very little sustained reassurance in patients. Patients may show relief about negative tests in the consulting room but that relief does not translate into longer-term assurance that ongoing symptoms are not concerning.


MANAGING MUS Central to managing patients with MUS is some form of explanation. Patients expect explanations for their symptoms, regardless of whether they are due to organic disease or to central processing of sensations. Simply reassuring them that there is nothing wrong is generally not helpful, particularly when the patient has had repeated consultations and tests. Syndrome labels can be useful in this setting – where patients meet criteria for a syndrome such as fibromyalgia or IBS, there is no good reason not to discuss it. Some patients find more detailed explanations of dysfunctional bodily mechanisms very useful. These can commonly be found on patient-oriented websites such as for chronic pain or in books on the topic. Patients given effective explanations for their symptoms


may benefit from techniques to limit symptoms and reduce symptom-related distress or limitations. Treatments include self-management support, specialist psychological treatment and pharmacotherapy. Self-management support aims to teach symptom-control techniques, including progressive muscle relaxation as well as more advanced techniques such as sensory grounding. Specialist psychological support may be appropriate for patients with multiple symptoms or high levels of disability. Cognitive behavioural therapy (CBT) is the most commonly used approach but other treatments can be effective in some situations. Pharmacotherapy is largely limited to pain management (avoiding strong opioids in fibromyalgia) and to treatment of comorbid depression or anxiety. Patients with MUS vary greatly: from those with occasional relatively minor and self-limiting symptoms in one body system to others with severe disability due to multiple symptoms. A recent prognostic classification for use in generalist settings employs the notion of “multiple symptoms, multiple systems, multiple occasions” as a way of assessing the likelihood of sustained problems. In this scheme, the more systems (e.g. cardiopulmonary, GI, musculoskeletal) involved and the more occasions, the less likely it is that symptoms will resolve without specific action.


COMBINING SAFETY WITH EFFECTIVE TREATMENT Doctors in any specialty can manage patients with MUS. Doing so effectively requires confidence in explaining symptoms in a way that patients find acceptable, supporting self-management and being able to handle emotional distress and mental health problems if they emerge. Doing so safely requires attention to clinical detail, judicious use of diagnostic tests and a balance between firm reassurance with symptom management and closing down other diagnostic possibilities too quickly. As the science which enables us to explain MUS becomes stronger, the art of maintaining this balance will remain.


Dr Chris Burton is professor of primary medical care at the University of Sheffield


MDDUS INSIGHT / 13


“Investigations ‘to reassure the patient’ have very little value”


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