Medically Unexplained Neurologic Symptoms: A Primer for Physicians Who Make the Initial Encounter

Abstract

Medically unexplained symptoms are ubiquitous in clinical practice. Medical use costs of medically unexplained symptoms are projected at approximately $256 billion per year. When initially seen, these symptoms are often baffling, not only to the patients but also to the physicians who encounter them. Because of this, properly diagnosing them is seen generally as difficult at best, leading to massive overuse of unnecessary testing. Subsequently, their management can be cumbersome. All this burdens the patients with unnecessary costs, financially and emotionally. This primer discusses historical perspectives of these and the changing nomenclature, and outlines how to think about these complex symptoms and neurologic findings that will enable a positive diagnosis rather than a diagnosis of exclusion. We also offer useful heuristic principles of their management so that physician-patient relationships can be better maintained and the quality of life of these patients can be improved by way of some simple, economic approaches.

Quantifying positive communication: Doctor’s language and patient anxiety in primary care consultations

“…This diagnosis per exclusionembased on what is not wrongis perhaps reflected in the absence of a different message strategy in positive messages for patients with MUS. Recently, however, it has been argued that the nomenclature of unexplained symptoms should be based on positive diagnosis rather than exclusion of other possibilities [41]. The emphasis should be on what complaints the patient does have instead of which symptoms are not present.…”

Minimum Electromyographic Burst Duration in Healthy Controls: Implications for Electrodiagnosis in Movement Disorders

“…Making the correct diagnosis in certain hyperkinetic movement disorders can be challenging, particularly when FMD is within the differential (eg, dystonia, 16 myoclonus 17 ). When FMDs are not recognized, unnecessary and costly investigation ensues, 18 appropriate early therapeutic interventions may not be provided, 19,20 and of more concern, inappropriate (and occasionally high risk) therapeutic interventions are considered 21 …”

Are Patients with Psychogenic Movement Disorders More Likely to be Healthcare Workers?

“…Yet many authors continue to list employment in healthcare as a hint or clue suggesting a PMD. 7,8,16,18,19,21,22,25,26 The origin of the suggestion that PMD patients are more likely to be employed in healthcare is unknown. The earliest mention of such an association lists "Employed in allied health professions" in a table entitled, "Other medical factors suggesting psychogenic tremor" by Koller et al 19 By 2009, "Employed in allied health professions" was still listed as a diagnostic clue but was qualified as "infrequent," suggesting that some doubt had been cast on the validity of this association.…”

“…18 Reported risk factors for the development of a PMD include young age, female gender, history of abuse, current or past psychiatric disorder, lower levels of education and socioeconomic status, and employment as a healthcare worker. 5,7,8,16,[19][20][21][22][23][24][25][26] That healthcare workers are at greater risk for development of a PMD comes from the idea that disorders observed in the workplace are assumed by the vulnerable patient. 15 Yet, despite its repeated mention in the PMD literature, based largely on anecdotal evidence, 7,8,16,18,19,21,22,25,26 employment in healthcare has not been validated as occurring more frequently in patients with a PMD compared to organic movement disorders.…”