Is it true that more than half of medical consultations are for MUS? A look at the evidence.

Firstly, can I just repeat that as a physician doing outpatients for 35 years the proportion of patients for whom I was unable to provide a diagnosis for their primary concern, or reason for referral, was somewhere around 2-5%. That might be very different in gastroenterology but I think it would be standard for most specialities.

The figures around 50% are universally concocted by a small group of physicians who want to make a living out of psychosomatic medicine. That will apply to review resources like UpTo Date where the relevant section will be written by the relevant enthusiasts.

My impression is that Diane thinks that the shunting of people with undiagnosed symptoms to mental health care is a 'huge' problem. It is a very serious problem and perhaps particularly in primary care. But the 50% figures are completely irrelevant to this because the psychological diagnosis MUS does not in any way equate to the non-psychological concept of a medically unexplained symptom.

In most clinic visits I would have a referral for a particular key symptom or a concern about a particular diagnosis. I would take a full history and elicit maybe 15 symptoms, some of which I would regard as not relevant and not even write down, some I would write down and consider not of concern and some I would write down and consider potentially providing evidence for an explanation of the key problem. So I might end up diagnosing a rotator cuff tendinitis in the shoulder having noted that the patient was prone to headaches and the occasional dizzy spell, quite serious but longstanding pains in both knees and occasional back pain.

Of course a MUS enthusiast can go to town on that but at no point in this visit am either I or the patient bothered that they might end up being sent to mental health. All we are concerned about is the likely prognosis of a shoulder pain causing loss of sleep. Most patients are not even looking for treatment as long as they know what is wrong and how soon things are likely to get better.

There seem to be three different questions here. Firstly, are the 50% figures based on good evidence? The answer is no. Do they represent standard medical thought? The answer to that is that they represent standard thought amongst MUS enthusiasts and GPs dumb enough to believe that stuff. But not a most hospital physicians interested in actual explanations. Do these figures represent the proportion of clinic visits where there is no explanation for the key presenting problem? Absolutely not, as one can see from the sloppy way the figures have been derived. So they tell us nothing about the size of the problem of unexplained symptoms being sent to mental health care and are irrelevant to the ethical issues around that.

 

As previously discussed in threads here on S4ME and on other forums:

One of the UpToDate editors for the UpToDate CFS/ME pages (Stephen J Gluckman MD) had served as an independent reviewer for the draft of the IOM's expert panel report:

https://www.nap.edu/read/19012/chapter/1#vii

(...)

Reviewers

(...)

Italo Biaggioni, Vanderbilt University
Susan Cockshell, University of Adelaide
Stephen Gluckman, University of Pennsylvania

(...)

"Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the report’s conclusions or recommendations, nor did they see the final draft of the report before its release."​

Within three days of the initial version of the IOM Report having been released, Gluckman went into the UpToDate CFS pages and inserted the term Systemic exertion intolerance disease (SEID) throughout the CFS pages, as though adoption of the term by the Report's stakeholder sponsor agencies was a given.

Whereas, at that point, none of the sponsor agencies had had time to review the Panel's Report, consider its Recommendations or issue statements on whether all or selected of the Report's various Recommendations were being taken forward for evaluation, testing and potential adoption; nor had any agency issued a road map for evaluation.

Gluckman did not include, initially, any caveat that the Report's Recommendation for a change of terminology to SEID and new criteria were just that - a Recommendation for consideration amongst a list of other, as yet unevaluated, Recommendations.


To tout UpToDate site as a credible, authoritative source of medical information with a rigorous editorial process is risible: https://www.uptodate.com/home/editorial


The CFS/ME pages on UpToDate are in any case very poorly edited [1].

1 S4ME thread: UpToDate ME/CFS information:
https://www.s4me.info/threads/uptodate-me-cfs-information.5755/

 

My concern about the 52% figure for MUS is that the default diagnosis for a patient with MUS is that they are mentally ill. Gaslighting of patients with mental health problems seems to be rampant in any discipline. People who are mentally ill are often denied effective pain relief and accurate diagnosis of their physical health problems. The info I've seen on this thread suggests that the "worst" area for MUS is gynaecology with a declared rate of 66% of patients or appointments involving MUS. For decades gynaecologists (who were mostly male - I'm not sure about the gender breakdown now) have assumed that painful periods are evidence of "normal function" in women and that not being able to cope with the pain is caused by women being feeble, attention-seeking, hypochondriacal wastes of space who can't cope with the normal functioning of their own bodies. If gynaecologists view 66% of their patients in this way then vast numbers of affected women are doomed to have wrecked lives, fertility problems, destroyed careers, problems defecating, problems urinating, severe back pain and thigh pain, painful intercourse, destroyed relationships. But this is all blamed on the sufferer. They don't get pain relief, instead they are gaslighted and blamed.

If the percentage of patients with MUS is reduced to something more realistic it could help millions of women around the world.

 

/

Then let them explain why my period pain when I was a teenager disappeared after a few years being real bad. Sometimes it was so bad as being in labour.

 

I'm glad you got relief from the problem eventually.

 

Because that's what's used in practice. It's wrong, but it's what medical professionals are told by the best available process at their disposal. It's the same basic problem as with ME being a disease that is incorrectly operationalized as a mood disorder or something to that effect (everyone basically have their own personal interpretation because of how vaguely it's presented). In both cases it's wrong, but it's the perception that is used to inform guidelines and clinical care.

This is a bit like a popular myth having an effect in practice, not because it's true, but merely because people believe it's true. Whether it's 50%, 80%, or 17% is irrelevant, it's wild extrapolation from incomplete data. But it becomes relevant because it is believed and applied in practice.

If things were measured this way, the exact situation would exist with car repairs. The vast majority of car problems that are reported are tiny or too much trouble to figure out. By this process the majority of car mechanic "consults" result in mechanically unexplained symptoms. It's the same false positive. It's false data that is only relevant because it is incorrectly trusted.

We're seeing the same thing with the "mental health crisis", when it is clear that the vast majority of those are a combination of eager overdiagnosis and undiagnosed disease. They're fake numbers in the sense that they don't represent reality, but they still matter because the process that reports them is trusted.

 

Full text:

https://link.springer.com/article/10.1186/s12875-018-0812-8

Coding of medically unexplained symptoms and somatoform disorders by general practitioners – an exploratory focus group study
N. J. Pohontsch1* , T. Zimmermann1 , C. Jonas2 , M. Lehmann2 , B. Löwe2 and M. Scherer

December 2018

Pohontsch et al. BMC Family Practice (2018) 19:129 https://doi.org/10.1186/s12875-018-0812-8

--------------------------------------


By the way, SNOMED CT, the mandatory terminology system for use in NHS primary care at the point of care since April 2018 and scheduled for adoption across all NHS secondary care settings from 2020, has a number of Concept terms.

All three of these SNOMED CT SCTID Concept terms sit under the supertypes: Finding reported by subject or history provider (finding) >General symptom (finding).


Unexplained symptoms continue (finding)
SCTID: 161904006

which is mapped to ICD-10 R68.8 Other specified general symptoms and signs

[The ICD-10 R68 - R69 codes are Chapter XVIII: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified codes.]

also

Medically unexplained symptom (finding)
SCTID: 702537003

which is mapped to ICD-10 R69.X Unknown and unspecified causes of morbidity


The SNOMED CT UK Edition contains an additional SCTID Concept term which is not included in the SNOMED CT International Edition:

Medically unexplained symptoms (finding)
SCTID: 887761000000101

which is also mapped to ICD-10 R68.8 Other specified general symptoms and signs

 

I'm not sure why.

Yes, I can see that. My only experience of the term Medically Unexplained Symptoms is in the context of BPS people attributing it to psychosomatic symptoms, and I tend to believe it is politically driven, given it makes it easier to treat people on the cheap, and if it doesn't work then dismiss them completely because it must be their fault. Is MUS ever used in its genuine sense, as in unexplained because science has not explained it yet?

 

Small question. By who's authority do we accept the term MUS? Is it some official medical term that is used across medical specialties?

The reason I ask is that I wonder if it could be lobbied for the term pre-clinical symptoms. This has been my experience over many decades of illness. A particular vague symptom starts on it's own with no way of identifying what it might be about. Then years later it forms part of a now constellation of symptoms that crystalize into a known illness with an identifiable marker.

It's like medicine expects that when you walk in the illness has just come on full blown like days earlier you were the picture of health.

 

In the UK, the mandatory classification and terminology systems for use in NHS clinical settings are:

WHO's ICD-10 (Version 2015)
SNOMED CT UK Edition

SNOMED CT's terminology Concept codes are mapped to ICD-10 codes for interoperability.

There is no specific term for Medically unexplained symptoms in ICD-10, in the "clinical modifications" of ICD-10 or in the forthcoming ICD-11.


The ICD-10 PHC (The Diagnostic and Management Guidelines for Mental Disorders in Primary Care: ICD-10 Chapter V Primary Care Version), was published in 1996. It was intended as a simplified guideline to 25 "common mental disorders" developed as a diagnostic tool for use by practitioners without psychiatric training, by non medically trained health workers, for use in training, in low resource settings, low- to middle-income countries etc. NB: The guideline consists of only 25* mental disorders ie. there are no other abridged ICD-10 chapters for general medical conditions.

*There are circa 450 mental and behavioural disorders classified within Chapter V of ICD-10.

In the ICD-10 PHC, there is an F45 Unexplained somatic complaints category, which corresponds to ICD-10's F45 Somatoform disorders block. The ICD-10 PHC F45 category is more recently referred to by the chair of the working group that had developed the publication as "medically unexplained symptoms."

Unlike ICD-10 (and eventually ICD-11) the ICD-10 PHC publication is not mandatory for use by WHO member states. ICD-10 PHC has been under revision for ICD-11 PHC, for which 27 "common mental disorders" are proposed to be included. WHO has published no ETA for its completion and release.

For ICD-11 PHC, Bodily stress syndrome (BSS) is proposed to replace the ICD-10 PHC categories: F45 Unexplained somatic complaints (also referred to as "medically unexplained symptoms"); and F48 Neurasthenia. The Bodily stress syndrome (BSS) disorder construct is being developed by the WHO, advised by an external Primary Care Consultation Group (PCCG) (which again is chaired by emeritus Prof, Sir David Goldberg, who is now in his mid 80s). This is a different working group to the working group that developed the SSD-like, Bodily distress disorder (BDD) that is going forward for the main ICD-11 classification. The PCCG is proposing a differently conceptualized disorder construct for ICD-11 PHC to the construct being used for the main ICD-11, which captures a different patient population.

The WHO hopes that the ICD-11 PHC, when it is completed and released, will have greater utility than the ICD-10 PHC was considered to have. But I stress again, that the ICD-11 PHC will be a non mandatory guideline and its content does not override the ICD-10 and ICD-11 code sets.

It is not possible to predict the extent of the take-up of the ICD-11 PHC or which member states might make use of it in primary care settings.

WONCA's ICPC-2 (International Classification of Primary Care, Second edition) has established use as a primary care terminology in a number of member states and it includes terminology for both mental disorders and general medical conditions - as opposed to the ICD-10 PHC (1996), which contains just 25 "common mental disorders."


As mentioned in my previous post, the SNOMED CT terminology system includes the Concept terms: Unexplained symptoms continue (finding) and Medically unexplained symptom (finding). The SNOMED CT UK Edition additionally includes the Concept term: Medically unexplained symptoms (finding), which is exclusive to the UK Edition and is assigned a different Concept code. No definitions accompany these SNOMED CT terms.

SNOMED CT SCTID codes map to ICD-10 codes and these three codes are mapped to ICD-10 R codes (the Symptoms, signs chapter).

SNOMED CT includes dozens of Concept terms under (finding) which correspond to the ICD-10 Symptoms, signs R codes.

So there are many codes in both systems that can be used to record symptoms for which no diagnosis classifiable elsewhere is recorded.


This is the text from the WHO's ICD-10 Chapter XVIII Symptoms, signs:

https://icd.who.int/browse10/2016/en#/XVIII

Chapter XVIII
Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified
(R00-R99)

This chapter includes symptoms, signs, abnormal results of clinical or other investigative procedures, and ill-defined conditions regarding which no diagnosis classifiable elsewhere is recorded.

Signs and symptoms that point rather definitely to a given diagnosis have been assigned to a category in other chapters of the classification. In general, categories in this chapter include the less well-defined conditions and symptoms that, without the necessary study of the case to establish a final diagnosis, point perhaps equally to two or more diseases or to two or more systems of the body. Practically all categories in the chapter could be designated 'not otherwise specified', 'unknown etiology' or 'transient'. The Alphabetical Index should be consulted to determine which symptoms and signs are to be allocated here and which to other chapters. The residual subcategories, numbered .8, are generally provided for other relevant symptoms that cannot be allocated elsewhere in the classification.

The conditions and signs or symptoms included in categories R00-R99 consist of:

1. cases for which no more specific diagnosis can be made even after all the facts bearing on the case have been investigated;
   
   
2. signs or symptoms existing at the time of initial encounter that proved to be transient and whose causes could not be determined;
   
   
3. provisional diagnoses in a patient who failed to return for further investigation or care;
   
   
4. cases referred elsewhere for investigation or treatment before the diagnosis was made;
   
   
5. cases in which a more precise diagnosis was not available for any other reason;
   
   
6. certain symptoms, for which supplementary information is provided, that represent important problems in medical care in their own right.

Excl.:
abnormal findings on antenatal screening of mother (O28.-)
certain conditions originating in the perinatal period (P00-P96)

R00-R09 Symptoms and signs involving the circulatory and respiratory systems
R10-R19 Symptoms and signs involving the digestive system and abdome
R20-R23 Symptoms and signs involving the skin and subcutaneous tissue
R25-R29 Symptoms and signs involving the nervous and musculoskeletal systems
R30-R39 Symptoms and signs involving the urinary system
R40-R46 Symptoms and signs involving cognition, perception, emotional state and behaviour
R47-R49 Symptoms and signs involving speech and voice
R50-R69 General symptoms and signs
R70-R79 Abnormal findings on examination of blood, without diagnosis
R80-R82 Abnormal findings on examination of urine, without diagnosis
R83-R89 Abnormal findings on examination of other body fluids, substances and tissues, without diagnosis
R90-R94 Abnormal findings on diagnostic imaging and in function studies, without diagnosis
R95-R99 Ill-defined and unknown causes of mortality



If you are in the US, there is similar text at the beginning of ICD-10-CM Chapter 18: Symptoms, signs etc.

--------------------

(My highlighting below)

http://www.londonhp.nhs.uk/wp-content/uploads/2011/03/MUS-whole-systems-approach.pdf

Medically Unexplained Symptoms (MUS)
A whole systems approach

July 2009 – December 2010

Page 20

"It may be possible within the new polyclinic model that the routine of psychologists working
with consultants would develop. Equally, they could work in hospitals in more structured ways
such as a ‘pelvic pain’ clinic.

"We would suggest that one consultant in each department should lead on this area of the
work, helping other consultants to think about difficult presentations, ensuring patients can
access the psychologist appropriately and reviewing the care of patients where no biological
explanation can be found. At present, patients are referred back to primary care or on to
another secondary care department, thus allowing the clinician to maintain the idea that
medically unexplained symptoms are not part of their work.

"It will be necessary for acute clinicians working in these clinics to code patients that they feel
may have MUS. There are often no codes available to do this in these specialities. We would
advise therefore that the ICD codes F44, F45 and F48 are used as ‘catch-all’ codes. These
would include any situation where the clinicians felt there was an element of MUS affecting the
patient and their management. This is necessary in order for outcomes to be quantifiable.
These codes are to be used to monitor outcomes; clinicians can use the codes where
appropriate, in conjunction with other codes."


(Note that under F48.0 Neurasthenia (and its inclusion: Fatigue syndrome) there is an exclusion (Excl.) for G93.3.)

Also note:




But there are no exclusions for G93.3 under the ICD-10 F45.x codes.

So an additional F45.x diagnosis can be added to an existing or new diagnosis of G93.3, or to any other disease or condition.

"F45 Somatoform disorders
"The main feature is repeated presentation of physical symptoms together with persistent requests for medical investigations, in spite of repeated negative findings and reassurances by doctors that the symptoms have no physical basis. If any physical disorders are present, they do not explain the nature and extent of the symptoms or the distress and preoccupation of the patient."​

I have heard from several patients over the years (and prior to the development and roll-out of IAPT, MUS and PPS services) who have told me that in their medical records they had been assigned an F45.x code in addition to the G93.3 code.


For ICD-11, again, no specific term for "Medically unexplained symptoms."

Bodily distress disorder replaces most of the ICD-10 Somatoform disorder categories and also subsumes and replaces F48.0 Neurasthenia.

Like DSM-5's SSD, there is no longer the requirement for the chronic, distressing symptoms to be "medically unexplained." A patient may be diagnosed with BDD, or an additional diagnosis of BDD can be added in the presence of a general medical condition or disease:

"...If another health condition is causing or contributing to the symptoms, the degree of attention is clearly excessive in relation to its nature and progression."​

The criteria set for DSM-5's SSD and the more flexible disorder description texts for ICD-11's conceptualization of BDD are considerably looser and more easily met than the Somatoform disorders they replace.

This makes BDD very problematic for ME and CFS patients and I continue to push for exclusions for the three G93.3 legacy terms. Proposals for exclusions under BDD have been recently processed and rejected [1].


So in brief response to your question: in the UK NHS there is no mandatory ICD classification system that includes a coded for (or defined) term "Medically unexplained symptoms", there is no consensus definition, and there are other ICD-10 codes (in the R code chapter) that can be used for the recording of symptoms where no firm diagnosis can be recorded, which may be transitory symptoms, or prodromal symptoms.


1 Status of ICD-11 processed proposals v1:
https://dxrevisionwatch.com/status-of-icd-11-processed-proposals-v1/

 

Thank you @Trish for posting extracts from the German study in primary care.

The RCPSYCH site uses these figures:

https://www.rcpsych.ac.uk/mental-health/problems-disorders/medically-unexplained-symptoms

• About 1 in 4 people who see their GP have such symptoms.
• In a neurological outpatient setting, it is 1 in 3 patients or more*

References:

* The epidemiology of chronic syndromes that are frequently unexplained: do they have common associated factors? International Journal of Epidemiology, Volume 35, Issue 2, 1 April 2006, Pages 468 476, https://doi.org/10.1093/ije/dyi265 Aggarwal V R, McBeth J, Zakrzewska JM, Lunt M, Macfarlane G J


That first figure of 25% in GP settings may also include the so-called "FSSs."

 

Full paper available:

https://bmcfampract.biomedcentral.com/articles/10.1186/s12875-018-0791-9


Management of patients with persistent medically unexplained symptoms: a descriptive study

• Kate Sitnikova Email authorView ORCID ID profile,
• Rinske Pret-Oskam,
• Sandra M. A. Dijkstra-Kersten,
• Stephanie S. Leone,
• Harm W. J. van Marwijk,
• Henriëtte E. van der Horst and
• Johannes C. van der Wouden

Background

Medically unexplained symptoms (MUS), i.e. physical symptoms that cannot entirely be accounted for by a known somatic disease, are extremely common in primary care [1, 2]. Although most such symptoms are self-limiting, in some cases they persist and impair patients’ functioning [3]. In the latter case, persisting MUS may meet diagnostic criteria for (undifferentiated) somatoform disorder of the psychiatric classification system DSM-IV [4]. Since the introduction of DSM-5, somatoform disorders have been replaced by somatic symptom disorders [5]. The main criteria for somatic symptom disorder no longer require the nature of physical symptoms to be unexplained, but focus on maladaptive cognitions, emotions and/or behaviour with respect to the physical symptom(s).

The prevalence of persistent MUS, such as those classified as somatoform disorders, is 3–10% in general practice [6, 7, 8]. Persistent MUS are disabling and are associated with high rates of comorbid mental health disorders [6, 9, 10]. There are high direct and indirect health care costs due to increased health care use and productivity loss due to sickness absence [11].

PDF for full paper: https://bmcfampract.biomedcentral.com/track/pdf/10.1186/s12875-018-0791-9

---------------------------------------------------------------------------------------------------------------------------------------------


Higher prevalence rates anticipated for DSM-5's SSD than the Somatoform disorders which SSD replaces:

In the DSM-5 field trials for (C)SSD, 15% of the "cancer and malignancy" study group (patients with a pre-existing diagnosis of cancer or coronary disease) met the criteria for an additional diagnosis when "one of the B type criteria" was required; if the threshold was increased to "two B type criteria" about 10% met the criteria for dual-diagnosis of diagnosed illness + Somatic Symptom Disorder.

For the 94 "irritable bowel and chronic widespread pain" study group, about 26% were coded when "one of the B type criteria" was required; 13% were coded when "two B type criteria" were required. The finalised SSD criteria, as published in May 2013, required only one from the "B type criteria" to meet the criteria for a diagnosis of SSD. So the SSD Work Group and the DSM-5 Task Force went forward with the less specific criteria option, despite the results of their own field trials.

7% of the "healthy" control group were also captured by (C)SSD.

ICD-11's BDD is very close conceptually to DSM-5's SSD, with similar disorder characterization text but no rigid criteria set, which permits practitioners greater flexibility and clinical judgement than SSD.


Comparison of SSD, BDD, BDS, BSS in classification systems Version 1 | July 2018, Chapman & Dimmock:
https://dxrevisionwatch.files.wordp...-bdd-bds-bss-in-classification-systems-v1.pdf

 

ICD-11's BDD delivers a quadruple whammy:

1 Uses SSD's disorder conceptualization and far looser criteria than the Somatoform disorders it replaces; requires only a single chronic, distressing symptom + "excessive" psychobehavioural responses to the symptom(s) or health concerns;

2 No rigid criteria set, permitting greater flexibility and clinical judgement; decision to code based on highly subjective, difficult to measure constructs like disproportionate and persistent attention and excessive time and energy devoted to symptoms or health concerns;

3 Symptom aetiology no longer relevant for the diagnosis: can be applied as a "bolt-on" diagnosis to patients with chronic, distressing symptoms associated with any diagnosed general medical conditions;

4 Re-purposes a disorder name that has been used interchangeably since 2007 for the differently conceptualized Fink et al (2010) BDS.


Comparison of SSD, BDD, BDS, BSS in classification systems Version 1 | July 2018, Chapman & Dimmock:
https://dxrevisionwatch.files.wordp...-bdd-bds-bss-in-classification-systems-v1.pdf

 

@NelliePledge From my point of view MUS comes across as the ultimate "Get out of jail free card" for any doctor whose diagnostic skills are poor. If they don't know what diagnosis to give they can just blame the patient and pass them on to the therapists who've had a week's training in CBT. And it wouldn't surprise me if some doctors save money by refusing to diagnose something that might cost their practice a lot of money. One example of this might be hypothyroidism, which is a condition that currently entitles patients to free prescriptions for life. People with the condition in the UK are not officially diagnosed with overt hypothyroidism until their TSH is > 10 and their Free T4 is below range. There are other countries in Europe who diagnose when TSH > 3.

And as regards delays to cancer treatment, that is already well established :

Thousands of cancer patients face NHS treatment delays

 

I've read several times that it's become rather common for MS patients to be misdiagnosed with ME or FM early on.

It would definitely be good for their patients if they did monitor this, none of it is good for them and nerve damage tends to be permanent so it has enormous impacts in their case.

I doubt MS is alone with this problem.

 

https://ejcrim.com/index.php/EJCRIM/article/download/430/564

Dysautonomia: an Explanation for the Medically Unexplained?
Senthil Chandrasekaram1, Ranga H Fernando2, Vikram Aarella1, Emily T Mudenha1, Devaka JS Fernando1
1Department of Endocrinology and Diabetes,King's Mill Hospital, Sherwood Forest Hospital NHS Foundation Trust, Sutton-in-Ashfield, UK
2University of Manchester, Manchester, UK

"Patients attending specialist clinics with medically unexplained physical symptoms (MUS) account for a high proportion of frequent clinic visits, multiple investigations and health care costs, with emotional and psychological effects[1].

MUS have been divided into four categories: 1) MUS subsequently confirmed as MUS; 2) MUS initially medically explained and subsequently confirmed as medically explained; 3) MUS initially thought to be explained but later found to be unexplained (missed unexplained); and 4) MUS initially thought to be unexplained and later found to be explained (missed explained)[1].

Dysautonomia comprises a collection of conditions which may occur in different combinations in different individuals[2] and include postural orthostatic tachycardia syndrome (POTS), inappropriate sinus tachycardia, vasovagal syncope, pure autonomic failu re, neurocardiogenic syncope, neurally mediated hypertension, orthostatic hypotension, orthostatic hypertension, autonomic instability, paroxysmal sympathetic hyperactivity and cerebral salt wasting syndrome[2].
We describe a series of patients with symptoms not fitting into organ-based specialities which were incorrectly labelled as psychological in origin, who had dysautonomia, thus falling into the missed explained category.

...Failure to recognise dysautonomia as a clinical entity delayed diagnosis and had a significant adverse impact."