Medically unexplained symptoms: are we making progress?

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The BJGP editorial and associated papers^1–4 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