Medically Unexplained Symptoms Research Articles

Cost-effectiveness of interventions for medically unexplained symptoms: A systematic review.

BackgroundIn primary and secondary care medically unexplained symptoms (MUS) or functional somatic syndromes (FSS) constitute a major burden for patients and society with high healthcare costs and societal costs. Objectives were to provide an overview of the evidence regarding the cost-effectiveness of interventions for MUS or FSS, and to assess the quality of these studies.MethodsWe searched the databases PubMed, PsycINFO, the National Health Service Economic Evaluation Database (NHS-EED) and the CEA registry to conduct a systematic review. Articles with full economic evaluations on interventions focusing on adult patients with undifferentiated MUS or fibromyalgia (FM), irritable bowel syndrome (IBS) and chronic fatigue syndrome (CFS), with no restrictions on comparators, published until 15 June 2018, were included. We excluded preventive interventions. Two reviewers independently extracted study characteristics and cost-effectiveness data and used the Consensus on Health Economic Criteria Checklist to appraise the methodological quality.ResultsA total of 39 studies out of 1,613 articles met the inclusion criteria. Twenty-two studies reported costs per quality-adjusted life year (QALY) gained and cost-utility analyses (CUAs). In 13 CUAs the intervention conditions dominated the control conditions or had an incremental cost-effectiveness ratio below the willingness-to-pay threshold of € 50,000 per QALY, meaning that the interventions were (on average) cost-effective in comparison with the control condition. Group interventions focusing on MUS (n = 3) or FM (n = 4) might be more cost-effective than individual interventions. The included studies were heterogeneous with regard to the included patients, interventions, study design, and outcomes.ConclusionThis review provides an overview of 39 included studies of interventions for patients with MUS and FSS and the methodological quality of these studies. Considering the limited comparability due to the heterogeneity of the studies, group interventions might be more cost-effective than individual interventions.RegistrationStudy methods were documented in an international prospective register of systematic reviews (PROSPERO) protocol, registration number: CRD42017060424.

Epistemological and methodological paradoxes: secondary care specialists and their challenges working with adolescents with medically unexplained symptoms

BackgroundEarly adolescence is considered a critical period for the development of chronic and recurrent medically unexplained symptoms (MUS), and referrals and system-initiated patient trajectories often lead to an excess of examinations and hospitalizations in the cross-section between mental and somatic specialist care for this group of patients. Dimensions of the relationship and communication between clinician and patient are shown in primary care studies to be decisive for subsequent illness pathways, often creating adverse effects, but knowledge on clinical communication in specialist care is still scarce.MethodsThis study explores communicative challenges specific to clinical encounters between health professionals and adolescent patients in specialist care, as presented through interviews and focus group data with highly experienced specialists working in adolescent and child services at a Norwegian university hospital.ResultsThe results are presented in a conceptual model describing the epistemological and methodological paradoxes inherent in the clinical uncertainty of MUS. Within these paradoxes, the professionals try to solve the dilemmas by being creative in their communication strategies; applying metaphors and other rhetorical devices to explain complex ideas; creating clinical prototypes as a way to explain symptoms and guide them in clinical action; relying on principles from patient-centered care involving empathy; and trying to balance expertise and humility.ConclusionThe challenges in communication arise as a result of opposing discourses on biomedicine, family, health and adolescence that create dilemmas in everyday clinical work. By moving away from a positivist and biomedical framework towards an interpretive paradigm, where culturally derived and historically situated interpretations are used to understand the social life-world of the patient, one can create a more humane health service in accordance with ideals of patient-centered care.

Addressing the needs of patients with medically unexplained symptoms: 10 key messages.

Many GPs find the care of patients with medically unexplained symptoms (MUS) challenging. Therefore, the WONCA Working Party for Primary Mental Health asked for MUS guidance for family doctors worldwide in order to improve the care of patients with MUS globally. This article is a summary of this guidance. MUS are physical symptoms that have existed for several weeks and for which adequate medical examination or investigation have not revealed any condition that sufficiently explains the symptoms. MUS is a working hypothesis based on the (justified) assumption that somatic or psychiatric pathology have been adequately detected and treated, but that the clinical condition presented by the patients was not adequately resolved. Any change in symptoms could be a reason to revise the working hypothesis of MUS.1 For some patients with physical symptoms, a somatic or psychiatric condition may be present. However, if the physical symptoms are more severe or more persistent, or limit functioning to a greater extent than expected based on the condition in question, they too are referred to as MUS. MUS can be seen as a continuum ranging from self-limiting symptoms to recurrent and/or persisting symptoms and symptom disorders. The group with recurrent and/or persisting symptoms is especially relevant in primary care as these …

Attending away from the body predicts increased physical symptom reports at six months in primary care patients

ObjectiveHigh symptom reporting (HSR) and medically unexplained symptoms (MUS) are associated with considerable distress, disability, healthcare utilization and costs, but are poorly understood, and current treatments are of limited benefit. Most models of HSR and MUS implicate cognitive-perceptual factors, such as increased body-focused attention, reduced perceptual thresholds and a tendency to experience somatic misperception, but little is known about the causal role of these variables. We investigated this issue by studying whether there is a longitudinal relationship between perceptual-attentional variables and later clinical outcomes in primary care patients. MethodPrimary care patients (N = 102) completed clinical (physical symptom reporting, health anxiety and healthcare utilization) and perceptual-attentional (body-focused attention, perceptual threshold, somatic misperception) measures at baseline and then again six months later (N = 72). Hierarchical regression was used to examine cross-lagged relationships between baseline and follow-up scores. ResultsContrary to expectation, attending away from the body at baseline predicted increased not decreased symptom reporting six months later. Neither perceptual threshold nor somatic misperception predicted clinical outcomes at six months. ConclusionsThese findings suggest that body avoidance, rather than increased body focus, contribute to the development of HSR. Future studies should consider the potential clinical benefits of reducing bodily avoidance, via techniques that promote adaptive engagement with bodily sensations.

The proportion of women with central sensitivity syndrome in gynecology outpatient clinics (GOPDs).

Patients in gynecology outpatient clinics (GOPDs) may present with symptoms that do not correlate well with the observed pathology and are usually labelled as having a functional disorder or medically unexplained symptoms (MUS). Underlying central sensitivity syndrome (CSS) with central sensitization (CS) as a potential mechanism may be responsible for some of their symptoms. The aim of this study is to identify the proportion of women with central sensitivity syndrome attending GOPDs. This was a prospective study. All women attending a GOPD included in the study were asked to complete a validated Central Sensitization Inventory (CSI). The responses were graded on a Likert scale from 0 (never) to 4 (always). The total score ranges from 0 to 100. For screening purposes, a single CSI cutoff score of 40 was used to identify the group of women who may have central sensitization syndrome. Three hundred twenty-six women participated in the study. Overall, 123 (37%) women achieved a score above 40. This could be interpreted as these patients having increased risk of underlying central sensitization. Of these, 43 had a previously confirmed diagnosis of migraine, 55 (44%) depression, 39 (31.7%) anxiety, 11 fibromyalgia (FM), 34 irritable bowel syndrome (IBS) and 16 chronic fatigue syndrome (CFS/ME). Managing patients and their expectations in gynecological outpatient departments when symptoms are inconsistent with observable pathological findings is challenging. This is further complicated when patients have a concomitant central sensitivity syndrome, which can also influence the surgical outcome. Identifying these patients is a key factor for appropriate management.

Management of patients with persistent medically unexplained symptoms: a descriptive study

BackgroundIn 2013 the Dutch guideline for management of medically unexplained symptoms (MUS) was published. The aim of this study is to assess medical care for patients with persistent MUS as recorded in their electronic medical records, to investigate if this is in line with the national guideline for persistent MUS and whether there are changes in care over time.MethodsWe conducted an observational study of adult primary care patients with MUS. Routinely recorded health care data were extracted from electronic medical records of patients participating in an ongoing randomised controlled trial in 30 general practices in the Netherlands. Data on general practitioners’ (GPs’) management strategies during MUS consultations were collected in a 5-year period for each patient prior. Management strategies were categorised according to the options offered in the Dutch guideline. Changes in management over time were analysed.ResultsData were collected from 1035 MUS consultations (77 patients). Beside history-taking, the most frequently used diagnostic strategies were physical examination (24.5%) and additional investigations by the GP (11.1%). Frequently used therapeutic strategies were prescribing medication (24.6%) and providing explanations (11.2%). As MUS symptoms persisted, GPs adjusted medication, discussed progress and scheduled follow-up appointments more frequently. The least frequently used strategies were exploration of all complaint dimensions (i.e. somatic, cognitive, emotional, behavioural and social) (3.5%) and referral to a psychologist (0.5%) or psychiatrist (0.1%).ConclusionsManagement of Dutch GPs is partly in line with the Dutch guideline. Medication was possibly prescribed more frequently than recommended, whereas exploration of all complaint dimensions, shared problem definition and referral to mental health care were used less.

Internists' dilemmas in their interactions with chronically ill patients; A comparison of their interaction strategies and dilemmas in two different medical contexts.

BackgroundInternists appear to define productive interactions, key concept of the Chronic Care Model, as goal-directed, catalyzed by achieving rapport, and depending on the medical context: i.e. medically explained symptoms (MES) or medically unexplained symptoms (MUS).ObjectiveTo explore internists’ interaction strategy discourses in the context of MES and MUS.MethodsWe interviewed twenty internists working in a Dutch academic hospital, identified relevant text fragments in the interview transcripts and analyzed the data based on a discourse analysis approach.ResultsWe identified four interaction strategy discourses: relating, structuring, exploring, and influencing. Each was characterized by a dilemma: relating by ‘creating nearness versus keeping distance’; structuring by ‘giving space versus taking control’; exploring by ‘asking for physical versus psychosocial causes’; and influencing by ‘taking responsibility versus accepting a patient’s choice. The balance sought in these dilemmas depended on whether the patient’s symptoms were medically explained or unexplained (MES or MUS). Towards MUS the internists tended to maintain greater distance, take more control, ask more cautiously questions related to psychosocial causes, and take less responsibility for shared decision making.Discussion and conclusionsAdopting a basic distinction between MES and MUS, the internists in our study appeared to seek a different balance in each of four rather fundamental clinical dilemmas. Balancing these dilemmas seemed more difficult regarding MUS where the internists seemed more distancing and controlling, and tended to draw on their medical expertise. Moving in this direction is counterproductive and in contradiction to guidelines which emphasize that MUS patients warrant emotional support requiring a shift towards interpersonal, empathic communication.

Depressive symptom profiles and survival in older patients with cancer: Latent class analysis of the ELCAPA cohort study

High symptom reporting (HSR) and medically unexplained symptoms (MUS) are associated with considerable distress, disability, healthcare utilization and costs, but are poorly understood, and current treatments are of limited benefit. Most models of HSR and MUS implicate cognitive-perceptual factors, such as increased body-focused attention, reduced perceptual thresholds and a tendency to experience somatic misperception, but little is known about the causal role of these variables. We investigated this issue by studying whether there is a longitudinal relationship between perceptual-attentional variables and later clinical outcomes in primary care patients.Primary care patients (N = 102) completed clinical (physical symptom reporting, health anxiety and healthcare utilization) and perceptual-attentional (body-focused attention, perceptual threshold, somatic misperception) measures at baseline and then again six months later (N = 72). Hierarchical regression was used to examine cross-lagged relationships between baseline and follow-up scores.Contrary to expectation, attending away from the body at baseline predicted increased not decreased symptom reporting six months later. Neither perceptual threshold nor somatic misperception predicted clinical outcomes at six months.These findings suggest that body avoidance, rather than increased body focus, contribute to the development of HSR. Future studies should consider the potential clinical benefits of reducing bodily avoidance, via techniques that promote adaptive engagement with bodily sensations.

Serotonin transporter (5-HTTLPR) polymorphism and psychosocial variables related to post-traumatic stress symptoms in breast cancer patients

High symptom reporting (HSR) and medically unexplained symptoms (MUS) are associated with considerable distress, disability, healthcare utilization and costs, but are poorly understood, and current treatments are of limited benefit. Most models of HSR and MUS implicate cognitive-perceptual factors, such as increased body-focused attention, reduced perceptual thresholds and a tendency to experience somatic misperception, but little is known about the causal role of these variables. We investigated this issue by studying whether there is a longitudinal relationship between perceptual-attentional variables and later clinical outcomes in primary care patients.Primary care patients (N = 102) completed clinical (physical symptom reporting, health anxiety and healthcare utilization) and perceptual-attentional (body-focused attention, perceptual threshold, somatic misperception) measures at baseline and then again six months later (N = 72). Hierarchical regression was used to examine cross-lagged relationships between baseline and follow-up scores.Contrary to expectation, attending away from the body at baseline predicted increased not decreased symptom reporting six months later. Neither perceptual threshold nor somatic misperception predicted clinical outcomes at six months.These findings suggest that body avoidance, rather than increased body focus, contribute to the development of HSR. Future studies should consider the potential clinical benefits of reducing bodily avoidance, via techniques that promote adaptive engagement with bodily sensations.

Diagnostic Criteria for Psychosomatic Research (DCPR) and DSM-5 in primary care

High symptom reporting (HSR) and medically unexplained symptoms (MUS) are associated with considerable distress, disability, healthcare utilization and costs, but are poorly understood, and current treatments are of limited benefit. Most models of HSR and MUS implicate cognitive-perceptual factors, such as increased body-focused attention, reduced perceptual thresholds and a tendency to experience somatic misperception, but little is known about the causal role of these variables. We investigated this issue by studying whether there is a longitudinal relationship between perceptual-attentional variables and later clinical outcomes in primary care patients.Primary care patients (N = 102) completed clinical (physical symptom reporting, health anxiety and healthcare utilization) and perceptual-attentional (body-focused attention, perceptual threshold, somatic misperception) measures at baseline and then again six months later (N = 72). Hierarchical regression was used to examine cross-lagged relationships between baseline and follow-up scores.Contrary to expectation, attending away from the body at baseline predicted increased not decreased symptom reporting six months later. Neither perceptual threshold nor somatic misperception predicted clinical outcomes at six months.These findings suggest that body avoidance, rather than increased body focus, contribute to the development of HSR. Future studies should consider the potential clinical benefits of reducing bodily avoidance, via techniques that promote adaptive engagement with bodily sensations.

Psychophysiological adjustment in ovarian cancer survivors: A correlational study

High symptom reporting (HSR) and medically unexplained symptoms (MUS) are associated with considerable distress, disability, healthcare utilization and costs, but are poorly understood, and current treatments are of limited benefit. Most models of HSR and MUS implicate cognitive-perceptual factors, such as increased body-focused attention, reduced perceptual thresholds and a tendency to experience somatic misperception, but little is known about the causal role of these variables. We investigated this issue by studying whether there is a longitudinal relationship between perceptual-attentional variables and later clinical outcomes in primary care patients.Primary care patients (N = 102) completed clinical (physical symptom reporting, health anxiety and healthcare utilization) and perceptual-attentional (body-focused attention, perceptual threshold, somatic misperception) measures at baseline and then again six months later (N = 72). Hierarchical regression was used to examine cross-lagged relationships between baseline and follow-up scores.Contrary to expectation, attending away from the body at baseline predicted increased not decreased symptom reporting six months later. Neither perceptual threshold nor somatic misperception predicted clinical outcomes at six months.These findings suggest that body avoidance, rather than increased body focus, contribute to the development of HSR. Future studies should consider the potential clinical benefits of reducing bodily avoidance, via techniques that promote adaptive engagement with bodily sensations.

Therapeutic impasses in medically unexplained symptoms

Despite patients with medically unexplained symptoms (MUS) being amongst the most challenging clinical populations with which to work, current trends have encouraged practitioners to consider therapeutic difficulties in increasingly simplistic terms. This paper argues that the challenges faced when working with those with MUS are inextricably linked to social and cultural factors associated with the contested nature of their illness, and that these socio-cultural factors are replicated in the therapeutic relationship.

Quantifying positive communication: Doctor’s language and patient anxiety in primary care consultations

ObjectivePositive communication is advocated for physicians during consultations with patients presenting medically unexplained symptoms (MUS), but studies generally focus on what is said rather than how it is said. This study quantified language use differences of general practitioners (GPs), and assessed their relation to patient anxiety. MethodsLanguage use of 18 Dutch GPs during 82 consultations was compared for patients with MUS versus medically explained symptoms (MES). Message content (positive or negative) was differentiated from its directness (direct or indirect), and related to changes in patient’s state anxiety (abbreviated State Trait Anxiety Inventory; STAI). ResultsIn total, 2590 clauses were identified. GPs approached patients with MES with relatively more direct (vs. indirect) positive and indirect (vs. direct) negative messages (OR 1.91, 95% CI 1.42–2.59). Anxiety of both patient groups increased when GPs used more direct (vs. indirect) negative messages (b?=?0.67, 95% CI 0.07–1.27) ConclusionsGPs use different language depending on the content of messages for patients with MES, but not MUS. Direct negative messages relate to an increase in patient anxiety. Practice implicationsGPs could manage patient’s state anxiety by expressing negative messages in an indirect rather than direct manner.

For debate: Forty years of fabricated or induced illness (FII): where next for paediatricians? Paper 2: Management of perplexing presentations including FII

Perplexing medical presentations encompass many situations encountered by paediatricians, where a child is reported to have symptoms or disabilities that impact significantly on their everyday functioning, and yet thorough medical...

A life-stress, emotional awareness, and expression interview for primary care patients with medically unexplained symptoms: A randomized controlled trial.

Lifetime trauma, relationship adversities, and emotional conflicts are elevated in primary care patients with medically unexplained symptoms (MUS), and these risk factors likely trigger or exacerbate symptoms. Helping patients disclose stressors, increase awareness and expression of inhibited emotions, and link emotions to physical symptoms may improve health. We developed an emotional awareness and expression interview that targets stressful life experiences and conflicts and then tested its effects on primary care patients with MUS. Patients (N = 75) with MUS were recruited at a family medicine clinic and randomized to an interview condition or treatment-as-usual (TAU) control condition. In a single 90-min interview in the clinic, the interviewer elicited disclosure of the patient's stressors, linked them to the patient's symptom history, and encouraged emotional awareness and expression about unresolved relationship trauma or conflict. At baseline and 6-week follow-up, patients completed self-report measures of their physical and psychological health. Analyses of covariance, controlling for baseline symptoms, compared patients in the interview condition with TAU at 6-week follow-up. Compared with TAU, the interview led to significantly lower pain severity, pain interference, sleep problems, and global psychological symptoms. This study provides preliminary evidence for the value of integrating a disclosure and emotional awareness and expression interview into the primary care setting for patients with MUS. (PsycINFO Database Record

‘I didn’t want to be Psycho no. 1’: Identity struggles in narratives of patients presenting medically unexplained symptoms

The aim of this article was to explore identity struggles related to the experience of living with medically unexplained symptoms (MUS) in illness narratives of patients with MUS. These patients pose therapeutic and communication challenges as their symptoms do not have an obvious underlying diagnosis. Previous studies have shown that their stories can best be described as ‘chaos narratives’, lacking a chronological development of symptoms or ‘legitimacy narratives’, through which patients seek to legitimize their invisible symptoms. The study draws on 21 interviews with MUS patients. The examples were selected from two contrasting cases in order to show how the patients accomplish their identity struggles through distinctive discursive tools, such as metaphors, modality, personal pronouns, evaluative devices, as well as characteristic interactional structure, navigating around the three identity dilemmas: continuity and change, self and other, and agent or undergoer.

A psychosocial intervention for the management of functional dysphonia: complex intervention development and pilot randomised trial

BackgroundMedically unexplained loss or alteration of voice—functional dysphonia—is the commonest presentation to speech and language therapists (SLTs). Besides the impact on personal and work life, functional dysphonia is also associated with increased levels of anxiety and depression and poor general health. Voice therapy delivered by SLTs improves voice but not these associated symptoms. The aims of this research were the systematic development of a complex intervention to improve the treatment of functional dysphonia, and the trialling of this intervention for feasibility and acceptability to SLTs and patients in a randomised pilot studyMethodsA theoretical model of medically unexplained symptoms (MUS) was elaborated through literature review and synthesis. This was initially applied as an assessment format in a series of patient interviews. Data from this stage and a small consecutive cohort study were used to design and refine a brief cognitive behavioural therapy (CBT) training intervention for a SLT. This was then implemented in an external pilot patient randomised trial where one SLT delivered standard voice therapy or voice therapy plus CBT to 74 patients. The primary outcomes were of the acceptability of the intervention to patients and the SLT, and the feasibility of changing the SLT’s clinical practice through a brief training. This was measured through monitoring treatment flow and through structured analysis of the content of intervention for treatment fidelity and inter-treatment contamination.ResultsAs measured by treatment flow, the intervention was as acceptable as standard voice therapy to patients. Analysis of treatment content showed that the SLT was able to conduct a complex CBT formulation and deliver novel treatment strategies for fatigue, sleep, anxiety and depression in the majority of patients. On pre-post measures of voice and quality of life, patients in both treatment arms improved.ConclusionThese interventions were acceptable to patients. Emotional and psychosocial issues presented routinely in the study patient group and CBT techniques were used, deliberately and inadvertently, in both treatment arms. This CBT “contamination” of the voice therapy only arm reflects the chief limitation of the study: one therapist delivered both treatments.Trial registrationRegistered with the ISRCTN under the title: Training a Speech and Language Therapist in Cognitive Behavioural Therapy to treat Functional Dysphonia - A Randomised Controlled Trial.Trial Identifier: ISRCTN20582523 Registered 19/05/2010; retrospectively registered. http://www.isrctn.com/ISRCTN20582523

Patients\u2019 experiences of living with medically unexplained symptoms (MUS): a qualitative study

BackgroundPatients with medically unexplained symptoms (MUS) are common in primary care, and pose a communicative and therapeutic challenge to GPs. Although much has been written about GPs’ frustration and difficulties while dealing with these patients, research presenting the patients’ perspectives on MUS still seems to be scarce. Existing studies have demonstrated the patients’ desire to make sense of symptoms, addressed the necessity for appropriate and acceptable explanation of MUS, and revealed stigmatization of patients with symptoms of mental origin. Treatment in primary care should focus on the patient’s most essential needs and concerns. The objective of this paper is to explore Polish patients’ perspectives on living with MUS.MethodsA qualitative content analysis of 20 filmed, semi-structured interviews with patients presenting MUS (8 men and 12 women, aged 18 to 57) was conducted. All patients were diagnosed with distinctive somatoform disorders (F45), and presented the symptoms for at least 2 years. The interviews were transcribed verbatim and analysed independently by two researchers.ResultsFour major themes emerged: (1) experiences of symptoms; (2) explanations for symptoms; (3) coping; (4) expectations about healthcare. Within the first theme, the patients identified the following sub-themes: persistence of symptoms or variability, and negative emotions. Patients who observed that their symptoms had changed over time were better disposed to accept the existence of a relationship between the symptoms and the mind. The second theme embraced the following sub-themes: (1) personal explanations; (2) social explanations; (3) somatic explanations. The most effective coping strategies the patients mentioned included: the rationalization of the symptoms, self-development and ignoring the symptoms. The majority of our respondents had no expectations from the healthcare system, and stated they did not use medical services; instead, they admitted to visiting psychologists or psychiatrists privately.ConclusionPatients with MUS have their own experiences of illness. They undertake attempts to interpret their symptoms and learn to live with them. The role of the GP in this process is significant, especially when access to psychological help is restricted. Management of patients with MUS in the Polish healthcare system can be improved, if access to psychologists and psychotherapists is facilitated and increased financial resources are allocated for primary care. Patients with MUS can benefit from a video/filmed consultation with a follow-up analysis with their GP.

Depression and unexplained somatic symptoms in multiple sclerosis: MRI and quality of life correlates

Background Medically unexplained symptoms (MUSs) are considered a huge burden on both physicians and patients alike and can be regarded as a form of multiple sclerosis (MS) mimic, which should be carefully investigated together with other psychiatric comorbidity-like depression and anxiety in MS patients to overcome its negative influence on patients’ quality of life. Aim The aim of our thesis research was to determine the rate of comorbidity between MS, the unexplained somatic symptoms and depression, and correlation with MRI findings, and to study the impact of the unexplained somatic symptoms, depression and disabilities on quality of life in patients with MS. Patients and methods This study was conducted on 30 patients and 30 controls. All patients were evaluated by clinical assessment and radiological assessment using MRI of brain and spine. Both patients and controls were evaluated by Patient Health Questionnaire-15 for unexplained somatic symptoms, Beck Depression Inventory for depression and 36-item Short Form Health Survey for health-related quality of life. Conclusion MS patients had an increased incidence of medically unexplained somatic symptoms and depression versus the matched normal participants, which in turn was responsible for the decline of their quality of life. Most MUS in MS patients resulted from the burden of the primary disease. However, the probability of whether these MUS could be a relapse could not be confirmed or excluded.

Management for Medically Unexplained Symptoms (MUS) in Primary Care Medicine

Management for Medically Unexplained Symptoms (MUS) in Primary Care Medicine