Medically unexplained physical symptoms

Medically unexplained physical symptoms (MUPS or MUS) or Persistent Physical Symptoms are symptoms for which the doctor is unable to find a cause, for example unexplained dizziness or unexplained tiredness. Medically unexplained symptoms may be mild, and can resolve within a few weeks without treatment, but some are more persistent. In practice, "medically unexplained" may be used to extremely broadly to describe either symptoms of a diagnosis not yet fully understood by medicine, especially ME/CFS, fibromyalgia or irritable bowel syndrome, or symptoms that are not known to be linked to a medical condition, or symptoms a medical professional judges to be out of proportion to the related physical cause or illness.

MUS or MUPS are sometimes referred to as Functional Somatic Symptoms (FSS) or diagnosed as Bodily Distress Syndrome (BDS) - both of which are mental illnesses - despite being classified as physical illnesses under the World Health Organization's current ICD-10 classification, and the latest ICD-11 classification. Functional Neurological Disorder (FND) is also regarded as medically unexplained symptom.

In the UK there is currently a PROSPERO systematic review of medically unexplained symptoms and their treatments being undertaken by a number of authors including Peter White, first author of the controversial PACE trial for ME/CFS, into MUS.

Somatization and psychologization
A key assumption often made is that medically unexplained physical symptoms are symptoms which have no physical cause - rather than no known physical cause, and so are assumed be caused by somatization: the physical expression of emotional distress. Symptoms, or entire diagnosed illnesses such as ME/CFS or fibromyalgia, are assumed to have no underlying illness process but to have "psychosomatic" symptoms or "psychogenic illness".

The MUS approach has been used inappropriately to reclassify diagnosed physical illness, including ME/CFS, as a mental health, which can then result in appropriate treatment, for example medical neglect, and in some severely ill patients, forced psychiatric treatment and forced exercise therapy combined with medical neglect, factors which contributed to the death of Sophia Mirza from ME/CFS.

Absence of evidence of a physical cause
Medically unexplained symptoms are often referred to as lacking evidence of any organic pathology (physical cause) - but including patients with symptoms judged to be out of proportion to the illness or injury is common practice; this is problematic because it relies not on medical or psychological tests for MUS but on a doctor's current knowledge of a diagnosed illness or injury, and on medical science's current expectation of particularly severe cases of the each diagnosis. For example, a doctor or psychiatrist assessing a person with very very severe ME may be unaware that paralysis, seizures and speech problems can occur and the illness can, in some cases, kill, so this lack of knowledge may lead to an incorrect diagnosis of MUS, with cognitive or cognitive treatments that may cause significant harm.

Historically, illnesses that were previously misunderstood or not yet identified were blamed on patients' personality, for example William Henry Day's concept of the "migraine personality" in 1878, Diamond and Dalessio (1973) claims that "up to 90% [of those with migraines] have a psychogenic basis for their complaint", patients were labeled as "untrustworthy", "drug-seeking", or as potential malingerers. Lupus, multiple sclerosis, and Lyme disease are all examples of illnesses that were previously assumed to have a psychological origin simply because of the "absence of evidence" of a physical cause.

English (2000) states that "Absence of evidence may reflect insufficient research, inadequate technology, poor methods, flawed paradigms, closed minds, or lack of clinical experience; for example, in 1980, there was no clear evidence that AIDS was viral—blood products were considered “safe.”"

Criticism and controversy
The whole MUS concept - where the same treatments and approaches are used for many different syndromes or groups of symptoms - all of which are then regarded as "non-diseases" - has been criticized, especially with wrongly including the neurological disease of ME. In the UK, the effect of this is that patients regarded as having MUS conditions or symptoms are treated under the Improving Access to Psychological Therapies (IAPT) programme, a mental health-only approach which does not have the facilities or skills to treat physical health problems.

The inclusion of ME/CFS under MUS has been heavily criticized by patients with ME, especially in the UK which is obliged to follow the World Health Organization's classification system - which recognizes ME / CFS / Post-viral syndrome under neurological diseases, and excludes then from other categories.

An article in Positive Health stated that MUS will divert funding from the UK's mental health system by wrongly including ME/CFS.

The Countess of Mar has asked questions about the problems of MUS and ME/CFS in the UK's House of Lords.

Dr James Coyne has found that Peter White, lead author of the highly controversial PACE trial and advisor to the UK Department for Work and Pensions, did not disclose his financial interests with health insurers for the PROSPERO review.

A patient advocate has critiqued the basis and motive of the rollout of MUS in the UK.

Costs of medically unexplained symptoms
A highly influential study by Bermingham et al attempted to calculate the health care costs of patients with MUS, but incorrectly included costs of treating diseases that are not classified as MUS, including ME/CFS.

Further controversy has erupted with the repeated incorrect references to Bermingham et al. which have been published in further reviews and articles by influential journals. Dr David Tuller, a public health professional at Berkeley has repeatedly highlighted this, contacting Carolyn Chew-Graham and others who incorrectly cited the paper and the journals that published it to request corrections.

Medical neglect
Medically unexplained symptoms recommendations includes avoiding doing "unnecessary" diagnostic tests, and avoiding "symptom focusing", leaving people with a physical illness at risk of medical neglect due to the lack of investigation, failure to correctly diagnose other causes for symptoms or other illnesses, and lack of biomedical treatment.

Biopsychosocial model
The biopsychosocial model (BPS) is frequently used to provide treatment for medically unexplained physical symptoms. A key part of this model is the use of psychological approaches, often including a form of psychotherapy called cognitive behavioral therapy. In patients with ME/CFS, patient groups and a number of different authors, have reported that the biopsychosocial approach has led to substantial rates of harm and multiple types of harm have been identified in this patient group. A survey of over 2,000 British patients with ME/CFS was conducted in 2019 to help inform the revision of the NHS treatment guidelines, and found that the treatment was more harmful then helpful. The survey reported that more than 1 in 5 patients developed new symptoms while undergoing cognitive behavioral therapy for ME/CFS, 26% said their physical health had deteriorated as a result, with only 16% reporting improved physical health. Alarmingly, 26% found their mental health deteriorated with this psychological approach.

The psychologization of patients' illness in the absence of psychological symptoms assumes that psychological help must be needed or beneficial in patients with medically unexplained symptoms, despite the fact that an unknown number of patients may have symptoms caused by an undiagnosed medical condition, a medical condition not yet recognized by modern science, or a recognized medical condition like ME/CFS that is not fully understood yet.

Patient experiences
Patients with medically unexplained physical symptoms have described many types of negative medical encounters, including:
 * harmful medical advice or treatment
 * inappropriate psychological explanations) (the psychologization of symptoms)
 * disbelief and disrespectful treatment from doctors and health care professionals
 * marginalization of patients' experiences
 * lack of physical examination and damaging health advice
 * disregarding patients' knowledge and autonomy

Improving Access to Psychological Therapies
Improving Access to Psychological Therapies (IAPT) is the treatment arm of the MUS rollout in the UK.

The Journal of Health Psychology published 'Improving Access to Psychological Therapies (IAPT) - The Need for Radical Reform' by Michael Scott which used the PACE trial as an example of inflated recover from psychological treatments concluded that the IAPT similarly had little evidence to justify the treatments even for psychological conditions.

The editor of the Journal of Health Psychology, Dr David Marks, published an editorial in July 'IAPT under the microscope' which concluded "A service based on the promise of savings by taking people off benefits is a political hot potato. There is an urgent need for an independent review of IAPT by impartial experts."

Notable studies and articles

 * 2010, The cost of somatisation among the working‐age population in England for the year 2008–2009 (Full text)
 * 2015, Managing medically unexplained illness in general practice (Full text)
 * 2017, “It´s incredible how much I´ve had to fight.” Negotiating medical uncertainty in clinical encounters (Full text)
 * 2017, Contesting the psychiatric framing of ME/CFS (Full text)


 * 2019, Bodily Distress Syndrome: Concerns About Scientific Credibility in Research and Implementation (Full text)
 * 2018, Why Bioethics Should Be Concerned With Medically Unexplained Symptoms (Full text)

Letters, talks and blogs

 * 2019, It's time to pay attention to Chronic Fatigue Syndrome


 * 2015, Dr Jim Bolton presents Medically Unexplained Symptoms

Learn more

 * Medically unexplained symptoms - Royal College of Psychiatrists
 * Trial by Error: Some thoughts on MUS and Bermingham: My letter to Professor Payne - David Tuller


 * Medically unexplained symptoms - NHS

The fact that doctors are unable to find a condition causing these symptoms isn't unusual in medicine, and it doesn't mean that nothing can be done to help you.
 * Wikipedia - Medically unexplained physical symptoms