CoChat
Sign Up
Cited by 129Psychosomatic Disorders and Their TreatmentsMedicine, History, and PhilosophyFibromyalgia and Chronic Fatigue Syndrome Research

“Medically unexplained” symptoms and symptom disorders in primary care: prognosis-based recognition and classification

Open access
Rosendal, Marianne, Olde Hartman, Tim C, Aamland, Aase, van der Horst, Henriette, Lucassen, Peter, Budtz-Lilly, Anna, Burton, Christopher·2017·BMC Family Practice
DOI 10.1186/s12875-017-0592-6PMC PMC5297117
Open this paper in CoChat — free accountOpen PDF

Abstract

BACKGROUND: Many patients consult their GP because they experience bodily symptoms. In a substantial proportion of cases, the clinical picture does not meet the existing diagnostic criteria for diseases or disorders. This may be because symptoms are recent and evolving or because symptoms are persistent but, either by their character or the negative results of clinical investigation cannot be attributed to disease: so-called "medically unexplained symptoms" (MUS). MUS are inconsistently recognised, diagnosed and managed in primary care. The specialist classification systems for MUS pose several problems in a primary care setting. The systems generally require great certainty about presence or absence of physical disease, they tend to be mind-body dualistic, and they view symptoms from a narrow specialty determined perspective. We need a new classification of MUS in primary care; a classification that better supports clinical decision-making, creates clearer communication and provides scientific underpinning of research to ensure effective interventions. DISCUSSION: We propose a classification of symptoms that places greater emphasis on prognostic factors. Prognosis-based classification aims to categorise the patient's risk of ongoing symptoms, complications, increased healthcare use or disability because of the symptoms. Current evidence suggests several factors which may be used: symptom characteristics such as: number, multi-system pattern, frequency, severity. Other factors are: concurrent mental disorders, psychological features and demographic data. We discuss how these characteristics may be used to classify symptoms into three groups: self-limiting symptoms, recurrent and persistent symptoms, and symptom disorders. The middle group is especially relevant in primary care; as these patients generally have reduced quality of life but often go unrecognised and are at risk of iatrogenic harm. The presented characteristics do not contain immediately obvious cut-points, and the assessment of prognosis depends on a combination of several factors. CONCLUSION: Three criteria (multiple symptoms, multiple systems, multiple times) may support the classification into good, intermediate and poor prognosis when dealing with symptoms in primary care. The proposed new classification specifically targets the patient population in primary care and may provide a rational framework for decision-making in clinical practice and for epidemiologic and clinical research of symptoms.

The claims and statistics of this paper haven’t been checked yet.

Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.

A few free checks a day · papers already verified open instantly · results are public

Integrity signals

Registry

Crossref · 10.1186/s12875-017-0592-6

Cites

Statistics

Claims the paper makes

The claims and statistics of this paper haven’t been checked yet.

Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.

A few free checks a day · papers already verified open instantly · results are public

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

The self-check needs the paper’s full text.

The citation lists haven’t been fetched yet

References 80 · Cited by 129

Research works printed but not linked: 65

  1. [3]Elnegaard S Andersen RS Pedersen AF Larsen PV Sondergaard J Rasmussen S Balasubramaniam K Svendsen RP Vedsted P Jarbol DE Self-reported symptoms and healthcare seeking in the general population--exploring “The symptom iceberg” BMC Public Health 2015 15 685 10.1186/s12889-015-2034-5 26195232 PMC4509464 · DOI
  2. [4]Sharpe M Somatic symptoms: beyond ‘medically unexplained’ Br J Psychiatry 2013 203 5 320 1 10.1192/bjp.bp.112.122523 24187064 · DOI
  3. [6]Fink P Rosendal M Olesen F The classification of somatisation and functional somatic symptoms in primary care Aust N Z J Psychiatry 2005 39 772 81 10.1080/j.1440-1614.2005.01682.x 16168035 · DOI
  4. [7]Rask MT Andersen RS Bro F Fink P Rosendal M Towards a clinically useful diagnosis for mild-to-moderate conditions of medically unexplained symptoms in general practice: a mixed methods study BMC Fam Pract 2014 15 118 10.1186/1471-2296-15-118 24924564 PMC4075929 · DOI
  5. [8]Olde Hartman TC Hassink-Franke L Dowrick C Fortes S Lam C van der Horst H Lucassen P van Weel-Baumgarten E Medically unexplained symptoms in family medicine: defining a research agenda. Proceedings from WONCA 2007 Fam Pract 2008 25 4 266 71 10.1093/fampra/cmn041 18596048 · DOI
  6. [9]Bourke JH Langford RM White PD The common link between functional somatic syndromes may be central sensitisation J Psychosom Res 2015 78 3 228 36 10.1016/j.jpsychores.2015.01.003 25598410 · DOI
  7. [11]Deary V Chalder T Sharpe M The cognitive behavioural model of medically unexplained symptoms: a theoretical and empirical review Clin Psychol Rev 2007 27 7 781 97 10.1016/j.cpr.2007.07.002 17822818 · DOI · Paper page
  8. [12]Cagnie B Coppieters I Denecker S Six J Danneels L Meeus M Central sensitization in fibromyalgia? A systematic review on structural and functional brain MRI Semin Arthritis Rheum 2014 44 1 68 75 10.1016/j.semarthrit.2014.01.001 24508406 · DOI
  9. [13]Lipowski ZJ Somatization: a borderland between medicine and psychiatry CMAJ 1986 135 6 609 14 3489512 PMC1491312
  10. [14]Burton C Weller D Sharpe M Functional somatic symptoms and psychological states: an electronic diary study Psychosom Med 2009 71 1 77 83 10.1097/PSY.0b013e31818f2acb 19124614 · DOI
  11. [15]Henningsen P Zipfel S Herzog W Management of functional somatic syndromes Lancet 2007 369 9565 946 55 10.1016/S0140-6736(07)60159-7 17368156 · DOI · Paper page
  12. [16]Picariello F Ali S Moss-Morris R Chalder T The most popular terms for medically unexplained symptoms: the views of CFS patients J Psychosom Res 2015 78 5 420 6 10.1016/j.jpsychores.2015.02.013 25791667 · DOI
  13. [17]Marks EM Hunter MS Medically unexplained symptoms: an acceptable term? Br J Pain 2015 9 2 109 14 10.1177/2049463714535372 26516565 PMC4616968 · DOI
  14. [18]Rosendal M Carlsen AH Rask MT Moth G Symptoms as the main problem in primary care: a cross-sectional study of frequency and characteristics Scand J Prim Health Care 2015 33 2 91 9 10.3109/02813432.2015.1030166 25961812 PMC4834508 · DOI
  15. [19]Rosendal M Bro F Fink P Christensen KS Olesen F Diagnosis of somatisation: effect of an educational intervention in a cluster randomised controlled trial Br J GenPract 2003 53 497 917 22 PMC1314743 14960214
  16. [20]Steinbrecher N Koerber S Frieser D Hiller W The prevalence of medically unexplained symptoms in primary care Psychosomatics 2011 52 3 263 71 10.1016/j.psym.2011.01.007 21565598 · DOI
  17. [21]Aamland A Malterud K Werner EL Patients with persistent medically unexplained physical symptoms: a descriptive study from Norwegian general practice BMC Fam Pract 2014 15 107 10.1186/1471-2296-15-107 24885524 PMC4041895 · DOI
  18. [22]Verhaak PF Meijer SA Visser AP Wolters G Persistent presentation of medically unexplained symptoms in general practice Fam Pract 2006 23 4 414 20 10.1093/fampra/cml016 16632487 · DOI
  19. [23]Swanson LM Hamilton JC Feldman MD Physician-based estimates of medically unexplained symptoms: a comparison of four case definitions Fam Pract 2010 27 5 487 93 10.1093/fampra/cmq051 20634265 · DOI
  20. [24]Toft T Fink P Oernboel E Christensen K Frostholm L Olesen F Mental disorders in primary care: prevalence and co-morbidity among disorders. results from the functional illness in primary care (FIP) study Psychol Med 2005 35 8 1175 84 10.1017/S0033291705004459 16116943 · DOI
  21. [25]Budtz-Lilly A Vestergaard M Fink P Carlsen AH Rosendal M Patient characteristics and frequency of bodily distress syndrome in primary care: a cross-sectional study Br J Gen Pract 2015 65 638 e617 23 10.3399/bjgp15X686545 26324499 PMC4540402 · DOI
  22. [26]Lowe B Spitzer RL Williams JB Mussell M Schellberg D Kroenke K Depression, anxiety and somatization in primary care: syndrome overlap and functional impairment Gen Hosp Psychiatry 2008 30 3 191 9 10.1016/j.genhosppsych.2008.01.001 18433651 · DOI · Paper page
  23. [28]Rolfe A Burton C Reassurance after diagnostic testing with a low pretest probability of serious disease: systematic review and meta-analysis JAMA Intern Med 2013 173 6 407 16 10.1001/jamainternmed.2013.2762 23440131 · DOI · Paper page
  24. [29]Murray AM Toussaint A Althaus A Lowe B The challenge of diagnosing non-specific, functional, and somatoform disorders: a systematic review of barriers to diagnosis in primary care J Psychosom Res 2016 80 1 10 10.1016/j.jpsychores.2015.11.002 26721541 · DOI
  25. [30]Wileman L May C Chew-Graham CA Medically unexplained symptoms and the problem of power in the primary care consultation: a qualitative study Fam Pract 2002 19 2 178 82 10.1093/fampra/19.2.178 11906984 · DOI
  26. [31]Hahn SR Kroenke K Spitzer RL Brody D Williams JB Linzer M de Gruy FV III The difficult patient: prevalence, psychopathology, and functional impairment J GenIntern Med 1996 11 1 1 8 8691281
  27. [32]Hinchey SA Jackson JL A cohort study assessing difficult patient encounters in a walk-in primary care clinic, predictors and outcomes J Gen Intern Med 2011 26 6 588 94 10.1007/s11606-010-1620-6 21264521 PMC3101981 · DOI
  28. [33]Fink P Surgery and medical treatment in persistent somatizing patients J Psychosom Res 1992 36 5 439 47 10.1016/0022-3999(92)90004-L 1535658 · DOI
  29. [34]Warren JW Morozov V Howard FM Wesselmann U Gallicchio L Langenberg P Clauw DJ Before the onset of interstitial cystitis/bladder pain syndrome, the presence of multiple non-bladder syndromes is strongly associated with a history of multiple surgeries J Psychosom Res 2014 76 1 75 9 10.1016/j.jpsychores.2013.10.013 24360145 · DOI
  30. [35]Flynn TW Smith B Chou R Appropriate use of diagnostic imaging in low back pain: a reminder that unnecessary imaging may do as much harm as good J Orthop Sports Phys Ther 2011 41 11 838 46 10.2519/jospt.2011.3618 21642763 · DOI
  31. [36]Rosendal M Carlsen AH Rask MT Symptoms as the main problem: a cross- sectional study of patient experience in primary care BMC Fam Pract 2016 17 29 10.1186/s12875-016-0429-8 26965443 PMC4785648 · DOI
  32. [37]Dirkzwager AJ Verhaak PF Patients with persistent medically unexplained symptoms in general practice: characteristics and quality of care BMC Fam Pract 2007 8 33 10.1186/1471-2296-8-33 17540013 PMC1894968 · DOI
  33. [38]Johansson EE Hamberg K Lindgren G Westman G “I’ve been crying my way”--qualitative analysis of a group of female patients’ consultation experiences Fam Pract 1996 13 6 498 503 10.1093/fampra/13.6.498 9023524 · DOI
  34. [39]Salmon P Peters S Stanley I Patients’ perceptions of medical explanations for somatisation disorders: qualitative analysis BMJ 1999 318 7180 372 6 10.1136/bmj.318.7180.372 9933202 PMC27727 · DOI
  35. [40]Nettleton S Watt I O'Malley L Duffey P Understanding the narratives of people who live with medically unexplained illness Patient Educ Couns 2005 56 2 205 10 10.1016/j.pec.2004.02.010 15653250 · DOI
  36. [41]Giroldi E Veldhuijzen W Mannaerts A van der Weijden T Bareman F van der Vleuten C “Doctor, please tell me it’s nothing serious”: an exploration of patients’ worrying and reassuring cognitions using stimulated recall interviews BMC Fam Pract 2014 15 73 10.1186/1471-2296-15-73 24762333 PMC4008437 · DOI
  37. [42]Ring A Dowrick C Humphris G Salmon P Do patients with unexplained physical symptoms pressurise general practitioners for somatic treatment? A qualitative study BMJ 2004 328 7447 1057 61 10.1136/bmj.38057.622639.EE 15056592 PMC403850 · DOI
  38. [43]Kornelsen J Atkins C Brownell K Woollard R The meaning of patient experiences of medically unexplained physical symptoms Qual Health Res 2016 26 3 367 76 10.1177/1049732314566326 25583957 · DOI
  39. [44]Burton C, Lucassen P, Aamland A, Hartman TO. Explaining symptoms after negative tests: towards a rational explanation. J R Soc Med. 2014. PMC4368455 25389231
  40. [45]Klaus K Rief W Brahler E Martin A Glaesmer H Mewes R The distinction between “medically unexplained” and “medically explained” in the context of somatoform disorders Int J Behav Med 2013 20 2 161 71 10.1007/s12529-012-9245-2 22678925 · DOI
  41. [46]White PD Rickards H Zeman AZ Time to end the distinction between mental and neurological illnesses BMJ 2012 344 e3454 10.1136/bmj.e3454 22628005 · DOI
  42. [47]Balint M The doctor, his patient and the illness, vol. second 1957 N. Y International Universities Press Inc
  43. [48]Risor MB Illness explanations among patients with medically unexplained symptoms: different idioms for different contexts Health (London) 2009 13 5 505 21 10.1177/1363459308336794 19696133 · DOI
  44. [49]Liden E Bjork-Bramberg E Svensson S The meaning of learning to live with medically unexplained symptoms as narrated by patients in primary care: a phenomenological-hermeneutic study Int J Qual Stud Health Well-being 2015 10 27191 10.3402/qhw.v10.27191 25887965 PMC4401824 · DOI
  45. [50]Peters S Rogers A Salmon P Gask L Dowrick C Towey M Clifford R Morriss R What do patients choose to tell their doctors? Qualitative analysis of potential barriers to reattributing medically unexplained symptoms J Gen Intern Med 2009 24 4 443 9 10.1007/s11606-008-0872-x 19089505 PMC2659146 · DOI
  46. [54]Croft P Altman DG Deeks JJ Dunn KM Hay AD Hemingway H LeResche L Peat G Perel P Petersen SE The science of clinical practice: disease diagnosis or patient prognosis? Evidence about “what is likely to happen” should shape clinical practice BMC Med 2015 13 20 10.1186/s12916-014-0265-4 25637245 PMC4311412 · DOI · Paper page
  47. [55]Dinant GJ Buntinx FF Butler CC The necessary shift from diagnostic to prognostic research BMC Fam Pract 2007 8 53 10.1186/1471-2296-8-53 17854488 PMC2034563 · DOI
  48. [57]Diagnostic and Statistical Manual of Mental Disorders (5th ed.), DSM-5, vol. Fifth edition. Washington, DC: American Psychiatric Association; 2013.
  49. [60]Jackson J Fiddler M Kapur N Wells A Tomenson B Creed F Number of bodily symptoms predicts outcome more accurately than health anxiety in patients attending neurology, cardiology, and gastroenterology clinics J Psychosom Res 2006 60 4 357 63 10.1016/j.jpsychores.2006.02.006 16581359 · DOI
  50. [61]Tomenson B Essau C Jacobi F Ladwig KH Leiknes KA Lieb R Meinlschmidt G McBeth J Rosmalen J Rief W Total somatic symptom score as a predictor of health outcome in somatic symptom disorders Br J Psychiatry 2013 203 5 373 80 10.1192/bjp.bp.112.114405 24072756 · DOI
  51. [62]Creed FH Davies I Jackson J Littlewood A Chew-Graham C Tomenson B Macfarlane G Barsky A Katon W McBeth J The epidemiology of multiple somatic symptoms J Psychosom Res 2012 72 4 311 7 10.1016/j.jpsychores.2012.01.009 22405227 · DOI
  52. [63]Olde Hartman TC Borghuis MS Lucassen PL van de Laar FA Speckens AE van Weel C Medically unexplained symptoms, somatisation disorder and hypochondriasis: course and prognosis. A systematic review J Psychosom Res 2009 66 5 363 77 10.1016/j.jpsychores.2008.09.018 19379952 · DOI
  53. [64]Creed F Barsky A A systematic review of the epidemiology of somatisation disorder and hypochondriasis J Psychosom Res 2004 56 4 391 408 10.1016/S0022-3999(03)00622-6 15094023 · DOI · Paper page
  54. [65]Valentin GH Pilegaard MS Vaegter HB Rosendal M Ortenblad L Vaeggemose U Christensen R Prognostic factors for disability and sick leave in patients with subacute non-malignant pain: a systematic review of cohort studies BMJ Open 2016 6 1 e007616 10.1136/bmjopen-2015-007616 26739716 PMC4716223 · DOI
  55. [66]Mallen CD Peat G Thomas E Dunn KM Croft PR Prognostic factors for musculoskeletal pain in primary care: a systematic review Br J Gen Pract 2007 57 541 655 61 17688762 PMC2099673
  56. [67]Kamaleri Y Natvig B Ihlebaek CM Bruusgaard D Does the number of musculoskeletal pain sites predict work disability? A 14-year prospective study Eur J Pain 2009 13 4 426 30 10.1016/j.ejpain.2008.05.009 18599328 · DOI
  57. [69]Aaron LA Buchwald D A review of the evidence for overlap among unexplained clinical conditions Ann Intern Med 2001 134 9 Pt 2 868 81 10.7326/0003-4819-134-9_Part_2-200105011-00011 11346323 · DOI
  58. [72]Steinbrecher N Hiller W Course and prediction of somatoform disorder and medically unexplained symptoms in primary care Gen Hosp Psychiatry 2011 33 4 318 26 10.1016/j.genhosppsych.2011.05.002 21762827 · DOI
  59. [74]Jackson JL Passamonti M The outcomes among patients presenting in primary care with a physical symptom at 5 years J Gen Intern Med 2005 20 11 1032 7 10.1111/j.1525-1497.2005.0241.x 16307629 PMC1490256 · DOI
  60. [75]McGorm K Burton C Weller D Murray G Sharpe M Patients repeatedly referred to secondary care with symptoms unexplained by organic disease: prevalence, characteristics and referral pattern Fam Pract 2010 27 5 479 86 10.1093/fampra/cmq053 20679139 · DOI
  61. [76]Who International statistical classification of diseases and related health problems. Tenth revision 1992 Geneva World Health Organization 3376487
  62. [77]Creed F Gureje O Emerging themes in the revision of the classification of somatoform disorders Int Rev Psychiatry 2012 24 6 556 67 10.3109/09540261.2012.741063 23244611 · DOI
  63. [78]Frostholm L Oernboel E Christensen KS Toft T Olesen F Weinman J Fink P Do illness perceptions predict health outcomes in primary care patients? A 2-year follow-up study J Psychosom Res 2007 62 2 129 38 10.1016/j.jpsychores.2006.09.003 17270570 · DOI
  64. [80]Rosendal M Vedsted P Christensen KS Moth G Psychological and social problems in primary care patients - general practitioners’ assessment and classification Scand J Prim Health Care 2013 31 1 43 9 10.3109/02813432.2012.751688 23281962 PMC3587306 · DOI
  65. [81]Nettleton S ‘I just want permission to be ill’: towards a sociology of medically unexplained symptoms Soc Sci Med 2006 62 5 1167 78 10.1016/j.socscimed.2005.07.030 16135395 · DOI

Authors
Rosendal, M., Olde Hartman, T. C., Aamland, A., van der Horst, H., Lucassen, P., Budtz-Lilly, A., & Burton, C.
Affiliations
  • University of Southern Denmark (DK)
  • Uni Research (Norway) (NO)
  • Radboud University Nijmegen (NL)
  • Aarhus University (DK)
  • Northern General Hospital (GB)
Corresponding author
Rosendal, Marianne
ORCID
Venue
BMC Family Practice
Publisher
Springer Science and Business Media LLC
Published
2017-02-07
Volume
18
Issue
1
Pages
18-18
ISSN
1471-2296 (ISSN-L)
DOI
10.1186/s12875-017-0592-6
PMC
PMC5297117
OpenAlex
W2586313935
Cited by
129
References
80
Citations by year
2026: 20 · 2025: 9 · 2024: 14 · 2023: 12 · 2022: 10 · 2021: 19 · 2020: 12 · 2019: 15 · 2018: 11 · 2017: 7
FWCI
10.11
Type
journal article
Language
en
Open access
Licence
cc-by
Locations
  • BMC Family Practice (publishedVersion, cc-by)
  • Europe PMC (PubMed Central) (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • Pure Amsterdam UMC (publishedVersion, other-oa)
  • White Rose Research Online (University of Leeds, The University of Sheffield, University of York) (acceptedVersion)
  • University of Southern Denmark Research Portal (University of Southern Denmark) (acceptedVersion, cc-by)
  • Amsterdam UMC (VU Amsterdam) - Institutional Repository (submittedVersion)
  • Radboud Repository (Radboud University) (submittedVersion)
  • Radboud Repository (Radboud University) (submittedVersion, other-oa)
  • Data Archiving and Networked Services (DANS) (submittedVersion)
Topics
  • Health Sciences › Medicine › Psychiatry and Mental health › Psychosomatic Disorders and Their Treatments
  • Health Sciences › Medicine › Psychiatry and Mental health › Medicine, History, and Philosophy
  • Health Sciences › Medicine › Psychiatry and Mental health › Fibromyalgia and Chronic Fatigue Syndrome Research
Keywords
medically unexplained symptoms, primary care, symptom classification, multiple symptoms, multiple systems, iatrogenic injury, clinical decision-making, quality of life
MeSH terms
Clinical Decision-Making, Humans, Primary Health Care, Prognosis, Quality of Life, Referral and Consultation, Somatoform Disorders

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

Are you an author, or do you see a problem with this page? Request a review