The Joint Commissioning Panel for Mental Health has published: Guidance for commissioners of services for people with medically unexplained symptoms

The term Medically Unexplained Symptoms (MUS) refers to persistent bodily complaints for which adequate examination does not reveal sufficient explanatory structural or other specified pathology.

The Joint Commissioning Panel for Mental Health (JCP-MH)  is a collaboration co-chaired by the Royal College of General Practitioners and the Royal College of Psychiatrists.

This guide aims to:

  • describe MUS and the associated outcomes
  • outline current service provision for MUS and detail the components of a high quality comprehensive MUS service, and
  • highlight the importance of commissioning comprehensive MUS services.

The guidance gives a list of Functional Somatic Syndromes (aka MUS):

  • Irritable Bowel Syndrome (Gastroenterology)
    Bloating, constipation, loose stools, abdominal pain
  • Chronic Fatigue Syndrome/Myalgic Encephalomyelitis
    (Infectious Diseases, Endocrinology, Rheumatology, Pain Clinics)
    Fatigue (particularly post-exertional and long recovery) pain, sensitivity to smell
  • Post Concussion Syndrome (Neurology)
    Headache, vomiting, dizziness
  • Chronic Pelvic Pain (Gynaecology)
    Pelvic pain, painful sex, painful periods
  • Fibromyalgia/Chronic Widespread Pain (Rheumatology)
    Pain and tender points, fatigue
  • Hyperventilation (Respiratory Medicine)
    Chest pain, palpitations, shortness of breath
  • Non-cardiac chest pain (Cardiology)
    Shortness of breath
  • Temporo-mandibular Joint Dysfunction (Dentist, Oral Medicine)
    Jaw pain, teeth grinding
  • Multiple Chemical Sensitivity (Allergy clinic)
    Reaction to smells, light

The ME community challenges the classification of ME as medically unexplained:

carersfight blog post from Stonebird: Why ME must be removed from JCPMH

  • ME is not a Functional Somatic Syndrome (FSS)
  • Myalgic Encephalomyelitis (ME) is listed in the WHO International Classification of Diseases (ICD), chapter 6, under Disorders of Brain at ICD-10 G 93.3. It is not classified as a mental health disorder.
  • Numerous clinicians and researchers have affirmed many underlying biological abnormalities in ME
  • A “Functional Somatic” interpretation of ME creates a chicken and egg situation where you have to have the tests to prove you are ill, but the psychiatrists have denied you those tests , so you will not have the proof to prove you are ill.  Read more

Margaret Williams: Absence Of Evidence

For decades, the proponents of the now-infamous PACE Trial — particularly Professors Simon Wessely and Peter White — have maintained that without hard evidence of organic pathology, they will not accept the WHO classification of ME/CS as an organic disorder and they insist that it is a functional somatic syndrome (FSS).

In other words, ignoring the existing evidence-base of pathoaetiology, since there is not as yet a definitive test for ME/CFS, they believe that absence of evidence really is evidence of absence, so they continue to categorise ME/CFS as a behavioural disorder that can be “cured” by cognitive behavioural therapy (CBT) and graded exercise therapy (GET) and they advise Departments of State that these interventions are both effective and cost-effective.

Read more about the lack of evidence of both clinical benefit and cost effectiveness of CBT and GET for ME/CFS

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2 Responses to ME classified as a medically unexplained mental health issue by GPs & psychiatrists

  1. Liz says:

    ‘Guidance for Commissioners of Services for People with Medically Unexplained Symptoms’ by the Joint Commissioning Panel for Mental Health

    Q: When services have already been cut to the bone, where does the Government find an extra £20 billion plus in ‘efficiency savings?’
    A: Encourage doctors to diagnose patients who have challenging symptoms as being MUS patients in need of psychiatric care – psychotherapy – CBT- rather than sending them for further investigations and assessments, thereby cutting secondary care costs by reducing outpatient clinics and other diagnostic services.

    The above document is seriously flawed and discriminates against women. It cites references that directly contradict what is written in the text. I have notified the Health and Wellbeing Boards in England about this but they’re not interested, they told me to contact the JCPMH! So much for them “work[ing] together to improve the health and wellbeing of their local population and reduce health inequalities.”
    Examples of glaring flaws –

    On page 6 of the JCPMH document the authors state that:

    “On average, 52% of patients accessing outpatient services have MUS, with the highest rates relating to gynaecology clinics (66%) and the lowest rate (37%) relating to dental services.” – and shows the table. But the cited paper says that
    “This study has limitations. Firstly, the required sample size was not obtained due to the low response rate.” And “Secondly, although we considered using the diagnosis stated in case notes 3 months after the initial visit as an improvement in defining medically unexplained symptoms, the final diagnosis is still subject to change afterwards. This may cause over diagnoses of medically unexplained symptoms which later may be reversed.” So not a good study to cite!
    On page 6 of the JCPMH document the authors say that “The risks or associated factors for MUS include being female, younger in age, and currently employed”. They cite reference number 18 for this statement.
    Except when you read that referenced paper -“Childhood risk factors for adults with medically unexplained symptoms: results from a national birth cohort study” by Hotopf M, Mayou R, Wadsworth M, and Wessely S
    – then you discover that the study doesn’t support their statement. The paper says that “Physical symptoms were slightly more common in women, but this difference was not significant.”
    On page 3 the authors cite another paper – “Frequent attenders with medically unexplained symptoms: service use and costs in secondary care” by Steven Reid, Simon Wessely, Tim Crayford, Matthew Hotopf which revealed that there was no difference in MUS occurrence related to gender, and the researchers said: ” The absence of a female excess in the somatising patients was unexpected given that this is a near-universal finding in studies of medically unexplained symptoms. This highlights the role that higher consultations rates in females may have as a confounding variable in such studies.” ie that there are only more female than male MUS patients because generally women tend to consult more than men (eg for proven physical conditions).
    On page 9 of the JCPMH document under – IMPACT ON CLINICIANS – General Practitioners- the authors say that “GPs also reported that they often find it stressful to work with patients with MUS” – which IS borne out by the paper they cite….but also in that cited paper, and what the JCPMH document authors fail to mention, is that GPs found MUS patients interesting from a diagnostic and therapeutic point of view and also that the majority of GPs did not consider them a drain on their time. Instead they chose to paint a wholly negative picture of MUS patients.
    Again on page 9 they cite a study “Medically unexplained symptoms and the problem of power in the primary care consultation: a qualitative study” by Wileman, L., May, C., & ChewGraham, C.A. to show that “the negative emotions experienced by doctors can have a major impact on the doctor-patient relationship, resulting in their personal feelings impacting on their professional judgement.” NB Professor ChewGraham is one of the JCPMH authors so has cited her own study. But look at the study and you find that the study is ‘limited in scope’ and was with a ‘relatively small group of doctors’ so is not ‘generalizable to the wider population of GPs’. The JCPMH document authors are using a non-generalizable study to make a sweeping statement that will be inferred by the reader to apply to all doctors.

    This whole document is appallingly poor and flawed. But its purpose is to convince Commissioners, Health and Wellbeing Boards and other funding bodies to implement the MUS directives which divert funding away from secondary services – outpatient clinics and diagnostic services and into IAPT instead. Future funding of the IAPT programme is contingent upon reduction in those services – see Transformation Call to Bid NHS England document – under IAPT – Mental Heath Call to Bid and its Application Form . .

    So be glad you’re in Wales, well for the time being anyway!

  2. Andy H says:

    Given the UK is bound by law to comply with the WHO classification, one has to wonder if they have crossed over a legal boundary.