Practice Uncertainties

How should we manage adults with persistent unexplained physical symptoms?

BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j268 (Published 08 February 2017) Cite this as: BMJ 2017;356:j268
  1. Madelon den Boeft, general practitioner1,
  2. Nikki Claassen-van Dessel, general practitioner trainee, PhD student1,
  3. Johannes C van der Wouden, associate professor1
  1. 1Department of General Practice and Elderly Care Medicine, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
  1. Correspondence to: J C van der Wouden j.vanderwouden{at}vumc.nl

What you need to know

  • If you consider symptoms to be unexplained, explore all symptom dimensions (somatic, cognitive, emotional, behavioural, and social) and perform a focused but thorough physical examination

  • Share your findings with the patient and provide a tangible explanation for the symptoms

  • Evidence on effectiveness of various pharmacological and psychological interventions in reducing symptoms is limited, though cognitive behavioural therapy has been shown to have a small beneficial effect

Persistent physical symptoms are common and include those symptoms that last at least three months and are insufficiently explained by a medical condition after adequate examination and investigation.12 Examples include unexplained abdominal pain, musculoskeletal pains, fatigue, headache and dizziness. These symptoms are often associated with functional impairment and psychological distress among patients, and increase healthcare costs.2345 Observational studies in primary care report that women, especially those aged 35-45 years, more commonly present with these symptoms.25

Defining and categorising an unexplained symptom is tricky and disputed (see box 1).910 Sometimes symptoms fit criteria for somatoform or psychiatric disorders set out in the Diagnostic and Statistical Manual of Mental Disorders IV (DSM IV)6 or functional somatic syndromes such as irritable bowel syndrome. In other cases there is no label to offer the patient.

Box 1: Terminology used in this article

  • Persistent unexplained physical symptoms—Physical symptoms existing for ≥3 months not sufficiently explained by an underlying medical condition after adequate examination and investigation2

  • Somatoform disorders—Psychiatric disorders (DSM-IV, ICD-10) with persistent unexplained physical symptoms as key factor6

  • Undifferentiated somatoform disorder—One or more physical symptoms without medical explanation with clinically significant suffering or functional impairment, existing for ≥6 months6

  • Functional somatic syndrome—A combination of unexplained physical symptoms occurring together (such as irritable bowel syndrome or chronic fatigue syndrome)7

  • Somatic symptoms disorder—Recently introduced term (DSM 5): somatic …

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