a substantial proportion of patients who repeatedly present to hospitals with symptoms for which conventional pathology can not be identified , show evidence of psychological distress that is either not expressed or is unrecognized in the general practice consultation .
the phenomena has two aspects : the expression of psychological illness through physical symptoms , and repeated medical help - seeking for multiple medical symptoms without organic disease .
somatization diagnosis is a prevalent , expensive , and a difficult - to - treat problem for general practitioners .
it is also reported that some cultures stigmatize psychological disorder more than others . to overcome the confusion around the term somatization ,
neither somatized mental distress nor somatization disorders adequately account for most patients seen with mups .
patients show up at hospitals with symptoms for a variety of reasons , including the disruption caused by the severity of the symptoms and the patients concerns about what they mean .
there was a paucity of studies done on mups in kerala , a south indian state .
the objective of this study was to examine the sociodemographic and other clinical variables associated with mups .
the clinical sample was taken from the general / internal medicine outpatient clinic of the government medical college , thrissur , kerala , india .
the medical doctor , with psychiatry experience , saw the potential patients together with the physicians on mondays in the clinic .
the referred cases meeting the criteria for mups were enrolled for the study , for approximately three years .
the medical doctor discussed the cases with the consultant psychiatrist ( pk - second author ) and confirmed the diagnosis .
the criteria for mups were one or more physical symptoms after appropriate investigation , which could not be explained by a general medical condition , and the symptoms caused clinically significant distress or impairment in social and occupational functioning , in excess of what would be expected from the history and physical examination and laboratory findings .
the medical doctor with psychiatry experience completed the questionnaire , which included the sociodemographic profile , with details regarding frequency of physical complaints , duration of symptoms , the number of visits to the doctor , investigations done , psychosocial and environmental stressors , and personality disorder .
the symptoms were assessed using the symptom enquiry checklist used in the world health organization international study on somatoform disorders ( 1994 ) , which had 73 questions . in this cross - sectional study ,
we provide descriptive information on the sociodemographic variables , summarized in table 1 , and clinical variables , summarized in tables 2 and 3 , of 48 participants enrolled in this exploratory study .
there were a total of 274 symptoms , which is an average of 5.7 symptoms per patient .
in contrast to the female - to - male ratio of 5 : 1 ( dsm - iv - tr ) , we found a female - to - male ratio of 7 : 1 .
this may be because of the difference in the western population versus the indian population .
the medical knowledge of urban people may be discouraging them from reporting psychological distress as a physical disease .
consistent with dsm - iv - tr , our study also showed that avoidant and obsessive compulsive personality disorders were commonly associated with mups .
in contrast , we did not find an association between mups and paranoid , histrionic , and antisocial personalities .
the preponderance of females in this study is not consistent with the usual hospital data in india . in conditions where community data shows a higher prevalence of females , hospital data shows male predominance .
however , the findings were contrary in case of mups in this study . for physical manifestations arising from psychological distress ,
. the severity , chronic nature , and social acceptance of symptoms may be the reasons for this discrepancy .
it may be that the predominance of adults in this study reflects the usual hospital patient population . seeking out treatment
however , in the eca study done in us , in 3,132 community respondents with somatization disorder , the majority was unmarried or divorced , which is consistent with the western culture . in india , women may be bearing the strain of marital conflict , expressing it through culturally acceptable physical symptoms .
this has been reported in a study from the neighboring state of tamil nadu , another southern state in india .
consistent with our results , headache was the most common symptom and obsession scores were also high in the quoted study done in tamil nadu .
a medical doctor in india has relatively insignificant exposure in psychiatry during the medical school / college training period .
after the training they practically have no avenues to get further exposure to psychiatry as a mental health professional 's work , in isolation .
hence , a physician who is not a psychiatrist is without adequate confidence to diagnose a psychiatric syndrome .
the more the patient is investigated , the more a patient is convinced about the physical basis . on account of the psychogenic etiopathophysiology ,
although it has been estimated that 5% of the patients in general practice present with severe forms of somatization , this disorder is clearly underdiagnosed , and on many occasions physicians tend to repeatedly pursue an organic etiology for the patients complaints , using multiple test procedures , medication , and surgical operations instead of recognizing a somatization disorder.[1216 ] finally , patients with a somatization disorder tend to withdraw from pleasurable activities and have less productivity because of discomfort , fatigue or fear of exacerbation of their symptoms . in a review on somatizing and psychologizing patients
, there were no consistent differences between people with psychiatric disorders , who presented with psychological symptoms versus who presented with physical symptoms .
although 25% of the affected patients present with only psychological symptoms , the remainder may accept the possibility of a psychosocial component to their physical symptoms , even if they do not volunteer it during the consultation .
practical reasons , such as lack of time , or a sense that problems are not relevant or amenable to treatment , seem more important than failure to recognize their own mental distress , which may explain why patients choose not to disclose psychological problems during consultations .
one of the few longitudinal studies identified a pattern whereby symptoms occurring at a time of newly increased stress tended to be attributed to stress .
patients came to doctors with mups only if the stress persisted . in our study , a medical doctor with psychiatry experience who was not a psychiatrist easily elicited the stressors .
lack of time is not a restraining factor to elicit stressors / stress , only an orientation and an inclination for it is required .
patients may often perceive doctors as denying the validity of their symptoms.[92022 ] even as doctors have medical models of illnesses ; patients also have lay models , which are complex and broadly consistent .
these include the name of the condition and its symptoms , the personal consequences of it , how long will it last , and the extent to which it can be controlled or cured .
there are eight dimensions proposed : four on the etiology ( stress , environment , lifestyle , and weak constitution ) , three concerning mechanism ( wearing out , internal structure , and internal function ) , and a final dimension of concern raised by the symptom proposed .
patients are able to accept a medical opinion when doctors develop non - blaming models of conditions with their patients and form constructive alliances against the illness.[92022 ] illness belief models explore how patients see illness as threatening .
the doctors seek to reduce that threat through treatment and reassurance . unfortunately , reassurance is not always effective ; between a third and half of the patients report a continuing concern about serious illness after normal cardiac ultrasound or angiography .
psychological models of threat reduction suggest two separate processes : emotional - heuristic ( calming , protecting , and threat - avoiding ) , and cognitive - systematic ( information - seeking and threat - analyzing ) .
although emotional , threat avoiding , verbal and non - verbal reassurance may be effective in alleviating distress in the short term , it may not be effective to weaken illness representations .
if symptoms recur , repeated reassurance is likely to produce a cycle of reassurance seeking and giving that is self - perpetuating .
in contrast , the cognitive model of threat analyzing is more threatening for patients in the short term , but more likely to produce long - term changes , which in turn , may be associated with improvement
. the physician tends to be initially concerned to rule out treatable medical conditions , and when none are found , leads to  excessive help - seeking behavior .
patient relationship , as the patients sense that their doctor has lost interest in them or view them as bothersome .
although many physicians are eager to refer the patient for psychiatric evaluation and treatment , patients might see the referral as their doctor 's way of questioning the reality of their symptoms .
this challenge has encouraged the development of treatment approaches for somatization disorder that meet the different demands of the patient and the referring physician .
kaiser - permanente , a us health maintenance program has shown that somatizing patients could bankrupt the healthcare financing system and these patients can be helped leading to reduced healthcare costs . the  affective cognitive behavioral therapy is recommended for physicians , for the treatment of mups , which includes the following : providing continuity of care , avoiding unnecessary tests and procedures , providing frequent , brief , and regular office visits , always performing a physical examination , avoiding making disparaging comments like ,  your symptoms are all in your head , setting reasonable therapeutic goals like maintaining the functioning despite ongoing pain . in a review on human psychoneuroimmunology studies , authors found that immune modulation by psychosocial stressors or interventions could lead to actual health changes .
the major strength of this study is the large sample size ( n=48 ) in an indian population .
one more strength is the unique clinical sample having the features of both a rural setting and a tertiary care hospital . in our study
, we could not calculate the prevalence , because we did not have the total number of patients who showed up at the medicine clinic on mondays .
our study included subjects with mups and not with a dsm - iv - tr diagnosis of somatization or somatoform disorder .
however , somatization disorder terminology will be changed to simple and complex somatic symptom disorders in dsm - v .
another limitation of this study was that we could not analyze an association between mups and comorbid psychiatric diagnoses . in the hospital where this study was done
, the patients presenting to the clinics had only their prescriptions , without a documented diagnosis .
to our knowledge this is the first psychosocioeconomic study of mups done in kerala , india .
more studies are warranted focusing on non - pharmacological treatment and psycho - education on mind 
future studies should also shed light on specific cytokines associated with mups for personalized management , which is a national institute of mental health mission and priority .
there is also a need for studies to examine the effect of a combination of antidepressants and cognitive behavioral therapy on mups .
 background : there is a paucity of studies done on medically unexplained physical symptoms ( mups ) in kerala , india . 
 the objective of this study was to examine the sociodemographic and other clinical variables associated with this condition.materials and methods : the clinical sample was taken from the general medicine clinic of a tertiary care hospital , in kerala . 
 the referred cases meeting the criteria ( n=48 ) for medically unexplained physical symptoms were enrolled for this cross - sectional study . 
 the medical doctor with experience in psychiatry completed the questionnaire.results:most of the patients were middle - aged females from rural areas . 
 the most common symptom reported was headache . 
 most of the patients had symptoms for five years or more and had seen two - to - five consultants . 
 a majority of the patients had undergone special investigations and a few had expensive and invasive investigations . 
 cluster c personality disorders were the most common associated personality disorders with medically unexplained physical symptoms.conclusions:to our knowledge this is the first psychosocioeconomic study on medically unexplained physical symptoms , done in kerala , india . 
 medically unexplained physical symptoms cause loss of productivity and economic burden and are a major public health problem . 
 future studies are warranted focusing on non - pharmacological treatment , psycho - education on mind  
 body association , and medical models on specific cytokines associated with medically unexplained physical symptoms for personalized management , and to examine the effect of a combination of pharmacotherapy and cognitive behavioral therapy . 
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
STRENGTHS AND LIMITATIONS
CONCLUSIONS AND FUTURE DIRECTIONS