Medically unexplained symptoms
- Undiagnosed condition
- Rare manifestations of a known condition
- or symptoms without apparent explanation
The most difficult to manage are probably those in the last category where the patient and/or their family believes strongly that they are in the first.
Many sociocultural, familial, and emotional factors determine a person's response to physical/psychological phemonena eg pain, and these will also affect the likelihood of seeking medical attention to explain and treat the problem.
In practice, a series of investigations of increasing invasiveness/cost/complexity are undertaken, usually with reducing likelihood of finding a positive result. It probably becomes more difficult to accept that symptoms do not have a purely physical explanation the longer a biological diagnosis has been considered, which in turn increases the demands for further investigations/treatments. Differential diagnoses should be considered early on and appropriate investigations undertaken without unnecessary delay. Once these have been excluded, it is important to move on to symptom management and functional rehabilitation.
The key to management is engagement. Many patients and their families feel that no-one believes them, that they are making it up or exaggerating their problems. Having a doctor who takes the time to listen, believes what they say and respects their personal opinions is the first stage to engagement. Voltaire said that medicine is about entertaining the patient while nature effects the cure!
Once medical explanations have been largely excluded, it is important to introduce to the patient the possibility that there may be psychological factors which contribute to the symptoms, and/or psychological techniques to help dealing with symptoms.
Where medical treatment is considered, it should be explained carefully (including licensed vs unlicensed indications, possible side effects), and consented to by patient and carers. Patients are likely to emphasize the possible benefits from treatments suggested by anecdotal reports. In these cases, reasonable therapeutic objectives should be agreed and a plan made to withdraw treatment if no benefit is observed. Beware unexpected side effects of treatments eg dietary deficiencies, analgesic headache.
Pain may be best dealt with by a specialist pain team, as gabapentin, acupuncture, TENS machines etc may be offered in addition to analgesics. But pain does not determine the pace of rehabilitation: function can improve before pain.
Patients like explanations, eg visceral hypersensitivity in the case of recurrent abdominal pain. They will not appreciate obvious wild theorizing, so it is important to be explicit about what is hypothesizing cf known facts, personal experience with other patients. It may or may not be useful to explain how medicine offers incomplete understanding of many human experiences.
Chronic symptoms will inevitably have an emotional as well as social impact. Increasing emotional literacy is an important aim. Relaxation techniques may help, and possible resources in terms of friends and family should be identified. At the same time, the potential for positive as well as negative gains should be explored. Cognitive Behavioural Therapy appears to be helpful.
Allied Health Professionals
Occupational therapy and physiotherapy may help maintain function and offer aids to living. Beware dependency however, and maintain clear objectives of achieving good functional outcomes.
It is important to recognize how medicine changes, and how new explanations/diagnoses may appear.