Is there a better term than “Medically unexplained symptoms”?

Introduction 

The European Association of Consultation Liaison Psychiatry and Psychosomatics (EACLPP) is preparing a document aimed at improving the quality of care received by patients who have “medically unexplained symptoms” or “somatisation” [1]. Part of this document identifies barriers to improved care and it has become apparent that the term “medically unexplained symptoms” is itself a barrier to improved care. This is because the term is not acceptable to some patients and doctors. It defines the patient's symptoms by what they are not, rather than by what they are, and it reflects dualistic thinking – regarding symptoms as either “organic” or “non-organic”/“psychological”.

The authors of this paper met in Manchester in May 2009 to review thoroughly this problem of terminology and make recommendations for a better term.. The deliberations of the group form the basis of this paper. Our discussion concerned terminology applicable to the more severe and persistent common symptoms of unknown aetiology, so often seen in primary care, and the recognised disorders, which present with symptoms that escape orthodox medical or surgical disease explanations. The latter include the disorders currently listed in the Somatoform disorders chapters of the American Diagnostic and Statistical Manual of Mental Disorders (DSM) and the WHO International Classification of Diseases (ICD). Our priority was to identify a term or terms that would facilitate management – that is it would encourage joint medical psychiatric/psychological assessment and treatment and be acceptable to physicians, patients, psychiatrists and psychologists.

In the first step, we reviewed why the term “medically unexplained symptoms” is so often unhelpful. In the second step we established a set of criteria which may be used to judge any alternative term. In the third step we applied these criteria to the various terms which have been used to describe this group of complaints.

“Medically unexplained symptoms” – one advantage, but many reasons to discontinue use of the term 

The term “medically unexplained symptoms” has gained some popularity during recent years among general practitioners and others to describe the bodily complaints of their patients when the aetiology is unclear. The term implies that the complaints cannot be fully explained by structural bodily pathology. Used in this way, the term “medically unexplained symptoms” is like a pre-diagnostic statement: it implies that currently there is no “organic cause” for the problem but it leaves open the potential aetiology of the problem.

Unfortunately, any advantage of using this term in a purely descriptive diagnostically noncommittal way is outweighed by a number of disadvantages which, in our opinion, and in that of many others, discredits further use of the term “medically unexplained symptoms”.

From a clinical point of view the phrase “medically unexplained” is a negative statement, withholding from the patient that which he or she usually seeks most - a positive explanation for their symptom(s) and support [2], [3].

Conceptually, referring to a symptom as “medically unexplained” is ambiguous in at least two senses:

A more fundamental problem with the concept underlying “medically unexplained symptoms” is the dualism it fosters. A patient's symptom is seen either as an organic one (“medically explained”) or, medically “unexplained”, which may be taken to imply a psychological cause. This dualism is still enshrined in our classifications of diseases (ICD has a separate chapter for “mental “ disorders and DSM is only concerned with mental disorders) despite the fact that we know now that human illness is determined by a mixture of biological, psychological and social factors.

To overcome this problem of dualism there are several possible alternatives. One requires that we describe, in every patient, relevant factors on all three dimensions (biological, psychological and social) contributing to his or her suffering [5], [6]. However, such an approach across the whole range of medical problems might be difficult to realise in practise.

Secondly, if we accept the existing division of disorders into primarily physical/organic or mental/psychological categories, then a third category of overlapping or “interface” disorders becomes necessary. The disorders which are captured with a term like “medically unexplained symptoms” are neither predominantly organic nor predominantly psychological; they bridge the organic – psychological divide so they belong to an interface category of disorders, where both dimensions are of diagnostic and therapeutic relevance. There is a serious problem with this latter approach as, for many of us, it is confusing and seems obsolete to use “organic” and “psychological” as separate concepts, with an “interface” between them as all symptoms are manifestations of CNS activity and thus have a biological or “organic” basis.

A third approach is concerned solely with the description of symptoms or clusters of symptoms. (e.g. fatigue, pain, sleep problems or widespread bodily pain) [7], [8]. This approach makes no assumptions about aetiology. It also allows symptoms to be described in patients whether or not they suffer from other, well-recognised organic disease (such as cancer or rheumatoid arthritis).

Criteria to judge the value of alternative terms for “medically unexplained symptoms” 

Ten criteria were developed in order to judge the value of potential terms which might be used to describe the group of symptoms currently referred to as medically unexplained symptoms. Obviously, this list of criteria does not claim to be exhaustive, but we believe that it captures the most important aspects. The criteria are that the term:

Terms suggested as alternatives for “medically unexplained symptoms” 

The group reviewed terms which are used currently or have been proposed for the future. An extensive list was abbreviated to the following 8 terms or categories:

The terms we reviewed were:

As discussed above, the term “medically unexplained symptoms” clearly fails criteria 1, 3 and 6, possibly also 4 and 5. Therefore we recommend that the term not be used in the future.

The term somatoform disorder is known to be unacceptable to many patients and doctors and, because the diagnosis relies on “medically unexplained symptoms”, it classically endorses the organic/psychological dualism.

The term Symptom defined illness or syndrome is unlikely to be widely accepted among patients and doctors alike; it lacks a clear core concept and does not easily fit with a concurrent pathologically established disease.

Somatic symptom disorder is not a term that is likely to be embraced enthusiastically by doctors or patients; it has an uncertain core concept, dubious wide acceptability across cultures and does not promote multidisciplinary treatment.

In our discussion, the terms which fit most closely the criteria we have set out above were the following: bodily distress (or stress) syndrome/ disorder, psychosomatic or psychophysical disorder, functional (somatic) syndrome or disorder.

The term bodily distress disorder fulfils most criteria from the list above with the exception of criterion 10 (the acronym BDD is in use already to indicate Body Dysmorphic Disorder). In the discussion it became clear that there is a semantic uncertainty as to the notion of distress: for Danish and German participants of the meeting this term does not necessarily imply a psychological component (there can be distress solely in the form of bodily complaints like pain and dizziness), whereas for the British participants the notion of distress seems to be inextricably linked to a psychological state (pain and other bodily complaints “causing” distress, not being a form of distress).

The term “psychosomatic disorder” also fulfils most criteria of the list. Although it is accurate in describing the problem in terms of both psychological and somatic components, it generally has negative connotations [9] outside of some, especially German- speaking countries. This difference may be due to the fact that in Anglophone countries the term is exclusively linked to the more or less Freudian tradition of psychogenic explanations of disease. In these countries, the term “psychosomatic medicine” does seem to be more generally acceptable and those psychiatrists who offer “psychosomatic medicine” or “psychological medical” clinics find that patients are not put off by these labels. Thus there seems to be a difference according to whether we use the term “psychosomatic” to describe symptoms/ disorder or a type of healthcare.

The term “psychophysical / psychophysiological disorder” is similar in its immediate meaning to “psychosomatic disorder”. It has the advantage that it is not bound to the tradition of assuming a psychogenic origin. However, “physical” is not a widely used description for bodily complaints.

The term “functional somatic disorder or syndrome” fulfils most criteria; it is reasonably widely accepted because it is neutral as to mental or organic backgrounds. There is some confusion regarding its core concept as it may refer to a functional disturbance of the organs implied in the bodily complaints (the traditional understanding) or a functional disturbance of the brain systems underlying symptom experience (the currently favoured view).

Conclusion 

It is not easy to reach a consensus about the term that should replace “medically unexplained symptoms”. There are difficulties with concept, acceptability and language.

With regard to the concept, the choice seems to be between a purely descriptive term – eg symptom-defined disorder - or one which implies an aetiology that encompasses both organic and psychological elements. Acceptability is paramount as any term that is not acceptable to patients and doctors will be an obstacle to improved care. Difficulties with language means that a term that is acceptable in one language may not be in another; in addition one term also can oscillate between different meanings within one language.

What is the best way forward? The processes leading to the preparation of the EACLPP document and to DSM-V is a mixture of well established expert- and evidence-based approaches. To come forward with a good term after dismissing “medically unexplained symptoms” (and somatoform disorders), necessitates the collecting of opinions from a broad range of stakeholders in the field (doctors in specialist somatic care including pain clinics, primary care, mental health; patients, healthcare planners, managers etc.) in order to maximise the likelihood that the new term will be accepted and used widely across all fields of medicine, not only psychiatry or psychosomatic medicine. However, good linkage of these efforts with the DSM- and ICD-processes will be crucial in order to maximize the likelihood that any new term will be used broadly and promote, not hinder, appropriate physical and psychological treatments.