Table 5 Quotes of FPs in relation to the different subgroups of patients with MUPS

The anxious MUPS patient

FG4;FP4: ‘I often see anxious patients, who have a bad connection with their body and who are in panic because of it and are not easily reassured. They always hope to find reassurance in all kinds of additional examinations.’

FP1: ‘Yes’. FP2: agrees

FG5;FP2: ‘Is it not predominantly anxiety or an alarming feeling. It is constantly being overwhelmed by signals, physical signals that they cannot make sense of. I believe that patients are being overwhelmed and do not know what to do with all those symptoms. And therefore they come directly to us, as an authority to tell them what it is.’

FG5;FP3: ‘I am sure that they feel the tingles, the palpitations and the headaches and then they think: “Oh My God, what is this? Let this be nothing serious.” They tend to give a catastrophizing explanation to it.’

The unhappy MUPS patient

FG1;FP3: ‘It is the recurrent thing, I mean, the fact that patients come back all the time with headache and then stomach ache and then the next time something else again, while their mood clearly fluctuates, than you do not have the depressive disorder. So it is the time that clarifies it.’

FG2;FP1: I think that in patients with MUPS their mood is not as severely disturbed as in the case of a real depressive disorder. But in some patients with MUPS their mood can be low due to their symptoms. In the consultation room they can be apathetic.’

The passive MUPS patient

FG4;FP4:‘They hand the problem over to you and you should have the solution. They want to take tablets, but really working on solving their symptoms, they do not want that. They want it all, but not coming from them.’

FG2;FP3: ‘They do not have the coping strategies to get over it. They are powerless.’

FP1: ‘Yes, it just happens to them.’

FP3: ‘It just happens to them and they cannot defend themselves.’

FP2: ‘Yes, that is it. It happens to them and they express it in a certain manner: with a stomach ache at that certain moment.’

FG1;FP4: ‘There is a group that always externalizes problems and symptoms. This can evoke a feeling of irritability in the doctor. It makes me feel powerless, because I do not get a way in.’

FG5;FP5: ‘They look for an explanation, but an external one, not in themselves.’

The distressed MUPS patient

FG4;FP1: ‘Patients with moderately severe MUPS are often people who have periods where they are just not so comfortable, because, I do not know, they have troubles at work or in their relationship. Everyone has phases in their lives when they are feeling suboptimal. These [patients] are the easy ones’.

FG4;FP3: ‘A high stress-level and a high level of expectations of themselves. So with a certain group of patients I often think about a burnout. If you burden yourself long enough, you will eventually get MUPS.’

FG6; FP4: There are patients where you do not know what is wrong and where you think “Maybe there is some kind of abnormality t5:39 that we just have not discovered yet”.’

FG4;FP5: ‘Patients with a different ethnic background have a tough life and when they consult with symptoms from the musculoskeletal system I think “Yes I understand those symptoms, I would have had the same symptoms with that kind of work”.’

FG3;FP2: ‘I think that they sometimes persist in their own model of explanations; they do not want to look in other directions. There are so many psychosocial problems. People do not make choices or they are completely overloaded and then I think “Yes, with three children and this and that, I would be very tired”, but they seem to believe that everything should be possible or something like that.’

FG5;FP1: ‘Sometimes you just have vulnerable patients, who do not have a strong support system and therefore they come to you.’

The puzzling MUPS patient

FG1;FP1: ‘We all know people who present themselves extremely balanced in your consultation room and tell you very clearly that they have symptoms and in whom you find zero abnormality. Nothing wrong at home, or something like that. Absolutely no abnormality at all.’

FG1;FP3: ‘Of course there are some patients where there is absolutely no explanation at all and I am more inclined to keep searching for one and to refer them for additional examinations.’

FG6; FP4: There are patients where you do not know what is wrong and where you think “Maybe there is some kind of abnormality that we just have not discovered yet”.’

FP2: ‘I agree that is possible.’

FP4: ‘Yes, that we cannot give an explanation with our current knowledge but in 24 years our diagnosis may be totally different.’

FP3:’There are certain things still unexplainable now, but maybe not in another 100 years. Lyme is always a good example of such a thing.’

FG6;FP1: Often they have given you cues in the history taking phase. So you can use physiology and certain explanation models, like adrenaline that is released in a certain situation, which can give you palpitations. But when there is absolutely no clue, then I think “This is really unexplained”.’