The term “medically unexplained symptoms” describes symptoms for which no clear medical cause is found. Medically unexplained symptoms are common and represent 15-30% of all visits to primary care doctors. Common symptoms that may be unexplained include fatigue, dizziness, and various pains. Medically unexplained symptoms are also common reasons for referrals and are frequently seen by specialists. Common symptoms seen by specialties include chest pain (cardiology), pelvic pain (gynecology), shortness of breath (pulmonology), abdominal pain (gastroenterology), and neurologic symptoms (neurology).
Medically unexplained symptoms can reflect one of four underlying realities:
There is a medical cause (also referred to as an organic cause or physiological reason) for the symptom but the patient’s medical team hasn’t figured it out. This could be because the presenting symptoms are nonspecific, meaning that the same symptom can result from multiple causes. As an example, fatigue can be a symptom of heart failure, multiple sclerosis, anemia, thyroid dysfunction, sleep apnea, malaria, and dozens of other illnesses. It could also be because the underlying cause is rare (or even unknown) and the patient has not yet seen someone who can figure it out. Lastly, it may be the patient’s medical providers have a bias that is preventing them from coming to the correct diagnosis. Provider biases can arise from stereotypes (e.g. this Black man is coming to the ED complaining of pain because he is an addict), past experiences (e.g. almost every patient I see with fatigue has sleep apnea so that must be the cause), or jumping to premature conclusions and not being willing to listen to further evidence.
There is a psychological cause for the symptom but the patient does not believe this is the true cause or the patient’s medical team hasn’t uncovered or communicated this possibility clearly. Psychological factors are common causes of physical symptoms. These factors can include acute stress (e.g. your child develops abdominal pain in the morning on school days because they are having trouble at school), anxiety (common symptoms include insomnia, fatigue, chest pain, shortness of breath), and depression (common symptoms include memory loss, difficulty concentrating, abdominal pain). It has also been found that people who have experienced significant traumas may be more prone to developing physical symptoms due to the impact of trauma on their brain, body, and nervous system.
There is a lifestyle cause for the symptom but the patient does not believe this is the true cause or the patient’s medical team hasn’t uncovered or communicated this possibility clearly. By lifestyle cause, I am referring to daily behaviors that can impact your health, or in other words, good or bad habits. Lifestyle factors include diet, sleep, activity levels, exercise, work, chronic stress, relaxation, and use of substances (e.g. alcohol, tobacco or other drugs). While it is not surprising that what we do to our body regularly can cause symptoms and affect how we feel, it is also not uncommon to overlook these potential causes as they have become so routine that people often don’t notice them anymore as choices with consequences.
These symptoms are part of a more complex syndrome like fibromyalgia, chronic fatigue syndrome, myofascial pain syndrome, or multiple chemical sensitivity. These syndromes are common and also controversial (they are collectively known as “contested illnesses”) with significant active debate in the medical community as to whether there is an organic medical underlying cause. Regardless of the underlying cause, there is no doubt that these illnesses cause significant suffering and disability. Unfortunately, persons with these diagnoses often have to overcome significant stigma and discrimination in order to get proper and helpful care.
Medically unexplained symptoms cause significant distress to patients seeking answers and care. They also cause distress to healthcare providers who are often untrained in how to diagnose, treat, and communicate around these symptoms and who frequently find themselves trapped trying to do what they think the patient wants (i.e. give them more tests and a “real diagnosis”) and to not offend them in leading them to what they think is the right diagnosis.
In Part I of this series, we will look into when it is worth your while to seek additional testing and second (or third or sixth) opinions to secure a diagnosis.
In part II we’ll provide a broad overview of the fascinating topic of how psychological factors can cause physical symptoms with a focus on how to know if this might be the cause of your symptoms and how to begin getting them under control.
In Part III we will talk about lifestyle factors that can impact your health and lead to chronic symptoms as well as tips to improve these lifestyle choices.
In Part IV we will discuss contested illnesses, including multiple chemical sensitivities, fibromyalgia, and chronic fatigue syndrome, with a focus on how to optimize your diagnosis and care.