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Medically unexplained symptoms: are we making progress?

Sarah C Evans
British Journal of General Practice 2019; 69 (683): 284. DOI: https://doi.org/10.3399/bjgp19X703853
Sarah C Evans
Herts Urgent Care. Email:
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All letters are subject to editing and may be shortened. General letters can be sent to bjgpdisc{at}rcgp.org.uk (please include your postal address for publication), and letters responding directly to BJGP articles can be submitted online via eLetters. We regret we cannot notify authors regarding publication.

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The BJGP editorial and associated papers1–4 about medically unexplained symptoms (MUS) do not consider dissociation, beyond a passing reference to hysteria. Dissociation is any detachment from surroundings or from physical and emotional experiences, and can be regarded as a coping mechanism.5 The previous use of ‘functional’, to describe MUS, implies a dissociative disorder.

Up to 10% of the population has a form of dissociative disorder,6 which could account for many of the thorny issues we encounter daily in general practice. This might include eating disorders, substance abuse, derealisation, somatisation, trauma, fibromyalgia, chronic pain, and compliance.

There is increasing understanding of the role dissociation has in post-traumatic stress disorder (PTSD),7 which also throws light on the development of adult difficulties relating to childhood abuse and trauma. Childhood issues are more prevalent among people with MUS; the Lamahewa et al paper here shows 26% for abuse and 32% for trauma.2

Not surprisingly for what is accepted as a mixed bag of illness and aetiologies,1 the meta-analysis of cognitive behavioural interventions for people with MUS shows only weak effects.3 Using trauma or a short dissociation screen8 could be a useful way to differentiate pathways for management of unexplained somatic disorders in primary care.

Formally identifying dissociative disorders, complex PTSD, and childhood trauma or abuse among those with MUS, then developing strategies to support people more appropriately,9 may provide a fruitful way forward for this stubbornly difficult part of general practice.

  • © British Journal of General Practice 2019

REFERENCES

  1. 1.↵
    1. Malterud K,
    2. Aamland A
    (2019) Br J Gen Pract, Medically unexplained symptoms: are we making progress? DOI: https://doi.org/10.3399/bjgp19X701885.
  2. 2.↵
    1. Lamahewa K,
    2. Buszewicz M,
    3. Walters K,
    4. et al.
    (2019) Br J Gen Pract, Persistent unexplained physical symptoms: a prospective longitudinal cohort study in UK primary care. DOI: https://doi.org/10.3399/bjgp19X701249.
  3. 3.↵
    1. Jones B,
    2. Williams AC de C
    (2019) Br J Gen Pract, CBT to reduce healthcare use for medically unexplained symptoms: systematic review and meta-analysis. DOI: https://doi.org/10.3399/bjgp19X701273.
  4. 4.↵
    1. Gol J,
    2. Terpstra T,
    3. Lucassen P,
    4. et al.
    (2019) Br J Gen Pract, Symptom management for medically unexplained symptoms in primary care: a qualitative study. DOI: https://doi.org/10.3399/bjgp19X701849.
  5. 5.↵
    1. Wikipedia
    Dissociation (psychology). https://en.wikipedia.org/wiki/Dissociation_(psychology) (accessed 8 May 2019).
  6. 6.↵
    1. Wikipedia
    Dissociative disorder. https://en.wikipedia.org/wiki/Dissociative_disorder (accessed 8 May 2019).
  7. 7.↵
    1. Levine PA
    (1997) Waking the tiger: healing trauma — the innate capacity to transform overwhelming experiences (North Atlantic Books, Berkeley, CA).
  8. 8.↵
    1. Wikipedia
    Dissociative Experiences Scale, https://en.wikipedia.org/wiki/Dissociative_Experiences_Scale (accessed 8 May 2019).
  9. 9.↵
    1. Kennedy F,
    2. Kennerley H,
    3. Pearson D
    , eds (2013) Cognitive behavioural approaches to the understanding and treatment of dissociation (Routledge, London).
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British Journal of General Practice: 69 (683)
British Journal of General Practice
Vol. 69, Issue 683
June 2019
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Medically unexplained symptoms: are we making progress?
Sarah C Evans
British Journal of General Practice 2019; 69 (683): 284. DOI: 10.3399/bjgp19X703853

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Medically unexplained symptoms: are we making progress?
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British Journal of General Practice 2019; 69 (683): 284. DOI: 10.3399/bjgp19X703853
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