Somatic Symptom and Related Disorders (#2): Management of Medically Unexplained Symptoms in Primary Care.

Kroenke (1) published the following stepped approach for evaluation and management of medically unexplained symptoms in primary care setting:

STEP #1: Determine Severity

(a) for acutely serious (chest pain, sudden changes in consciousness, labored breathing etc.) –> do expedited diagnostic evaluation.

(b) for minor symptoms (muscle pain, fatigue, stomach upset etc.) –> they are self limiting, respond to symptom-specific therapies and often resolve at a follow up visits.

(c) for persistent symptoms at follow up –> move to next step #2 below.

STEP #2: Assess and Treat Psychiatric Symptoms and Functional Syndromes

(a) Screen for depression and anxiety (using Patient Health Questionnaire) –> treat with pharmacotherapy and/or referral to psychotherapy.

(b) Assess for functional syndromes –> initiate syndrome specific therapy.

STEP #3: Develop Plan for Managing Medically Unexplained Symptoms (MUS)

Initiate personalized treatment plan for patient failing Step #1 and Step #2 above.

(a) Help patients to feel understood:

  • detailed evaluation of physical and psychological symptoms.
  • evaluate for patient’s beliefs regarding illness and prior treatment.
  • perform physical examinations (as indicated).
  • focus on findings experiences that both patient & physician can agree on and validate.

(b) Negotiate on agenda:

  • avoid communication to patient that “all is in their head”.
  • provide each assessment feedback
  • clarify patient’s reactions to feedbacks & treatment preferences.

(c) Take actions:

  • create the explanation in collaboration with patient.
  • negotiate requests for medical investigations and interventions
  • continue with physical & psychiatric symptoms monitoring.
  • have specific plans for coping with stress, self-management, lifestyle changes, or watchful waiting.

(d) Terminate consultation:

  • make follow up appointments if needed.
  • educate patient that plan will be reconsidered if symptoms gets worse or new symptoms develops in future.
  • emphasize on importance of continued collaboration.


  1. Int J Methods Psychiatr Res. 2003;12(1):34-43.
  2. Am J Lifestyle Med. 2016 Mar-Apr; 10(2): 109–119.

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Dr. Harvinder Singh, M.D. (Admin)

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