MUPS can also include symptoms (e.g., pain) that are inconsistent or out of proportion with identified disease or structural injury. MUPS is one of the most common diagnostic groups accounting for up to about 30% of primary care complaints and over 50% of new referrals to medical specialists. In addition to client suffering, MUPS can result in excessive and lengthy medical examinations despite normal findings, increased medical visits, poor treatment outcomes and client disability, secondary health anxiety, as well as client and health provider frustration.
Despite an enormous body of research indicating that our emotional systems have widespread effects on the body, emotional factors are still overlooked by many health care providers in cases of MUPS. Accordingly, clients are often given reassurance and told that their symptoms are benign, medically unexplained, or anxiety-based, which does not resolve the symptoms for many clients. Somatization is a common phenomenon that involves the automatic translation of unprocessed emotions into the onset or worsening of bodily symptoms and complaints for a large proportion of MUPS. From the toddler who gets a stomach ache leaving a parent for school to the executive who has an acute headache following conflict with a colleague, somatization can automatically convert emotions directly into physical, neurocognitive, and motor symptoms. Unfortunately, because standard medical testing does not routinely capture emotional factors, somatization patterns in MUPS often goes unaddressed.
COMMON SOMATIZATION PATTERNS
Chest and Abdominal Pain
Back, Neck and Joint Pain
Nausea and Digestive Problems
Fatigue and Sleep Problems
Dizziness, Confusion, and Weakness
Memory, Concentration, and Visual Problems
Dr. Elliott uses a diagnostic approach for MUPS applied in emergency, specialty, and family medicine settings affiliated with the Centre for Emotions and Health at Dalhousie University (https://medicine.dal.ca/departments/department-sites/psychiatry/research/emotions-health.html). The approach uses a collaborative emotion-focussed interview with clients interested in seeing if emotional factors may be part of their problems. The approach does not assume that somatization or emotional factors are present or absent in a particular case based on history or file information. Instead, the approach requires at least some client curiosity and willingness to investigate whether or not there is any direct evidence of emotional factors in a client’s symptoms during interview.
It is certainly understandable that some clients may have engagement barriers to participating in another assessment given that most referred clients have already had multiple investigations and repeated disappointments. Engagement barriers are addressed with clients during a brief orientation to the assessment so that they are able to actively participate in the interview for their own benefit. The diagnostic interview involves collaborative efforts to help clients carefully engage and observe their emotional processes, body responses, thoughts, and interaction patterns that emerge while repeatedly examining their symptoms and situations where they improve or worsen. Findings are continually reviewed and evaluated together based on how the body and symptoms respond during interview. Somatization is considered likely with significant increases, decreases, or removal of unexplained symptoms in relation to repeated emotional focus during interview. Importantly, the reality of the client’s symptoms is not in question. Instead, the cause of the symptoms is the focus of the diagnostic interview. Evidence of somatization or emotional factors in one’s symptoms opens the door for treatment targeting these factors directly for symptom removal rather than medical treatments that do not address emotional factors.
Based on degree of somatization and response to diagnostic interview, clients have a number of options. In cases with major symptom improvement or removal during interview, clients are referred for a follow-up session to assess if initial gains are maintained. In cases with clear evidence of emotional factors contributing to symptoms during interview, clients are referred for a course of emotionally-focussed therapy with monitoring for gradual symptom removal. A proportion of clients can also obtain symptom relief or removal from completing self-management approaches to somatization and related pain issues (e.g., www.curablehealth.com, www.unlearnyourpain.com). In cases with unclear or no findings consistent with emotional factors and somatization, clients can discuss whether or not to try additional interviews. Brief consults regarding diagnostic interview findings are also available for referring physicians and health providers for health care planning purposes. Please see MUPS Information Handout below for any interested clients.