Many people have experienced a situation where they have felt an inexplicable pain in some part of their body for weeks on end, or feel particularly tired lately. So you go to the doctor, who may give you a test or two, but can’t find the cause of these symptoms.
Despite a dizzying array of high-tech medical tests, the reality is that many symptoms, such as fatigue and headaches, have no explanation. In most cases, patients are relieved after their doctors rule out the possibility of a major illness. However, other patients are still plagued by mysterious symptoms and go back to the doctor again and again, fearing that they may have some malady that the doctor has not detected.
Now, for patients who are plagued by medically unexplained symptoms, some family physicians and internists are using treatments such as cognitive behavioral therapy and relaxation therapy to help them see these symptoms in a different light.
This reflects the fact that giving too much attention to such symptoms usually makes the patient feel worse. The goal of this type of treatment is to teach patients to make peace with their symptoms and to see them as harmless, or even to ignore them. Recent studies have shown that this type of treatment can reduce symptoms and ease the worries that come with them (which may be equally important).
Unexplained symptoms frustrate doctors and patients alike. Patients may feel that their concerns are not being taken seriously and that they seem to be imagining everything. Doctors may feel helpless to do anything about it – and may feel resentful for the time taken up by these patients.
Most people don’t want to hear, ‘I don’t actually know,’ and so on,” says Susan H. McDaniel, associate director of the Division of Family Medicine at the University of Rochester Medical Center in Rochester, New York. But the truth is often that we don’t know.”
Arthur Barsky, a professor of psychiatry at Harvard Medical School, says, “We think the good outcome is not necessarily that the symptoms go away, but that they no longer cause distress or worry.”
Medically unexplained symptoms are extremely common, and a 2011 study of 620 first-time patients in Germany found that medically unexplained symptoms accounted for two-thirds of all reported symptoms. The study was published in the journal Psychosomatics. Other studies have estimated that 10 to 20 percent of patients in the United States who are initially diagnosed have medically unexplained symptoms, and that these symptoms impair the patient’s health in some way. About 5 to 7 percent have a more serious mental illness, somatization disorder, and these patients have symptoms (both medically explainable and unexplainable) that last more than six months and are accompanied by severe anxiety.
(This is different from hypochondria, which refers to a patient who has no physical symptoms or mild symptoms but suspects that he or she is suffering from a serious illness. Hypochondriasis is no longer a diagnostic term and has been replaced by the term “illness anxiety disorder” in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders.)
Any symptom may be medically unexplained. The most common are fatigue, back pain, headaches and abdominal pain, doctors say. Dizziness, vertigo and numbness sometimes have no exact medical cause either.
Hannah Letterman (Hannah Letterman) was 17 years old in high school when she suddenly felt nauseous, headachey and dizzy. At the time, I could feel my feet trapped in a circle,” she says. I couldn’t read, I couldn’t do my homework, and talking to people only lasted a few minutes.” Reitman, now 19, is a freshman in Rochester, N.Y.
The feeling lasted for months. She went to several doctors and underwent numerous tests. Eventually, at the University of Rochester Epilepsy Center, she was referred to psychologist William Watson for treatment. Dr. Watson asked her to keep a symptom diary: to note behaviors, thoughts and feelings that seemed to cause her symptoms to lessen or worsen. During weekly psychotherapy sessions, Reitman says, she tried to work on “really accepting her emotions, whatever they were. The approach has worked. Reitman says she still has some residual symptoms, but her body is “fully functioning again. She initially felt that attributing her symptoms to psychological causes was silly and ridiculous, but now she’s slowly coming around to the idea.
Robert C. Smith, a professor of medicine and psychiatry at Michigan State University College of Human Medicine, said that some patients with medically unexplained symptoms who visit their doctors almost once a month may have underlying Psychological problems that trigger these symptoms and “doctor-seeking” behavior. These symptoms, he said, “are red flags for an underlying mental illness,” such as depression or anxiety.
Dr. Smith and colleagues have developed a treatment for first-time patients. It includes antidepressants and removes narcotic painkillers that can worsen depression, supplemented by relaxation therapy, exercise and other methods.
The Journal of General Internal Medicine published a paper in 2006 on a study of 206 patients who had seen their doctors an average of more than 13 times a year before the study, and about 60 percent of them were found to have major depression. Compared to the control group, those who received treatment (four nurse practitioners visited and treated patients 12 times in a year) had less psychological distress and were better able to cope with their illness.
A study published in 2013 investigated 89 patients. The 89 patients had frequent visits to their primary care physicians for medically unexplained symptoms and were very concerned about their health. In that study, Dr. Barsky and his colleagues found that both cognitive behavioral therapy and relaxation training relieved symptoms and improved mental status, reducing the damage caused by symptoms. Within a year of the study’s conclusion, the number of doctor visits for these patients decreased to an average of about 8.8 visits, compared to 10.3 visits before the study began.
The cognitive behavioral therapy was divided into four to eight phases and was administered by nurse practitioners or internal medicine physician assistants who had received multiple fellowship training. During treatment, Dr. Barsky said, the nurse practitioner or physician assistant first teaches patients to change their “bad ideas” about health and illness, such as the misconception that “health is the absence of any illness. They are then instructed to stop “bad disease behaviors,” such as excessively searching the Internet for information about their condition or constantly visiting the doctor to seek a diagnosis.
Patients were also asked to learn to take their attention away from their symptoms. As soon as they find themselves thinking about the symptoms, they move on to a range of enjoyable things. Patients who received cognitive behavioral therapy also learned relaxation techniques like meditation.
Wanda Filer, a family physician in York, Pennsylvania (York), says she doesn’t take lightly patients who have medically unexplained symptoms and push them to a bunch of specialists or have them do a lot of tests, which she feels is a “treatment disaster. The likelihood of misdiagnosis increases. You can “find a small cyst that might not be a problem, but it causes the patient a lot of distress.
Molly Cooke, president of the American College of Physicians and a practicing internist in San Francisco, says some of her patients are “very observant,” especially those who suffer from chronic abdominal pain. Dr. Cooke tells her patients, “You’re a superb observer of what’s going on in your body. The gastrointestinal tract is actually very active, but many people don’t perceive that.”
For patients with vague symptoms in this category, she agrees with them on a time frame to continue probing. If the illness continues to bother them over the next few months or weeks, depending on the situation, she will perform more tests on the patient. I hope that these vague symptoms will go away or be replaced by a range of other symptoms,” she says. Many people feel that it’s not too good to go to the doctor with few symptoms.”