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
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
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
"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
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
This is intended to reassure the patient, yet the effect may be just the
"All patients get is a 21st-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
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
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>.▪