Identifying primary or comorbid psychiatric disease and psychosocial issues also is integral to managing patients with MUPS. This may be difficult because some patients might be hesitant to discuss psychosocial issues, whereas others may be unaware of psychiatric symptomatology or the connection between mental and physical illness. When possible, it may be useful to clarify symptomatology as:
- primarily somatic (expression of psychological illness through physical means)
- primarily psychiatric (psychiatric illness presenting with physical symptoms) or
- bordering between somatic and psychiatric.
CASE CONTINUED: Collaboration and improvement
You diagnose Mrs. B with major depressive disorder and prescribe fluoxetine, titrating her up to 40 mg/d. Mrs. B also begins weekly psychodynamic psychotherapy. In collaboration with her PCP, you decide to refer Mrs. B to physical therapy and direct psychotherapy toward coping strategies, with the hope of improving functionality. Although she continues to have musculoskeletal symptoms after completing physical therapy, Mrs. B notices moderate improvement and feels less distressed by these symptoms.
After 1 year of fluoxetine treatment, Mrs. B’s depressive symptoms improve. In psychotherapy, her fixation on physical symptoms and desire to establish a diagnosis gradually lessen. As her emotional trauma from childhood abuse unravels, psychotherapy shifts toward improving affect regulation. During this time Mrs. B experiences an increase in unexplained chest pain and shortness of breath, which later abate.
Continued follow-up with a gastroenterologist leads to a diagnosis of celiac disease. With treatment, her GI symptoms resolve.
What do patients want?
Begin MUPS treatment by developing a supportive, empathic relationship with the patient. Carefully listen to the patient’s description of his or her symptoms. Elucidating patients’ experience often is challenging because their narratives frequently are complex, nonlinear, and limited by time.18 Patients’ models for understanding their symptoms also may be complex.18 They may be reluctant to share their explanations, fearing they will be unable to communicate the complexity of their beliefs or their symptoms will be oversimplified.18
Focus on understanding what the patient seeks from the physician—emotional support vs diagnosis vs treatment. In a prospective naturalistic study, the content of MUPS patients’ narratives was correlated with what they sought from their physician.17 Patients who sought emotional support frequently discussed psychosocial problems, issues, and management. Patients who wanted an explanation for their symptoms often mentioned physical symptoms, explanations, and diseases. Those who were looking for additional testing or intervention often directly addressed this with the physician.17
Although many patients desire a diagnosis and somatic treatment, this is not always their primary agenda. Many MUPS patients seek emotional support or confirmation of their explanatory model.17,18 Patients’ desires for emotional support, medical explanation, diagnosis, or somatic intervention often are neither clearly nor explicitly stated. Despite this, patients hope their physician understands the extent of their problems and value those who help them make sense of their narratives.18 Misunderstanding patients’ agendas can result in a mismatch of treatment expectations and fracture the patient-physician relationship. Developing mutual expectations is crucial to building rapport, improving collaborative care, and avoiding unnecessary, potentially harmful interventions.
Psychotherapic interventions
Psychopharmacologic treatment is indicated for MUPS patients who have comorbid psychiatric conditions.
Research of psychotherapy in MUPS has been plagued by methodologic problems and inconsistent results.3 Group therapy, short-term dynamic therapy, hypnotherapy, and cognitive-behavioral therapy (CBT) have been studied. In a trial of 140 MUPS patients who received 1 session of CBT, 71% experienced improvement in physical symptoms, 47% in functional status, and 38% in measures of psychological distress.19 A review of 34 randomized controlled trials involving 3,922 patients with somatoform disorders who received CBT found that some patients with MUPS responded after 5 to 6 sessions.3
Cognitive techniques focus on identifying and restructuring automatic, dysfunctional thoughts that may compound, perpetuate, or worsen somatic symptoms. Behavioral techniques include relaxation and efforts to increase motivation. A CBT treatment plan may involve establishing goals, addressing patients’ understanding of their symptoms, obtaining a commitment for treatment, and negotiating the details of the treatment plan.8,12
Supportive techniques also are valuable in treating MUPS patients. Educate patients and treating physicians that there is a neurophysiologic basis for the patient’s physical symptoms and that symptoms may wax and wane. Reinforcement of functional improvement through concrete, practical solutions can help patients develop healthy, adaptive coping skills. Encouraging patients to move beyond somatic complaints to discuss social and personal difficulties can lead to more effective management of these problems.
Clearly communicate your initial impressions, diagnoses, and treatment plan to other members of the treatment team. A consultation letter from the psychiatrist to the PCP has been shown to decrease costs and slightly improve the patient’s functional status, symptoms, and quality of life.20 When possible, educate the PCP and specialists about the dynamics, challenges, biases, and frustrations physicians commonly face when caring for MUPS patients.