Every doctor encounters patients who complain of symptoms without identifiable physical causes. According to a recent review in The Lancet, one third of all symptoms lack somatic explanations.
How can these patients be helped, and what crucial question should always be asked? The Medscape German edition discussed this topic with Professor Peter Henningsen, a coauthor of the review, at the German Congress for Psychosomatic Medicine and Psychotherapy. Henningsen is the director of the Clinic and Polyclinic for Psychosomatic Medicine and Psychotherapy at the University Hospital Rechts der Isar of the Technical University of Munich, Munich, Germany.
One Common Factor
Patients often experience a wide range of symptoms that appear without any obvious cause. These symptoms include persistent pain, dizziness, cardiovascular complaints, digestive disorders, gait disturbances, exhaustion, and fatigue. There's often a notable gap between perceived distress and the impairment of a patient's physical functions and examination findings.
In recent years, a descriptive umbrella term has emerged for these health challenges: Persistent physical symptoms. This term includes functional physical complaints lasting for months or longer without a clearly identifiable organic cause, such as chronic fatigue syndrome, irritable bowel syndrome, fibromyalgia, or multiple chemical sensitivity. It also encompasses persistent complaints in patients with an underlying condition.
According to the review, 70% people with chronic kidney disease experience fatigue; 63% patients with coronary artery disease have persistent pain in their arms, legs, or joints; and 31% patients with ulcerative colitis in remission report persistent gastrointestinal symptoms.
In International Classification of Diseases (ICD), 10th Revision, the term "somatoform disorders" is used when no organic causes are identifiable. However, ICD-11 has replaced this term with the category of "somatic symptom disorders."
"For this diagnosis, it is no longer necessary to rule out physical causes entirely," explained Henningsen. "Instead, the focus is on psychologic and behavioral abnormalities, anxiety, increased attention to symptoms, frequent doctor consultations, and the conviction of having a serious physical illness."
This new diagnostic approach is considered sensible because it focuses on the patient's experience of their illness. However, it has also been criticized for potentially "psychiatrizing" patients with genuine physical ailments.
The 'Prediction Machine'
Understanding the new model is crucial. "It's about grasping what is happening with a person who persistently complains of physical symptoms," said Henningsen.
Previously, the bottom-up model of perception, which started from the pain stimulus, was widely accepted. It was believed that pain could secondarily cause psychologic symptoms. However, the role of the brain has now come to the forefront. Terms like "predictive processing" or "predictive coding" are key: The brain constantly makes predictions about the most likely interpretation of sensory impressions.
These predictions incorporate expectations, beliefs, and past experiences with symptoms, which unconsciously influence these predictions. Therefore, expectations play a role in perception for all patients regardless of whether they have an organic precondition. This phenomenon can result in patients experiencing symptoms despite minimal or no sensory input.
"Perception is always biopsychosocial," Henningsen emphasized, and diseases are not strictly physical or psychological but rather a combination of both. The proportions of these components vary, especially in chronic illnesses, where expectations play a more significant role in pain perception than they do in fresh injuries. Because predictive processing is a general mechanism of perception, it can be involved in various diseases.
The good news is that many factors contributing to persistent physical symptoms, such as increased attention to symptoms, dysfunctional expectations, or avoidance behavior, can be positively influenced.
What Can Doctors Do?
Henningsen recommended that doctors treating patients with functional physical complaints focus on the following three key aspects:
- Consider the subjective experience. "The psychologic aspect is relevant in every illness. Always ask, 'How are you coping with your symptoms? What are your expectations for the future?'" Henningsen explained. For instance, if a patient has been experiencing back pain for weeks, feels it's getting worse, and believes that they will no longer be able to work, this is a significant prognostic factor. Such a patient is less likely to return to work compared with someone who is confident in their recovery.
- Communicate mindfully. The way doctors communicate with patients about their symptoms is crucial. Henningsen illustrated this with a patient with tension headaches. "An MRI might show a slight increase in signal intensity. If the doctor casually says, 'It could be MS, but I don't think so,' the patient will fixate on the mention of MS."
- Treat body and mind. There is no either-or in therapy. For example, medications can help with irritable bowel syndrome but so can psychotherapeutic measures — without implying that the condition is purely psychologic. Exercise therapy can demonstrate that pain does not increase with movement, thus positively changing a patient's expectations and reducing symptoms.
A Doctor's 'Toolbox'
A Norwegian study published last year in eClinicalMedicine, a Lancet journal, demonstrated the effectiveness of such an approach for treating medically unexplained physical symptoms (MUPS) in general practice.In this study, 541 patients with MUPS participated in a two-arm, cluster-randomized trial. In total, 10 clusters of 103 general practitioners were each divided into two groups. One group used the Individual Challenge Inventory Tool (ICIT) for 11 weeks, while the other received usual treatment.
The ICIT, a structured communication tool based on cognitive-behavioral therapy, was developed by the study's lead author, a general practitioner. Participating general practitioners were trained in using the ICIT.
Individual Challenge Inventory Tool
The ICIT is designed to help general practitioners efficiently treat patients with MUPS. Its primary goal is to empower patients and enhance their coping skills in daily life and work.
General practitioners using the ICIT were instructed to follow these three steps:
- Validate the patients' feelings.
- Present a symptom explanation model based on the concept of allostatic overload.
- Develop a collaborative activity plan, such as a task list, problem list, or list of options, tailored to the patient's specific issues.
Patients in the study received two or more sessions with their general practitioners. Outcomes were assessed individually, and the primary outcome was patient-reported change in function, symptoms, and quality of life as measured by the Patient Global Impression of Change. Secondary endpoints included work capability.
In the intervention group, 76% (n = 223) experienced significant overall improvement in function, symptoms, and the quality of life compared with 38% (n = 236) in the control group receiving usual care (mean difference, −0.8; 95% CI, −1.0 to −0.6; P < .0001).
After 11 weeks, sick leave decreased by 27 percentage points in the intervention group (from 52.0 to 25.2), while it dropped by only four percentage points in the usual care group (from 49.7 to 45.7).
"ICIT in primary care led to significant improvements in treatment outcomes and a reduction in sickness absence for patients with MUPS," the authors concluded.
Guideline Under Revision
Medications alone often fail to adequately alleviate persistent physical symptoms. The S3 guideline "Functional Physical Complaints" lists various alternative therapies such as yoga and psychologic interventions.
Henningsen and his team are revising this guideline, and publication is expected later this year. While no major changes in therapy recommendations are anticipated, the focus will be on making the guideline more user-friendly.
"It is crucial for doctors to consider psychosocial factors," said Henningsen. "'Both-and instead of either-or' is our motto."
This story was translated from the Medscape German edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.