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Patients Need Help With Unexplained Symptoms

Patients with medically unexplained symptoms have a memory bias that overestimates the probabilities of explanations they hear during visits to the doctor.

Between 25 percent and 50 percent of primary care visits include some discussion of symptoms that the physician cannot explain with a conventional medical diagnosis. These medically unexplained symptoms are the "bane of modern medicine," but the primary care system is not equipped to handle such complaints, according to Javier I. Escobar, M.D.

Escobar is a professor and chair of the Department of Psychiatry at the University of Medicine and Dentistry of the New Jersey Robert Wood Johnson Medical School in Piscataway, N.J.

These symptoms are probably less the result of conditions unknown to medical science than to some form of psycho-social distress, said Escobar in an interview. Physicians generally try to allay the concerns of such patients by telling them that their symptoms are not the result of some physical illness. However, such verbal reassurance does not seem helpful with these patients.

A new study says that such attempts at reassurance may not work because patients appear to recall doctors' conclusions selectively. The study examined responses of 85 subjects to fictional audiotaped reports describing a medical situation, a social situation, and a "neutral" situation involving a car crash. The subjects were divided into a somatization group (with unclear medical symptoms), a clinical control group with major depression, and a healthy control group. A group with confirmed medical disorders was not included. Subjects were asked to rate the likelihood of a medical explanation of the symptoms described in the tapes.

The study was conducted by Winfreid Rief, Andrea Maren Heitmuller, Katja Reisberg, and Heinz Ruddel of the Department of Clinical Psychology at the University of Marburg, Germany, and appeared in the August online journal Plos Medicine.

All three groups exhibited the same general memory ability, but the patients with medically unexplained symptoms overestimated the likelihood of medical causes of symptoms, said the authors. "This bias in remembering likelihood estimates was found only for the medical report situation, not for the social or neutral situation."

The differences between the groups were modest but statistically significant. About 15 percent of patients with unexplained symptoms saw a medical explanation of the events, compared with 10 percent of the depressed subjects and 5 percent of the healthy controls.

The results indicate that patients with unexplained symptoms have a memory bias that overestimates the probabilities of causes they hear during visits to the doctor.

"Our results show that medical reassurance and the presentation of negative test results can lead to patients' remembering overestimated probabilities for medical explanations, especially in patients with unclear somatic complaints," wrote Rief and colleagues. "Check-back questions on what patients have understood from doctors' reports and asking patients for summaries about the provided information could help to detect this memory bias and offer the opportunity to correct the remembered likelihood estimates."

The exigencies of contemporary primary medical care may work against that solution, said Escobar, who also wrote an editorial accompanying the article by Rief and colleagues.

"Primary care people are trained to do quick, seven-minute assessments," said Escobar. When facing unexplained symptoms, they are inclined to tell patients: "There's nothing medically wrong with you."

This is intended to reassure the patient, yet the effect may be just the opposite.

"All patients get is a 21^st-century reassurance, a brief mechanical statement that they don't have some medical condition," said Escobar. "I don't think it's really reassuring."

A closer examination of these patients' symptoms might reveal that most meet the criteria for anxiety or depression, he said. Cognitive-behavioral therapy appears to work better than medications or other interventions in this group.

The ideal solution to helping patients with unexplained symptoms, said Escobar, is to make psychiatrists and psychologists available at primary care sites to apply brief, nonpharmacological interventions in the examining room.

His department is trying just that under the terms of a grant from the National Institute on Mental Health, but the problem remains how to do it in the real world. Some systems (like Kaiser-Permanente) have used psychiatric nurses or psychologists in primary care settings to help identify patients with depression, but reimbursement remains a problem in other systems.

"We need to work more closely with primary care physicians and transcend the boundaries of the psychiatric clinic," said Escobar.

"Why Reassurance Fails in Patients With Unexplained Symptoms—An Experimental Investigation of Remembered Probabilities" is posted at <http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0030269>. "Does Simple `Reassurance' Work in Patients with Medically Unexplained Physical Symptoms?" is posted at <http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0030313>.

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