Medically Unexplained Symptoms Research Articles

What Do Patients Choose to Tell Their Doctors? Qualitative Analysis of Potential Barriers to Reattributing Medically Unexplained Symptoms

Despite both parties often expressing dissatisfaction with consultations, patients with medically unexplained symptoms (MUS) prefer to consult their general practitioners (GPs) rather than any other health professional. Training GPs to explain how symptoms can relate to psychosocial problems (reattribution) improves the quality of doctor-patient communication, though not necessarily patient health. To examine patient experiences of GPs' attempts to reattribute MUS in order to identify potential barriers to primary care management of MUS and improvement in outcome. Qualitative study. Patients consulting with MUS whose GPs had been trained in reattribution. A secondary sample of patients of control GPs was also interviewed to ascertain if barriers identified were specific to reattribution or common to consultations about MUS in general. Thematic analysis of in-depth interviews. Potential barriers include the complexity of patients' problems and patients' judgements about how to manage their presentation of this complexity. Many did not trust doctors with discussion of emotional aspects of their problems and chose not to present them. The same barriers were seen amongst patients whose GPs were not trained, suggesting the barriers are not particular to reattribution. Improving GP explanation of unexplained symptoms is insufficient to reduce patients' concerns. GPs need to (1) help patients to make sense of the complex nature of their presenting problems, (2) communicate that attention to psychosocial factors will not preclude vigilance to physical disease and (3) ensure a quality of doctor-patient relationship in which patients can perceive psychosocial enquiry as appropriate.

General practitioners' responses to the initial presentation of medically unexplained symptoms: a quantitative analysis.

BackgroundPhysicians in primary and secondary care are frequently confronted with patients with medically unexplained symptoms (MUS). In order to solve their patients' problems and out of a fear of overlooking a serious disease, many physicians give their patients full physical examinations and interventions, thereby incorrectly confirming the somatic nature of their condition. Preventing somatization could be achieved by examining the patient's symptom presentation for clues to underlying psychosocial issues and by an appropriate physician response.MethodsNinety-seven videotaped medical visits from primary care patients presenting MUS for the first time were analyzed. Patients' presentations were categorized in: (1) symptoms only; (2) symptoms with a clue to an underlying concern; or (3) symptoms with an explicit concern. General practitioners' (GPs') responses to patients' presentation were classified into ignoring or more or less exploring responses. Exploring responses were further subdivided in non-directional explorations, clue explorations and medical explorations.ResultsResults show that most patients presented their symptoms together with a reference to an underlying concern. Yet, most of them did so in an implicit way. GPs usually explored the concern presented by the patients, but most often in a medical way only.ConclusionTo address the potential psychological basis of patients' medically unexplained symptoms, GPs should pay more attention to the specific clues patients present to them. Likewise, in order to receive full attention, patients should try to present their concerns more explicitly.

Predictors of antecedent factors in psychogenic nonepileptic attacks

To elucidate the role of antecedent factors in psychogenic nonepileptic attacks (PNEA). In a consecutive series of 288 patients with PNEA, clinical and demographic variables were entered into binary logistic regression models and tested for their power to predict commonly reported antecedent factors. Three quarters (75.4%) of patients reported traumatic antecedent factors: 32.5% reported sexual abuse, 26.0% physical abuse, 18.7% bereavement, 8.3% health-related trauma, and 8% accident or assault. A total of 8.6% had learning disability (LD) and 10.8% had epilepsy. Antecedent trauma in general was predicted by later age at onset (p = 0.011), and medically unexplained symptoms (MUS) other than PNEA (p = 0.004); its absence was predicted by LD (p = 0.016). Sexual abuse was predicted by female gender (p < 0.001), physical abuse (p < 0.001), self-harm (p < 0.001), and MUS (p < 0.001): its absence was predicted by LD (p = 0.019) and health-related trauma (p = 0.023). Bullying was predicted by early onset of PNEA (p = 0.012). Health-related trauma was predicted by late age at onset (p < 0.001); its absence was predicted by sexual abuse (p = 0.020). LD was predicted by male gender (p = 0.019), epilepsy (p = 0.005), circumstantial triggering of spells (p < 0.001), and pseudostatus (p = 0.012). Epilepsy was predicted by LD (p = 0.001) and early age at onset (p = 0.013). The clinical predictors that we found provide further evidence of heterogeneity of psychogenic nonepileptic attacks populations related to antecedent factors. Some predictive clusters may have clinical utility in the early stages of assessment: in particular the combination of medically unexplained symptoms and self-harm should raise the possibility of undisclosed sexual abuse.

Negative affect and 24-hour ambulatory physiological recordings as predictors of spontaneous improvement of medically unexplained symptoms

The predictive value for spontaneous improvement in individuals suffering from medically unexplained symptoms (MUS) was explored of (1) anxiety and depression obtained from questionnaires, (2) negative affective states obtained from experience-sampling, and (3) ambulatory-assessed real-life physiological recordings. Sixty-seven individuals with MUS and 61 healthy controls were included. Twenty-four hour ambulatory recordings of cardiac autonomic activity, respiration, end-tidal CO(2) and saliva cortisol were combined with experience-sampling of somatic complaints and mood. Complaints were assessed again after one year. Although a reduction in symptoms (25%) was found, this could not be predicted from initial anxiety and depression. Improvement was somewhat related to relatively low diary reports of fatigue, especially in the late-afternoon and evening (3% variance explained). From the physiological measures only relatively high PetCO(2) values in the morning predicted improvement (5% explained). It was concluded that spontaneous recovery from MUS is hard to predict from self-reported distress and ambulatory physiological recordings.

Medically unexplained presentations and quality of life: A study of a predominantly South Asian primary care population in England

Primary care subjects from a predominantly South Asian inner-city setting in Manchester, UK, were studied. We aimed to determine whether medically unexplained symptoms (MUS) are associated with worse health-related quality of life than medically explained symptoms (MES), after controlling for differences in sociodemographic variables, number of somatic symptoms, and levels of anxiety and depression. One hundred nineteen subjects attending general practice completed questionnaires to assess somatic symptoms, anxiety, depression, and quality of life. Doctors' records were later studied to ascertain whether the presentation was medically explained. Thirty-nine subjects (33%) had medically unexplained presentations. Compared to patients with MES, those with MUS had significantly more somatic symptoms (6.9 vs. 4.3, P<.001), higher levels of anxiety (Hospital anxiety and depression scale -- anxiety score) (9.8 vs. 6.7, P=.004), depression (Hospital anxiety and depression scale -- depression) (6.8 vs. 4.5, P=.005), and poorer health-related quality of life (EuroQol standardized score 54.6 vs. 73.3, P=.001). On multiple regression analysis, anxiety, depression, and somatic symptom scores independently ( P<.01) predicted quality of life, after controlling for demographic factors. Whether the presentation was medically unexplained or not did not contribute to the regression model ( P=.85). Our findings suggest that it is the number of somatic symptoms and the associated anxiety/depression that account for greater impairment in people's health-related quality of life, and not whether they have a medical explanation for their symptoms.

War-Related Medically Unexplained Symptoms, Prevalence, and Treatment: Utilizing EMDR Within the Armed Services

The mental health impact of war is often underestimated by military, government, and media officials who focus primarily on well-known conditions like depression and posttraumatic stress disorder (PTSD) while ignoring the complex toll of modern warfare. These effects are clearly evident in “war syndromes,” many of which can be collectively understood as medically unexplained symptoms (MUS). The current study provides a brief historical review of combat-related MUS as well as an analysis of present evidence of a possible “Iraqi War Syndrome.” An overview of past and current treatments for combat MUS is followed by a single case study treating an Iraqi war combat veteran with combat-related MUS with eye movement desensitization and reprocessing (EMDR). Therapy resulted in significant improvement of the patient’s 1-year psychophysical condition and comorbid PTSD. We provide a detailed account of those treatment sessions as well as a discussion of EMDR’s potential to simultaneously treat a range of combat-related psychophysical conditions without requiring extensive homework or self-disclosure that some military patients may resist. The results are promising, but they require further research.

SOMS-2: translation into portuguese of the screening for Somatoform Disorders

The diagnosis of Somatization Disorder (SD) requires the presence of somatic medically unexplained symptoms (MUS) which must be assessed so that organic diseases may be excluded. SOMS-2 is a self-report measure for SD that assesses medically unexplained symptoms by requiring participants to answer affirmatively and qualify any of the complaints as MUS, only if they have obtained from his doctor the opinion that the said complaint is not due to an organic disease. According to the authors, original SOMS-2 has a good internal consistency with Cronbach's a = .87 and a good correlation between selfratings and interview (r = .75). After obtaining the author's permission, translation from and into English has been made by experienced translators. The resulting questionnaire has been used on a small group of patients. Afterwards the items in which there were difficulties in understanding during the pretest were identified and experienced practitioners were asked for suggestions. The resulting version was answered by 123 primary health care patients (sample I). After some modifications of the SOMS-2, another group of 190 primary health care patients answered the questionnaire (sample II). Most patients, in the first sample, found it difficult to understand that, in order to answer affirmatively it was necessary to answer three questions: 1) is the symptom present? 2) has your doctor found no clear causes for the symptom? 3) does the symptom affect your well-being? The difficulties in understanding items 21 and 45 (pre-test) were confirmed. Items 11, 28 and 38 were more easily understood when worded differently. In sample I, less than 5% of positive answers were given to items 20, 21, 23, 40, 43, 45, and 51. Probably because of the low education level of the Portuguese population which this sample reflects, difficulties in carrying out the instructions given at the beginning made it advisable to modify the SOMS-2, so that the three implicit questions in each question of the SOMS-2 were divided into two columns (two explicit questions). Simultaneously attention must continue on controlling severity criterion (the third implicit question). After phase I, the items with an answer rate of less than 5% were eliminated. The majority of them are coincident with the low answer rate items found by the authors of the original version. The next step is to study the internal consistency and the correlation between results of self-ratings and interview, of the resulting version, in order to establish the validity of the SOMS-2 in these populations.

Understanding the explanatory model of the patient on their medically unexplained symptoms and its implication on treatment development research: a Sri Lanka Study

BackgroundPatients with medically unexplained symptoms (MUS) are often distressed, disabled and dissatisfied with the care they receive. Illness beliefs held by patients have a major influence on the decision to consult, persistence of symptoms and the degree of disability. Illness perception models consist of frameworks to organise information from multiple sources into distinct but interrelated dimensions: identity (the illness label), cause, consequences, emotional representations perceived control and timeline.Our aim was to elicit the illness perceptions of patients with MUS in Sri Lankan primary care to modify and improve a CBT intervention.MethodAn intervention study was conducted in a hospital primary care clinic in Colombo, Sri Lanka using CBT for MUS. As a part of the baseline assessment, qualitative data was collected using; the Short Explanatory Model Interview (SEMI), from 68 patients (16–65 years) with MUS. We categorised the qualitative data in to key components of the illness perception model, to refine CBT intervention for a subsequent larger trial study.ResultsThe cohort was chronically ill and 87% of the patients were ill for more than six months (range six months to 20 years) with 5 or more symptoms and 6 or more visits over preceding six months. A majority were unable to offer an explanation on identity (59%) or the cause (56%), but in the consequence domain 95% expressed significant illness worries; 37% believed their symptoms indicated moderately serious illness and 58% very serious illness. Reflecting emotional representation, 33% reported fear of death, 20% fear of paralysis, 13% fear of developing cancer and the rest unspecified incurable illness. Consequence and emotional domains were significant determinants of distress and consultations. Their repeated visits were to seek help to alleviate symptoms. Only a minority expected investigations (8.8 %) or diagnosis (8.8%). However, the doctors who had previously treated them allegedly concentrated more on identity than cause. The above information was used to develop simple techniques incorporating analogies to alter their perceptionsConclusionThe illness perception model is useful in understanding the continued distress of patients with persistent symptoms without an underlying organic cause. Hence it can make a significant contribution when developing and evaluating culturally sensitive patient friendly interventions.

Medically unexplained symptoms in family medicine: defining a research agenda. Proceedings from WONCA 2007

Medically unexplained symptoms (MUSs) are frequently presented in primary care. Unfortunately, knowledge of these patients and/or symptoms in primary care is still limited. Available research comes mainly from Europe and North America, while the perspectives of cultures such as Africa, Asia and South America are relatively unknown. To bring cultural perspectives together, a symposium and workshop on MUS in primary care was held at the WONCA World Conference 2007 in Singapore. Main goals of this symposium and workshop-apart from presenting ongoing research and bringing together experts in MUS-were to detect knowledge gaps in MUS and to establish priorities in MUS research. This publication focuses on the proposed research agenda. Using a nominal group technique, we generated research topics and set priorities. Research topics were grouped into research themes. Participants' (66 researchers and GPs from 29 nationalities) most important research topics were 'formulating a broadly accepted definition of MUS', 'finding a strategy to recognize MUS better and at an earlier stage', 'studying the value of self-management and empowerment in patients with MUS' and 'finding predictors to decide which strategy will best help the individual patient with MUS'. Priorities in research themes of MUS are as follows: (i) therapeutic options for patients with MUS and (ii) problems in consultations with these patients. More research on MUS in primary care is needed to improve the consultations with and management of these patients. Internationally primary care conferences are excellent for exchanging ideas and formulating central issues of research.

Evidence for a Specific Link Between the Personality Trait of Absorption and Idiopathic Environmental Intolerance

Absorption as a personality trait refers to the predisposition to get deeply immersed in sensory (e.g., smells, sounds, pictures) or mystical experiences, that is, to experience altered states of consciousness. Absorption is markedly related to constructs openness to experiences, hypnotic suggestibility, imagination, and dissociation. Although absorption was hypothesized to be a risk factor for medically unexplained symptoms (MUS), the construct has yet not been investigated in individually suffering from idiopathic environmental intolerance (IEI), formerly better known as multiple chemical sensitivity (MCS). IEI is a complex condition marked by MUS, which patients attribute to various chemical substances that are typically detectable by their odor (e.g., exhaust emissions, cigarette smoke). The current study investigated whether IEI was related to the personality trait of absorption. In a longitudinal study, 54 subjects with IEI were compared to 44 subjects with a somatoform disorder (SFD), but without IEI, and 54 subjects with neither SFD nor IEI (control group, CG). Self-report measures of somatic symptoms, severity of IEI, and level of absorption were collected both at a first examination and 32 mo later. On both assessments, subjects with IEI and individuals with SFD reported similar highly elevated levels of MUS, compared to CG. In contrast to SFD, IEI was specifically related to elevated absorption scores. IEI was specifically associated with a tendency to experience self-altering states of consciousness. Since absorption is related to both openness to unusual experiences and elevated imaginative involvement, absorption might contribute to IEI via two routes by (1) enhancing the susceptibility for IEI-specific convictions and (2) fostering classical conditioning processes of MUS via enhanced cognitive-imaginative representations of assumed IEI triggers.

The base rate of effort test failure in patients with medically unexplained symptoms

Background “Effort tests” (i.e., tests that indicate whether appropriate effort is being made) are increasingly used in neuropsychological assessments. However, not all failures on effort tests are necessarily attributable to lack of effort. Understanding the factors that contribute to failure on effort tests has important clinical implications. Objectives This study aimed (a) to establish the extent to which patients with medically unexplained symptoms (MUS) presenting to neurology fail effort tests, (b) examine the performance of “mild” and “strong” simulators on effort tests, and (c) compare the performance of simulators and MUS patients. Methods Forty-three MUS patients, 35 mild simulators, and 39 strong simulators undertook a battery of effort tests. The groups were matched for age, estimated IQ, and gender. The MUS patients were not involved in litigation. Results The failure rate (defined as failing two or more effort tests) was 11% in the MUS group, 94% in the mild simulation groups, and 100% in the strong simulation group. Conclusions A minority of nonlitigant MUS patients who present to neurology fail effort tests. Possible reasons for this are discussed. In that they do not produce below-chance performance (in contrast with many of the simulators), there is no clear indication of deliberate failure, though this cannot be ruled out. The very high failure rate in the mild simulation group (who were instructed not to overact) indicates the sensitivity of effort tests to lack of effort and the value of including such tests in neuropsychological assessments.

Assessment and immediate management of patients with medically unexplained symptoms in primary care and general hospital settings

Abstract Medically unexplained symptoms (MUS) are physical symptoms that doctors cannot fully explain by organic pathology, which distress or impair the functioning of the patient. They are disproportionate in the distress or effects on functioning compared with the physical pathology that is present. MUS usually have a physiological explanation that is most often reversible. There may or may not be an associated emotional disorder or psychosocial problem. MUS is an expensive problem and some patients with MUS may repeatedly consult primary care or secondary care health services. MUS require patient-centred communication and good clinical diagnostic skills for their proper diagnosis. Most MUS are self-limiting but others are associated with long-standing poor function. However, around 10% of MUS are in fact early manifestations of underlying physical pathology, so the main tasks of the doctor are accurate clinical assessment, clinical vigilance, ongoing support and explanation to the patient. Explanation must fit with the patient’s understanding of their problems and their beliefs about their symptoms. The assessment of MUS and its management are outlined, including a four-stage model for managing MUS: stage 1: feeling understood; stage 2: establishing the agenda through negotiation; stage 3: action stage (clarification, acknowledgement of distress, explanation treatment; stage 4: termination of the consultations. Additional approaches for frequent attendance with MUS are also discussed.

Doctors' attachment style and their inclination to propose somatic interventions for medically unexplained symptoms

Objective We tested the theory that general practitioners (GPs) offer somatic intervention to patients with medically unexplained symptoms (MUS) as a defensive response to patients' dependence. We predicted that GPs most likely to respond somatically after patients indicated symptomatic or psychosocial needs had attachment style characterised by negative models of self and others. Method Twenty-five GPs identified 308 patients presenting MUS and indicated their own models of self and others. Consultations were audio recorded and coded speech-turn-by-speech-turn. We modeled the probability of GPs proposing somatic intervention on any turn as a function of their models of self and other and the number of prior turns containing symptomatic or psychosocial presentations. Results Prior psychosocial presentations decreased the likelihood of GPs offering somatic intervention. The decrease was greatest in GPs with most positive models of self and, contrary to prediction, least positive models of others. The positive relationship between prior somatic presentations and the likelihood that GPs offered somatic intervention was unrelated to either model. Conclusion Findings are incompatible with our theory that GPs propose somatic interventions defensively. Instead, GPs may provide somatic intervention because they value patients (positive model of others) but devalue their own psychological skills (negative model of self).

Are patients with somatization disorder highly suggestible?

High suggestibility is widely regarded as an important feature of patients with medically unexplained symptoms (MUS), particularly those with multiple MUS [i.e. somatization disorder (SD)], although there are few empirical data attesting to this assumption. A study was therefore conducted to compare levels of non-hypnotic suggestibility in patients with SD and medical controls. A modified version of the Barber Suggestibility Scale was administered to 19 patients with SD and 17 controls with an established organic dystonia. Patients with SD were no more suggestible than control patients. Dystonia controls were more likely to deliberately comply with suggestions than the SD patients. Contrary to popular belief, high suggestibility is not necessarily a feature of SD.

Are physical symptoms among survivors of a disaster presented to the general practitioner? A comparison between self-reports and GP data

BackgroundMost studies examining medically unexplained symptoms (MUS) have been performed in primary or secondary care and have examined symptoms for which patients sought medical attention. Disasters are often described as precipitating factors for MUS. However, health consequences of disasters are typically measured by means of questionnaires, and it is not known whether these self-reported physical symptoms are presented to the GP. It is also not known if the self-reported symptoms are related to a medical disorder or if they remain medically unexplained. In the present study, three research questions were addressed. Firstly, were self-reported symptoms among survivors presented to the GP? Secondly, were the symptoms presented to the GP associated with a high level of functional impairment and distress? Thirdly, what was the GP's clinical judgment of the presented symptoms, i.e. were the symptoms related to a medical diagnosis or could they be labeled MUS?MethodsSurvivors of a man-made disaster (N = 887) completed a questionnaire 3 weeks (T1) and 18 months (T2) post-disaster. This longitudinal health survey was combined with an ongoing surveillance program of health problems registered by GPs.ResultsThe majority of self-reported symptoms was not presented to the GP and survivors were most likely to present persistent symptoms to the GP. For example, survivors with stomachache at both T1 and T2 were more likely to report stomachache to their GP (28%) than survivors with stomachache at only T1 (6%) or only T2 (13%). Presentation of individual symptoms to the GP was not consistently associated with functional impairment and distress. 56 – 91% of symptoms were labeled as MUS after clinical examination.ConclusionThese results indicate that the majority of self-reported symptoms among survivors of a disaster are not presented to the GP and that the decision to consult with a GP for an individual symptom is not dependent on the level of impairment and distress. Also, self-reported physical symptoms such as headache, back pain and shortness of breath are likely to remain medically unexplained after the clinical judgment of a GP.

Doctors' responses to patients with medically unexplained symptoms who seek emotional support: criticism or confrontation?

Objective Consultations about medically unexplained symptoms (MUSs) can resemble contests over the legitimacy of patients' demands. To understand doctors' motivations for speech appearing to be critical of patients with MUSs, we tested predictions that its frequency would be related to patients' demands for emotional support and doctors' patient-centered attitudes as well as adult attachment style. Methods Twenty-four general practitioners identified 249 consecutive patients presenting with MUSs and indicated their own patient-centered attitudes as well as adult attachment style (positive models of self and others). Before consultation, patients self-reported their desire for emotional support. Consultations were audio recorded and coded utterance by utterance. The number of utterances coded as criticism was the response variable in the multilevel regression analyses. Results Frequency of criticism was positively related to patients' demands for emotional support, to doctors' belief in sharing responsibility with patients and to doctors' positive model of themselves. It was inversely associated with doctors' belief that patients' feelings were legitimate business for consultation and was unrelated to their model of others. Conclusions From the perspective of doctors, speech that appears to be critical probably reflects therapeutic intent and might therefore be better described as “confrontation.” Understanding doctors' motivations for what they say to patients with MUSs will allow for more effective interventions to improve the quality of consultations.

Medically unexplained symptoms and between-group differences in 24-h ambulatory recording of stress physiology

People with medically unexplained symptoms (MUS) often have a comorbid history of stress and negative affect. Although the verbal-cognitive and (peripheral) physiological stress systems have shown a great degree of independence, at the same time it is claimed that chronic stress and negative affect can result in a disregulated physiological stress system, which may lead to MUS. Previous studies could not demonstrate a straightforward between subject relationship between MUS and stress physiology, supporting the view of independence. The aim of the current study was to further explore this relationship using an improved methodology based on ecologically valid 24-h real-life ambulatory recordings. Seventy-four participants (19 male; 55 female) with heterogeneous MUS were compared with 71 healthy controls (26 male; 45 females). Momentary experienced somatic complaints and mood, heart rate, cardiac autonomic activity, respiration and saliva cortisol were monitored using electronic diary and ambulatory registration devices. Participants with MUS reported much more momentary complaints and negative affect as compared to controls. Although MUS seemed to be associated with elevated heart rate and reduced low and very-low frequency heart period variability, these effects disappeared after controlling for differences in sports behaviour. No group differences were found for cardiac autonomic activity, respiration, end-tidal CO2 and saliva cortisol. Our 24-h real-life ambulatory study did not support the existence of a connection between MUS and disregulated peripheral stress physiology. Future studies may instead focus on central measures to reveal potential abnormalities such as deviant central processing of visceral signals in MUS patients.

Development of a paradigm for measuring somatic disturbance in clinical populations with medically unexplained symptoms

ObjectiveThis study aimed to develop an experimental paradigm, using healthy controls, to measure change in tactile sensitivity and response bias for subsequent testing of patients with medically unexplained symptoms (MUS). MethodsParticipants judged whether or not they detected a weak tactile pulse (presented in 50% of trials). Performance in two conditions (tactile pulses presented with or without a concomitant light) was compared using signal detection analysis to assess whether a task-irrelevant light can invoke the sensation of touch, even in its absence. ResultsThe results showed that the presence of a concurrent light significantly improved participants' detection of the tactile stimulus by 13.7% [t(18)=4.24, P<.001]. Also, more false alarms (perceiving that the touch was present when it was not) were made when the light was present [t(18)=2.10, P=.05]. Although differences in sensitivity between the light conditions were not significant [t(18)=1.14, P=.268], participants were more likely to report a touch, regardless of whether a touch was presented or not, in the light-present condition [t(18)=−3.84, P=.001]. ConclusionWhen discriminating weak vibration pulses on the finger from no stimulation, a simultaneous light was capable of creating the sensation of touch, even when it was not present. The findings of this research will be of interest to those studying psychosomatic disorders or MUS, where patients experience physical symptoms without an identifiable organic cause. This paradigm provides an experimental measure of such distortions in perception, which may elucidate underlying mechanisms of action.

Medically unexplained symptoms in children and adolescents

A review is presented of the range of medically unexplained symptoms (MUS) in children and adolescents, with an account of the main presentations that are recognised in clinical settings in paediatric and children's mental health services. A summary of both epidemiological and clinical studies of symptoms and their associations is given, followed by a brief overview of aetiological theories and of management interventions.

Heterogeneous medically unexplained symptoms and immune function

It has been suggested that dysregulation of immune-to-brain communication plays a role in the biopsychological process underlying medically unexplained symptoms (MUS). Immune and non-immune stressors can both be involved in the activation of the central sickness-behavioural-system leading to complaints like malaise, pain and fatigue. We hypothesized increased pro-inflammatory and/or reduced anti-inflammatory cytokine activity to exist in MUS patients. Twenty-seven participants (4 male; 23 female) with heterogeneous MUS were compared with 27 healthy controls (6 male; 21 females). Blood samples were analysed for leukocyte subset cell counts, in vitro T-cell mitogen-stimulated cytokine production (IL-2, IL-4, IL-5, IL-6, IL-10, TNF-α and IFN-γ) and in vitro monocyte cytokine release (IL-1β, IL-6, IL-8, IL-10 and TNF-α) in response to increasing concentrations of LPS. No significant group differences were found for any of the cytokines measured. One unexpected exception was an elevation in the number of circulating B and NK-cells in participants high on MUS. Nonetheless, no support was found for the hypothesized immunological dysregulation in peripheral blood leukocyte function of MUS patients.