The Most Destructive Diagnosis in Medicine
The myth of medically unexplained symptoms (MUS): All symptoms are explainable.
Posted April 26, 2021 | Reviewed by Jessica Schrader
- Medically Unexplained Symptoms (MUS) is a diagnosis on the rise, but it's a dodge.
- What is typically overlooked is the body's physiological response to threat/danger, whether mental or physical.
- The sensations cannot be seen on an imaging study, nor would you expect them to; that doesn't mean they did not occur.
- It is unclear why the term MUS exists, and it is deadly—it takes away hope.
There is a deadly diagnosis that has evolved and become increasingly embedded in chronic pain terminology: medically unexplained symptoms (MUS). It means that you are suffering with symptoms but we physicians don’t know the cause. Therefore, the solution is unclear and you are going to have to do the best that you can while living with them. By the way, we won’t be investigating the cause further—the diagnosis is like a sealed container—and you’ll probably be suffering with these symptoms indefinitely.
As a surgeon who has spent a lifetime dealing with patients with chronic pain, including myself, I have come to see that the MUS diagnosis is wholly inaccurate and should be immediately discarded. Every bodily symptom you experience results from an identifiable structural abnormality, and congenital/ genetic problem, or from your body’s physiological response to your surroundings. Symptoms don’t just happen. The correct diagnosis is MES (medically explained symptoms).
Physiology is the term that describes how the body functions. We stay alive because living creatures are able to maintain an incredibly delicate balance of the body’s acid/base balance, electrolytes, blood pressure, temperature, heart rate, and the list is long. It is a dynamic process that changes by the second in response to input from your surroundings.
We require safety (rest and relaxation) to regenerate and build up our reserves. When we are under any stress (threat), the body responds with elevated activity in multiple different organ systems in order to increase the chances of survival. Fuel stores are depleted and reserves are lowered as energy is shunted to muscles in the event of fast action is required.
Our bodies are intended to be mostly in “neutral” or what is called homeostasis. When you are going about your daily business without noticing how you are feeling, you are in homeostasis. It can be maintained for long periods of time because reserves are being replenished commensurate with your needs.
Any time your body is under any kind of mental or physical threat, your body’s physiology will react in a manner to bring you back into balance. There are three contributors of this scenario: your circumstances (input); the state of your nervous system (coping capacity); and output (body’s total neurochemical response).
By definition, anytime you sense any level of danger from any source, you are under threat—even if it lasts for just a few seconds. When you are in homeostasis, your body responds so quickly, you won’t notice the changes. However, when the threats begin to overwhelm your nervous system’s coping capacity, you’ll experience unpleasant symptoms.
The threats can be mental or physical and there are almost always multiple physical and mental responses. The physiological manifestations include:
- Changes in your immune system with increased inflammation.
- Your body’s metabolism (the rate you burn fuel). You are either storing fuel (anabolic state) or consuming it (catabolic state).
- Nervous system activity—you are designed to become more sensitized and alert when there is potential danger.
These are broad categories of the effects of threat. But, since there are so many organ systems required to keep you alive, numerous physical and mental symptoms are created. Every symptom that is not from an obvious anatomical problem is a result of this interaction of your body responding to sensory input from your surroundings that is interpreted as potentially dangerous. How else could you stay alive?
Examples of physical threats include viruses, bacteria, being attacked by a predator—human or animal—hunger, lack of shelter, poverty, lack of opportunity, being bullied at work or school, racism, authoritarianism, trapped in a difficult living or family situation, and physical maladies.
Mental threats are processed in a similar manner as physical ones with the same physiological response. They are more problematic in that humans have consciousness and many of our thoughts and emotions are unpleasant, and unlike visible threats like tigers or a severe storm, we cannot escape our thoughts. Repressed thoughts and emotions are even more impactable on your body’s neurochemical state. Many of our unpleasant thoughts are based on cognitive distortions or “stories” about our lives. Unfortunately, whether the threat is real or perceived it has the same deleterious effect.
Unpleasant sensory input progressively impacts your body at three levels.
- Illness/ Disease
When the threat is short-lived, your response will be appropriate to the situation and quickly disappears when it has passed or resolved. Almost every internal and external action of your body is directing you in a manner so you don’t feel unpleasant sensations. If you do sense danger, you are programmed to resolve it immediately. Examples are looking away from the sun, spitting out rancid food, pulling your bare foot back from hot pavement, frequently shifting in your chair to avoid skin breakdown, and avoiding an aggressive dog.
When threats are more prolonged, you will begin to suffer symptoms such as back pain, tension headaches, anxiety, poor appetite, nausea, urge to urinate, sexual dysfunction, burning sensations, skin rashes, dizziness, ringing in your ears, and insomnia. There are over 30 different physical symptoms that can occur.
But when threats are sustained, you have a significant chance of becoming seriously ill or developing a disease. It is well-documented that stress kills people and unfortunately the symptoms of a chronic illness also add to the threat load. This is particularly true in chronic pain.
The nature of your body’s physiology under threat
Environmental cues of threat set off a defensive response. Immediately, before you are even aware, your immune system girds for the possibility of injury by initiating inflammation (to protect cells against bacterial or other invasion), elevates metabolism to provide fuel for defense, increases the speed of nerve conduction—which increases your alertness but also your pain sensitivity—and elevates the levels stress hormones (cortisol, adrenaline, noradrenaline, histamines). Much of this defensive state is modulated by small signaling proteins called inflammatory cytokines.
So how do you think you feel when you are in this physiological state? Your heart is racing, you are sweaty, tired, anxious, overwhelmed, nervous, stomach feels tight, blood pressure is elevated, pain is worse, and your breathing is rapid. The bottom line is that you don’t feel great when your body is in this heightened neurochemical state. Are these symptoms imaginary? Not a chance. None of them.
The consequences of the diagnosis of MUS
First of all, if you don’t know the nature of a problem in any realm of life, you can’t solve it. That is exactly the implications of this label. In addition, it blocks curiosity and further exploration as to the nature of the problem. So, not only are treatable problems not being addressed, even doing a further workup becomes a lesser priority. Serious structural abnormalities can be missed when you are a “chronic pain patient with MUS.”
Examples in my practice were of two gentlemen who had been suffering from chronic pain and were being bounced around in the system. Their complaints were not being taken seriously. Both of them had a history that was distinctly different from what I normally hear from patients in chronic pain. One had bladder cancer and the other had lung cancer. By the time they were diagnosed, it was too late. So, it is still critical to carefully listen to the history of each patient and rule out a structural problem in the midst of all the symptoms created by the body’s physiological response to sustained threat. That requires time, attention, and being heard.
Additionally, the sustained levels of stress hormones cause many disruptive symptoms as well as the inflammatory cells physically destroying tissues. The list includes anxiety, depression, autoimmune disorders, irritable bowel or bladder syndrome, addictions, migraines, addictions, fibromyalgia, and chronic fatigue.
Every symptom anyone experiences is a result of a structural abnormality (uncommon), congenital/ genetic problem, or your body translating sensory input from your surroundings into physiological changes. Do not let anyone in any field tell you otherwise. Otherwise, you are experiencing a lot of unnecessary suffering.
Understanding a problem is the first step in solving it. It’s MES, not MUS.
1. Edwards T M, Stern A, Clarke DD, Ivbijaro G, & Kasney LM. (2010). The treatment of patients with medically unexplained symptoms in primary care: A review of the literature. Mental Health and Family Medicine, 7, 209–221.
2. Eisenberger NI, et al. An experimental study of shared sensitivity to physical pain and social rejection. Pain (2006);126:132-138.
3. Schubiner H and M Betzold. Unlearn Your Pain, 3rd edition. Mind Body Publishing, Pleasant Ridge, MI, 2016.
4. Smyth J, et al. Stress and disease: A structural and functional analysis. Social and Personality Psychology Compass (2013);7/4:217-227. 10.1111/spc3.12020