      2. functional somatic syndromes
         1. irritable bowel syndrome
         2. pre-menstrual syndrome
         3. fibromyalgia
         4. pain syndromes
         5. post-viral fatigue
         6. globus syndrome
         7. tension headache, motor and sensory symptoms
      3. Categorisation
         1. medically unexplained
         2. symptom unexplained by organic disease
         3. somatization and somatform
            1. definition:
            2. Somatization: the production of recurrent and multiple medical symptoms with no discernible organic cause
            3. Somatoform: disorders characterised by physical symptoms representing specific disorders for which there is no organic basis or known physiological cause but for which there is presumed to be a psychological basis
         4. hysterical and hypochondriacal
         5. functional symptoms
            1. disabling
            2. most are transient but for a sizeable minority becomes persistent
      4. What causes MUS
         1. social factors
            1. 'chest pain is dangerous'
            2. behaviour of other 'rest you are ill'
            3. what Drs do or say, eg. order more tests
            4. contributes to increase in severity and duration of MUS
         2. psychological factors
            1. fears and beliefs, eg. 'chest pain is dangerous'
            2. depression and anxiety have physical symptoms
            3. focusing of attention on the MUS- monitoring worrying problems
            4. underlying depressive, axiety or somatoform disorder
            5. most patients with these mental disorders preferentially report somatic rather than emotional symptoms
            6. as number of MUS increases, the percentage of patients with psychiatric morbidity increases.
         3. biological factors (including pathology)
            1. minor pathology - musculoskeletal
            2. effect of behavioural change-inactivity
            3. physiological changes - effect of hyperventilation
         4. iatrogenic
      5. development of MUS
         1. predisposing
            1. feel more at risk because..
         2. precipitating
            1. trying to find reason from situation/other people
         3. perpetuating
            1. events that prolong suspicion of disease
            2. eg cardiac tests
            3. events that seem to fit, eg becoming inactive, hyperventilation
   2. Prevalence of unexplained symptoms
      1. 1/3
      2. 'Although physical symptoms account for more than half of all visits to Drs, at least a third of these symptoms remain unexplained.'
2. ETC
   1. What to do
      1. Acknowledge symptoms
      2. give clear explanation
      3. advice
      4. prescribe
      5. refer
      6. perhaps screen for depression with few questions
         1. then treatment
   2. What not to do
      1. dismiss symptoms
      2. give vague explanation ('could be early cardiac disease')
      3. advice
      4. prescribe ('just in case')
      5. refer for lots of tests
3. Discuss the issues raised for both doctors and patients in the assessment and management of MUS
   1. assessment of MUS
      1. patients with unexplained symptoms really ill?
         1. 'ILL'
            1. feel unwell-symptoms
            2. can't function normally-disability
            3. see doctors-care seeking
            4. have traditionally defined pathology
            5. die of the illness
      2. misdiagnosis
         1. misdiagnosis of hysteria was regular from 1950 until 1970 when it finally declined.
   2. management of MUS
      1. doing nothing
         1. for the majority of neurology patients, their general health and symptoms had not changed
      2. how difficult to help did you find this patient?
         1. as the extent to which patient's symptoms are unexplained the more difficult it becomes to help them
4. Discuss the reasons for the under- recognition of MUS as a clinical problem
   1. overuse of healthcare service with no benefit to either party
   2. increased anxiety
   3. increased fear of disease
   4. depression
   5. increased disability
   6. decreased work function
      1. economically worse
   7. physically symptoms can get worse
   8. Medical syndromes such as fibromyalgia and chronic fatigue, etc. highlight patterns of somatic symptoms often in relation to particular bodily systems. Recent studies show there is substantial overlap between them.
   9. Psychiatric syndromes such as anxiety, depression, etc. highlight psychological processes and number of somatic symptoms irrespective of the bodily system to which they refer. Depression and anxiety often present with somatic symptoms that may resolve with effective treatment of these disorders. In other cases the appropriate psychiatric diagnostic category is a somatoform disorder.
5. Discuss the benefits of recognition and appropriate treatment of MUS and the potential harms which can occur when they are not recognised
   1. benefits
      1. improved QoL
      2. social and work functioning
      3. greater satsifaction on part of patient and doctor
      4. reduced use of healthcare services
      5. PREVENT
         1. raised fear of disease
         2. performing unnecessary investigations and treatments
         3. encouraging disability
   2. harms
      1. patient feeling disbelieved by doctor
         1. damage to doctor-patient relationship
         2. drive patients away from evidence based care
         3. 'premature efforts to reattribute somatic complaints to psychological mechanisms may be perceived as rejection'
      2. Iatrogenic factors arising from MUS
         1. appearance of uncertainty and inability to provide explanation
         2. failure to convince patient that complaint is accepted as genuine
         3. reassurance without positive explanation being given.
         4. ambiguous and contradictory advice