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£208,000 of taxpayers' money for a group incl. Peter White & Rona Moss-Morris to review MUS evidence

Dolphin

Senior Member
Messages
17,567
@Maxwhd highlighted this on Twitter. Then @dxrevisionwatch found some more info.

The NIHR along with the MRC are the two main ways UK taxpayers' money is spent on health and medical research

http://www.nets.nihr.ac.uk/projects/hta/142608

HTA - 14/26/08: Medically unexplained symptoms(MUS): primary care intervention

Project title Medically unexplained symptoms(MUS): primary care intervention
Research type Evidence Synthesis
Status Waiting to start
Start date September 2015
Publication date
September 2017

Cost £ 200,008.00
Chief Investigator Dr Joanna Leaviss
Co-investigators Dr Andrew Booth (University of Sheffield), Dr Marta Buszewicz (University College London), Ms Sarah Davis (University of Sheffield), Professor Rona Moss-Morris (King's College London),Professor Glenys Parry (University of Sheffield), Dr Alison Scope (University of Sheffield), Mrs Andrea Shippam (University of Sheffield), Professor Matt Stevenson (University of Sheffield),Miss Anthea Sutton (University of Sheffield), Professor Peter White (Queen Mary University of London), Dr Shijie Ren (University of Sheffield)
Contractor University of Sheffield

Plain English summary
Individuals who often present to their GP with symptoms that can not easily be explained even after physical examination and tests may be referred to as having 'medically unexplained symptoms' (MUS). These symptoms can vary from individual to individual in terms of their number and severity, and some patients report 'clusters' of symptoms which have been given a variety of names such as fibromyalgia, irritable bowel syndrome, or chronic fatigue syndrome. Diagnosis can be made by a range of diagnostic criteria or by the GP expertise. MUS are a key feature of somatoform disorders, which must meet specific diagnostic criteria. There is variation in the usage of the term MUS. For the purposes of our review, we will use the term MUS to refer to all of the above diagnoses. Patients with MUS may place a large burden on the health services, with annual costs to the NHS estimated at £3.1 billion. This is due to increased GP visits and referrals for specialist tests or treatments. Current treatments include pharmacological, psychological or physical interventions. Reviews of the existing evidence for the effectiveness of these interventions tend to focus on the 'syndromes' (clusters of symptoms). Evidence of effectiveness is mixed, with some reviews showing small to moderate improvements in physical symptoms and functioning, and some showing no effect. These differing results may be due to factors such as the way the intervention is delivered, e.g. by a specialist or GP, in a group or individually, or by the way the condition is defined, e.g. as specific syndromes or 'MUS' in general. The most common interventions delivered in primary care tend to be psychological therapies such as cognitive behavioural therapy or reattribution therapy, or physical exercise therapies, or behaviour therapies. Many of these therapies aim to change problem behaviours of the individual that may be making their symptoms worse. There are benefits of these therapies being delivered in primary care. Sometimes people with MUS do not want to be referred to psychological services, as they feel that this means their symptoms are not being taken seriously. Therefore patients may be more ready to engage with these therapies if they are delivered within the primary care setting. There is no clear evidence about whether these therapies are effective when they are delivered in primary care. However, it has been suggested that the doctor-patient relationship plays an important role in their effectiveness. We propose a systematic review of the evidence of the effectiveness of such treatments, and an analysis of whether they offer good value. We will also look at how acceptable they are to patients. We will use rigorous methodology to conduct searches for all the evidence relating to behavioural modification intervention that are delivered in a primary care or community based setting. We will extract information about whether the intervention improves symptoms, functioning and health related quality of life, and what the barriers and facilitators to its effectiveness might be. We will then statistically analyse the data to obtain an overall effect. We will also conduct cost-effectiveness analyses to determine whether or not these interventions offer good value.

Scientific summary
The term MUS is used to cover a wide range of symptoms which cannot clearly be explained by a general medical condition, even after a thorough examination and any relevant investigations. A UK MUS prevalence rate of 18% of consecutive attenders to UK GP practices has been estimated (Taylor et al 2012). MUS costs the UK NHS in excess of £3.1 billion per annum and taking into account quality of life and sickness absence, wider costs to the economy reach £14 billion annually (Bermingham et al. 2010). A range of pharmacological, psychological and physical therapies have been implemented in the treatment of MUS. Behavioural Modification Interventions such as Cognitive Behavioural Therapy (CBT), Graded Exercise Therapy (GET), and behaviour therapies are commonly delivered in primary care. We will conduct a systematic review, using rigorous methods, of the evidence on the clinical, cost-effectiveness and acceptability of behavioural modification interventions for MUS in primary care and community-based settings. Search strategy: we will conduct a comprehensive search of bibliographic databases, combining terms for MUS and related synonyms and primary care setting. Searches will not be limited by intervention as we anticipate overlap between interventions and inconsistencies in labels and definitions. Methodological search filters will be applied to identify systematic reviews, RCTs, and qualitative research and cost-effectiveness where appropriate. Inclusion criteria: Intervention interventions that aim to modify behaviour will be included. These include CBT, GET, behaviour therapies. Where the intervention is not explicitly behaviour modification, we will adopt a broad inclusion criteria, with studies included if i) at least one primary outcome is a functional or behavioural change measure, or ii) the stated explicit aim of the intervention is to change behaviour. Population studies of populations meeting the criteria for MUS, MUPS, or somatoform disorders. Functional somatic syndromes will be included. Setting studies in primary care or community-based settings. Design Randomised Controlled Trials. Comparator usual care, treatment as usual, or wait list, trials with a placebo control. We will also include head to head trials. Outcomes improvement in symptoms, functioning and/or health related quality of life; use of healthcare resources. Quantitative synthesis: a random effects network meta-analysis will be used, providing the relevant RCTs form a network of evidence. The random effects pairwise comparison will allow heterogeneity in treatment effects across studies. Random effects pairwise meta-analysis will be performed when data do not form a network. Qualitative synthesis: A realist synthesis will be conducted to provide added value to the quantitative synthesis by indicating patient and service provider issues around the acceptability of interventions. Thematic synthesis will be used to aggregate the findings. Cost-effectiveness: evidence on cost-effectiveness will be identified by conducting a systematic review of existing economic analyses, and undertaking a de novo model based evaluation where there is a lack of relevant existing analyses. Costs will be evaluated from an NHS and personal social services perspective. Health benefits will be estimated using quality-adjusted life years (QALYS) gained. Future costs will be discounted at 3.5% in line with NICE s current guidance.

Documents
Protocol http://www.nets.nihr.ac.uk/__data/assets/pdf_file/0016/150181/PRO-14-26-08.pdf (PDF File - 118.5 KB)
 

Dolphin

Senior Member
Messages
17,567
http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42015025520

Medically unexplained symptoms(MUS): primary care intervention

Joanna Leaviss, Glenys Parry, Matt Stevenson, Andrew Booth, Alison Scope, Sarah Davis, Shije Ren, Anthea Sutton, Peter White, Rona Moss-Morris, Marta Buszewicz

Citation
Joanna Leaviss, Glenys Parry, Matt Stevenson, Andrew Booth, Alison Scope, Sarah Davis, Shije Ren, Anthea Sutton, Peter White, Rona Moss-Morris, Marta Buszewicz. Medically unexplained symptoms(MUS): primary care intervention. PROSPERO 2015:CRD42015025520 Available from http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42015025520
Review question(s)
What is the clinical, cost-effectiveness and acceptability of behavioural modification interventions for Medically Unexplained Symptoms in primary care or community-based settings?

Searches
• MEDLINE & MEDLINE-In-Process

• EMBASE

• CINAHL

• PsycINFO

• The Cochrane Library

• Science & Social Sciences Citation Indexes via Web of Science

All databases will be searched from inception.

We will review non-English language studies that meet our inclusion criteria if they are conducted in high income countries, i.e. with analogous health systems to the UK.

Types of study to be included
Relevant systematic reviews, RCTs and economic evaluations will be extracted in the first instance and assessed for quality. In addition, qualitative research concerning barriers/facilitators of the effectiveness of behavioural modification interventions from the perspective of both patients and service providers will be retrieved. In the absence of RCT data, data from non-randomised comparative studies, pseudo-experimental studies, quasi-experiments and case report/series will be considered.

Qualitative studies:

(1) Studies reporting qualitative research or qualitative data elicited via a survey or a mixed-methods study to include qualitative data on the perspectives and attitudes of patients who have received behaviour modification interventions in a primary care or community based setting.

(2) Qualitative data, embedded in trial reports or in accompanying process evaluations, which can inform an understanding of how issues of acceptability are likely to affect the clinical effectiveness of interventions;

(3) Qualitative data, either from separately conceived research or embedded within quantitative study reports, reporting the acceptability of interventions to health care practitioners.

Condition or domain being studied
The term ‘MUS’ is used to cover a wide range of symptoms which cannot be clearly explained by a general medical condition, even after a thorough examination and any relevant investigations. Henningsen et al (2005) describe three main types of MUS: pain in different locations, for example headache, back pain, non-cardiac chest pain (NCCP); functional disturbance of organ systems; and complaints of fatigue or exhaustion. The term MUS may be applied to patients presenting with single symptoms, multiple symptoms, or clusters of symptoms that are related to one another and are specific to a certain organ system or medical specialty, for example chronic fatigue syndrome (CFS), irritable bowel syndrome (IBS), or fibromyalgia. The latter are usually referred to as functional somatic syndromes (FSS) (Wessely et al., 1999). Patients presenting with MUS may vary in terms of reported severity i.e. number of symptoms, functional disability or quality of life, and duration of symptoms.

Participants/ population
Studies of populations meeting the diagnostic criteria for MUS, MUPS, and somatoform disorders will be included. Diagnosis of MUS or MUPS may be either by validated instrument (e.g PHQ-15, SOMS, BSI) or clinician judgement. Diagnosis will not be restricted by duration, (apart from chronic pain where duration should be > 3 months), or severity e.g. number of symptoms. Patients with single symptoms will be included. Populations with FSS will be included, e.g. IBS, CFS, fibromyalgia. For somatoform disorders, diagnosis should be made by formal clinical interview and should meet criteria according to DSM IV or V, or ICD 9 or 10. Somatoform disorders will include somatisation disorder, somatoform disorders, pain disorders, persistent physical symptoms, bodily distress syndrome, bodily distress disorder, functional somatic syndrome, medically unexplained syndrome. Populations should include adults aged 18 years or over.

Intervention(s), exposure(s)
Behavioural modification interventions. We will include interventions that aim to modify behaviour. These include CBT, behaviour therapy, and GET. Where the intervention is not explicitly named as a behavioural modification intervention i.e. one of the above, we will adopt a broad definition of behavioural change interventions, and will include any intervention where i) at least one primary outcome is a functional or behavioural change measure or ii) the stated explicit aim of the intervention is to change behaviour. Interventions may therefore include but will not be exclusive to a range of psychotherapies, for example CBT, behavioural therapy, psychodynamic therapy, mindfulness, reattribution therapy. Interventions may also include other physical therapies, but only where behaviour change is a specified primary outcome or treatment mechanism. Interventions with multiple components will be included where one of the components can be considered a behavioural modification technique as defined by the above criteria. Individual and group interventions will be treated as separate interventions.

Comparator(s)/ control
Studies where ‘usual care’ is the comparator will be included. Due to variation in terminology, studies where the comparator is ‘treatment as usual’, or ‘wait list’ will also be included. Trials with a ‘placebo’ control, e.g. which control for time and attention, will be included. As a number of high-quality head-to-head trials of two or more experimental interventions have been identified, head-to-head trials will also be included, where at least one arm meets the definitions outlined above.

Context
Studies in primary care or community-based settings will be included. Whilst interventions must be conducted within a primary care or community-based setting (e.g. general practice, occupational health), they may be delivered by any health care discipline within that setting. Interventions may be face-to-face or delivered at a distance e.g. by internet or telephone, and may include computer-assisted interventions. Where interventions are physiotherapy-based, these may be delivered by a community physiotherapist but not by a hospital physiotherapist. With psychological interventions, these may be delivered by a psychologist or therapist within a primary care setting, but not by a psychologist or therapist following referral to secondary or tertiary care. IAPT interventions will be included if delivered in a primary care or community-based setting.

Outcome(s)
Primary outcomes
Patient level: Improvement in symptoms, functioning and/or health related quality of life. Measures of symptom improvement may be through assessment of severity or frequency and must be assessed using a generic or symptom specific validated instrument, for example EQ-5D/SF-36 for HRQL; Symptom Checklist (SCL) for symptom severity; Patient Health Questionnaire (PHQ-15).

Health care level: Use of healthcare resources (e.g. frequency of GP visits, diagnostic outpatient procedures, hospital admission, Emergency Department attendances).

Secondary outcomes
Depression or anxiety as diagnosed by a validated instrument e.g. Beck Depression Inventory (BDI) or Beck Anxiety Inventory (BAI), satisfaction with care, attrition (persistence and adherence).

Data extraction, (selection and coding)
A two-stage sifting process for inclusion of studies, (title/abstract then full paper sift) will be undertaken. Titles and abstracts of both the quantitative and qualitative studies will be scrutinised by one assessor according to the inclusion and exclusion criteria. There will be no exclusion on the basis of quality at this stage. All studies identified for inclusion using the abstract, together with any in which a decision on inclusion was not possible from these brief details, will be obtained for more detailed appraisal. Agreement on inclusion at title/abstract sift will checked by a second reviewer for 20% of the total search results. Agreement will be calculated using the kappa statistic. If the kappa statistic is below acceptable levels (0.7) then double-sifting will be undertaken. In the event of disagreement regarding the inclusion of a study, the opinion of the MUS experts in the project team will be sought.

Data extraction from included qualitative studies will be undertaken using a data extraction tool adapted and tailored for the precise purpose of the qualitative review. A framework for extraction will be developed to elicit data extraction elements related directly to the review question. Selective extraction of qualitative findings (Noyes and Lewin, 2011) will be undertaken on the basis that they are data pertaining to characteristics of the interventions of interest.

Study identification and data extraction for the cost-effectiveness review will be done by a single reviewer.

Risk of bias (quality) assessment
We will assess the quality of quantitative studies using the Cochrane Risk of Bias tool (Higgins et al, 2011) (or adapted/Cochrane psychological risk of bias tool; Lackner et al, 2004). Economic evaluations will be assessed using the Drummond quality check-list and the CHEERS statement on reporting standard.

Qualitative studies will be evaluated using the CerQual approach. CerQual (certainty of the qualitative evidence) (Glenton et al., 2013) aims to assess how much certainty can be placed in the qualitative evidence for the review finding, or in other words, how reliable the review finding is. This approach relies on assessing both the methodological quality of the individual included studies and the coherence of the review finding as defined by the extent to which a clear pattern across the individual study data is identifiable. To assess methodological quality individual studies will be appraised using an abbreviated version of the Critical Appraisal Skills Programme (CASP) quality-assessment tool for qualitative studies (CASP, 2011). The coherence of each review finding will then be assessed by looking at the extent to which a clear pattern across the data is identified and is contributed to by each individual study. This is assessed by examining whether the review finding is consistent across multiple contexts and whether it has incorporated explanations for any variation cross individual studies. Coherence is further strengthened where the individual studies contributing to the finding are drawn from a wide range of settings. Using the assessment of methodological quality and assessment of coherence together, the certainty of each review finding can be rated as high, moderate, or low.

Strategy for data synthesis
Quantitative studies: Published guidelines for meta-analyses produced by the Cochrane Collaboration (Ghersi et al 2011) will be adhered to when synthesising the evidence, ensuring the production of a rigorous review. Given that the intention is to compare all behavioural modification interventions, a random effects network meta-analysis will be used, providing that the relevant RCTs form a network of evidence. The random effects model will allow heterogeneity in treatment effects across studies. Random effects pairwise meta-analysis will be performed when data do not form a network of evidence.

For primary outcomes, meta-regression analysis will be used to explain any heterogeneity in treatment effects between studies where compatible data allow. The analysis will be conducted for the following potential treatment effect modifiers if data allows: i) recognised FSS, for example fibromyalgia, irritable bowel syndrome and chronic fatigue syndrome, and ‘somatoform disorders’ ii) who delivers the therapy, for example GP; specialist iii) number of sessions of intervention; iv) number of symptoms; v) duration of MUS

In the case that no evidence can be synthesised, we will use narrative synthesis to summarise the results of these studies.

Qualitative studies: Qualitative meta-synthesis will be undertaken to provide added value to the quantitative analysis by indicating patient and service provider issues around the acceptability of interventions. Specifically, thematic synthesis will be used to aggregate the findings (Thomas and Harden, 2008). The interaction between health service user and those delivering the service requires recognition that any intervention may alter context which, in turn, triggers mechanisms which produce outcomes. We will therefore use realist synthesis approaches, as used in our previous NIHR projects, to extend a consideration of what works? to ‘what about this set of behavioural interventions works for whom in what circumstances?” We will explore intervention theory while recognising that the group of medically unexplained symptoms is heterogeneous and therefore the mechanisms of achieving outcomes may differ significantly. To handle this methodological challenge we will follow recent good practice in realist synthesis which suggests working back from common outcomes in order to identify patterns of variation. It can be argued that the range of outcomes is potentially more finite than the range of intervention components and so an outcome led approach will give structure to the review and allow the integration of quantitative and qualitative data from the preceding stages of the review. We will also use existing behavioural modification taxonomies to inform our data extraction and subsequent analysis.

Through the realist synthesis approach we hope to identify those contextual factors that are associated with an increased likelihood of triggering mechanisms that would produce the desired behavioural change, for example perceived warmth and understanding of the GP. The intention is not to generate generalisable effect sizes as will be the case for the quantitative aspects of the review but rather to inform those commissioning and specifying services by generating statements about situations in which behavioural interventions may be more likely to be effective. We will endeavour to combine the interpretative strengths of realist synthesis with the systematic review-driven requirements to generate a comprehensive audit trail to ensure transparency.

Analysis of subgroups or subsets
i) recognised FSS, for example fibromyalgia, irritable bowel syndrome and chronic fatigue syndrome, and ‘somatoform disorders’ ii) who delivers the therapy, for example GP; specialist iii) number of sessions of intervention; iv) number of symptoms; v) duration of MUS

Dissemination plans
We will create links and engage with patient support groups that currently exist for syndromes such as CFS, Fibromyalgia, and Irritable Bowel Syndrome (IBS) in order to publicise the on-going work, as well as link in with professional bodies.

Findings from the review will be presented at relevant professional forums, i.e. societies for behavioural medicine, health economics, primary care, psychiatry and psychology and their associated conferences.

We will disseminate findings of the project to the academic community. The final project report will detail the background, methods and results of the quantitative and qualitative reviews, with statistical syntheses and cost-effectiveness evaluation providing conclusions and recommendations. The decision-analytic model will continue to be available for further analyses as the evidence base develops. We intend to disseminate the findings by publishing the systematic reviews and cost-effectiveness models in high quality journals. We will present the findings at national and international conferences.

Contact details for further information
Dr Leaviss

ScHARR

University of Sheffield

Regent Court

30 Regent Street

Sheffield S1 4DA

j.leaviss@sheffield.ac.uk

Organisational affiliation of the review
University of Sheffield

www.sheffield.ac.uk

Review team
Dr Joanna Leaviss, University of Sheffield
Professor Glenys Parry, University of Sheffield
Professor Matt Stevenson, University of Sheffield
Dr Andrew Booth, University of Sheffield
Dr Alison Scope, University of Sheffield
Dr Sarah Davis, University of Sheffield
Dr Shije Ren, University of Sheffield
Miss Anthea Sutton, University of Sheffield
Professor Peter White, Queen Mary University of London
Professor Rona Moss-Morris, King's College London
Dr Marta Buszewicz, University College London

Anticipated or actual start date
01 September 2015

Anticipated completion date
28 February 2017

Funding sources/sponsors
NIHR HTA project 14/26/08

Conflicts of interest
None known

Language
English

Country
England

Subject index terms status
Subject indexing assigned by CRD

Subject index terms
Humans; Primary Health Care; Somatoform Disorders

Stage of review
Ongoing

Date of registration in PROSPERO
24 August 2015

Date of publication of this revision
24 August 2015

DOI
10.15124/CRD42015025520

Stage of review at time of this submission Started Completed
Preliminary searches No No
Piloting of the study selection process No No
Formal screening of search results against eligibility criteria No No
Data extraction No No
Risk of bias (quality) assessment No No
Data analysis No No
 

A.B.

Senior Member
Messages
3,780
Understanding ways in which to make behavioural approaches more acceptable is likely to increase uptake.

You know your therapy is crap when patients will not touch it.

The "repeated health care seeking" should make it obvious that patients want effective biomedical treatment.
 
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alkt

Senior Member
Messages
339
Location
uk
would their qualitative data be the same data provided for the pace and get trials. or from the 209 papers that have s wessley's name on them. and why pay a bunch of dr's to do an auditors job. it smells bad.
 

Sean

Senior Member
Messages
7,378
These differing results may be due to factors such as the way the intervention is delivered, e.g. by a specialist or GP, in a group or individually, or by the way the condition is defined, e.g. as specific syndromes or 'MUS' in general.

Or maybe, just maybe, because IT DOESN'T WORK?

:bang-head::bang-head::bang-head:
 
Messages
1,446
.
£208,000 ??

Peter White still raking in the research funds then. Patients have to crowdfund fund ME bioresearch, but the CBT/GET endorsers seem to have access to a bottomless pot of research fund gold.

Imagine if all the £££millions handed out to Peter White and others for 'cfs' psychosocial studies in the last 20 years had instead gone to ME bioresearch.
 
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Simon

Senior Member
Messages
3,789
Location
Monmouth, UK
Evidence of effectiveness is mixed, with some reviews showing small to moderate improvements in physical symptoms and functioning, and some showing no effect

These symptoms can vary from individual to individual in terms of their number and severity, and some patients report 'clusters' of symptoms
In a different world, adding these two points together might lead to the conclusion that what's needed is a focus on understanding properly the basis of these illnesses, and not an assumption that mediocre results from generic treatments mean that researchers are on the right path.
 
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medfeb

Senior Member
Messages
491
In a different world, they might also think about the scientific validity and medical ethicality of throwing together all the conditions that have medically unexplained symptoms as a singular entity that can be studied and treated in the same way. They might also think about the limits of current knowledge and the implications of those limits for the stability of a disease category grounded on "unexplained"

For me, this article by AnneMarie Jutel on medically unexplained symptoms as a disease label gave useful perspective on this topic
http://www.palgrave-journals.com/sth/journal/v8/n3/full/sth200921a.html
Medically unexplained symptoms are a source of frustration for clinician and patient alike. They simultaneously test the credibility of the doctor and the patient; the former, for his or her inability to label the patient's complaint, and the latter, for the ignominy of being perceived to have a factitious symptom. This review explores the discursive construction of such symptoms in the medical literature in order to appreciate the context in which medicine understands and manages non-diagnosed complaints. It uses medically unexplained symptoms as a heuristic for understanding the role of classification in constituting medicine as a social authority. In the absence of diagnostic category, medically unexplained symptoms are recast as a discrete category of their own. However, this category implies the infallibility of the physician and the relevance of the medical model in all circumstances. It transfers responsibility for the disorder to the patient in a way that may hinder resolution, and it ignores socio-historical practices that influence when and why patients consult a physician.​
 
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sarah darwins

Senior Member
Messages
2,508
Location
Cornwall, UK
Oh, good grief. MUS is showing signs of becoming the world's most dangerous abbreviation. This feels like an attempt to undo several hundred years of scientific inquiry into human pathology.

Individuals who often present to their GP with symptoms that can not easily be explained even after physical examination and tests may be referred to as having 'medically unexplained symptoms' (MUS)

Yes, they may. They may also be termed "patients whose cases merit further medical investigation".

And "Cannot easily be explained ..." ??? Huh? I can't believe GPs would be thrilled at the idea that as soon as a difficult case presents itself they should hand it right on over to psychological services. Unless they're under so much time pressure that it comes as a relief, in which case ... boy, are we screwed.

Sometimes people with MUS do not want to be referred to psychological services, as they feel that this means their symptoms are not being taken seriously. Therefore patients may be more ready to engage with these therapies if they are delivered within the primary care setting.

The assumption inherent in statements like these — that anyone whose symptoms don't lead to an expedient diagnosis can be appropriately treated by psychological services — is jaw-dropping. One of the few things I do remember from high school science is my teachers drumming "assume nothing" into us. I think someone on this forum coined the phrase "anti-enlightenment" a while back. Precisely.
 

Sean

Senior Member
Messages
7,378
Sometimes people with MUS do not want to be referred to psychological services, as they feel that this means their symptoms are not being taken seriously. Therefore patients may be more ready to engage with these therapies if they are delivered within the primary care setting.

These guys still think it is all about the sales pitch, not the product itself.
 

Chrisb

Senior Member
Messages
1,051
I think there may be some progress in terms of social and self awareness on the part of some researchers. I used to see this "syndrome" referred to as MUPS. Presumably any connection between the researchers and Muppets was entirely coincidental.
 

worldbackwards

Senior Member
Messages
2,051
Presumably any connection between the researchers and Muppets was entirely coincidental.
iu

Which one's White then?