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• Half a lifetime ago, as I trudged through medical school, I learned that mental disorder, in forms as variable as repressed frustration to a downward lurch in serotonin production by nerve endings in the thalamus, sometimes takes on the form of physical symptoms that have no definable basis in physical illness.
  
  Had I realised at the time that my tutors were talking about up to one third of all medical problems that present to the average GP, and over 50 per cent of those that present to some hospital outpatient clinics, I might have paid more attention. But how was I to know? The topic took up only one talk in a course that featured nearly 2,000. I would be surprised if it gets a greater airing in the current syllabus, though it may be about to acquire one.
  
  Explaining MUS
  The term ‘medically unexplained symptoms’ (MUS) is set to become fashionable. It may yet achieve a permanent place in the healthcare lexicon, as it has all the qualities of a fine modern phrase. It is self-explanatory, it encompasses the entire field it is coined to describe, and it contains no pomposity.
  
  ‘Medically unexplained’ refers to symptoms or signs of physical distress or malfunction that cannot be accounted for by any physical disorder a patient is known to have. It includes both symptoms in the absence of apparent illness, and the emergence of severe symptoms in those who have only mild illness. Symptoms are often multiple or in clusters, though some patients have a single dominant one.
  
  The intention of the term is to exclude those symptoms caused by physical illness that has yet to be discovered, though inevitably there will be an unknowable but small proportion in this category. The two other main categories have psychological causes. However, MUS are often not clear-cut, and these categories tend to overlap in real life.
  
  Studies in primary care in the UK have concluded that between 15 and 30 per cent of patients who consult have MUS as a part of their problem.1 This figure does not include those who present with a mental health problem that does not involve physical symptoms.
  
  The range of MUS covers all manner of complaints affecting all parts of the body and all their conceivable functions. The most common seen in primary care are musculoskeletal (30 per cent), abdominal (18 per cent) and ear, nose and throat complaints (8 per cent), with more general complaints such as fatigue, dizziness and malaise also prominent.2, 3 The severity can range from muscle sprains made more taxing by school or college exams, to decades of unexplained paralysis or blindness.
  
  In the broader run of things, physical care facilities are drawn into assessing and treating manifestations of mental disorder in many ways. For example, considerable efforts are often made to spot or exclude possible physical causes of symptoms and deterioration where none is to be found, or to limit the impact of the physical effects of a psychological problem. Besides the cost burden of all this clinical activity, the eventual outcome is most often failure to recognise or to deal with the real cause of the problem.
  
  The cost of MUS
  The overall cost to healthcare systems of dealing with MUS is mind-boggling. The simplest and most frequently quoted figure for systems in the developed world is 16 per cent of total costs.4 In terms of the NHS, this equates to roughly £8.5 billion per year, costs accruing to every part of the healthcare system. This excludes the run-on costs into social care, disability pensions, carer costs and the broader community.
  
  In an NHS that is being asked to slice 15 per cent off its operating costs from spring 2011 without impacting the quality or availability of care, it may be that serious consideration of how best to tackle MUS has reached its moment.
  
  There are few ethically sound ways of cutting the cost of healthcare. Getting people better more effectively is one. Reducing negative test results and pointless interventions is another. Both can be achieved by a better approach to dealing with MUS. The case for improving our management of the psychosomatic component of medicine has always been clinically and financially sound. It is now topical too.
  
  The challenges of tackling MUS
  It has been accepted since ancient times that there are mechanisms by which the mind, brain and/or body transform psychological distress into physical symptoms. Instead of (or as well as) feeling anxiety, low mood or irritability, some individuals experience pain, paralysis, unexplained skin rashes and other symptoms. However, the mechanics of how this occurs are generally poorly understood, and indeed are likely to differ from one type of presentation to another. Moreover, even as knowledge is growing, the greater challenge, running in parallel, is that medical convention militates against formulations that allow for understanding a problem simultaneously in physical and psychological terms.
  
  Take the example of chronic pain. For decades we have known that if clinical depression and painful injuries or illnesses co-exist there is a chance that the one will exacerbate the other. The depressed brain will often register pain that is mild to moderate and occurs occasionally as being severe and lasting for much of the time.
  
  We know that there are typical changes to the pattern of pain in many such cases. Pain is worse in the morning; spreads into neighbouring areas of the body; worsens in direct or indirect proportion to mood; and can be felt in unconnected parts of the body simultaneously.
  
  Specialist pain journals have been full in recent years of descriptions of a variety of chronic pain syndromes, such as the complex regional pain syndromes (CRPS). CRPS have been sub-divided into a type that involves only the area around the site of the injury, and a second type that seems to involve how the brain and central nervous system (mis)process the pain signals coming from that part of the body. Debates have been conducted around what is (or is not) a reasonable level of pain, since pain is a subjective experience that cannot be measured objectively. However, there is no tradition of bringing together our knowledge of how depression affects individual experience of pain with our knowledge of how chronic pain affects the processing of pain signals. Physical and mental health specialists work in different fields, which is why multidisciplinary teams in pain clinics rarely include psychiatrists.
  
  Perhaps the greatest challenge of MUS – in my younger days I would have said scandal – is that the evidence suggests that there is a great deal we can do about some or all of these conditions. If we were to apply the psychological therapies and drug treatments, which we know stand a high chance of working, at points in patient pathways where they are known to impact best, patients would get better quicker, clinicians would be satisfied with a job well done, and the costs to the health service would come down. So why does it not happen?
  
  The answer lies mainly in the ways we have designed and implemented healthcare services in the UK, though to be fair it would be difficult to cite a healthcare system that handles things in a fundamentally better way. Traditional service structures tend to mirror our understanding of what constitutes illness, coupled with a certain amount of pandering to medical influence and fashionable causes.
  
  Few healthcare configurations reflect the clinical realities of illness. Our healthcare institutions, recreated in the structures of its professions, encourage the view that illnesses are so complex that considerable specialism is required. We divide specialities by parts of the body, the age of its inhabitant and/or the interventions intended. Each speciality homes in not only on one bit of us, but also often on specific approaches regarding what to do when that bit goes wrong. Each speciality spawns its own training schemes and articulates the need for greater and greater specialism among the professions expected to work within it. Further, doctors trained and practising in this era of techno-medicine become concerned when dealing with conditions that cannot be diagnosed using objective tests. They fear the culture of blame, shame and claim, and its practitioners, always lurking in the shadows.
  
  A way forward
  Some or all of the above factors may explain the muted response on the part of the NHS and other healthcare systems to deal with the otherwise obvious and major problem of MUS. Thus the challenge for an NHS intent on saving money by getting people better more effectively is how to restructure our approach to the delivery of healthcare, to enable more joined-up working.
  
  We need to define pathways of care that deal with the problems patients present, rather than relying on slotting patients into pathways designed to accommodate outmoded service configurations. Few if any existing patient pathways contain a point at which the 20-50 per cent of patients whose presenting problem has a major psychosomatic component have that part of their problem assessed and dealt with. Usually the only approach available is to refer patients to another inappropriate pathway.
  
  Successfully achieving the transformation to services that deal effectively with MUS will need major changes to how we train and deploy clinical staff. Creating a system that positively identifies and treats the psychological causes of MUS will challenge those who commission services as much as those who provide them. Teamwork at an unprecedented level will be key. Clinicians in acute hospitals and primary care will need to be aware of the signs that most or all of a patient’s ‘physical’ illness has its basis in mental health problems. They will also need to be able to differentiate between those who require a biological approach from those who need a psychological one.
  
  For therapists working in healthcare settings, such developments will offer almost unlimited possibilities, along with equally massive challenges. Those assessing what psychological approaches are required will need a working knowledge of the symptoms and signs of underlying physical disease in much the same way that many mental healthcare professionals have to get to grips with the biological/psychological interface in mental health work.
  
  This sort of change needs to happen in fairly short order, yet it has not happened in the first 60 years of the NHS, and the power of inertia cannot be underestimated. Whether it will happen and how soon is open to debate – though it may be sooner rather than later because of the cost implications of not acting: money is a powerful master. For the time being, we need to watch this (wide-open and centuries-old) space.

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  The complexity of MUS
  In real life, MUS do not usually fit into neatly defined categories of imitated illness, amplified symptoms or straightforward physical problems, as illustrated in the following brief examples.

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  Case example 1: breathing problems
  Mary has had asthma since childhood. It has generally been kept under fairly good control with various inhalers. However, she often has a bad time after a chest infection, as she did two months ago. A few months previously she crashed her car and has since become nervous when driving. Since then she has been having more asthma attacks, especially when she has to drive. She has also started smoking again.

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  Case example 2: ‘funny turns’
  Paul has had epilepsy since he was a teenager. Initially his attacks were diagnosed as emotional outbursts. At the time he found that alcohol and cannabis made life more bearable, and he has always used a bit too much of each. He is married and in work, but he struggles with both. Over the past year he has been having more attacks, some of which are pseudo-seizures. His wife cannot cope any more and has threatened to leave and take the children, which has increased his anxiety levels. He has been drinking more to deal with the stress.
  

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  Case example 3: living with diabetes
  Kylie’s doctor cannot get her diabetes under control but then he’s useless. She’s been in hospital three times in the last year, had to miss exams and everything. They want her to stick needles in herself like a junkie. They don’t know what these drugs do to you in the long run anyway. And picky diets are just so not cool unless you’re fat, which Kylie isn’t. Someone else can have diabetes – Kylie’s got better things to do. If they can’t work that out then that’s their fault.
  

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  The three categories of MUS
  
  Somatisation (imitated illness)
  Somatisation occurs when psychological distress manifests itself as a physical problem. The distress can be anything from an unresolved emotional conflict to an incipient psychotic illness, via all manner of psychosocial problems and neurobiological disorders.

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  Amplified symptoms
  Just as common and probably more so, is when an individual who is known to suffer from a particular illness or disorder develops symptoms that cannot be fully explained by the nature and extent of their physical condition.

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  Undiagnosed illness
  The fear is often that a patient with MUS might have a hitherto undiagnosed physical illness. This justification has been used for centuries to avoid positively diagnosing and tackling underlying mental distress.

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  Further reading
  Royal College of Psychiatrists and Royal College of General Practitioners. CR152: The management of patients with physical and psychological problems in primary care: a practical guide. London: Royal College of Psychiatrists and Royal College of General Practitioners; 2009. www.rcpsych.ac.uk/files/pdfversion/cr152.pdf
  
  Academy of Medical Royal Colleges and Royal College of Psychiatrists. No health without mental health: the ALERT summary report. London: Academy of Medical Royal Colleges and Royal College of Psychiatrists; 2009. www.rcpsych.ac.uk/pdf/ALERT%20print%20final.pdf
  
  Academy of Medical Royal Colleges and Royal College of Psychiatrists. No health without mental health: the supporting evidence. London: Academy of Medical Royal Colleges and Royal College of Psychiatrists; 2009. www.rcpsych.ac.uk/pdf/No%20Health%20without%20mental%20health%20the%20Evidence.pdf

• Dr Tim Webb is a Consultant in Adult Psychiatry and Medical Director of Suffolk Mental Health Partnership NHS Trust. His father was a GP, and his principal clinical interest is the management of common mental health problems in primary care.
  
  This article was first published in the January 2010 issue of HCPJ, the quarterly journal of BACP Healthcare. For further information about the BACP Healthcare division, email julie.camfield@bacp.co.uk

• References:
  

  1. Peveler R, Kilkenny L, Kinmonth AM. Medically unexplained physical symptoms in primary care: a comparison of self-report questionnaires and clinical opinion. Journal of Psychosomatic Research. 1997; 42: 253–260.
  2. Kirmayer LJ, Looper KJ, Taillefer S. Somatoform disorders. In Turner S, Hersen M (eds) Adult psychopathology. New York: John Wiley & Sons; 2003.
  3. Reid SWS. Frequent attenders with medically unexplained symptoms: service use and costs in secondary care. British Journal of Psychiatry. 2002; 180: 248-253.
  4. Barsky AJ. Somatisation increases medical utilisation and costs independent of psychiatric and medical co-morbidity. Archives of General Psychiatry. 2005; 62: 903-910.