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Environ Health Perspect. Aug 2002; 110(Suppl 4): 641–647.
PMCID: PMC1241219
Research Article

Caring for medically unexplained physical symptoms after toxic environmental exposures: effects of contested causation.

Abstract

Medically unexplained physical symptoms (MUPS) are persistent idiopathic symptoms that drive patients to seek medical care. MUPS syndromes include chronic fatigue syndrome, fibromyalgia syndrome, and multiple chemical sensitivities. When MUPS occur after an environmental exposure or injury, an adversarial social context that we call "contested causation" may ensue. Contested causation may occur publicly and involve media controversy, scientific disagreement, political debate, and legal struggles. This adversarial social context may diminish the effectiveness of the provider-patient relationship. Contested causation also may occur privately, when disagreement over the causes of MUPS takes place in the patient-provider context. These patient-provider disagreements over causation often occur because of the enigmatic nature of MUPS. We suggest that a context of contested causation may have serious negative effects on healthcare for individuals with MUPS. Context plays a larger role in MUPS care than it does for most medical care because of the uncertain nature of MUPS, the reliance of standard MUPS therapies on a potentially tenuous patient-provider partnership, and the clinical need to rely routinely on subjective MUPS assessments that often yield discordant patient and provider conclusions. Contested causation may erode patient-provider trust, test the provider's self-assurance and capacity to share power with the patient, and raise problematic issues of compensation, reparation, and blame. These issues may distract patients and providers from therapeutic goals. In occupational and military settings, the adverse impact of contested causation on the patient-provider partnership may diminish therapeutic effectiveness to a greater degree than it does in other medical settings. Contested causation therefore raises questions regarding generalizability of standard therapies for MUPS and related syndromes to these settings. Future research is needed to learn whether intuitively sensible and evidence-based MUPS therapies benefit occupational and military medical patients who are afforded care in the context of contested causation.

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Selected References

These references are in PubMed. This may not be the complete list of references from this article.
  • Kroenke K, Price RK. Symptoms in the community. Prevalence, classification, and psychiatric comorbidity. Arch Intern Med. 1993 Nov 8;153(21):2474–2480. [PubMed]
  • Kroenke K, Spitzer RL, Williams JB, Linzer M, Hahn SR, deGruy FV, 3rd, Brody D. Physical symptoms in primary care. Predictors of psychiatric disorders and functional impairment. Arch Fam Med. 1994 Sep;3(9):774–779. [PubMed]
  • Katon W, Russo J. Chronic fatigue syndrome criteria. A critique of the requirement for multiple physical complaints. Arch Intern Med. 1992 Aug;152(8):1604–1609. [PubMed]
  • Wessely S, Nimnuan C, Sharpe M. Functional somatic syndromes: one or many? Lancet. 1999 Sep 11;354(9182):936–939. [PubMed]
  • Aaron LA, Buchwald D. A review of the evidence for overlap among unexplained clinical conditions. Ann Intern Med. 2001 May 1;134(9 Pt 2):868–881. [PubMed]
  • Hyams KC. Developing case definitions for symptom-based conditions: the problem of specificity. Epidemiol Rev. 1998;20(2):148–156. [PubMed]
  • Guarino P, Peduzzi P, Donta ST, Engel CC, Clauw DJ, Williams DA, Skinner JS, Barkhuizen A, Kazis LE, Feussner JR. A multicenter two by two factorial trial of cognitive behavioral therapy and aerobic exercise for Gulf War veterans' illnesses: design of a veterans affairs cooperative study (CSP #470). Control Clin Trials. 2001 Jun;22(3):310–332. [PubMed]
  • Kroenke K, Swindle R. Cognitive-behavioral therapy for somatization and symptom syndromes: a critical review of controlled clinical trials. Psychother Psychosom. 2000 Jul-Aug;69(4):205–215. [PubMed]
  • Clauw DJ, Chrousos GP. Chronic pain and fatigue syndromes: overlapping clinical and neuroendocrine features and potential pathogenic mechanisms. Neuroimmunomodulation. 1997 May-Jun;4(3):134–153. [PubMed]
  • Aaron LA, Burke MM, Buchwald D. Overlapping conditions among patients with chronic fatigue syndrome, fibromyalgia, and temporomandibular disorder. Arch Intern Med. 2000 Jan 24;160(2):221–227. [PubMed]
  • Hodgson MJ, Kipen HM. Gulf War illnesses: causation and treatment. J Occup Environ Med. 1999 Jun;41(6):443–452. [PubMed]
  • White KP, Speechley M, Harth M, Ostbye T. Co-existence of chronic fatigue syndrome with fibromyalgia syndrome in the general population. A controlled study. Scand J Rheumatol. 2000;29(1):44–51. [PubMed]
  • Katon W, Lin E, Von Korff M, Russo J, Lipscomb P, Bush T. Somatization: a spectrum of severity. Am J Psychiatry. 1991 Jan;148(1):34–40. [PubMed]
  • Gureje O, Simon GE, Ustun TB, Goldberg DP. Somatization in cross-cultural perspective: a World Health Organization study in primary care. Am J Psychiatry. 1997 Jul;154(7):989–995. [PubMed]
  • Hyams KC, Wignall FS, Roswell R. War syndromes and their evaluation: from the U.S. Civil War to the Persian Gulf War. Ann Intern Med. 1996 Sep 1;125(5):398–405. [PubMed]
  • Straus SE. Bridging the gulf in war syndromes. Lancet. 1999 Jan 16;353(9148):162–163. [PubMed]
  • Uijt de Haag PA, Smetsers RC, Witlox HW, Krüs HW, Eisenga AH. Evaluating the risk from depleted uranium after the Boeing 747-258F crash in Amsterdam, 1992. J Hazard Mater. 2000 Aug 28;76(1):39–58. [PubMed]
  • Kouyanou K, Pither CE, Wessely S. Iatrogenic factors and chronic pain. Psychosom Med. 1997 Nov-Dec;59(6):597–604. [PubMed]
  • Richardson RD, Engel CC, Jr, McFall M, McKnight K, Boehnlein JK, Hunt SC. Clinician attributions for symptoms and treatment of Gulf War-related health concerns. Arch Intern Med. 2001 May 28;161(10):1289–1294. [PubMed]
  • Hadler NM. If you have to prove you are ill, you can't get well. The object lesson of fibromyalgia. Spine (Phila Pa 1976) 1996 Oct 15;21(20):2397–2400. [PubMed]
  • Sullivan MD, Loeser JD. The diagnosis of disability. Treating and rating disability in a pain clinic. Arch Intern Med. 1992 Sep;152(9):1829–1835. [PubMed]
  • Brown P, Zavestoski S, McCormick S, Linder M, Mandelbaum J, Luebke T. A gulf of difference: disputes over Gulf War-related illnesses. J Health Soc Behav. 2001 Sep;42(3):235–257. [PubMed]
  • Brown P. Popular epidemiology and toxic waste contamination: lay and professional ways of knowing. J Health Soc Behav. 1992 Sep;33(3):267–281. [PubMed]
  • Wilson IB, Cleary PD. Linking clinical variables with health-related quality of life. A conceptual model of patient outcomes. JAMA. 1995 Jan 4;273(1):59–65. [PubMed]
  • Engel Charles C, Jr, Liu Xian, Hoge Charles, Smith Samantha. Multiple idiopathic physical symptoms in the ECA study: competing-risks analysis of 1-year incidence, mortality, and resolution. Epidemiological Catchment Area. Am J Psychiatry. 2002 Jun;159(6):998–1004. [PubMed]
  • Reid S, Chalder T, Cleare A, Hotopf M, Wessely S. Chronic fatigue syndrome. BMJ. 2000 Jan 29;320(7230):292–296. [PMC free article] [PubMed]
  • Whiting P, Bagnall AM, Sowden AJ, Cornell JE, Mulrow CD, Ramírez G. Interventions for the treatment and management of chronic fatigue syndrome: a systematic review. JAMA. 2001 Sep 19;286(11):1360–1368. [PubMed]
  • Engel CC, Jr, Roy M, Kayanan D, Ursano R. Multidisciplinary treatment of persistent symptoms after Gulf War service. Mil Med. 1998 Apr;163(4):202–208. [PubMed]
  • Engel CC, Jr, Liu X, Clymer R, Miller RF, Sjoberg T, Shapiro JR. Rehabilitative care of war-related health concerns. J Occup Environ Med. 2000 Apr;42(4):385–390. [PubMed]
  • McCully KK, Sisto SA, Natelson BH. Use of exercise for treatment of chronic fatigue syndrome. Sports Med. 1996 Jan;21(1):35–48. [PubMed]
  • Weyerer S, Kupfer B. Physical exercise and psychological health. Sports Med. 1994 Feb;17(2):108–116. [PubMed]
  • Frost H, Klaber Moffett JA, Moser JS, Fairbank JC. Randomised controlled trial for evaluation of fitness programme for patients with chronic low back pain. BMJ. 1995 Jan 21;310(6973):151–154. [PMC free article] [PubMed]
  • Frost H, Lamb SE, Klaber Moffett JA, Fairbank JC, Moser JS. A fitness programme for patients with chronic low back pain: 2-year follow-up of a randomised controlled trial. Pain. 1998 Apr;75(2-3):273–279. [PubMed]
  • McCann IL, Holmes DS. Influence of aerobic exercise on depression. J Pers Soc Psychol. 1984 May;46(5):1142–1147. [PubMed]
  • Wallberg-Henriksson H, Rincon J, Zierath JR. Exercise in the management of non-insulin-dependent diabetes mellitus. Sports Med. 1998 Jan;25(1):25–35. [PubMed]
  • Eldar R, Marincek C. Physical activity for elderly persons with neurological impairment: a review. Scand J Rehabil Med. 2000 Sep;32(3):99–103. [PubMed]
  • Corner J, Plant H, A'Hern R, Bailey C. Non-pharmacological intervention for breathlessness in lung cancer. Palliat Med. 1996 Oct;10(4):299–305. [PubMed]
  • Buckelew SP, Conway R, Parker J, Deuser WE, Read J, Witty TE, Hewett JE, Minor M, Johnson JC, Van Male L, et al. Biofeedback/relaxation training and exercise interventions for fibromyalgia: a prospective trial. Arthritis Care Res. 1998 Jun;11(3):196–209. [PubMed]
  • Fulcher KY, White PD. Randomised controlled trial of graded exercise in patients with the chronic fatigue syndrome. BMJ. 1997 Jun 7;314(7095):1647–1652. [PMC free article] [PubMed]
  • Mannerkorpi K, Nyberg B, Ahlmén M, Ekdahl C. Pool exercise combined with an education program for patients with fibromyalgia syndrome. A prospective, randomized study. J Rheumatol. 2000 Oct;27(10):2473–2481. [PubMed]
  • Martin L, Nutting A, MacIntosh BR, Edworthy SM, Butterwick D, Cook J. An exercise program in the treatment of fibromyalgia. J Rheumatol. 1996 Jun;23(6):1050–1053. [PubMed]
  • Wearden AJ, Morriss RK, Mullis R, Strickland PL, Pearson DJ, Appleby L, Campbell IT, Morris JA. Randomised, double-blind, placebo-controlled treatment trial of fluoxetine and graded exercise for chronic fatigue syndrome. Br J Psychiatry. 1998 Jun;172:485–490. [PubMed]
  • Wigers SH, Stiles TC, Vogel PA. Effects of aerobic exercise versus stress management treatment in fibromyalgia. A 4.5 year prospective study. Scand J Rheumatol. 1996;25(2):77–86. [PubMed]
  • Janal MN. Pain sensitivity, exercise and stoicism. J R Soc Med. 1996 Jul;89(7):376–381. [PMC free article] [PubMed]
  • Sonstroem RJ. Exercise and self-esteem. Exerc Sport Sci Rev. 1984;12:123–155. [PubMed]
  • Hammett VB. Psychological changes with physical fitness training. Can Med Assoc J. 1967 Mar 25;96(12):764–769. [PMC free article] [PubMed]
  • Mengshoel AM, Vøllestad NK, Førre O. Pain and fatigue induced by exercise in fibromyalgia patients and sedentary healthy subjects. Clin Exp Rheumatol. 1995 Jul-Aug;13(4):477–482. [PubMed]
  • Sharpe M, Hawton K, Simkin S, Surawy C, Hackmann A, Klimes I, Peto T, Warrell D, Seagroatt V. Cognitive behaviour therapy for the chronic fatigue syndrome: a randomized controlled trial. BMJ. 1996 Jan 6;312(7022):22–26. [PMC free article] [PubMed]
  • Deale A, Chalder T, Marks I, Wessely S. Cognitive behavior therapy for chronic fatigue syndrome: a randomized controlled trial. Am J Psychiatry. 1997 Mar;154(3):408–414. [PubMed]
  • Lindström I, Ohlund C, Eek C, Wallin L, Peterson LE, Fordyce WE, Nachemson AL. The effect of graded activity on patients with subacute low back pain: a randomized prospective clinical study with an operant-conditioning behavioral approach. Phys Ther. 1992 Apr;72(4):279–293. [PubMed]
  • D'Zurilla TJ, Goldfried MR. Problem solving and behavior modification. J Abnorm Psychol. 1971 Aug;78(1):107–126. [PubMed]
  • Ostell A. Coping, problem solving and stress: a framework for intervention strategies. Br J Med Psychol. 1991 Mar;64(Pt 1):11–24. [PubMed]
  • Shusterman D. Problem-solving techniques in occupational medicine. J Fam Pract. 1985 Sep;21(3):195–199. [PubMed]
  • Morin CM, Azrin NH. Stimulus control and imagery training in treating sleep-maintenance insomnia. J Consult Clin Psychol. 1987 Apr;55(2):260–262. [PubMed]
  • Von Korff M, Gruman J, Schaefer J, Curry SJ, Wagner EH. Collaborative management of chronic illness. Ann Intern Med. 1997 Dec 15;127(12):1097–1102. [PubMed]
  • Mechanic D. The functions and limitations of trust in the provision of medical care. J Health Polit Policy Law. 1998 Aug;23(4):661–686. [PubMed]
  • Kouyanou K, Pither CE, Rabe-Hesketh S, Wessely S. A comparative study of iatrogenesis, medication abuse, and psychiatric morbidity in chronic pain patients with and without medically explained symptoms. Pain. 1998 Jun;76(3):417–426. [PubMed]
  • Quill TE. Somatization disorder. One of medicine's blind spots. JAMA. 1985 Dec 6;254(21):3075–3079. [PubMed]
  • Lin EH, Katon W, Von Korff M, Bush T, Lipscomb P, Russo J, Wagner E. Frustrating patients: physician and patient perspectives among distressed high users of medical services. J Gen Intern Med. 1991 May-Jun;6(3):241–246. [PubMed]
  • Walker EA, Katon WJ, Keegan D, Gardner G, Sullivan M. Predictors of physician frustration in the care of patients with rheumatological complaints. Gen Hosp Psychiatry. 1997 Sep;19(5):315–323. [PubMed]
  • Hahn SR, Thompson KS, Wills TA, Stern V, Budner NS. The difficult doctor-patient relationship: somatization, personality and psychopathology. J Clin Epidemiol. 1994 Jun;47(6):647–657. [PubMed]
  • Peters S, Stanley I, Rose M, Salmon P. Patients with medically unexplained symptoms: sources of patients' authority and implications for demands on medical care. Soc Sci Med. 1998 Feb-Mar;46(4-5):559–565. [PubMed]
  • Salmon P, Peters S, Stanley I. Patients' perceptions of medical explanations for somatisation disorders: qualitative analysis. BMJ. 1999 Feb 6;318(7180):372–376. [PMC free article] [PubMed]
  • Engel CC, Kroenke K, Katon WJ. Mental health services in Army primary care: the need for a collaborative health care agenda. Mil Med. 1994 Mar;159(3):203–209. [PubMed]

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