1. HEALTHCARE COUNSELLING AND
PSYCHOTHERAPY JOURNAL
JANUARY 2010 VOL 10 NO 1
Why we need to address medically unexplained symptoms
Miracles of mindbody medicine
Commissioning in a fast-changing world
Reflections on IAPT and race equality
Medically unexplained
symptoms

2. HCPJ is the quarterly professional
journal for counsellors and
psychotherapists in health care.
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Associate Editors
Rachel Freeth, psychiatrist and counsellor
Peter Jenkins, Senior Lecturer in
Counselling Studies, Salford University
Ewan Davidson, primary care counsellor
and healthcare counselling tutor
Sarah Hovington, primary care
counsellor and FHCP Executive Member
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 British Association for Counselling
and Psychotherapy
ISSN 1475-0724
1 Editorial
2 News
3 BACP Healthcare update
4 Why we need to address
medically unexplained
symptoms
Addressing medically unexplained
symptoms has huge potential to
reduce the burden of illness and the
cost of health services, writes Tim
Webb
9 Reattribution: does it
work?
Psychological reattribution of
medically unexplained symptoms
by GPs has shown limited success,
but is that because of the way it’s
delivered, asks Richard Morriss
13 Miracles of mindbody
medicine
A small but growing number of
healthcare professionals believe
that chronic pain is often a
psychophysical phenomenon that
can respond to psychological
treatment. Alan Gordon and
colleagues report
20 Teaching trainee
doctors about medically
unexplained symptoms
GPs often receive next to no training
in dealing with patients with
medically unexplained symptoms,
writes Marta Buszewicz
18 Exploring the meaning
of medically unexplained
symptoms
Medically unexplained symptoms
may represent an attempt to heal
from unacknowledged, deeply
unpleasant emotions, according to
the findings of a small-scale study
by Jean Penman
25 Securing funding
for primary care
psychological therapy
In 2007, Jane McChrystal decided
to take action to address her clients’
requests for further counselling
sessions in the practice where she
worked
27 Reviews
32 Commissioning in a fast-
changing world
HCPJ talks to practitioner-turned
mental healthcare commissioner
Helen Hardy
35 Research matters
36 Primary cares
37 On the receiving end
Counselling helped save my marriage
and my sanity, writes Olive Frost
38 Reflections on IAPT and
race equality
The Improving Access to
Psychological Therapies Programme
(IAPT) is unlikely to deliver race
equality as it stands, says
Ross O’Brien
41 Forthcoming events
Contents

3. U
p to one-third of people consulting a GP in primary
care will have medically unexplained symptoms
(MUS) – symptoms or signs of physical distress that
cannot be accounted for by any physical disorder – as part
of their problem. The financial burden of this phenomenon
is huge – up to 16 per cent of the total cost of healthcare
services in the developed world, excluding the run-on
costs into social care, disability pensions and the wider
community. There’s also an emotional cost for patients, who can experience
considerable frustration with the inability to achieve resolution.
Serious consideration about how to treat MUS, writes Tim Webb in our
leading article, has reached its moment. Major changes in how to deploy and
train clinical staff and creating a system that positively identifies and treats
psychological causes of MUS is a challenge, argues Webb, but for therapists
working in healthcare, developments will offer ‘unlimited possibilities’.
A growing interest in MUS in medical and therapeutic circles is evident.
Research is ongoing, and practitioners are coming together to discuss ways
forward in best practice. In his article on tension myoneural syndrome
(TMS) – a diagnosis that means that patients are told their pain is quite
real, but is caused by a physical response to a psychological process rather
than structural damage – Alan Gordon argues that when Dr John Sarno
first pioneered the idea, mind and body were looked at as separate entities.
Now, a paradigm shift in the way we view physical pain is taking place. MUS,
Gordon states, will soon be part of mainstream medicine.
Teaching trainee doctors about MUS is an initiative that could contribute
to this shift. Marta Buszewicz outlines her work at University College London
(UCL) medical school, with sessions aimed at helping students to identify
symptoms and discuss client management.
But how best to treat MUS? Richard Morriss considers the technique
of psychological attribution of MUS – which shows patients how anxiety
and depression might be related to bodily symptoms. Its limited success in
the past, he says, may be related to the way it has been delivered. As ever,
the quality of the relationship with patients is paramount – people who
remain unconvinced that psychological factors play a role may be willing to
entertain this possibility because they trust their clinician or therapist to act
in their best interests.
Jean Penman’s study, though on a small scale, potentially provides an
opening for counsellors and psychotherapists, in partnership with clients,
to investigate whether the approach of exploring their experience of
emotion and feeling around physical symptoms could bring benefits. In an
article which will be of great interest to practitioners, Penman outlines her
qualitative pilot study, undertaken to explain patient stories.
There may also be openings for counsellors and psychotherapists working
with MUS when it comes to commissioning services. With the current
changes taking place within psychological services, practitioners are being
increasingly asked to put their case to commissioners. MUS is one area they
could consider. In an interview which outlines her work as a primary care
psychological services commissioner, Helen Hardy offers advice on how
therapists can usefully contribute to providing holistic care.
Sarah Hovington
Primary care counsellor, FHCP Executive member and HCPJ Associate Editor
Healthcare advice from BACP
BACP’s Healthcare Team welcomes
your queries on any healthcare
counselling and psychotherapy related
issues. To get in touch, please email
us at healthcare@bacp.co.uk or
telephone 01455 883 300 (ext 331) to
leave a message for a member of the
team. Please remember to quote
your BACP membership number.
Contribute to HCPJ
HCPJ welcomes feedback, original
articles and suggestions for features
and themes for future issues. Please
send your emails, views and opinions
to hcpj.editorial@bacp.co.uk
Editorial
Subscribe to HCPJ
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HCPJ January 2010 1

4. 2 HCPJ October 2009
NewsHealth secretary pledges commitment to
universal access to talking therapies
S
peaking at the Psychological Therapies in the NHS conference, Health
Secretary Andy Burnham took the opportunity to renew the Government’s
commitment to completing the roll-out of IAPT. ‘The progress across the
country has been encouraging, the results impressive’, he said. ‘We know 100,000
people have already benefited from IAPT services. Recovery rates are now hitting 47
per cent. Now is the time to build on this platform’, he added.
The NHS has made a public pledge to broaden access to a range of NICE-
approved treatments, including interpersonal therapy, couples therapy, brief
dynamic therapy and counselling, as well as CBT. The next step will be publishing
guidelines and competency frameworks for each of the new therapies by early
2010. The other key focus is strong leadership within IAPT. Important work is
underway through the New Ways of Working for Psychological Therapists project.
Building on this, Mr Burnham announced a new leadership programme for IAPT
professionals, which would pave the way for experienced practitioners to study
for new Advanced Practitioner roles.
‘As funding moves from centrally allocated budgets to PCT baselines next year, my
challenge to you is to make the best possible case for investment locally’, he said.
‘You’ve got a compelling story to tell to commissioners, both on quality and value for
money. It’s important this story is expressed in the strongest terms’.
A further 52 new IAPT sites are launching before March 2010, bringing the total
number of IAPT sites to 115. www.iapt.nhs.uk 30/11/09 www.bps.org.uk 2/11/09
Hope on the horizon for mental health
O
n 7 December the Government launched New Horizons: a shared vision for
mental health, a new cross-governmental strategy into how mental health
and wellbeing can be incorporated into every aspect of people’s daily lives.
Replacing the National Service Framework for Mental Health, which came to an end
this autumn, New Horizons lays down the vision for mental health and wellbeing
provision over the next 10 years.
Speaking at the third Psychological Therapies in the NHS conference at the end of
November, Secretary of State for Health Andy Burnham stressed the radical nature
of the new strategy, which includes the national roll-out of the Improving Access to
Psychological Therapies (IAPT) programme, increasing job opportunities for people
with mental health conditions and improving the wellbeing of the workforce. ‘If
the National Service Framework supported the 600,000 with severe mental health
problems, and if IAPT is for the six million with depression and anxiety, New Horizons
is for the 60 million, every single one of us; recognition that good mental wellbeing
lies at the essence of a flourishing society’.
Two publications launched in parallel set out the Government’s vision and support
to help wellbeing at work and deliver better employment results for people with
mental health conditions. Working Our Way to Better Mental Health: A Framework
for Action is the first UK-wide Mental Health and Employment Strategy. Realising
Ambitions: Better Employment Support for People with a Mental Health Condition
is a review commissioned by DWP, which offers recommendations for improving
employment, health and wider support for people with mental health conditions.
Mental health charities gave the New Horizons strategy a guarded welcome.
Andrew McCulloch, Chief Executive of the Mental Health Foundation, said: ‘[The]
public health approach to mental health is perhaps the most ground breaking
aspect of the vision. The vision, however, lacks a long-term strategy as to how all the
objectives will be achieved. The next stage must be to work on the specifics, [and]
the challenge will be to do so with little resource’. Guardian 9/12/09; Department of
Health 10/12/09
NICE updates guidance on
treatments for depression
Antidepressants should not be used
routinely to treat depression in
adults with chronic health problems,
according to the treatment
regulator, NICE.
NICE recommends self-help,
structural physical exercise
and psychological therapy for
mild to moderate problems.
Cognitive behaviour therapy
(CBT), interpersonal therapy
and behavioural activation are
recommended for all severities
of depression. Couples therapy
based on behavioural principles is
recommended for those with mild
to moderate depression in people
who have a regular relationship
that may be contributing to their
depression, or where involving the
partner is considered potentially
beneficial. Brief dynamic therapy and
counselling are recommended for
those who decline medication and
other psychological therapies, who
prefer an alternative or who haven’t
responded to other interventions.
NICE has also produced a new
guideline on the treatment and
management of depression in adults
with chronic physical illnesses,
suggesting that mental health
problems are often overlooked
by doctors who concentrate on
patients’ physical symptoms. http://
guidance.nice.org.uk/CG90 9/09;
http://news.bbc.co.uk/1/hi/
health/8328263.stm 28/10/09
National Audit of
Psychological Therapies
The New Savoy Partnership
conference also saw the official
launch of the National Audit of
Psychological Therapies for Anxiety
and Depression (NAPT). Following
a successful pilot involving 24
services across England and Wales,
NAPT is now recruiting for the
full audit, which will begin in May
2010. The audit will evaluate four
dimensions of quality in primary
and secondary care: access,
appropriateness, acceptability and
outcomes, and will promote good
practice by providing participating
services with information about
their performance, including
benchmarking against other services.
For further information and to sign
up, visit www.rcpsych.ac.uk/napt or
telephone 0207 977 4974.

5. FHCP becomes BACP
Healthcare
Following consultation with members,
FHCP made a formal request to the
BACP Board of Governors to change
the name of the division to BACP
Healthcare. With the name change
approved, the Executive formed a
sub-group to work on re-branding
the Division. We will formally launch
the new brand in the April 2010 issue
of HCPJ with an article presenting
our vision for BACP Healthcare. Many
thanks to all members who gave
feedback on the name change, which
was largely supportive of the rationale
to:
• achieve a stronger identity and
stronger voice in the healthcare
sector
• clearly communicate that this
is a healthcare division of BACP
membership
• create an inclusive name for the
division that can hold the range of
counsellors, psychotherapists and
other psychological therapists and
practitioners working in healthcare.
New divisional chair appointed
Tina Campbell has been appointed
the new divisional chair following an
election at the Executive committee
meeting in October 2009. Tina takes
up the position from January 2010 as
current chair Carl Eaton stands down
under the Division’s terms of reference.
Tina’s breadth of experience and
knowledge will be invaluable in
representing members’ needs. Currently
counselling manager at Scotland’s
largest counselling service, Sandyford,
in Greater Glasgow and Clyde NHS,
Tina has been a counsellor and
supervisor for over 15 years, working
in a range of settings, including the
voluntary sector, private practice and
the NHS.
The Executive would like to thank
Carl Eaton and deputy chair, Derek
Hope, who is also standing down, for
all their hard work and commitment
over the past years.
BACP HEALTHCARE UPDATE
Bringing you information about developments in BACP’s Healthcare Division and the
work being carried out on members’ behalf…
Deputy chair sought
We are now seeking nominations
for the post of deputy chair. This is
open to individual members of the
Division. Those interested should
apply for a nomination paper to
julie.camfield@bacp.co.uk or phone
01455 883381. Nomination papers
need to be completed and returned
to Julie Camfield, Divisional Officer,
BACP House, 15 St John’s Business
Park, Lutterworth, LE17 4HB, before
Wednesday 10 February 2010. If
there is more than one candidate we
will proceed to elections.
To informally discuss the role of
deputy chair and the demands in
terms of time and energy please
e-mail the chair, Tina Campbell:
healthcare@bacp.co.uk
Calling practitioners in Wales
and Northern Ireland
If you are a counsellor or
psychotherapist in Wales or Northern
Ireland, and would like to be
involved in BACP Healthcare’s work,
the Executive committee would like
to hear from you.
In order to work on behalf of
counsellors and psychotherapists
effectively, BACP needs to have
input from frontline practitioners,
and the committee is keen to ensure
that members are represented
from all the four nations. England
and Scotland only are currently
represented.
BACP Healthcare is run entirely
by volunteers, with each Executive
committee member able to pursue
their areas of special interest in line
with organisational needs.
Please email: tina.campbell@bacp.
co.uk if you are interested to learn
more.
Executive recommends
across-the-board regulation
The Executive broadly welcomes
regulation as an opportunity to
define competences for safer
practice in counselling and
psychotherapy in its response to the
Professional Liaison Group’s (PLG)
draft consultation in October 2009.
However, it is also the view of
the Executive that, because of the
changing nature and diversity of
psychological therapies practice and
the potential to confuse the public
and be divisive, regulations should
be set across-the-board for all
psychological therapy practitioners
within the workforce with common
competences, including counsellors,
psychotherapists, CBT practitioners
and high-intensity workers.
The Division’s response to the
draft consultation addresses specific
points about the differentiation
of standards for counsellors and
psychotherapists, pointing out that
the proposal does not reflect current
practice (i.e. there is no evidence
of differences in competences and
training), but seeks to redefine it.
The response further comments on
standards of entry to the professions,
arguing the appropriateness of
graduate entry level qualifications
(NQF level 6) for both counselling
and psychotherapy, as this more
closely matches the reality of the
training market.
On the potential consequences of
the current proposals, the Executive
is concerned about the impact on
clients, for example patients with
a diagnosis of severe/enduring
mental illness, and clients who may
be excluded, such as those who
communicate in different languages,
including British Sign Language
(BSL).
The response also specifically
addressed the potential impact on
the NHS of the proposed changes,
including the review of job titles
and contracts, and the impact on
practitioners, including restriction of
employment opportunities for both
counsellors and psychotherapists.
Read the Divisional response in full
at www.fhcp.org.uk (see link on
front page).
HCPJ January 2010 3

6. Addressing medically unexplained symptoms has huge potential to reduce the
burden of illness and the cost of health services. Yet our systems of healthcare
delivery militate against it, writes Tim Webb
H
alf a lifetime
ago, as I
trudged
through medical
school, I learned that
mental disorder, in
forms as variable as
repressed frustration to a downward
lurch in serotonin production by nerve
endings in the thalamus, sometimes
takes on the form of physical symptoms
that have no definable basis in physical
illness.
Had I realised at the time that my
tutors were talking about up to one-
third of all medical problems that
present to the average GP, and over 50
per cent of those that present to some
hospital outpatient clinics, I might have
paid more attention. But how was I to
Why we need to
address medically
unexplained symptoms
know? The topic took up only one talk
in a course that featured nearly 2000.
I would be surprised if it gets a greater
airing in the current syllabus, though it
may be about to acquire one.
Explaining MUS
The term ‘medically unexplained
symptoms’ (MUS) is set to become
fashionable. It may yet achieve a
permanent place in the healthcare
lexicon, as it has all the qualities
of a fine modern phrase. It is self-
explanatory, it encompasses the entire
field it is coined to describe, and it
contains no pomposity.
‘Medically unexplained’ refers
to symptoms or signs of physical
distress or malfunction that cannot be
accounted for by any physical disorder
a patient is known to have. It includes
both symptoms in the absence of
apparent illness, and the emergence
of severe symptoms in those who have
only mild illness. Symptoms are often
multiple or in clusters, though some
patients have a single dominant one.
The intention of the term is to
exclude those symptoms caused
by physical illness that has yet to
be discovered, though inevitably
there will be an unknowable but
small proportion in this category.
The two other main categories have
psychological causes (see box below).
However, MUS are often not clear-cut,
and these categories tend to overlap in
real life (see box opposite).
Studies in primary care in the UK
have concluded that between 15 and
Shutterstock

7. HCPJ January 2010 5
addressing mus
The complexity of MUS
In real life, MUS do not usually fit into neatly defined categories of imitated
illness, amplified symptoms or straightforward physical problems, as
illustrated in the following brief examples.
Case example 1: breathing problems
Mary has had asthma since childhood. It has generally been kept under fairly
good control with various inhalers. However, she often has a bad time after
a chest infection, as she did two months ago. A few months previously she
crashed her car and has since become nervous when driving. Since then she
has been having more asthma attacks, especially when she has to drive. She
has also started smoking again.
Case example 2: ‘funny turns’
Paul has had epilepsy since he was a teenager. Initially his attacks were
diagnosed as emotional outbursts. At the time he found that alcohol and
cannabis made life more bearable, and he has always used a bit too much of
each. He is married and in work, but he struggles with both. Over the past
year he has been having more attacks, some of which are pseudo-seizures.
His wife cannot cope any more and has threatened to leave and take the
children, which has increased his anxiety levels. He has been drinking more to
deal with the stress.
Case example 3: living with diabetes
Kylie’s doctor cannot get her diabetes under control but then he’s useless.
She’s been in hospital three times in the last year. Had to miss exams and
everything. They want her to stick needles in herself like a junkie. They don’t
know what these drugs do to you in the long run anyway. And picky diets are
just so not cool unless you’re fat, which Kylie isn’t. Someone else can have
diabetes – Kylie’s got better things to do. If they can’t work that out then
that’s their fault.
The three categories of MUS
Somatisation (imitated illness)
Somatisation occurs when psychological distress manifests itself as a physical
problem. The distress can be anything from an unresolved emotional conflict
to an incipient psychotic illness, via all manner of psychosocial problems and
neurobiological disorders.
The severity can range from annoying to devastating. Most often emotional
upset is accompanied by pain or disability without apparent cause. However,
in the most serious instances, major loss of physical amenity (e.g. blindness or
paralysis) can occur without any organic sign of physical impairment or even any
emotional corollary.
Amplified symptoms
Just as common and probably more so, is when an individual who is known to
suffer from a particular illness or disorder develops symptoms that cannot be
fully explained by the nature and extent of their physical condition.
For example, a pain that should be resolving and occasional becomes in
practice crippling and ever-present, or a long-term condition that is well-
controlled by regular treatment goes out of control for no discernable
reason.
Undiagnosed illness
The fear is often that a patient with MUS might have a hitherto undiagnosed
physical illness. This justification has been used for centuries to avoid positively
diagnosing and tackling underlying mental distress.
The irony is that by fearing that they will miss some important health problem,
doctors do so, as the patient’s psychological problem goes unaddressed. This
begs the question as to whether there is really much difference between failing
to spot and treat a physical disorder and failing to spot and treat a mental one.
30 per cent of patients who consult
have MUS as a part of their problem1
.
This figure does not include those
who present with a mental health
problem that does not involve physical
symptoms.
The range of MUS covers all manner
of complaints affecting all parts of
the body and all their conceivable
functions. The commonest seen in
primary care are musculoskeletal (30
per cent), abdominal (18 per cent) and
ear, nose and throat complaints (8 per
cent), with more general complaints,
such as fatigue, dizziness and malaise
also prominent2,3
. The severity can
range from muscle sprains made more
taxing by school or college exams, to
decades of unexplained paralysis or
blindness.
Table 1 gives an abbreviated list
of common manifestations of MUS
in different specialities. It is not
a comprehensive list of instances
in which a mental health problem
imitates or exacerbates a physical
health problem. For example, it does
not include situations in which drugs
or other treatments for physical
Shutterstock

8. Medical
speciality
Physical presentation
of mental disorder
Physical problems worsened by mental health problems
Cardiology
• Unexplained chest pain
• Cardiac neurosis
• Depression after heart attack
• Anxiety and stress in hypertension
Gastro-enterology • Unexplained abdominal pain
• Chronic disorders (e.g. coeliac disease, Crohn’s disease, ulcerative colitis)
• Irritable bowel (IBS)
• Bowel resection / stoma
Neurology
• Conversion states
• Pseudo-seizures
• Epilepsy
• Migraine
• Psychiatric complications of organic brain disease (e.g. Parkinson’s,
multiple sclerosis)
• Brain injury (amplified function loss)
• Post-stroke depression
Diabetes
• Physical symptoms imitated by
depression
• Depression increasing
likelihood of physical
deterioration
• Adjustment problems to diagnosis
• ‘Brittle’ diabetes
• Needle phobia
• Abnormal eating behaviour
Endocrine
(other)
• Thyroid, parathyroid and adrenal-related mood disorders remaining after
resolution
Accident and
emergency
• Repeat attenders
• Factitious disorders
• Common mental disorders or psychosis worsening minor injuries
• Treatment refusal
• Disturbed behaviour increasing harm
Orthopaedics and
trauma
• Chronic (back) pain
• Repeated self-injury
• Pain and function loss worsened by post-traumatic stress disorder (PTSD)
and post-trauma depression/anxiety
• Depression after chronic pain
• Anxiety-related muscle spasm and tension worsening joint and muscle
pain
Plastic surgery
• Body dysmorphic disorder
• Self-esteem issues
• Delayed wound healing due to self-harm
• Adjustment after major surgery
• Post surgery delirium
ENT • Globus hystericus
• Tinnitus
• Hyperacusis
Renal/urology
• Sexual dysfunction
• Scrotal pain
• Adjustment to dialysis
• Depression from chronic renal failure
• Organic brain disorder from dialysis
• Impact from symptom of impotence
Rheumatology
• Unexplained joint pain /
swelling
• Depression from autoimmune disorders
• Immunosuppressant-related depression
• Impact from loss of mobility
• Amplified disability
Pain clinic
• Somatoform pain disorder
• Pain amplification
• Amplified pain
• Complex regional pain syndromes
• Other chronic pain syndromes
Respiratory
• Panic disorder presenting as
breathing attacks
• Asthma or chronic obstructive pulmonary disease (COPD) worsened by
anxiety and panic attacks
• Oxygen dependence due to stress or anxiety
Oncology • Unexplained general decline
• Adjustment to diagnosis
• Neuropsychiatric complications of cancer
• Amplification by depression
• Issues surrounding end of life
General medicine
• General malaise / anergia
• Medically unexplained
symptom clusters, including
multiple pain sites
• Factitious disorders (e.g.
Munchhausen’s syndrome)
• Oversensitivity to drug side effects
• Delirium effects
• Pathological obesity
• Fear of ill-health
addressing mus
6 HCPJ January 2010

9. illness induce or worsen mental
health problems, situations in which a
physical illness (such as an infection)
triggers a bout of depression or other
mental disorder, or situations in which
physical health problems are worsened
by an increase in smoking, the use of
alcohol or other substances, or the
immediate effects of deliberate self-
harm. And it makes no reference to the
impact of being treated in a hospital
environment, witnessing distressing
events, or seeing the effects of one’s
illness on others.
In the broader run of things, physical
care facilities are drawn into assessing
and treating manifestations of mental
disorder in many ways. For example,
considerable efforts are often made
to spot or exclude possible physical
causes of symptoms and deterioration
where none is to be found, or to limit
the impact of the physical effects of a
psychological problem. Besides the cost
burden of all this clinical activity, the
eventual outcome is most often failure
to recognise or to deal with the real
cause of the problem.
The cost of MUS
The overall cost to healthcare systems
of dealing with MUS is mind-boggling.
The simplest and most frequently
quoted figure for systems in the
developed world is 16 per cent of
total costs4
. In terms of the NHS, this
equates to roughly £8.5 billion per
year, costs accruing to every part of
the healthcare system. This excludes
the run-on costs into social care,
disability pensions, carer costs and the
broader community.
In an NHS that is being asked to slice
15 per cent off its operating costs from
spring 2011 without impacting the
quality or availability of care, it may be
that serious consideration of how best
to tackle MUS has reached its moment.
There are few ethically sound ways
of cutting the cost of healthcare.
Getting people better more effectively
is one. Reducing negative test results
and pointless interventions is another.
Both can be achieved by a better
approach to dealing with MUS. The
case for improving our management
of the psychosomatic component of
medicine has always been clinically and
financially sound. It is now topical too.
The challenges of tackling MUS
It has been accepted since ancient
times that there are mechanisms by
which the mind, brain and/or body
transform psychological distress
into physical symptoms. Instead
of (or as well as) feeling anxiety,
low mood or irritability, some
individuals experience pain, paralysis,
unexplained skin rashes, and other
symptoms. However, the mechanics
of how this occurs are generally
poorly understood, and indeed are
likely to differ from one type of
presentation to another. Moreover,
even as knowledge is growing,
the greater challenge, running in
parallel, is that medical convention
militates against formulations that
allow for understanding a problem
simultaneously in physical and
psychological terms.
Take the example of chronic pain.
For decades we have known that if
clinical depression and painful injuries
or illnesses co-exist there is a chance
that the one will exacerbate the other.
The depressed brain will often register
pain that is mild to moderate and
occurs occasionally, as being severe
and lasting for much of the time.
We know that there are typical
changes to the pattern of pain in
many such cases. Pain is worse in the
morning; spreads into neighbouring
areas of the body; worsens in direct or
indirect proportion to mood; and can
be felt in unconnected parts of the
body simultaneously.
Specialist pain journals have been
full in recent years of descriptions of
a variety of chronic pain syndromes,
such as the complex regional pain
syndromes (CRPS). CRPS have been
sub-divided into a type that involves
only the area around the site of the
injury, and a second type that seems
to involve how the brain and central
nervous system (mis)process the pain
signals coming from that part of the
body. Debates have been conducted
around what is (or is not) a reasonable
level of pain, since pain is a subjective
experience that cannot be measured
Hepatology
• Depression from liver disease
• Alcohol problems secondary to depression or anxiety disorder
Infectious diseases
• Chronic fatigue syndrome and myalgic encephalitis (ME)
• Glandular fever
• Adjustment to diagnosis (e.g. HIV, hepatitis C)
Geriatric medicine
• Pseudo-dementia
• Non-specific decline
• All the above with frailty issues
• Acute / chronic confusional states and later life problems (loss of partner,
role) impacting on physical health
Paediatrics
• Recurrent abdominal pain
• Covert self-harm
• Factitious illness presentation
(e.g. Munchausen’s by proxy)
• Neuro-developmental abnormalities making assessment difficult
• Non-adjustment to illness causing non-compliance with treatment (e.g.
diabetes)
• Family concerns worsening child’s health
Dermatology
• Obsessive washing
• Dermatitis artefacta
• Self-esteem issues and social phobia
Obstetrics and
gynaecology
• Unexplained abdominal pain
• Various types of sexual
dysfunction
• Effects of postnatal mental
disorder
• Poor treatment advice for mental disorder during pregnancy and breast
feeding
• Mental disorders associated with menstrual cycle
Table 1: Health problems in which medically unexplained symptoms are commonplace
addressing mus
HCPJ January 2010 7

10. objectively. However, there is no
tradition of bringing together our
knowledge of how depression affects
individual experience of pain with
our knowledge of how chronic pain
affects the processing of pain signals.
Physical and mental health specialists
work in different fields, which is why
multidisciplinary teams in pain clinics
rarely include psychiatrists.
Perhaps the greatest challenge of
MUS – in my younger days I would
have said scandal – is that the
evidence suggests that there is a great
deal that we can do about some or
all of these conditions. If we were to
apply the psychological therapies and
drug treatments that we know stand
a high chance of working, at points
in patient pathways where they are
known to impact best, patients would
get better quicker, clinicians would be
satisfied with a job well done, and the
costs to the health service would come
down. So why does it not happen?
The answer lies mainly in the ways
we have designed and implemented
healthcare services in the UK, though
to be fair it would be difficult to cite
a healthcare system that handles
things in a fundamentally better
way. Traditional service structures
tend to mirror our understanding
of what constitutes illness, coupled
with a certain amount of pandering
to medical influence and fashionable
causes.
Few healthcare configurations
reflect the clinical realities of illness.
Our healthcare institutions, recreated
in the structures of its professions,
encourage the view that illnesses
are so complex that considerable
specialism is required. We divide
specialities by parts of the body,
the age of its inhabitant, and/or the
interventions intended. Each speciality
homes in not only on one bit of us,
but also often on specific approaches
regarding what to do when that bit
goes wrong. Each speciality spawns its
own training schemes and articulates
the need for greater and greater
specialism among the professions
expected to work within it. Further,
doctors trained and practising in
this era of techno-medicine become
concerned when dealing with
conditions that cannot be diagnosed
using objective tests. They fear the
culture of blame, shame and claim and
its practitioners, always lurking the
shadows.
A way forward
Some or all of the above factors may
explain the muted response on the
part of the NHS and other healthcare
systems to deal with the otherwise
obvious and major problem of MUS.
Thus the challenge for an NHS intent
on saving money by getting people
better more effectively is how to
restructure our approach to the
delivery of healthcare, to enable more
joined-up working.
We need to define pathways of care
that deal with the problems patients
present, rather than relying on slotting
patients into pathways designed to
accommodate outmoded service
configurations. Few if any existing
patient pathways contain a point at
which the 20-50 per cent of patients
whose presenting problem has a major
psychosomatic component have that
part of their problem assessed and
dealt with. Usually the only approach
available is to refer patients to another
inappropriate pathway.
Successfully achieving the
transformation to services that deal
effectively with MUS will need major
changes to how we train and deploy
clinical staff. Creating a system that
positively identifies and treats the
psychological causes of MUS will
challenge those who commission
services as much as those who provide
them. Teamwork at an unprecedented
level will be key. Clinicians in acute
hospitals and primary care will need
to be aware of the signs that most or
all of a patient’s ‘physical’ illness has
its basis in mental health problems.
They will also need to be able to
differentiate those who require a
biological approach from those who
need a psychological one.
For therapists working in healthcare
settings, such developments will offer
almost unlimited possibilities, along
with equally massive challenges.
Those assessing what psychological
approaches are required will need a
working knowledge of the symptoms
and signs of underlying physical
disease in much the same way that
many mental healthcare professionals
have to get to grips with the
biological/psychological interface in
mental health work.
This sort of change needs to happen
in fairly short order, yet it has not
happened in the first 60 years of
the NHS, and the power of inertia
cannot be underestimated. Whether
it will happen and how soon is open
to debate – though it may be sooner
rather than later because of the cost
implications of not acting: money is a
powerful master. For the time being,
we need to watch this (wide open and
centuries old) space. n
Dr Tim Webb is a Consultant in Adult
Psychiatry and Medical Director of Suffolk
Mental Health Partnership NHS Trust. His
father was a GP, and his principal clinical
interest is the management of common
mental health problems in primary care.
References
1 Peveler R, Kilkenny L, Kinmonth
AM. Medically unexplained physical
symptoms in primary care: a comparison
of self-report questionnaires and clinical
opinion. Journal of Psychosomatic
Research 1997; 42: 253–60.
2 Kirmayer LJ, Looper KJ, Taillefer
S. Somatoform disorders. In:
Turner S, Hersen M (editors). Adult
psychopathology. New York: John Wiley
& Sons; 2003.
3 Reid SWS. Frequent attenders with
medically unexplained symptoms: service
use and costs in secondary care. British
Journal of Psychiatry 2002; 180: 248-53.
4 Barsky AJ. Somatisation increases
medical utilisation and costs
independent of psychiatric and medical
co-morbidity. Archives of General
Psychiatry 2005; 62: 903-10.
Further reading
Royal College of Psychiatrists and Royal
College of General Practitioners. CR152:
The management of patients with
physical and psychological problems in
primary care: a practical guide. London:
Royal College of Psychiatrists and Royal
College of General Practitioners; 2009.
Available via: www.rcpsych.ac.uk/
files/pdfversion/cr152.pdf Accessed
21/10/09.
Academy of Medical Royal Colleges. No
health without mental health. The ALERT
summary report and the supporting
evidence; July 2009. Available via:
http://www.rcpsych.ac.uk/pdf/
ALERT%20print%20final.pdf
http://www.rcpsych.ac.uk/pdf/No%20
Health%20without%20mental%20
health%20the%20Evidence.pdf Accessed
23/11/09.
addressing mus
8 HCPJ January 2010

11. M
edically
unexplained
symptoms
(MUS) refer to bodily
symptoms that do not
have a physical health
explanation. Most
patients with MUS of at least three
months’ duration have an underlying
emotional or stress-like problem, unless
there is a physiological explanation
such as a change in diet.
While MUS are very common in
the community, the prevalence of
persistent or recurring MUS that
require further management is
probably around three per cent of GP
consultations, and some authors have
quoted much higher rates1
. Up to 60
per cent of people with persistent
or recurring MUS have anxiety or
depressive disorders2
. Twice as many
Reattribution: does it work?
Psychological reattribution of medically unexplained symptoms by GPs has
shown limited success, but is that because of the way it’s delivered? Richard
Morriss has some answers
women as men present with MUS, and
the peak ages of presentation are the
50s and 60s, though MUS are seen
in all age groups, including young
children. There are increased rates in
South Asian populations, in the single,
separated and widowed, and in people
with a history of childhood sexual,
physical or emotional abuse. However,
it is important to note that people
with MUS do not necessarily have
any emotional problem, and there are
many non-psychological explanations.
Patients with MUS use health services
up to five times more frequently
than the general population3
, and
are adept at getting help from health
professionals whatever the system in
place for obtaining health care. My
own view is that if the problem of MUS
is to be tackled, the underlying needs of
patients have to be addressed.
Development of reattribution
A model for reattributing MUS
was developed for GPs by Gask
and Goldberg in the late 1980s.
It involved restructuring GP
consultations on MUS so that
people who consulted with bodily
symptoms who were also suffering
from depression or anxiety disorders
would receive an explanation
for their bodily symptoms4
. The
intention with such consultations
is to show patients how anxiety
and depression might be related
to the bodily symptoms that are
distressing them. It was thought
that such an explanation might be
sufficient to produce improvement
in many of those with mild anxiety
and depression, while for people
with more severe anxiety and
depression, it would be a starting
point to engage them in further
treatment, such as counselling,
psychotherapy or a course of
antidepressants. Reattribution
was developed by surveying the
practices of different types of
clinicians who were considered
successful in managing people with
mental disorders preceded by bodily
symptoms. Gask and Goldberg then
An important
learning point
for all health
professionals
working with MUS
is to remember
that MUS is
not a diagnosis
but a working
hypothesis
Shutterstock
HCPJ January 2010 9

12. benefits in terms of function and
physical symptoms compared with
treatment as usual by GPs5–10
.
However, there have tended to be
improvements in GP understanding
of MUS, GP satisfaction with
treatment, and patient satisfaction10–
12
. In addition, it seems that there
may be a subgroup of patients with
mild-to-moderate depression and
anxiety problems with MUS who
benefit from reattribution8,9
.
In the most detailed of these
studies, the Medically Unexplained
Symptoms Trial (MUST), GPs
successfully delivered reattribution
in 70 per cent of cases, but the only
significant patient outcome was
that patients thought their health
was worse10
. A detailed study of
communication between GPs and
patients with MUS showed that
although a substantial number
communicated their psychological
needs to the GP, these were often
ignored13
. Moreover, reattribution
training resulted in GPs detecting
and talking extensively with patients
about their emotional problems, but
only at a relatively superficial level.
In addition, while GPs often gave
the ‘making the link’ explanation in
the way they were taught, this was
to some extent undermined because
they still tended to give explanations,
arrange investigations, prescribe
drugs and refer for the physical
health problems these patients
presented.
Previous research has shown that
people become more disheartened
about their health if they are given
unclear or mixed messages (see box
opposite for example)14
. Qualitative
research with patients and GPs in the
MUST study also revealed a high level
of complexity of problems among
patients with MUS in primary care
(Table 2)15,16
. Taken together, the
findings suggest that it is unlikely
that a single technique, such as
reattribution, would be sufficient
for the needs of all patients with
MUS. However, reattribution might
still be a useful approach if it is used
selectively by GPs among a range
of options for management. On the
basis of this research, Linda Gask and
I have recently proposed the ‘FEAT’
model for GPs to use with patients
with MUS (Table 3)17
. In the FEATTable 1. Reattribution of MUS: model and worked example
1. Feeling understood
GP takes history of physical symptoms,
mood and other psychological
symptoms, social context. Asks about
patient’s beliefs re nature and cause,
consequences of current health
problem; previous similar problems. GP
performs relevant physical examination.
Example
Simon, a 42-year-old supervisor, gets
backache each day and headaches at
the end of the day. The pain is worse in
the mornings and evenings, and better
on Saturdays and holidays. Recently he
had to make colleagues redundant. He
also has money problems due to loss of
overtime.
1. Making the link
Three elements explanation:
The physical symptom (1) is linked
to the psychosocial problem (2) by a
mechanism (3, e.g. a correlation in time).
Mechanism: backache started when
redundancies became likely at work. GP
links to:
• Physical effects of stress or anxiety
(e.g. backaches occur because person
is tense about work and home
situation). Muscles when tense start
to ache (e.g. arms ache if carrying
heavy luggage).
• Effects of mood (e.g. a person when
depressed is less able to cope with
pain).
• Family history (e.g. mother went to
bed with headache every time there
was an argument at home) may have
parallels with present situation
3. Broadening the agenda
GP feeds back symptoms from physical
examination and investigation.
Exploration – whether patient thinks
current symptoms and psychosocial
problems (if they present) could
be related. Further exploration of
psychosocial problems if relevant.
Physical examination – muscles in
back generally tense. No restriction of
movement. Patient shows no sign of
injury. Perhaps tension in back might be
related to tension at work? Patient does
not dismiss idea. Talks about arguments
at home.
4. Negotiating further
treatment
• No further action
• Symptomatic treatment (e.g.
physiotherapy to free muscles of
tension, and ibuprofen tablets)
• Explore relationship between
symptoms and psychosocial stress
through keeping a diary, asking
family members. If patient still not
convinced, GP can offer further
appointment to review diary of
symptoms and stress.
• Treatment of underlying psychosocial
problem (e.g. through counselling,
antidepressants). For example, patient
may want to discuss issues at home
and work with a counsellor.
there were three stages to the
reattribution model4
, but feedback
from GPs after an initial patient
outcome study, together with the
findings of research that involved
observing consultations between
GPs and patients, encouraged the
development of a fourth stage
‘Negotiating further treatment’, as
shown5
.
Outcome of reattribution
studies
A number of outcome studies
have been conducted using the
reattribution model. In terms of
the outcomes of patients with
MUS, these have either shown no
improvement or only moderate
shaped these techniques into a
structured consultation consistent
with the usual way a GP would start
a consultation. In a recent study, the
average length of a reattribution
consultation by GPs was found to
be 13 minutes – about one minute
longer than usual consultations with
such patients. Gask, myself and other
researchers in Germany, Denmark and
the Netherlands subsequently applied
reattribution to patients with MUS, a
larger group than those with anxiety
or depressive disorders presenting
with bodily symptoms5–8
.
Table 1 shows the four stages
of reattribution, using a worked
example from a GP consultation
employing reattribution. Originally
reattribution
10 HCPJ January 2010

13. model, reattribution is only one of a
range of approaches to working with
MUS.
Two further findings from the
MUST study are worth highlighting.
First, up to 10 per cent of patients
in primary care who are considered
by GPs to have MUS subsequently
develop physical health problems
that explain their original bodily
symptoms first labelled as MUS.
Second, after reattribution, patients
with MUS believed that their bodily
symptoms did have an emotional
cause, but were worried that in
future consultations their GP would
not take their physical symptoms
seriously16
. An important learning
point for all health professionals
working with MUS is to remember
that MUS is not a diagnosis but a
working hypothesis. If a patient with
MUS develops new symptoms that
might be related to their original
MUS, then their doctor or nurse
needs to re-evaluate these symptoms
in case there is an underlying physical
health problem. Hence, in the FEAT
model, the patient is encouraged to
see their GP again if they have new or
worsening symptoms, and the GP tells
the patient that he or she is happy
to be consulted if there are any fresh
physical health problems.
Implications for counsellors
and psychotherapists
The best results of research into
reattribution have come from a
Dutch study in which GPs worked
with patients with MUS over a
number of consultations, delivering
reattribution and techniques
designed to tackle illness worry. The
study showed improvements in the
patients’ symptoms and functioning,
together with economic benefits
from reductions in income support
payments and the use of healthcare
services over two years6
.
Reattribution may be best used
by GPs, nurses and doctors as a
way of preparing a patient with
MUS for a course of counselling
or psychotherapy, since patients
without such preparation often fail to
attend for psychological treatment18
.
It may be usefully employed by
counsellors and psychotherapists for
those patients with MUS who are
still uncertain whether they have an
underlying emotional problem or not,
but are open to the possibility19,20
. In
such cases, psychological treatment
could follow after a course of perhaps
four to eight sessions of reattribution
and tackling illness worry delivered by
either the GP or a counsellor.
It must be borne in mind that many
patients with MUS can also have
other underlying chronic physical
health conditions. In addition, quite
often patients will accommodate
an explanation that they have
emotional problems contributing to
MUS or worse functioning because
they are not coping well with these
physical health conditions and their
consequences. Such patients may
be willing to accept the explanation
Mixed messages about
health increase anxiety
• Doctor: ‘Your chest pain is
nothing to worry about. Try to
relax more, and if the pain gets
too bad, pop this tablet under
your tongue’.
• Patient at interview, 24 hours
after the GP consultation: ‘If
there was nothing wrong with
me, why did the doctor tell me
to relax more and take a tablet?
I am afraid the doctor is not
telling me everything. Really I’ve
got a serious health problem
that he can’t do much about’.
• Interviewer: ‘How do you feel
about this?’
• Patient: ‘I feel terrible, worse
than ever. I am worried’.
• A patient’s relationship with
their GP and therapist is an
important determinant of outcome,
particularly in terms of trusting
them to take health problems
seriously.
• The patient may be unclear about
their symptoms and the cause of
these.
• Patients are often concerned that
GPs will not take their physical
health problems as seriously as
they used to once MUS have been
identified.
• Patients sometimes receive
conflicting advice regarding a
physical health problem (e.g. one
explanation by their GP or therapist
and a different opinion from a
hospital specialist).
• The patient may have a range of
health problems (e.g. a chronic
physical disease as well as MUS).
• Patients may not reveal emotional
symptoms to their GP (so no
referral on to therapist). This may
be because they:
- consider that emotional problems
are private
- do not trust GP with this
information.
In either case it wastes the GP’s time
because there is nothing he or she
can do other than prescribe tablets
the patient does not want.
1. Feeling understood
2. Evaluation by GP of the nature of the problem
3. Action by GP (one or more of the following):
Help patient to understand their symptoms and possible causes
Earn trust of patient by explaining what help GP is willing to provide
Broadening agenda, followed by making the link (reattribution)
Limit health care consultations – concern about health can become a problem,
generating stress and further appointments
Give emotional support and/or identify sources of support in family and social
circle.
4. Termination of consultation
No further action
Symptomatic treatment
Explore relationship between symptoms and psychosocial stress through diary,
asking family members
Treatment of underlying psychosocial problem (e.g. counselling, prescription of
antidepressants), and ask patient to make a further appointment if there are
further symptoms or the symptoms get worse.
Table 3. FEAT model
Table 2. Complexity of
problems with MUS
reattribution
HCPJ January 2010 11

14. that mood, anxiety and other
psychological or social difficulties
may be contributing to their
problems with coping, symptoms
and/or functioning. Most important
of all is the quality of the therapeutic
relationship. People with MUS who
remain sceptical or unconvinced
that psychosocial factors may be
playing a role in their condition
may be willing to entertain this
possibility because they trust their
therapist or GP to act in their best
interests16
. However, if patients with
MUS remain unconvinced about the
relevance of psychological problems
to their MUS after reattribution,
they should be referred back to the
referring health professional or their
GP. Finally, it should be noted that
although reattribution is one of the
easier psychological approaches to
MUS to learn, other approaches, such
as cognitive behaviour therapy21
or psychodynamic interpersonal
therapy22
, can be usefully applied in
such cases. The relative effectiveness
of such approaches and their
appropriateness in different
situations are currently unknown. n
Richard Morriss is Professor of Psychiatry
and Honorary Consultant Psychiatrist
at the University of Nottingham and
Nottinghamshire Healthcare Trust.
His research interests include bipolar
disorder, depression, psychological
treatments, primary care psychiatry,
medically unexplained symptoms, chronic
widespread pain and chronic fatigue
syndrome.
References
1. Verhaak PF, Meijer SA, Visser AP, Wolters
G. Persistent presentation of medically
unexplained symptoms in general practice.
Family Practice 2006; 23: 414-20.
2. Morriss R, Dowrick C, Salmon P et al.
Cluster randomised controlled trial of
training practices in reattribution for
medically unexplained symptoms. British
Journal of Psychiatry 2007; 191: 536-42.
3. Barsky AJ, Orav EJ, Bates DW.
Somatization increases medical utilization
and costs independent of psychiatric and
medical comorbidity. Archives of General
Psychiatry 2005; 62: 903-10.
4. Goldberg D, Gask L, O’Dowd T. The
treatment of somatisation: teaching
techniques of reattribution. Journal of
Psychosomatic Research 1989; 33: 689-95.
5. Morriss R, Dowrick C, Salmon P, Peters
S, Rogers A, Dunn G. Turning theory into
practice: rationale, feasibility and external
validity of an exploratory randomized
controlled trial of training family
practitioners in reattribution to manage
patients with medically unexplained
symptoms (the MUST). General Hospital
Psychiatry 2006; 28: 343-51.
6. Blankenstein AH. Somatising patients in
general practice reattribution, a promising
approach (PhD thesis). Vrije Universiteit,
The Netherlands; 2001.
7. Larisch A, Schweickhardt A, Wirsching
M, Fritzsche K. Psychosocial interventions
for somatizing patients by the general
practitioner: a randomized controlled trial.
Journal of Psychosomatic Research 2004;
57: 507-14.
8. Toft T, Fink P, Christensen KS et al.
Treatment of somatoform disorders in
primary care; a randomized controlled
trial studying the effect on disability,
satisfaction with care and health care
utilization. Journal of Psychosomatic
Research 2003; 55; 118.
9. Morriss RK, Gask L, Ronalds C, Downes-
Grainger E, Thompson H, Goldberg D.
Clinical and patient satisfaction outcomes
of a new treatment for somatized mental
disorder taught to general practitioners.
British Journal of General Practice 1999;
49: 263-7.
10. Morriss RK, Gask L. Treatment of
patients with somatized mental disorder:
effects of reattribution training on
outcomes under the direct control of the
family doctor. Psychosomatics 2002; 43:
394-9.
11. Rosendal M, Olesen F, Fink P, Toft
T, Sokolowski I, Bro F. A randomised
controlled trial of brief training in
assessment and treatment of somatisation:
effects on patient outcome. General
Hospital Psychiatry 2007; 29: 364-73.
12. Rosendal M, Bro F, Sokolowski I, Fink P,
Toft T, Olesen F. A randomised controlled
trial of brief training in assessment and
treatment of somatisation: effects on
GPs’ attitudes. Family Practice 2005; 22:
419-27.
13. Morriss R, Gask L, Dowrick C et al.
Randomised trial of reattribution on
psychosocial talk between doctors and
patients with medically unexplained
symptoms. Psychological Medicine 2009;
Jul 2: 1-9 [Epub ahead of print].
14. Coia P, Morley S. Medical reassurance
and patients’ responses. Journal of
Psychosomatic Research 1998; 45: 377-86.
15. Dowrick C, Gask L, Hughes JG et
al. General practitioners’ views on
reattribution for patients with medically
unexplained symptoms: a questionnaire
and qualitative study. BMC Family
Practice 2008; 9:46.
16. Peters S, Rogers A, Salmon P et al.
What do patients choose to tell their
doctors? Qualitative analysis of potential
barriers to reattributing medically
unexplained symptoms. Journal of
General Internal Medicine 2009; 24:
540-2.
17. Morriss R, Gask L. Assessment and
immediate management of patients with
medically unexplained symptoms in
primary care. Psychiatry 2009; 8: 179-83.
18. Arnold IA, Speckens AE, van Hemert
AM. Medically unexplained physical
symptoms: the feasibility of group
cognitive-behavioural therapy in primary
care. Journal of Psychosomatic Research
2004; 57: 517-20.
19. Wilkinson P, Mynors-Wallis L.
Problem-solving therapy in the treatment
of unexplained physical symptoms in
primary care; a preliminary study. Journal
of Psychosomatic Research 1994; 38:
591-8.
20. Schweickhardt A, Larisch A,
Wirsching M, Fritzsche K. Short-term
psychotherapeutic interventions for
somatising patients in the general
hospital: a randomized controlled study.
Psychotherapy and Psychosomatics 2007;
76: 339-46.
21. Escobar JI, Gara MA, Diaz-Martinez
AM et al. Effectiveness of a time-limited
cognitive behaviour therapy type
intervention among primary care patients
with medically unexplained symptoms.
Annals of Family Medicine 2007; 5: 328-
35.
22. Guthrie E, Creed F, Dawson D,
Tomenson B. A randomised controlled
trial of psychotherapy in patients with
refractory irritable bowel syndrome.
British Journal of Psychiatry 1993; 163:
315-21.
Reattribution
training resulted in
GPs detecting
and talking
extensively with
patients about
their emotional
problems, but
only at a relatively
superficial level
reattribution
12 HCPJ January 2010

15. E
veryone has
experienced
physical pain at
one point or another,
but for some that
pain is severe and
persistent. Albert
Schweitzer once said that ‘pain is a
more terrible lord of mankind than
even death itself’1
– and many people
who experience pain chronically would
likely agree.
For years the medical community has
struggled to understand the cause of
many forms of chronic pain, which is
prevalent worldwide. In the USA alone,
over 70 million adults suffer from
chronic pain2
, resulting in a cost to the
public of over $100 billion annually3
.
Common treatments for chronic pain
include acupuncture, transcutaneous
Miracles of
mindbody medicine
A small but growing number of healthcare professionals believe that chronic pain
is often a psychophysical phenomenon that can respond well to psychological
treatment. Alan Gordon and colleagues tell the story of tension myoneural
syndrome (TMS)
electrical nerve stimulation, ultrasound,
nerve blocks, physical therapy, trigger
point injections, medication, and
surgery4
. Evidence has shown that
these interventions have limited
effectiveness with regard to long-
term pain relief5
. One of the world’s
foremost pain experts, Dr Patrick
Wall, recently wrote that it was time
for a paradigm shift in the way we
understand pain1
. It is the aim of this
article to provide a new perspective
on the purpose of and treatment for
chronic pain conditions.
The mindbody connection
In the late 1960s and early 70s, Dr John
Sarno was the director of outpatient
services at the Rusk Institute of
Rehabilitation Medicine, New York
University Langone Medical Center.
Treating clients primarily with neck,
shoulder, and back pain, he practised
conventional pain management
techniques and grew frustrated with
the results, which were unpredictable
and inconsistent. More troubling still
was the fact that clients often did not
have pain where one would expect,
given the findings of their physical
examinations4
.
Sarno began to take a deeper look
at his clients’ medical histories. He
was surprised to find that 88 per
cent of them had a history of one
or more tension-related conditions,
such as ulcers, headaches, or irritable
bowel syndrome. He began to
wonder, ‘Is it possible that the bulk of
musculoskeletal pain is not the result
of structural damage, but is in fact
tension-related?’6
The puzzle of pain
For over a century, physicians and psychologists have been interested in
the connection between the mind and physical pain symptoms. Sigmund
Freud, Jean-Martin Charcot, and Franz Alexander wrote extensively on the
subject7
. But only recently has research started to explore the depth of the
connection.
Whiplash
Whiplash is the term used to describe head or neck pain resulting most
often from a rear-end traffic collision. Research has shown that about 10 per
cent of whiplash injuries result in permanent disability8
. The director of the
Association of British Insurers recently reported that whiplash had become
an epidemic in the UK9
, while in Norway two per cent of the population have
chronic disability as a result of the injury10
. The medical community has been
confounded by this phenomenon, as there is no structural reason why this
condition should persist and become chronic11
.
In an attempt to understand this enigmatic syndrome better, a team of
researchers turned to Lithuania. In Lithuania, the general public has little
Continued overleaf.
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HCPJ January 2010 13

16. Tension myoneural syndrome
After surveying the research on
musculoskeletal pain (see box
opposite) and meeting with thousands
of clients, Sarno concluded that
the majority of neck, shoulder, and
back pain syndromes were not the
result of nerve, muscle, or ligament
damage, but rather the consequence
of psychological processes. He referred
to the condition as tension myositis
syndrome (TMS6
, recently renamed
tension myoneural syndrome). In
addition to musculoskeletal pain,
Sarno found that fibromyalgia,
repetitive strain injury (RSI),
headaches, tendonitis, gastrointestinal
disorders, pelvic pain, and various
other pain syndromes were also
physical manifestations of the same
underlying psychological process4,7
.
In 1979, Sarno began bringing
clients with medically unexplained
symptoms together for seminars
on the nature of their pain. They
covered the onset of TMS pain,
its underlying purpose, how it is
perpetuated, and the steps necessary
to overcome the symptoms. Often, this
psychoeducation alone was enough
to bring relief to long-time pain
sufferers. In some cases, he referred
clients to psychologists specialising in
TMS for further treatment4,6
.
Physiology of TMS
When pain sufferers are initially
given a diagnosis of TMS, a common
response is, ‘Are you saying that it’s
all in my head?’ The answer is an
unequivocal, ‘No’. Although the origin
of the pain is not structural in nature,
the pain is most definitely real4,6,7
.
John Sarno theorised that the
autonomic nervous system is
responsible for the great majority of
chronic pain conditions. This system
controls the circulation of the blood
in the body: for example, an increase
of blood flow to the cheeks when a
person is embarrassed; a physiological
reaction to a psychological trigger. The
autonomic nervous system can also
reduce blood flow to certain muscles,
nerves, ligaments and tendons in the
body. When this occurs, there is less
oxygen available to the tissues, and
the result will be symptoms, such
as pain, numbness, tingling, and
sometimes weakness4
. Various studies
have supported this hypothesis20,21,22
.
mindbody medicine
Continued from overleaf.
awareness about the potentially disabling consequence of whiplash injury. The
researchers were interested in whether this lack of awareness would impact
on the syndrome’s prevalence. They interviewed 202 collision victims, as well
as 202 control subjects. Their findings stunned the medical community. Not
a single collision victim had persistent head or neck pain as a result of their
accident12
. The syndrome simply did not exist, prompting one medical journal
to publish an article entitled, ‘The best approach to the problem of whiplash?
One ticket to Lithuania, please’13
.
The surprising results of the Lithuanian study led a group of researchers
to hypothesise that the cause of chronic whiplash was unrelated to physical
injury. To test this theory, they set up an experiment where 51 volunteers
were involved in a placebo collision. The study involved a simulated car
crash, with corresponding sights and sounds to make it appear to the subjects
that an accident had taken place, though there was virtually no physical
impact on the body. Three days after this placebo collision, 20 per cent of
the study subjects reported symptoms of whiplash, and four weeks after
the experiment, 10 per cent were still symptomatic. The mere thought that
one was in an accident was sufficient to bring about pain in these subjects.
Furthermore, the researchers found that psychological factors were highly
predictive in determining who would develop pain14
.
Back pain
In the USA, low back pain is second only to the common cold as the reason
cited by patients for seeking medical care15
. But despite the fact that manual
labour has decreased, and medical technology vastly improved, back pain
is far more prevalent than it was 40 years ago16
. Indeed, between 1964 and
1994, the rate of disability claims related to low back pain increased by 14
times the rate of population growth15
.
Although magnetic resonance imaging (MRI) is often used to diagnose the
source of back pain, it is an ineffective assessment tool. Authors of a New
England Journal of Medicine article found that 64 per cent of people with
no back pain have disc bulges or protrusions, and concluded that such spinal
abnormalities are often incidental and unrelated to pain16
. Further studies
have indicated that there is no relationship between lower back pain and disc
degeneration17
. In fact, 85 per cent of back pain has been found to have no
apparent physical cause18
. Like whiplash, the enigma of chronic back pain has
continued to puzzle the medical community.
A group of researchers at the University of Washington shed some light
on this phenomenon. In one of the largest studies ever conducted on back
pain, the investigators found that psychological factors were more predictive
of the onset of back pain than any of the physical variables analysed. Of
particular interest, they found that subjects who stated that they ‘hardly ever’
enjoyed their work tasks were two and a half times more likely to report
back pain than subjects who ‘almost always’ enjoyed their work tasks.’19
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14 HCPJ January 2010

17. TMS: a practitioner perspective
TMS recovery: a UK perspective
My work as a physiotherapist of over 20
years was until recently based on physical
diagnoses and a physical approach to
treatment. Nevertheless, for many years
I was puzzled by inconsistencies in the
ways that patients presented and their
treatment outcomes. For example, why did
so many patients with diagnosed structural abnormalities,
such as spinal stenosis, severe disc degeneration and
prolapse, become pain free, and remain so, after gentle
hands-on treatment, some even cancelling spinal surgery?
Why did so many ‘injuries’ have no apparent cause, and pain
persist despite no definitive diagnosis?
My search for answers to these questions involved
extensive reading and research on the mindbody relationship,
and my discovery of tension myoneural syndrome (TMS).
My professional development into working with patients
with TMS included visiting John Sarno in New York in 2007,
and ongoing peer review with other TMS specialists in the
USA (where the majority of practitioners work with patients
individually, with just a handful running more structured
programmes, like Sarno’s). Most TMS recovery programmes
involve individual face-to-face appointments and/or group
sessions, and one is run completely online.
The decision to develop my own TMS recovery programme
was based on a desire to provide a structured course that
could be available to anyone, as long as they attended
initially for diagnosis. The programme follows an initial six-
week phase, supported by a course workbook, and regular
follow-up via telephone or face-to–face meetings, a web-
based seminar (webinar) and email support throughout.
Ongoing support is available to those who need it, and has
been taken up throughout the UK and Europe.
A retrospective study into the results of patients with
TMS attending the Huddersfield Pain Relief Centre showed
that 20 of the 24 who followed either the full TMS recovery
programme or their own self-directed learning after a
diagnosis, reported a greater than 80 per cent subjective
improvement in pain and functioning. Similar results were
recorded a year later in the 20 patients who could be
contacted, reinforcing for me the importance of this work,
especially for those who have tried everything else but are
still living with chronic pain.
My own steps to raise the profile of TMS in the UK
have included delivering seminars to medical doctors and
other healthcare professionals. Undoubtedly, mainstream
medical thinking around chronic pain continues to hold
back the development of TMS awareness, despite an interest
among some GPs. My ongoing plan is to develop a training
programme for medical professionals who are interested in
TMS, and eventually to set up a research project to study the
results in people undertaking TMS recovery. n
Georgina Oldfield is a chartered physiotherapist at the Pain Relief
Centre in Huddersfield, where she works using the TMS model. For
further information see www.tmsrecovery.com
As a chiropractor for over 20 years, I
have treated many people with recurring
back and neck pain, sciatica, migraine
headaches and other physical pain.
X-ray and MRI results have indicated
problems in their spines, including
subluxation, disc degeneration, spurs,
and other abnormalities, which were usually pointed to as
the physical causes of the pain. Over recent years I found
I wanted to learn more about the mindbody connection,
so I completed a graduate programme in counselling. This
was when I researched tension myositis syndrome (TMS,
recently renamed tension myoneural syndrome) and the
corresponding theory that these findings are ‘normal
abnormalities’ that do not necessarily cause pain.
I soon began to recognise that patients who complained
of pain ‘only when standing’ or ‘only when exercising’ could
have TMS. I began to see patients in my practice who had
had a sudden onset of back or neck spasm so severe that
it kept them from work or normal daily activities, and on
inquiry found that a strong emotional stressor had usually
preceded the spasm. The evidence that TMS was present in
the majority of the chiropractic patients I was seeing became
so obvious to me after just a few months that I decided to
train with a TMS doctor to learn more. After attending his
workshops, I started educating my chiropractic patients
about TMS, and also developed a two-part workshop for
those who could accept the diagnosis of TMS and wanted to
end their pain.
I also see symptoms of TMS in my counselling clients.
Chronic pain limits a person’s ability to function fully, and
as a result clients may suffer depression, anxiety and other
psychological maladies. If a client is open to the idea that
TMS may be the cause of their pain, and undergoes a physical
examination to rule out physical causes, he or she can learn
how the unconscious mind is the origin of the physical pain.
The work John Sarno pioneered has helped many people
who are no longer restricted by physical pain, and have
gained a much deeper understanding of themselves. I look
forward to the day that this information becomes common
knowledge, and is utilised by healthcare professionals of
all types as another tool to alleviate human suffering and
decrease the enormous cost of medical care that burdens
society. n
Audrey Berdeski has been a chiropractor for over 20 years and is also
a psychodynamically trained psychotherapist who specialises in mind-
body healing.
mindbody medicine
HCPJ January 2010 15

18. When diagnosed with TMS, clients
are told that their pain, although
quite real, is not caused by structural
damage, but is a physical response to a
psychological process. In other words,
the mind is responsible for generating
the pain. This of course begs the
question: Why?
The purpose of TMS pain
Our bodies often try to help us in
ways that are difficult to understand.
Anxiety attacks, for example, are often
unwelcome and burdensome, but the
body’s underlying goal in producing
one is to increase the chances of
survival against a perceived threat23
.
The result may be unpleasant, but the
intent is noble. Our bodies are trying
to help us.
It is the same with pain. In 1918,
psychiatrist Henry Maudsley wrote
that ‘The sorrow which has no vent in
tears may make other organs weep’24
.
When our habitual ways of coping
psychologically are overwhelmed,
we are capable of somaticising
psychological pain25
. In such cases, the
mind senses that the emotions are too
painful to experience, so it attempts to
protect the psyche. Experiencing the
pain physically, as terrible as it may
feel, is more tolerable than feeling the
depth of the psychological pain.
This is primarily an unconscious
process. Neuroscientist Paul Whelan
wrote that ‘Most of what we do every
minute of every day is unconscious’26
.
Because of this, many people are
not aware that they have repressed
emotions. In fact, when many TMS
clients are initially interviewed,
they report that psychologically
they are ‘feeling fine’. It is only on
further inquiry that emotional pain is
discovered.
Due to a variety of life experiences,
certain emotions have the capacity
to become ‘off limits.’ For example, a
child who grows up with an alcoholic
mother may learn that anger is too
scary. An adolescent who was not
allowed to fully grieve her father’s
death may learn that sadness is not
acceptable. TMS clients avoid a variety
of feelings, including anger, sadness,
helplessness, dependency, envy, rage,
guilt, even happiness.
Sarno and the psychologists he
worked with found that when TMS
clients were focused on their physical
pain, they were less apt to focus on
deeper psychological pain7
. Many if
not most people have experienced the
process of distracting themselves from
difficult emotions. To relieve anxiety
or depression, people overeat, smoke,
drink alcohol, use drugs and bite
their fingernails. All these activities
serve to shift a person’s focus from
their emotional pain to a different
sensation. The generation of physical
pain is simply the mind’s way of
shifting this focus for us.
Treatment of TMS
Before a diagnosis of TMS is given,
it is essential that a physician rules
out a purely physical cause for a
client’s pain symptoms. Once TMS
has been clinically diagnosed, the
client’s acceptance of the diagnosis
is an integral part of recovery. This is
because as long as a client continues
looking at the pain physically, it will
continue to serve its psychological
purpose7
. One of the roles of the
TMS practitioner is to help the
client look at their pain as the
somatic expression of underlying
psychological processes. This is done
by educating the client with regard to
the effects of emotions on the body,
as well as pointing out correlations
between the physical pain and
emotional issues (E Sherman, personal
communication, 9/5/09).
One of the primary goals of TMS
treatment is to help clients reframe
the meaning of their pain4
. Instead of
focusing on the pain with a sense of
frustration, fear, and powerlessness,
the client learns to use the pain
as a guide to introspection7
. My
pain just increased, what is going
on psychologically right now? The
symptoms often serve as a signpost to
unaddressed emotional issues.
The pain exists for a reason. It is a
manifestation of emotions that, due
to experiences generated throughout
one’s life, have become difficult
to tolerate. An essential part of
treatment is to help clients learn to
recognise and identify these difficult
to tolerate emotions, and eventually
accept and express these painful parts
of themselves (E Sherman, personal
communication, 9/5/09).
As a result of Sarno’s treatment
programme, many of his chronic pain
clients began showing significant
improvement. Indeed, he had a much
higher success rate treating pain
psychologically than he had had
years earlier utilising a variety of
physical interventions. However, after
Once TMS has been clinically
diagnosed, the client’s acceptance of the
diagnosis is an integral part of recovery
mindbody medicine
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16 HCPJ January 2010

19. publishing his findings in the late
1970s and early 1980s, and despite
the success of the TMS model, he
encountered significant resistance
from the medical community,
because the concepts it emphasised
contradicted mainstream medical
thinking7
. There was little belief at
the time that the mind was capable
of such profound effects on the body.
As a result, TMS treatment remained
relatively unknown.
Evidence for TMS
Sarno conducted three formal
retrospective studies at the Rusk
Institute in 1982, 1987, and 1999
to assess the effectiveness of TMS
treatment. In all, 371 randomly
selected chronic pain clients were
interviewed six months to three
years after treatment to determine
their level of pain and functional
ability. A total of 72 per cent
reported being free or nearly free
of pain with unrestricted activity,
while 16 per cent reported some
improvement, and 12 per cent
little to no improvement4,6,7
. One of
these three studies was unique in
that it included only clients with
documented herniated discs. Over
a third had been previously advised
by physicians to undergo surgery.
However, when interviewed between
one and three years after TMS
treatment, a remarkable 88 per cent
of these clients reported being free or
nearly free of pain4
.
Howard Schubiner of Providence
Hospital, Michigan, in conjunction
with researchers at the University
of Michigan, recently conducted the
first randomised controlled study of
TMS treatment. The study involved 45
clients with fibromyalgia, 24 of whom
were treated with a TMS approach
and 21 of whom were assigned to
a wait-list control group. After six
months, the intervention group had
significantly lower pain severity and
higher self-reported physical function.
Further randomised controlled trials
comparing the effectiveness of TMS
treatment to other pain treatment
models are currently underway
(H Schubiner, personal
communication, 28/7/09). In addition,
several functional MRI (fMRI) studies
(which measure brain activity) to
assess the pain pathways in the brain
before and after TMS treatment
are under discussion. These and
other studies aim to provide further
scientific evidence for the efficacy of
TMS treatment.
The future of TMS
For years, dozens of physicians and
psychologists have been treating
pain clients from a TMS perspective
throughout the USA and Europe. In
March 2009, they came together in
Ann Arbor, Michigan, for the first
professional TMS conference. At this
conference, research was presented,
theories discussed, and plans put into
place to bring greater awareness of
TMS to the medical community and
populations at large.
At present, a formal TMS
Association is in development, an
accreditation programme is in the
works, and funding for research
is being generated. The second
professional TMS conference is
scheduled for March 2010.
When John Sarno first introduced
the concept of TMS, the mind and
the body were looked at primarily
as independent entities. Physical
symptoms were treated physically,
and psychological symptoms treated
psychologically. Now, more than ever
before, the scientific community is
embracing the connection between
the mind and the body: eminent
neurobiologists are writing books
on the benefits of meditation,
prestigious universities are developing
psychoneuroimmunology centres.
Patrick Wall’s call for a paradigm shift
in the way we view physical pain is
taking place.
TMS treatment is gaining
momentum, and author and
physician, Dr Marc Sopher, speaks for
many when he writes: ‘Ultimately, I
am confident that TMS theory will
become part of mainstream medicine
for the simple reason that it is correct,
and more successful at alleviating
pain than any other modality’27
. n
Alan Gordon is a psychotherapist in Los
Angeles, California, and specialises in the
treatment of chronic pain.
He can be reached via email at
alantgordon@yahoo.com
References
1 Melzack R, Wall P. The challenge of pain.
London: Penguin Group; 2008.
2 Rosenblum A, Herman J, Fong C, Kipnis
S, Cleland C, Portenoy R. Prevalence
and characteristics of chronic pain
among chemically dependent patients in
methadone maintenance and residential
treatment facilities. JAMA 2003; 289:
2370-8.
3 National Institute of Health. NIH
guide: New directions in pain research I.
September 4, 1998. Available via: http://
grants.nih.gov/grants/guide/pa-files/
PA-98-102.html Accessed 7/10/09.
4 Sarno J. Healing back pain. New York:
Warner Books; 1991.
5 Wossmer B, Loosli P, Hochstrasser J.
Multidisciplinary treatment of chronic
pain – opportunities and challenges for
collaboration between psychosomatic
medicine and physiotherapy.
Therapeutishce Umschau 2007; 64(10):
595-9.
6 Sarno J. The mindbody prescription:
Healing the body, healing the pain. New
York: Warner Books; 1998.
7 Sarno J. The divided mind: The epidemic
of mindbody disorders. New York: Harper
Collins Publishers Inc; 2006.
8 Mills H, Horne G. Whiplash - manmade
disease? N Z Med J 1986; 99: 373–4.
9 Warning over whiplash ‘epidemic’. BBC
News. November 15, 2008: 1-3. Available
via: hppt://news.bbc.co.uk/2/hi/
health/7729336.stm.
10 Grady D. In one country, chronic
whiplash is uncompensated (and
unknown). Medical Science, New York
Times; May 7, 1996.
11 Malleson A. Chronic whiplash.
Psychosocial epidemic. Can Fam Physician
1994; 40: 1906-9.
12 Schrader H, Obelienniene D, Bovim G
et al. Natural evolution of late whiplash
syndrome outside the medicolegal
context. Lancet 1996; 347: 1207-11.
13 Ferrari R, Kwan O, Russell AS, Schrader
H, Pearce JMS. The best approach to
the problem of whiplash? One ticket to
Lithuania, please. Clin Exp Rheumatol
1999; 17: 321-6.
mindbody medicine
HCPJ January 2010 17

20. title?
I
n 2005, an
editorial in the
BMJ commented
that, ‘Current
theoretical and
practical training
in medically
unexplained symptoms (MUS) is
insufficient in most university
curricula and general practitioner
postgraduate training programmes’1
.
The majority of teaching in medical
schools concerns clear physical
symptoms linked with physical
findings and leading to a medical
diagnosis. It may not be until they
have qualified that young doctors
become aware of just how common
less clear-cut presentations are, which
can lead to uncertainties and anxieties
for both doctors and their patients
if there is doubt about how best to
manage such issues.
At University College London
(UCL) Medical School, fourth year
undergraduate medical students have
a three-hour teaching session on
MUS and somatisation during their
psychiatry rotation. This has been
running since 2003, and the tutors are
a small group of academic GPs with a
special interest in mental health issues.
Although it constitutes only a small
amount of teaching, this is more than
is given at most medical schools, many
of which do not appear to provide
any formal teaching in this area. The
session is divided into two parts: the
first half covers the concept of MUS
and acute somatisation, explaining
the definitions and helping students
Teaching trainee
doctors about
medically unexplained
symptoms
GPs often receive next to no training in dealing with
patients with medically unexplained symptoms. Yet
a little training in this area can go a long way, writes
Marta Buszewicz
to identify common symptoms or
presentations they may have seen that
fit the criteria. We discuss possible
reasons for such presentations,
including factors such as a family
history of physical symptoms being
used to indicate emotional distress.
The most important part of the
session is probably a discussion
about the management of such
presentations. We emphasise that
it is not a good idea to send people
for complex investigations simply to
provide reassurance if these are not
otherwise indicated. There is evidence
that, although negative investigations
may reduce people’s anxiety in the
short-term, in the longer term patients
are likely to be made more anxious by
having complex medical investigations
carried out for MUS, as it can make
them fear that their doctors are
concerned there is something serious
going on that has not been identified.
We encourage the students to give
clear explanations to patients as to
what may be causing their symptoms
(for example, an increased awareness
of normal physiological stimuli), as
well as screening for symptoms of
anxiety and depression in case there
is an accompanying psychological
difficulty. We stress the importance
of working with patients to find an
explanation which makes sense to
both the patient and the physician,
and which hopefully reduces the
anxiety patients may have about their
symptoms.
The teaching session is illustrated
by videos of GP-patient interactions,
14 Castro WH, Meyer SJ, Becke ME,
Nentwig CG, Hein MF, Ercan BI et al.
No stress - no whiplash? Prevalence
of ‘whiplash’ symptoms following
exposure to a placebo rear-end collision.
International Journal of Legal Medicine
2001; 114: 316-22.
15 Jensen M, Brant-Zawadzki M,
Obuchowski N, Modic M, Malkasian
D, Ross J. Magnetic resonance imaging
of the lumbar spin in people without
back pain. The New England Journal of
Medicine 1994; 331: 69-73.
16 Harkness E, Macfarlane G, Silman
A, McBeth J. Is musculoskeletal pain
more common now than 40 years ago?:
Two population-based cross-sectional
studies. Rheumatology 2005; 44(7):
890-5.
17 Savage RA, Whitehouse GH, Roberts
N. The relationship between the
magnetic resonance imaging appearance
of the lumbar spine and low back pain,
age, and occupation in males. European
Spine Journal 1997; 6(2);106-14.
18 White AA, Gordon SL. Synopsis:
Workshop on idiopathic low-back pain.
Spine 1982; 7: 141-9.
19 Bigos SJ, Battié MC, Fisher LD et al. A
prospective study of work perceptions
and psychosocial factors affecting the
report of back injury. Spine 1991; 16(1):
1-6.
20 Fassbender HG, Wegner K.
Morphology and pathogenesis of soft
tissue rheumatism. Z Rheumaforsch
1973; 32(9): 355-74.
21 Lund N, Bengtsson A, Thorborg P.
Muscle tissue oxygen pressure in primary
fibromyalgia. Scandinavian Journal of
Rheumatology 1986; 15: 165-173.
22 Ashina M, Stallknecht B, Bendtsen L
et al. In vivo evidence of altered skeletal
muscle blood flow in chronic tension-
type headache. Brain 2002; 125: 320-6.
23 Levine P, Frederick A. Waking the
tiger: Healing trauma. Berkley, CA: North
Atlantic Books; 1997.
24 Lutz T. Crying: The natural and
cultural history of tears. New York:
Norton & Company; 1999.
25 McDougall, J. Theaters of the
body: A psychoanalytic approach to
psychosomatic illness. New York: W.W.
Norton; 1989
26 Szegedy-Maszak M. Mysteries of the
mind: Your unconscious is making your
everyday decisions. US News and World
Report 28/2/05; 53-61.
27 Sopher M. A family doctor’s
experience with mindbody medicine.
In: Sarno J. The divided mind. New York:
Harper Collins; 2006.
mindbody medicine
18 HCPJ January 2010

21. The majority of teaching in medical
schools concerns clear physical symptoms
linked with physical findings and leading to
a medical diagnosis. It may not be until they
have qualified that young doctors become
aware of just how common less clear-cut
presentations are
filmed using a real GP and an actor as
a simulated patient. They demonstrate
the ways in which people may present
with MUS, and give examples of
helpful and not-so-helpful discussions
with the doctor; which are followed
by a group discussion. The second half
of the teaching session covers chronic
presentations of somatisation and the
predisposing factors for these, as well
as suggested management approaches.
This again emphasises not over-
investigating new symptoms if they
do not suggest serious disease, and
addressing any psychological or social
factors that may be present.
The teaching session has consistently
been highly rated by UCL medical
students in their anonymous feedback
as interesting and valuable to them.
More recently we have been invited to
extend this teaching to GP trainees on
the recommendation of several former
GP trainees who joined our department
and said they wished they had had
such a session during their training. GP
trainees are doctors in their final three
years of training in general practice
before they become qualified GPs, and
who are likely to be being exposed to
presentations of MUS in much greater
numbers than they have come across
previously. Studies of qualified GPs
indicate that they often find such
patients stressful and frustrating2
, so
it seems important to talk about ways
of working with these problems at an
earlier stage, when young doctors are
forming opinions on such consultations
and learning how best to manage
them. We have so far taught this
session only once to GP trainees, but
their response was extremely positive,
so we plan to extend it to other groups
of GPs in training in north London.
We give the GP trainees a similar
training session to that which we
deliver to medical students, although
tailored to suit their specific needs.
We also ask the trainees to complete
questionnaires about their attitudes
to working with such patients, both
before the training session and a
couple of months afterwards, to
see if there is any change, as well
as conducting in-depth qualitative
interviews to uncover more detail
of what they think and feel about
working with such patients. The
longer-term aim is to develop teaching
modules which can be used more
widely in medical schools and GP
training schemes nationally. n
Dr Marta Buszewicz is a part-time GP
and Senior Lecturer in Primary Care in the
Research Department of Primary Care
& Population Health, University College
London.
References
1. Rosendal M. Management of medically
unexplained symptoms. BMJ 2005; 330: 4-5.
2. Wileman L, May C, Chew-Graham A.
Medically unexplained symptoms and
the problem of power in the primary acre
consultation: a qualitative study. Family
Practice 2002; 19: 178-82.
training doctorsGetty
HCPJ January 2010 19

22. Exploring the meaning of
medically unexplained symptoms
For a minimum
of 20 per cent of
consultations in
primary care, no
organic cause can be
found for presented
symptoms of physical
ill-health1,2,3
. Research suggests that the
proportion rises to at least 33 per cent
of presentations in specialist outpatient
clinics4
. Such physical ailments
without evidence of organic disease
are commonly known as medically
unexplained symptoms (MUS)5
. Rief
et al6
identify such symptomatology
as common in the general population.
As individuals search for help, the
repeated reassurance that nothing is
wrong can expose them to a sense of
shame and humiliation7
. In the long
term, the high utilisation of medical
services8
and inability to achieve
resolution leaves sufferers with feelings
of hopeless dissatisfaction9
and a
chronic sense of disability.
There has been much debate in
recent years regarding the naming
and classification of MUS, alongside
trials of cognitive behavioural
treatment programmes10
. There are
Medically unexplained symptoms may represent an attempt to heal from
unacknowledged, deeply unpleasant emotions, according to the findings of a
small-scale study by Jean Penman
fascinating accounts of casework and
theoretical perspectives11
. Yet despite
the high cost of MUS in terms of
consultations and investigations, little
resourced attention has been paid to
implementing an effective healthcare
pathway for sufferers within the NHS.
This article reports the findings of a
qualitative pilot study, undertaken to
explore patient stories in depth to see
what could be learned. The aim was
to identify common themes in the
development of medically unexplained
symptoms that could provide evidence
to support the development of a
patient-centred care pathway.
Methods
A qualitative method of
research known as interpretative
phenomenological analysis (IPA)12
was used to explore individuals’
perspectives on their ill health and
formulate tentative themes through
analysis of participants’ interviews.
Semi-structured interviews were
initially prepared; the format was
subsequently adapted towards the use
of a free association narrative interview
method13
.
Entry criteria for participants were
as follows:
• Symptoms remaining medically
unexplained and/or unresponsive
to treatment at the time of
interview
• At least six months’ experience of
the same set of symptoms
• Referred (at some stage) by their
GP to a specialist consultant for
the diagnosis of their symptoms
• Seen at least once by a specialist
physician/surgeon
• Over 18 years of age
• Unknown previously by the
researcher either in a work or
social capacity.
Colleagues were asked if they knew
of anyone who met the criteria, who
would be willing to be involved in the
study. Potential subjects were initially
sent a participant information sheet,
written in user-friendly language
and mailed to the subject’s preferred
address. This outlined the design of
the study and requirements of the
participants and researcher, and
covered issues of confidentiality, data
protection, the right to withdraw at
any time and the right to refuse to
answer any of the questions without
detriment. Participants were advised
of their right to contact the research
supervisor at any time and of a
pathway to primary care counselling
should distressing issues arise on which
they required further help. Participants
were also asked for their consent to
use short extracts from the transcripts
for the purposes of research, teaching
and future publication. All these
elements were discussed in person
with participants at our first meeting.
Taped interviews were conducted
in individual participants’ homes for
one hour each on two occasions, at
least a week apart. The format of
the interviews is given in Table 1.
First interview
1. Can you tell me a little about yourself and your physical symptoms?
2. What do you consider is the cause of the symptoms?
3. What do others think is the cause?
4. How does your ‘condition’ affect you? And your relationships/work/future?
5. Do you think your body is telling us something?
Second interview
1. How have you been since we met?
2. What did you think and feel about the first interview?
3. Researcher to explore the lead of the participant – focusing on feelings expressed
when the person talks about their symptom(s).
Table 1. Interview framework
20 HCPJ January 2010