Addressing the needs of patients with

Medically Unexplained Symptoms (MUS)

Produced by the WONCA Working Party on Mental Health, Task Group
Chair: Dr Tim olde Hartman (tim.oldehartman@radboudumc.nl)
Members: Prof Cindy Lam (clklam@hku.hk), Prof Christopher Dowrick (cfd@liverpool.ac.uk), Dr
Sandra Fortes (sandrafortes@gmail.com), Dr David Clarke (drdave@stressillness.com), Dr Jinan Usta
(ju00@aub.edu.lb),

Aim: Providing a guidance for Family Doctors all over the world in the management of patients
with Medical Unexplained Symptoms (MUS)

10 key points

1. Medically Unexplained symptoms (MUS) are physical symptoms that have existed for
several weeks and for which adequate medical examination or investigation have not
revealed any medical condition that sufficiently explains the symptoms.
2. MUS is an ongoing working hypothesis, based on the (justified) assumption that somatic
or psychiatric pathology have been adequately detected and treated but the clinical
condition presented by the patient was not adequately resolved. Any change in symptoms
could be a reason to revise the working hypothesis of MUS.
3. MUS can be seen as a continuum ranging from self-limiting symptoms, to recurrent
and/or persisting symptoms and symptom disorders.
4. Factors that play a role in understanding the causes of MUS can be categorized into
predisposing, precipitating and perpetuating factors and can be linked to the
biopsychosocial model.
5. Family doctors can set a working hypothesis of MUS after a broad biopsychosocial
exploration of the symptoms, extensive exploration of psychosocial contributing factors,
and an evaluation of the severity of MUS.
6. Family doctors should focus on the doctor-patient relationship and doctor-patient
communication as these are essential elements in the management of MUS, and in
themselves are strong therapeutic agents within patient-centered care.
7. Family doctors should provide a targeted and tangible explanation in the patient’s
language and cultural models about what is causing the symptoms, based on the
information obtained during the structured exploration of the symptoms.
8. In the initial phase family doctors should focused on creating a safe environment for
patients to talk about (the context of) their symptoms, aiming at symptom management,
self-management strategies and self-care in order to offer support to the patient and
reach symptomatic relief.
9. Family doctors should deliver proactive care, aiming at one coordinating care provider,
and deliver care in a stepped-care approach in which the stages of severity of MUS are
connected to the (intensity of the) management.
 10. As MUS are perceived very differently across cultures, family doctors should develop
‘cultural competence’ when dealing with migrants with MUS or patients with MUS from
culturally heterogeneous populations.

Definition of MUS

Medically Unexplained Symptoms are physical symptoms that have existed for several weeks and
for which adequate medical examination or investigation have not revealed any condition that
sufficiently explains the symptoms.

MUS is a working hypothesis based on the (justified) assumption that somatic or psychiatric
pathology have been adequately detected and treated but the clinical condition presented by the
patient was not adequately resolved. Any change in symptoms could be a reason to revise the
working hypothesis of MUS.[olde Hartman 2013]

For some patients with physical symptoms a somatic or psychiatric condition may be present, but if
the physical symptoms are more severe or more persistent or limit functioning to a greater extent
than expected based on the condition in question, they too are referred to as MUS.

MUS can be seen as a continuum ranging from self-limiting symptoms, to recurrent and/or persisting
symptoms and symptom disorders.

Causes of MUS

In 1977 George Engel introduced the biopsychosocial model. This model implies that in order to give
patients a sense of being understood, clinicians have to understand and respond adequately to
patients’ suffering. In order to reach this, clinicians must attend simultaneously to the biological,
psychological, and social dimensions of illness. This biopsychosocial model is fully integrated in the
philosophy of primary care.

The term MUS implies there is no clear explanation for the origin of the symptoms. However, factors
that play a role in MUS can be categorized into predisposing, precipitating (i.e. exacerbating) and
perpetuating (i.e. maintaining) factors. These factors can be linked to the biopsychosocial model.
The different elements of the biopsychosocial model and the predisposing, precipitating and
perpetuating factors can play a role in varying degrees in understanding the causes of MUS.
Furthermore, they can be used in the explanation of MUS during the clinical encounter.
Table 1. predisposing, precipitating, perpetuating factors and the biopsychosocial model in MUS

Predisposing factors
Biological Psychological Social
Genetics Current life stresses Illness experience in family
Chronic health problems Psychological trauma Illness behavior in family
Serious childhood illness Adverse childhood experiences Neglecting self-care of
Physical, sexual or emotional personal needs
abuse (in childhood) Cultural beliefs and
Unsafe parental bonding expectations
Depression Health systems characteristics
Anxiety disorders
Post-traumatic Stress
Other psychiatric disorders
Personality characteristics
(alexithymia, neuroticism)

Precipitating factors
Biological Psychological Social
Infectious diseases Stress overload Negative life-events (loss of a
Accident / trauma Depression beloved one, impending
Surgery Anxiety disorders resignation)
Other psychiatric disorders Difficult living conditions
Recent life event linked to past High workload
trauma Limited social support on work
Ongoing contact with abusive Mass media reports on health
important others issues/concerns

Perpetuating factors
Biological Psychological Social
Decrease ability to exercise Inability to modify current Lack of social support
Decreased capacity and worries and anxiety Illness gain
resilience Depression Learned behavior
Increased sensitivity and Dysfunctional illness cognitions Family dynamics
perception (sensitization, Low self-esteem
hypervigiliance) False attributions
Catastrophizing thoughts
Role and behavior of the
clinician
 Diagnosing MUS

MUS always remains a working hypothesis, as in a limited number of cases it could become clear
over time that the symptoms were in fact caused by somatic pathology [Morris et al, 2007]. In case of
alarming symptoms (according to the family doctor) or changes in the pattern of symptoms
(according to the patient), the working hypothesis MUS should be reconsidered and physical re-
examination or additional investigations might be needed.[olde Hartman 2013]

Exploration of symptoms
The biopsychosocial model proposes illness to be viewed as a result of interacting mechanisms at the
biomedical, interpersonal and environmental or contextual levels. Therefore the exploration of
symptoms in patients with MUS should focus on the exact chronology of the symptoms themselves,
including where and when the symptoms appear (context of the symptoms), which potential causes
of MUS are present, patients’ ideas, concerns and expectations (i.e. ICE), and patients’ illness
behaviour and in a patient’s life and on the social environment of the patient.
This exploration results in a better understanding of the patient and the nature of the
symptoms.[olde Hartman 2017]
A list of symptom dimensions with sample questions follows:
1. Symptom focus. Which specific symptoms are bothering you at the moment? (location,
duration, severity, pattern, accompanying symptoms, use of medication).
2. Ideas. What are your own ideas and thoughts about these symptoms? (origin and persistence
of the symptoms (including chronological aspects and when symptoms are present),
contributing factors to the symptoms, patient’s own influence on the symptoms, what
aspects of their lives the patients considered to be associated with the symptoms).
3. Concerns. Do you have any concerns or worries about these symptoms? (anxiety or panic for
what exactly, uncertainty, depressed, despair).
4. Effects. What effect do these symptoms have on you? (absence of work, avoidance of
physical activity, ignoring the symptoms, other behaviour that inhibit recovery). Do these
symptoms interfere with your daily life and social activities?
5. Reaction of others. How do other people react to your symptoms (relationship, friendships,
work).
6. Expectations. What do you expect will happen with your symptoms in the future? What do
you expect from treatments for your symptoms?

Exploration of potential psychosocial contributing factors

As MUS often (but not always) can be linked to psychosocial stress, the family doctor needs to pay
attention to these issues. Important in this regard is to listen very carefully to what patients
communicate. In 95% of the MUS consultations patients present psychosocial cues or hints.
However, it is important that Family doctors do not ignore these cues. Picking up these cues and
exploring them in depth by using open ended questions (“What do you mean by [...]”) often results in
a deeper understanding of the patients’ symptoms. When psychosocial stress is present, discussing
and treating these issues often leads to symptomatic improvement. A list of these psychosocial
problems (with sample questions) follows:
1. Current life stresses – Are you experiencing stress at the moment? Did you have a stressful
experience just before the start of your symptoms?
2. Limited Self-Care Skills – Do you care for others but have difficulty putting yourself on the list
of people for whom you care?
3. Adverse Childhood Experiences (ACEs) – Were you under stress as a child? Would you feel
sad or angry if a child you care about was growing up just as you did? Do you still interact
with anyone who mistreated you as a child?
 4. High workload – What work do you do at the moment? Do you like your job? How are your
working times? Do you take work with you at home?
5. Problems in interpersonal relationships – Do you face problems in relationships with
important others?

Identifying comorbid psychiatric disorders

As patients with anxiety disorder, depression or PTSD can present with physical symptoms, for
example fatigue or palpitations, it is important to explore whether there is a comorbid anxiety
disorder, depression or PTSD (see also above). Furthermore, the presence of a comorbid psychiatric
disorder can be a predisposing or precipitating factor in MUS. In case such a comorbid psychiatric
disorder is present the clinician first has to treat the comorbid psychiatric disorder according to the
existing guidelines (see for example the WHO mhGAP intervention guide 2.0). For diagnosing and
treating anxiety disorder, depression or PTSD we refer to existing disease specific guidelines. When
this treatment proceeds the working hypothesis MUS can be reconsidered based on the remaining
symptoms.

Evaluation
Based on the exploration of symptoms (and with it the identification of predisposing, precipitating
and perpetuating factors), the clinician is able to evaluate the severity of MUS. MUS can be
considered on a severity scale from mild via moderate to severe. The greater the number and the
longer the duration of symptoms presented, the more number of bodily systems affected (for
example gastro-intestinal, cardio-pulmonary, musculoskeletal), the more number of consultations
with the physicians and the more the level of functioning is impaired, the greater the severity of MUS
is. The severity established by the physician guides the stepped care approach described below.[olde
Hartman 2013]

Management of MUS

Important elements in the management of MUS

We distinguish a number of important elements in the management of MUS. Most of these elements
and its content are described in and extracted from a recent review of national guidelines and
Cochrane reviews. [olde Hartman 2017]

Importance of doctor-patient relationship

Patients with MUS evoke difficulties in the family doctor encounter and challenge the doctor-patient
relationship. A good doctor-patient relationship is associated with patient satisfaction and improved
health outcomes and is an important condition for a good treatment course. Furthermore, the
doctor-patient relationship can be strengthened by recognizing the patient’s illness, taking the
patient and his/her symptoms seriously, showing empathy and interest in the patients´ life context
and problems that are related to the presence of MUS. The family doctor should take an open,
empathic, active supporting attitude to the symptoms and their management, in order to build a
sustainable and equal working relationship. The physician needs to convey to the patient that the
impact of the symptoms is understood and the physician acts with sensitivity to the difficulties that
the patient experiences. The management of patients with MUS is most successful when there is a
continuing and warm doctor-patient relationship. [olde Hartman 2017]
Importance of doctor-patient communication
Doctor-patient communication is essential for the treatment of MUS, as patients seek understanding
for their symptoms. To achieve this, the family doctor has to focus on consultations skills: (1) a
structured exploration of the symptoms, (2) paying attention to cues and hints, (3) providing a
summary and (4) explicit communication about expected results of biomedical investigations.

So, family doctors should explore the patient’s reasons for encounter, ideas, concerns and
expectations (ICE) about the symptoms, and assess for potential predisposing, precipitating and
perpetuating in a structured way using open questions. This exploration validates the patient’s sense
of suffering and provides a detailed insight into the bio-psycho-social background of the symptoms
which is needed for a shared understanding of the symptoms. Paying attention to cues and hints in
the story of the patients (i.e. psychosocial background of the symptoms) can be reached to listen
attentively and very carefully for what the patient is telling you and by asking open questions in order
to reach understanding of the cues and hints provided. Provision of a summary by the family doctor
is a tool in the communication with these patients. Such a summary should include the topics that
have been discussed in the consultation. It gives the patient the opportunity to check whether the
doctor understands the problem and to complement deficits. Explicit communication about expected
results of biomedical investigations is essential. When discussing treatment, the doctor should
communicate with the patient in an open and accommodating dialogue in which the advantages and
disadvantages of further testing and treatment can be discussed.[olde Hartman 2017]

Importance of explanation
Family doctors should provide a targeted and tangible explanation in the patient’s language and
cultural models about what is causing the symptoms. Information obtained during the structured
exploration of the symptoms should be incorporated in this explanation. Patients benefit from
“explanation that makes sense, removes any blame from the patient, and generates ideas about how
to manage the symptoms”. [Burton 2015] Recent research on explanations provides suggestions for
constructing plausible and acceptable explanations for symptoms. Patients need to be able to
exchange ideas with their doctors on the explanatory models they have and build up a common
understanding on how these symptoms develop within explanatory models that are culturally
acceptable, especially when the biological links between problems, emotions and symptoms are
clarified. Explanations that are co-created by patient and family doctor are most likely to be accepted
by patients.[den Boeft et al. 2017] However, although evidence for the effectiveness of those
explanatory models in reassuring patients is limited, a patient-centered approach is always the best
model to improve self-management and patient empowerment. According to existing consensus
targeted and tangible explanations in the patient´s language and cultural models are necessary to
reassure patients with MUS about the absence of a somatic disease.

One general explanation that most patients can comprehend is that “when a person’s stress level is
too high or persists for too long, this can lead to physical symptoms very much like tension can lead
to headache, fearful situations can cause a ‘knot’ in the abdomen or embarrassment can cause
blushing.”
Here are some examples of explanatory models that could be used in daily primary care (adapted
from olde Hartman 2013).
1. Capacity – burden model:
The balance between four factors (i.e. support, stress, strength and vulnerability) is of
importance. If vulnerability and strength are unbalanced in a person, this can lead to
symptoms.
2. Stress model:
High levels of stress is correlated with fatigue, pain and somatoform disorders. Psychological
distress plays an important role in this relationship. That means that certain psychosocial
factors combined with a chronically high level of stress can result in MUS.
3. Somato-sensory amplification model:
Focusing attention on physical sensations leads to more physical sensations (for example:
thinking of itching results in itching). Furthermore, this might result in concerns or anxiety in
patients. Consequently a vicious circle of maintaining and amplifying the physical symptoms
is started.
4. Neurobiological model:
There exists a complex interaction between neurobiological processes (autonomic nervous
system, HPA axis and the immune system), environmental factors, attention and behavior.
Activation of the autonomic nervous systems generates symptoms, as well as activation of
the HPA axis does (for example adrenalin gives an increase in heartrate and breathing
frequency). Activation of the immune system can result in a sickness response.
5. Vicious circles:
Vicious circles play an important role in maintaining symptoms, irrespective of the origin of
the symptoms. This is a result of the interpretation of symptoms and resulting disease
behavior and/or help-seeking behavior.
6. Sensitization:
Previous and repeated stimuli of pain and other symptoms in the past make the central
nervous system more susceptible to these stimuli. Benign stimuli are interpreted as malign.
7. Cultural way of understanding:
All explanatory models must be culturally meaningful. It is important for health professionals
to be culturally humble, respecting and understanding how different cultures explain the
many ways emotional distress relates to physical symptoms. One example is the “nerves”
complaints among Latinos’ patients that associate “shaken nerves” as a major mechanism
causing MUS.

Symptom management
Many patients with MUS improve without specific treatment. Although around 30% of the symptoms
that patients present to their family doctor are unexplained (in specialist care this is even higher, up
to 70%) only a minority of these MUS become persistent and disabling. [Verhaak et al, 2006]

When symptoms persist for more than several weeks, the physician may decide to prescribe
medications addressing the specific symptom(s) presented, for example analgesics for pain, tricyclic
antidepressants for neuropathic pain, or beta blockers for disturbing tachycardia. This symptom
management aiming at symptomatic relief via physiological means is advisable especially in the initial
phase. When considering pain management, short term analgesia with for example acetaminophen
or NSAID (if no contraindication) can be prescribed. In all cases Family doctors have to balance
symptomatic treatment with potential adverse effects or risks.[Chitnis et al, 2014]
A Cochrane review on pharmacological treatments for patients with MUS concluded that there is
little evidence for the effectiveness of medication (tricyclic antidepressants, new-generation
antidepressants (i.e. SSRI’s and SNRI’s) and natural products (i.e . different herbs and St. John’s
worth)) in the treatment of patients with MUS. [Kleinstauber 2014]
Self-care and self-management
The physician can advise patients on self-management strategies and self-care. The physician can
empower the patient to carry on with (or return to) their normal daily activities as much as possible
despite experiencing symptoms. The physician can suggest scheduling activities and exercises,
practicing a regular sleep pattern, practicing a regular and healthy diet and relaxation exercises.[van
Gils 2016; Henningsen 2007]
Self-help and behavioural activation can reduce symptoms and improve quality of life of patients
with MUS. Engagement in pleasurable activities such as regular exercise, pursuit of a hobby or social
activities can counteract the discomfort or suffering from MUS and reduce stress. See also WWPMH
guidance on non-drug interventions for common mental health problems
(http://www.globalfamilydoctor.com/News/MentalHealthresourceGPFPRoleinnondruginterventions.
aspx).

A stepped-care approach
Family doctors should deliver proactive care and make regular follow-up appointments during the
course of treatment based on the patient’s need. Furthermore, it is important that one care provider,
preferably the family doctor keeps control and coordination of the care process. However, this care
provider could also be a community psychiatric nurse, psychologist or occupational health physician.
The stages of severity of the symptoms can be connected to management options in a stepped-care
approach. Family doctors should assess the patient’s risk profile on the basis of severity of MUS and
complexity of the disorder (number and duration of symptoms, level of functional impairment,
psychosocial stress, psychological comorbidity and experienced difficulties in the doctor-patient
relationship). In table 1 the stepped care approach as described in several primary care guidelines is
shown (adapted from Olde Hartman 2017).10
The more severe or complex the symptoms and limitations are, the more intense and complex is the
treatment needed for the recovery of the patient. For example when in a patient with mild MUS
stress has been uncovered during the exploration of the symptoms, stress relieve is often the only
treatment needed to relieve MUS. This can be done by (1) asking patients to compile a list of
significant life stresses both present and past and search together how to reduce one or more
stresses, (2) recommending 2 to 5 hours of self-care time (purely for personal enjoyment) every
week, and/or (3) suggesting relaxation techniques and/or mindfulness medication. In patients with
moderate to severe MUS referral to mental health care could be indicated. The most severely
affected patients need a close collaboration between professionals with a divergent range of skills
and expertise in secondary or tertiary care (i.e. the final step in the stepped care approach).
 Cultural issues in the management of MUS

Physical symptoms are an important part of different “idioms of distress”, which are socially accepted
patterns of presenting emotional distress (including anxiety and depressive disorders) that vary due to
cultural background. There are several factors that contribute to these patterns, including some
previously discussed in this document, but the cultural accepted way to communicate and elaborate
emotional suffering is one of the core points, especially when “individualist” or “collectivist” cultures
are involved. In the former, personal and subjective ways of expressing emotional distress are valued,
while in the latter preserving group cohesion is the most important point and so it is considered
inadequate to verbalize feelings and emotions associated with conflicts or negative emotions. But the
physical symptoms associated with emotional distress cannot be suppressed, may become quite
disturbing and disabling, and represent the most important reason for searching health care.
Trying to build an international cultural background when MUS are concerned may be quite difficult.
On one side, it has been found that the most frequent groups of physical symptoms associated with
MUS, currently being studied as “Bodily Stress Syndrome”, are universal and similar to those found in
previously described “cultural-bound syndromes”, such as “Hwa-Byung” in Korea or as “Nervios” in
Latin America. But, on the other hand, functional syndromes are not acknowledged and diagnosed in
the same way world-wide. Recognition of chronic fatigue syndrome in Brazil and UK differ dramatically
within a similar frequency of core symptoms in general population of the two countries.[Cho 2008]
The most important consequence of this problem is the need for primary care physicians to develop
“cultural competence“ when dealing with migrants or culturally heterogeneous populations. The
“Cultural Formulation Interview”* can be used as an instrument to help professionals approaching
patients from different backgrounds represents the recognition of the importance of cultural
determinants in every day practice in health care. [Kirmayer 2013; Luiz-Fernandez 2017]

*
https://www.google.nl/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0ahUK
EwibvbjV_JHYAhXQo6QKHeBvCZ0QFggwMAA&url=https%3A%2F%2Fwww.psychiatry.org%2FFile%25
20Library%2FPsychiatrists%2FPractice%2FDSM%2FAPA_DSM5_Cultural-Formulation-
Interview.pdf&usg=AOvVaw0yl4EMDbxmpSbT2uVcJfOL

Recommendations

Every Family doctor encounter patients with MUS. Good consultation and communications skills and
building a therapeutic relationship with these patients are prerequisites in high quality management
of MUS. Furthermore, collaboration with the patient and with other healthcare professionals is
essential. Family doctors have the position to deliver patients with MUS the high quality of care they
need.
 References

Burton C, Lucassen P, Aamland A, et al. Explaining symptoms after negative tests: towards a rational
explanation. J R Soc Med. 2015;108(3):84-8

Chitnis A, Dowrick C, Byng R, et al. Guidance for health professionals on medically unexplained
symptoms. London: Royal College of General Practitioners and Royal College of Psychiatrists, 2014.

Cho HJ, Menezes PR, Bhugra D, et al. The awareness of chronic fatigue syndrome: a comparative
study in Brazil and the United Kingdom. J Psychsom Res. 2008;64(4):351-5

Den Boeft M, Huisman D, Morton L, et al. Negotiating explanations: doctor-patient communication

with patients with medically unexplained symptoms – a qualitative analysis. Fam Pract.
2017;34(1):107-113

Henningsen P, Zipfel S, Herzog W. Management of functional somatic syndromes. Lancet

2007;369:946-55.

Kleinstauber M, Witthoft M, Steffanowski A, et al. Pharmacological interventions for somatoform

disorders in adults. Cochrane Database Syst Rev 2014; 11.

Kirmayer L. Lauren Ban. Cultural Psychiatry: research Strategies and Future directions. in Cultural
Psychiatry: Adv. Psychosom Med. Basel, Karger. Alarcon RD ( Ed). 2013, vol33, pp97-114

Lewis-Fernandez RL; Kirmayer LJ.; Garnaccia P.; Ruiz P. (2017) Cultural Concepts of Distress. In Sadock
B; Sadock V & Ruiz P.(Eds) Comprehensive Textbook of Psychiatry New York; Lippincott, Williams and
Wilkins.

Olde Hartman TC, Blankenstein AH, Molenaar B, et al. NHG Standaard SOLK [NHG Guideline on
Medically Unexplained Symptoms (MUS)]. Huisarts en Wetenschap 2013; 56(5): 222.
(https://www.nhg.org/sites/default/files/content/nhg_org/uploads/standaard/download/final_m10
2_solk_guideline_sk_mei13_0.pdf)

Olde Hartman TC, Rosendal M, Aamland A, et al. What do guidelines and systematic reviews tell us
about the management of medically unexplained symptoms in primary care? BJGP Open 2017; DOI:
10.3399/bjgpopen17X101061

Van Gils A, Schoevers RA, Bonvanie IJ, et al. Self-help for medically unexplained symptoms: a
systematic review and meta-analysis. Psychosom Med. 2016;78(6):728-39

Verhaak PFM, Meijer SA, Visser AP, et al. Persistent presentation of medically unexplained symptoms
in general practice. Fam Pract 2006;23(4):414-20
Table 1. Stepped-care approach in guidelines (adapted from Olde Hartman et al. 2017)

Dutch family doctor guideline Danish family doctor guideline German multidisciplinary guideline Dutch multidisciplinary guideline
Mild - Psycho-education Symptoms - Normalization, Step 1 - General principals of Mild MUS - Biopsychosocial
MUS - (Self-)management advice and mild explanation, therapy (empathy, watchful approach by family
- Shared time-contingent functional biopsychosocial waiting, acknowledgement doctor
plan disorders approach of the symptoms, - Psycho-education
- Follow-up - Follow-up explanation) - Short-term CBT
- therapy by family doctor
or medical specialist or
psychosomatic primary
healthcare

Moderate - Psychosomatic Moderate - Explanations and TERM Step 2 - Regular consultations Moderate - case-management by
MUS physio/exercise therapy functional model1 - Therapy by family doctor MUS medical specialist,
- Mental health nurse disorders - Regular consultations or medical specialist PLUS psychiatrist or family
practitioner - Cooperation with psychotherapy doctor
- Social psychiatric nurse specialist (in charge of - Pain as core symptom: - medication (for co-
assessment, treatment antidepressant morbidity)
plan, and supervision) - Pain not as core symptom: - CBT
antidepressant in case of
psychiatric comorbidity

Severe - Multidisciplinary team / Severe - Specialist clinic Step 3 - Specialist clinic with Severe - CBT
MUS treatment centre functional - Multidisciplinary multidisciplinary treatment MUS - treatment by a
disorders treatment multidisciplinary team in
- CBT2 and GET3 tertiary care
- consider
pharmacological
treatment

1. The Extended Reattribution and Management model

2. Cognitive Behavioural Therapy
3. Graded Exercise Therapy