Talk:Medically unexplained physical symptoms

'Typically, the possibility that MUPS are caused by prescription drugs or other drugs is ignored' A well known fact in the real world (though obviously not by doctors as it would appear). Perhaps someone else should go for full and proper sourcing etc. — Preceding unsigned comment added by 82.75.140.248 (talk) 20:28, 6 September 2016 (UTC) Good idea, proper sources. However, I'm not familiar with any sources in the English language that state this. However, it is common knowledge. Medicine's dirty 'little' secret. Recently I stumbled on one source, not that well suited for an encyclopedia https://www.madinamerica.com/2017/09/if-psychiatrists-took-truth-serum/ A classic example would be withdrawal from benzodiazepines, antidepressants, antipsychotics. Any foreign agent to the body could cause problems, including prescription drugs. What is commonly known but usually denied (cognitive dissonance) deserves a place in the article. So, what do we do about this ? Ignore it altogether ? Or, is this one formal enough ? http://www.bmj.com/content/356/bmj.j268/rr-1 — Preceding unsigned comment added by 82.75.168.58 (talk) 14:05, 15 September 2017 (UTC)

I
I removed:
 * NIH-funded studies are now underway to compare different treatment approaches for health anxiety and hypochondriasis: a  study in the NYC area and a study in the Boston area.  In these studies, patients will be given one of four treatments: supportive therapy with fluoxetine, supportive therapy with placebo, cognitive behavior therapy, or cognitive behavior therapy with fluoxetine. For more information you can also visit external links.

from the external links, since it's to do with hypochondria, and not MUPS (unless you consider all MUPS to be hypochondria,) Herd of Swine 22:14, 23 April 2007 (UTC)

Also, "now" is undefined and "underway" is speculative. :-) Guido den Broeder 10:05, 15 October 2007 (UTC)

Hi everybody, I hope I edited correctly and that it was suitable enough. Nomorebigots (talk) 05:49, 14 May 2008 (UTC)
 * Uh-oh. You named him without showing the dictated admiration... Guido den Broeder (talk) 07:16, 14 May 2008 (UTC)

Removed from the article
I removed the following from the article as being unreferenced:
 * "One of the most widely-known promoters of the concept that these illnesses form a distinct and unitary category is Simon Wessley. His work is highly controversial, has been the subject of a book, Denigration by Design, and has played a role in another book, Osler's Web.  The Countess of Mar has officially raised questions about his work."

Please do not restore this to the article without supplying a cite that supports it. -- 80.168.225.15 (talk) 08:11, 20 May 2008 (UTC)
 * It was rather superfluous as Wessely's publications are already referenced to in the text. The controversial nature of his ideas is mentioned in the article Simon Wessely. Guido den Broeder (talk) 08:40, 20 May 2008 (UTC)

Dead Link
I found what appears to be a source for the dead link I just tagged here. I'm a little confused as to where the statement that MUPS is most commonly associated with GWI comes from, though. While I'll grant that "Gulf War Illness" is bolded within the text of table A-1, I believe that's solely because the appendix is based on military medicine, not because it's the most common term. I see no indication that the bold is intended to indicate how common the term is.

Also, unless I've missed something here, I would suggest that we change the wording in the intro to include conditions that are not commonly linked. Rightly or wrongly, CFS, Fibro, GWI, and MCS are often lumped together in peoples' minds (and sometimes in medical literature, etc.), but MUPS covers a much broader range than that as indicated by the table, including back pain, bladder symptoms, PMS, and a wide variety of other areas. --Rob (talk) 04:16, 11 July 2009 (UTC)


 * The dead link should get replaced from a MEDRS, i agree, GWI is uncommon beside FM and CFS and IBS. There is alot of other MUPS like sick building syndrome and these can be added to article with MEDRS. RetroS1mone   talk  13:49, 11 July 2009 (UTC)


 * The material fails verification anyway, The source doesn't say, "The term is commonly used to refer to Gulf War illness and more occasionally to other symptom-based diagnoses such as fibromyalgia, chronic fatigue syndrome, and multiple chemical sensitivity."  The internet archives page lists the original link.   Ward20 (talk) 19:40, 11 July 2009 (UTC)


 * No, it certainly doesn't say anything even remotely resembling that. I think the original reference to GWI was only because it was bolded in the table in the document.  As I said above, I think we should probably incorporate a number of other examples from the table in the document.  Also, does anybody have any thoughts on what link we should use for the document?  Is the Internet Archive a suitable version, or should we go with the link I found (probably not the best choice), or something else entirely? --Rob (talk) 20:09, 11 July 2009 (UTC)


 * I don't think any paticular illness should be described in the lead. It will only cause problems fighting over which ones should be stuffed in there. The lead should just describe the topic. Scanning the medically unexplained symptoms reviews on pubmend shows opinions about this entitiy are all over the place. Ward20 (talk) 22:51, 11 July 2009 (UTC)


 * You've got a point there. Maybe just change it to something like "a variety of conditions" or "a vast array of conditions" (though that last is perhaps less encyclopedic-sounding). --Rob (talk) 00:17, 12 July 2009 (UTC)


 * I'm not sure the present source supports, "MUS is commonly used to refer to..." I don't see that validated in the abstract but I haven't been able to review the whole article. Ward20 (talk) 03:44, 17 July 2009 (UTC)

(outdent) Yeah, I went ahead and changed it to not mention specific conditions by name in the header. There's really no way to say "these ones are worth mentioning but those ones aren't", and there's far too many in the table given in the dead source to list them all. Certainly none of the other sources I noticed picked those specific illnesses out either. --RobinHood70 (talk) 04:56, 17 July 2009 (UTC)


 * Encyclopedia should give common examples. There is a way to say what ones are worth mentioning, it is which are more common and which are studied in the medical literature and which examples are in the medical literature. Ward 20 says, "I don't see that validated in the abstract" here is what abstract says, "Examples of syndromes consisting of MUPS include chronic fatigue syndrome, fibromyalgia, multiple chemical sensitivities, somatoform disorders, and 'Gulf War Syndrome.'" Here is meta-analytic review of 244 studies, says four MUPS syndromes have enough studies for meta analysis, "irritable bowel syndrome (IBS), nonulcer dyspepsia (NUD), fibromyalgia (FM), and chronic fatigue syndrome (CFS)." Another reivew in abstract, "MUPS syndromes include chronic fatigue syndrome, fibromyalgia syndrome, and multiple chemical sensitivities."  Another review, "Beyond somatisation: a review of the understanding and treatment of medically unexplained physical symptoms (MUPS)"  has five main MUPS syndromes like CFS and fibromyalgia. They all say CFS and FM, some say IBS or MCS.  RetroS1mone   talk  12:51, 17 July 2009 (UTC)


 * I agree, those are examples of MUS syndromes, no question there. I just think we need to be careful not to bias the article further in favour of certain conditions when there are so many that are encompassed by the term.  For now, I've re-worded it to be closer to the cited source, which did not say that MUPS commonly referred to those illnesses, just that those were examples of syndromes consisting of MUPS (as you stated in your quotation of it). --RobinHood70 (talk) 00:50, 18 July 2009 (UTC)


 * Rob and Ward20 i do not want to be disrespectful but pls read the abstract, it says "Medical science, with its emphasis on identifying etiologically meaningful diseases comprised of homogeneous groups of patients, has split MUPS into a number of diagnostic entities or syndromes, each with its own hypothesized pathogenesis. However, research suggests these syndromes may be more similar than different, sharing extensive phenomenological overlap and similar risk factors, treatments, associated morbidities, and prognoses. Examples of syndromes consisting of MUPS include chronic fatigue syndrome, fibromyalgia, multiple chemical sensitivities, somatoform disorders, and 'Gulf War Syndrome.'" I put the bold in, it says overlap. RetroS1mone   talk  03:54, 18 July 2009 (UTC)


 * Yes, I did read that, and "phenomenological overlap" is much like saying that a cold, flu, and allergies have overlapping phenomena...that doesn't mean the conditions themselves overlap. You might want to get a second opinion on your interpretation of that phrasing from WikiProject Medicine or somewhere similar, though.  Also, I like what you've done with the "one use of the term" phrasing.  I think that helps clarify that there are a number of different usages. --RobinHood70 (talk) 08:41, 18 July 2009 (UTC)

Treatment Section
I'm not sure if it's the best tag to use, but I couldn't find anything better, so I've added a Disputed-section tag to the Treatment section. This is based on the fact that the sources used in the introduction state that MUPS can refer to a vast array of conditions, depending on what area of medicine you're talking about. Interstitial cystitis, for example, is considered a MUPS but is not generally treated with CBT, anti-depressants, etc. Similarly, premenstrual syndrome is also listed as a MUPS in the same source, but is also not generally treated with any of the methods mentioned in the Treatment section. I think for anything listed in that section, we need to clearly indicate which forms of MUPS the source indicates the treatments are intended for. --Rob (talk) 04:57, 11 July 2009 (UTC)


 * The article does not say, CBT is used to treat every MUS, it says CBT is found in multiple RCTs to be the most effective treatment of MUS. The reviews say that. How is that fact dispute? When you disagree pls add a fact tag to disputed part or put a inline comment pls.
 * I will put in a new part about different MUS and CBT and antidepressants. RetroS1mone   talk  13:57, 11 July 2009 (UTC)


 * The problem is that by just saying that it's the most effective treatment of MUS, it implies all forms of MUS unless stated otherwise. The new addition you put in makes that much more clear - I just re-ordered the paragraphs and did a little minor editing to make it clear right from the outset of that section.  As it stands now, I'm happy to leave the dispute tag (or whatever else might've been appropriate) off.  The problem was not with the sources themselves (which is why a Fact tag would've been inappropriate), but rather with the vagueness of the section in terms of what was addressed by it and what wasn't.


 * I've also added a couple of Fact tags after the re-order because I think each statement is significant on its own and would benefit from the specific page or section in the source being cited for clarity. It would obviously be even better if online sources could be found to back up those statements, but failing that, the specific pages should be cited for each. --Rob (talk) 17:37, 11 July 2009 (UTC)


 * Another concern I have about the Treatment section is the possible synthesis of MUPS and somatoform/somatization disorders. Much of the information in the Treatment section seems to be attributed to books that deal with somatoform/somatization disorders and unless it's specifically stated in the relevant text that this is intended to apply more broadly to MUPS as a whole, it would be synthesis to put it together with the History and Usage section.  While many conditions that are covered under the broad category of "MUPS" are likely mental in origin, many, like Interstitial Cystitis, are clearly not mental in origin, as indicated in the "Causes" section on that page. --Rob (talk) 21:18, 12 July 2009 (UTC)


 * I did not know they are books, but i add the source for the fact tags, a nice table is in the paper w all hte trials and the evidence for different catagory, may be a table is good here?? I do not know how but i can learn. I have also more reviews to add for this section but i am very busy. RetroS1mone   talk  04:46, 13 July 2009 (UTC)


 * "Books" was poor wording on my part...I should have said "sources". Reproducing the table might constitute a copyright violation, so it might be best to leave it out, though I suppose a similar style of table might be useful.  As for tables on Wikipedia, they're not easy...or at least they're not on the wiki I use more often; I can only assume they're equally difficult here.  If you do decide to add a table, it might be best to copy & paste a similar table from another article, then just make the changes. --RobinHood70 (talk) 06:01, 13 July 2009 (UTC)

Contested causation
This section title is confusing because Engel specified 'Contested causation' following toxic exposure or injury, mainly with reference to army personnel., but that context is missing here. More confusing still is the sudden turn to the One or Many? functional somatic syndromes debate. New headings all round, I would have thought. BTW, White's highly relevant and focussed critique appears in a valid MEDRS secondary source. Sam Weller (talk) 10:43, 12 July 2009 (UTC)


 * It is highly relavent but it is a opinion editorial, does he have MEDRS papers that says it bc that would be good. I do not disagree the different view point is here, i disagree about editorials MEDRS. RetroS1mone   talk  04:48, 13 July 2009 (UTC)


 * While White's critique could be considered an editorial opinion, it's in what I believe is a peer-reviewed journal and my understanding of WP:MEDRS is that editorial opinions are allowed when they help to present all sides of a controversy. Specifically, the MEDRS page says:  "Make readers aware of any uncertainty or controversy. A well-referenced article will point to specific journal articles or specific theories proposed by specific researchers." (Emphasis added.)


 * Also, in a section called "Contested causation", I think it's only appropriate to highlight that there may be physical causes as well. Right now, the majority of the section refers to somatic causation and the problems that may cause in dealing with patients. --RobinHood70 (talk) 05:55, 13 July 2009 (UTC)


 * In this section it says: Wessely claims that providing a label for a set of symptoms "is not a neutral act, since specific labels are associated with specific beliefs and attitudes," and "even when organic illness is certain, the illness label can result in adverse behaviour changes."[9] When looking at the full-text, this is shortly followed by a rather important statement which has been omitted: "So, there is conflicting evidence on whether labelling is helpful or not for the individual with MUS.[44]" While it's been previously argued that applying specific labels (like "CFS") may have a negative impact, it's also been argued that the terms (and in many cases the concepts) "medically unexplained", "somatization", "functional" etc themselves can have a negative impact and should be avoided or abandoned (see and ). The first review  also says that the concern of applying CFS label isn't usually borne out by experience (although I didn't check out the cited sources [510,511]). I haven't really looked into this issue much. -  Tekaphor  ( TALK ) 12:01, 13 July 2009 (UTC)


 * I am agreeing on Sam Weller the title of section is confusing. What is a better title? Lets change it to sth better. RetroS1mone   talk  05:40, 14 July 2009 (UTC)

Unexplained physical symptoms (UPS)
There are only two articles and no reviews mentioning Unexplained physical symptoms (UPS) using a medline search for ("Unexplained physical symptoms" UPS). I am removing the term from the lead per WP:WEIGHT. The UPS link redirects back to Medically unexplained physical symptoms anyway. Ward20 (talk) 23:21, 19 July 2009 (UTC)

Balance
Some editors say this article is a POV fork, pls help put in balance and weight from MEDRS. I made edit about patient perspective on the names and the BMJ review 2008 advise to doctors about not blaming patient, i am hoping, we can make it a better article. RetroS1mone  talk  03:44, 22 July 2009 (UTC)


 * "Symptoms are generally not thought to be psychiatric in origin" + "MUPS may be synonymous with somatization disorder[6] or psychosomatic illness, where the cause or perception of symptoms is mental in origin." Sam Weller (talk) 21:59, 22 July 2009 (UTC)


 * That just goes to show the variety of views of MUPS that are out there. Perhaps we should re-word the article to present the fact that MUPS means very different things to different people. --RobinHood70 (talk) 22:25, 22 July 2009 (UTC)


 * Authors of articles seem to have an agenda to describe MUPS as they would like it to be and there isn't much agreement. To make matters more complicated in the Fibromyalgia article RetroS1mone piped medically unexplained syndrome to MUPS. I searched the terms "medically unexplained syndrome" and medically unexplained symptoms and came up with 6 studies. Two talked about FM but didn't seem to establish any intent to link the phrases in an intentional manner.  Ward20 (talk) 01:18, 23 July 2009 (UTC)


 * A syndrome is a constellation of symptoms. A condition with medically unexplained symptoms is a medically unexplained syndrome. It is not OR it is definitions. RetroS1mone   talk  03:01, 23 July 2009 (UTC)


 * That definition makes approx. 66% of women that walk into a gynecology clinic with medically unexplained symptoms have a "medically unexplained syndrome". That is an exceptional claim. Sorry, editor's definitions are OR until links are provided, "A condition with medically unexplained symptoms is a medically unexplained syndrome." Please supply WP:RS for that. Ward20 (talk) 06:10, 23 July 2009 (UTC)

"Symptoms were considered medically unexplained when there was evidence of a comprehensive diagnostic workup, with the results of all investigations negative, and either psychosocial reasons were suggested or a diagnosis was made that implied a medically unexplained syndrome (eg, fibromyalgia, irritable bowel syndrome, chronic fatigue syndrome, etc)." doi 10.1542/peds.2005-0109

"Medical specialties have also played a part in naming symptoms-based syndromes, leading to a number of specialist-based diagnoses, for example, irritable bowel syndrome (gastroenterology), non-cardiac chest pain (cardiology), and chronic pelvic pain (gynaecology). Should we be interested in these syndromes and are these '''syndrome-based diagnoses the most accurate and useful way to conceptualize them?" "The classification of medically unexplained symptoms as one syndrome or many discrete syndromes has been debated widely." doi 10.1093/ije/dyl035

"A symptom was designated as definitely medically unexplained if there was evidence of a thorough investigation of the symptoms, with negative results, and either psychosocial reasons were suggested for the presentation or a diagnosis was made that implied a medically unexplained syndrome (for example, fibromyalgia, irritable bowel syndrome, etc)." PMC30552

"Several distinct medically unexplained syndromes with heterogeneous somatic symptoms have been identified such as chronic fatigue syndrome, irritable bowel syndrome, fibromyalgia, multiple chemical sensitivity, non-cardiac chest pain, hyperventilation syndrome, etc. ([Barsky and Borus, 1999], [Nimnuan et al., 2001] and [Wessely et al., 1999]). These syndromes show considerable overlap in their core symptoms (e.g., headache, fatigue and malaise), share many non-symptom characteristics (e.g., emotional distress), and respond to the same treatment (e.g., cognitive behavioural therapy) ([Barsky and Borus, 1999] and [Wessely et al., 1999]). Therefore, the specificity of these syndromes has been questioned in the literature and the search for a common biopsychological mechanism has been suggested as a fruitful approach to gain insight in the underlying process." doi 10.1016/j.bbi.2007.04.008

"adults with medically unexplained physical symptoms" and "The final diagnosis was a recognised medically unexplained syndrome (e.g. fibromyalgia, irritable bowel syndrome)."

"This article addresses whether multi-symptom reporting in Gulf veterans are types of medically unexplained symptoms and whether the alleged Gulf War Syndrome is best understood as a medically unexplained syndrome." "We concluded that ill health in Gulf veterans and the alleged Gulf War Syndrome is best understood within the medically unexplained symptoms and syndromes constructs." 10.1098/rstb.2006.1815

Medically unexplained stroke-like symptoms, "A medically unexplained syndrome was assumed to be present if ....." cat.inist.fr/?aModele=afficheN&cpsidt=16512945 FS Nazir 2005

"Physical symptoms account for more than half of all outpatient visits in the United States each year, and yet one-third to half of all such presentations lack a clear physical explanation (1,2). Such conditions are labeled on the basis of excluding known disease and as a group they have been designated as functional somatic syndromes or medically unexplained syndromes (3,4). One such medically unexplained syndrome is chronic fatigue syndrome (CFS)" Jason W. Busse 10.1007/978-1-59745-008-9

Article "War Syndromes: The Impact of Culture on Medically Unexplained Symptoms" PMC1088250 Example, non-ulcer dyspepsia was MUS "This example suggests that it is unlikely that non-ulcer dyspepsia will ever again be a prominent medically unexplained syndrome" BC cause was found and treatment is now available.

"Chronic fatigue syndrome (CFS) is an exemplar of a medically unexplained syndrome." HJ Cho - 2005

"Chronic Fatigue Syndrome (CFS) remains a medically unexplained syndrome – that is we do not understand the fundamental biological mechanisms" www.rsm.ac.uk/chronicfatigue08/abs.pdf

Neurobehavioral Medicine and Stress-Related Disorders, Hellhammer et al 3805582951 "With respect to stress-related disorders, another specific trans-NIH initiative has recently been announced by the NIH, which has been named ‘MUSIC’ (the Medically Unexplained Syndrome Institutional Collaborative): "Medically unexplained syndromes (MUS) present the most common problems in medicine. Most medical specialties treat (at least one) MUS; e.g. urologists treat interstitial cystitis, gastroenterologists treat irritable bowel syndrome, gynecologists treat chronic pelvic pain, rheumatologists treat chronic fatigue syndrome and fibromyalgia, psychiatrists treat panic disorder, etc." RetroS1mone   talk  23:04, 23 July 2009 (UTC)

"MUPS may be synonymous with somatization disorder[12] or psychosomatic illness, where the cause or perception of symptoms is mental in origin",  - to quote the existing text of the article. That these two may be synonymous is surely a ludicrous suggestion. This, logically, could only be true if it were the case that all actual physical causes of medical symptoms were already understood by current medical science. Any sane assessment of the current state, and recent history, of the development of medical knowledge excludes such a happy scenario for the foreseeable future. Therefore (as defined in this pages) "MUPS" and "somatization disorder" cannot plausibly be true synonyms (though of course there will be an overlap between the patient populations in each category). It is part of the business of medical research to continue disentangling these two patient categories. The phenomenon that really merits investigation is the repeated statement of absurd proposals of this kind - surely a manifestation of a group psychiatric defect (a delusion) of the medical profession itself (professional hubris). (Can anyone suggest an alternative explanation?) —Preceding unsigned comment added by 83.217.170.175 (talk) 03:40, 2 January 2010 (UTC)

15 to 30% or 30-50%??
?????????? .Ward20 (talk) 02:23, 23 July 2009 (UTC)


 * RetroS1mone added the reference R. Rogers Clinical Assessment of Malingering and Deception 3rd Edition, Guilford, 2008. ISBN 1593856997 for 30-50%. I searched the book for "medically unexplained physical symptoms", "medically unexplained symptoms", and "medically unexplained" and got 0 results on all searches. Am I doing something wrong? Ward20 (talk) 03:47, 23 July 2009 (UTC)


 * I think you are thinking "medically unexplained symptoms" is like a code word for FSS. Some people can think that but it is not a rule, basic meaning just means there is no identified cause, it means there is no known etiology, the doctor does not have a clue, medicine is in dark. "30-50% of all patient-initiated visits are for medical complaints with no identifiable physical cause" is from R. Rogers. It is another support of Nimnuan et al. that says medically unexplained symptoms. RetroS1mone   talk  03:55, 23 July 2009 (UTC)


 * Since the Rogers book references Nimnuan et al that talks about "medically unexplained symptoms" it is a proper source. The wording in the article is still a little off I believe because Kirmayer talks about primary care consultations and Nimnuan hospital and clinic settings.


 * Sources for this article are going to have to be specific to "medically unexplained symptoms". If we use all possible variations for "medically unexplained symptoms" such as no known etiology, no identifiable physical cause, and every other permutation, "medically unexplained symptoms" will have no meaning in the article. RobinHood70's comment about better defining what MUPS means in the article is a good one IMO. Ward20 (talk) 04:32, 23 July 2009 (UTC)


 * When I read the references listed, the difference was that the one that said 15-30% described "primary care", which means a physician who first assesses the symptoms; but the one that listed numbers as high as 66% specifically referred to "specialties", which means physicians to whom patients have been referred.


 * Also, if "medically unexplained symptoms" or similar wording does not appear in the text, then I believe it would be considered synthesis to infer that that's what they mean (though I'll admit, it certainly sounds like that's what's intended...but in light of the existing confusion surrounding the term, I think it's best to be safe). --RobinHood70 (talk) 05:05, 23 July 2009 (UTC)


 * Another thing occurs to me: is that book MEDRS?  It's doesn't appear to be peer-reviewed.  It's put out by Guilford Publications, which I don't see any reference to in MEDRS (either directly or indirectly).  I'm not making any judgment calls here, just making sure that we're following Wiki policy. --RobinHood70 (talk) 05:27, 23 July 2009 (UTC)


 * WP:MEDRS, "Medical textbooks published by academic publishers are often excellent secondary sources." RetroS1mone   talk  22:52, 23 July 2009 (UTC)


 * Thanks, I've read MEDRS and I'm aware of what it says about books. Are these academic publishers?  If so, how do we know this, exactly?  I see nothing anywhere on their website indicating who they're run by, what their credentials are, whether they're peer-reviewed, etc.  Like I said, it may well be that they are, I'm not making any judgment calls, I'd just like some reasonable justification of who they are before we go quoting them.  For all I know, Richard Rogers could be on their board of directors or something.  Again, I'm not making any accusations, just that since it's a book, we should be sure of who the publisher is and whether or not they're reputable. --RobinHood70 (talk) 01:14, 24 July 2009 (UTC)


 * Rogers is THE textbook on malingering, in its third edition now and Guilford is respected publisher of professional text. Rogers has 361 citations by scholarly articles, i do not know, if it is third edition or all editions, that is more citations then any malingering article or book i think. RetroS1mone   talk  03:43, 25 July 2009 (UTC)

RS1, "I think you are thinking "medically unexplained symptoms" is like a code word for FSS." The article itself states that MUPS/MUS is used by psychiatrists synonymously with FSS and somatization. Those are controversial labels in themselves, hence the controversy about you plastering MUPS all over CFS, FM, MCS, GWS etc. Where does the term MUPS/MUS appear most? Psychiatry or general medicine? Sorry to state the obvious for the umpteenth time, but tendentious labels with no ICD or DSM code should be treated extremely cautiously in an encyclopedia. Sam Weller (talk) 09:07, 23 July 2009 (UTC)


 * Sorry i forget to quote Nimnuan about percent, when you read more then the abstract,

"Our results show that between one-third and two-thirds of patients attending general medical clinics do not receive a biomedical explanation for their distress. Previous studies have suggested this in individual clinics — for example, only 16% of one series of new outpatients attendees to a US internal medicine clinic was a definite biomedical cause identified for symptoms [21]. Van Hemert et al. [10] conducted a survey in a Dutch medical outpatient clinic showed that 52% of new referrals remained medically unexplained. We have now extended this using a uniform methodology across a large number of medical specialities. We conclude that it is now time to acknowledge that the management of medically unexplained symptoms is one of the important tasks facing the specialist in internal medicine — indeed, in some clinics, it constitutes the majority of the work." RetroS1mone  talk  01:06, 24 July 2009 (UTC)

"Fourteen common physical symptoms are responsible for almost half of all primary care visits. Only about 10% to 15% of these symptoms are found to be caused by an organic illness over a 1-year period." RetroS1mone  talk  01:09, 24 July 2009 (UTC)

First use
I took out original research said Slavney first used MUS in 1985, that is wrong, 1972 paper "The patient must report at least 25 medically unexplained symptoms for a "definite" diagnosis" and there is alot more from 1970 to 1985 like 7412070 and 7241113. RetroS1mone  talk  01:14, 24 July 2009 (UTC)


 * I'm sure the phrase "medically unexplained symptoms" goes back a lot farther than the '70s...it's an easy enough series of words to put together in a medical setting. But we can't build an article about a random phrase, so the question becomes:  When was it used to indicate a specific category of illnesses?  I have no idea if Slavney was the first to do so or not, but I think that we're confounding the phrase with an actual category.  A common phrase is probably not notable by Wikipedia standards; a medical category might be if it's in wide use.  So I think we need to identify when this phrase was first coined to refer to a category of illnesses and prove that it's actually noteworthy.  Without an entry in DSM-IV or a similar medical reference, the notability of the concept really needs to be shown.  Also, as someone else said somewhere, if it is considered a medical category somewhere, we need to identify if it's primarily a psychiatric/psychological concept or a broader one.  Similarly, I think we're also confounding the category with related terms like "somatoform disorder" and "functional somatic symptoms".  Unless the source itself says that in that particular text they're intended to mean the same thing, any assumption that another text is making the same assumption would be synthesis. --RobinHood70 (talk) 01:43, 24 July 2009 (UTC)


 * Agreed about synthesis, Rob. Not only is MUPS missing from ICD and DSM, it's not a MESH term either, which should raise concerns. A quick Medline MUPS search shows that it is not a common term, and is used predominantly by psychiatrists and psychologists, whether writing in their own trade journals or in general medicine. And the article itself makes it very clear that psychiatrists have adopted MUPS/MUS as part of their FSS and somatization constellation. Sam Weller (talk) 08:54, 24 July 2009 (UTC)

Intro - psychiatric morbidity
I must object to the categorization of RetroS1mone's recent changes as "accurate". In the RESULTS section of Nimnuan (et al) study, it specifically states:
 * "Psychiatric morbidity per se was not associated with the presence of medically unexplained symptoms, but was more likely in those complaining of multiple symptoms."

In the Kirmayer work, it states:
 * "Physicians often assume that psychological factors account for these symptoms, but current theories of psychogenic causation, somatization, and somatic amplification cannot fully account for common unexplained symptoms."

How is:
 * "Symptoms may not be due exclusively to psychiatric factors but psychiatric co-morbidity is common."

...an accurate representation of those two statements? --RobinHood70 (talk) 04:03, 25 July 2009 (UTC)


 * The sources say, there is more then psych factors only, they are a big part but they do not say all symptoms are from them. You wrote, "Symptoms are generally not thought to be psychiatric in origin" that is not right. RetroS1mone   talk  04:11, 25 July 2009 (UTC)


 * I agree that the sources say there are more than psychiatric factors only, but the first one says "not associated" (the source of my "generally not thought to be psychiatric") and the second one says "cannot fully account for". Clearly, they both indicate that some cases are psychiatric in nature (which is reflected in the "generally" and in the "multiple symptoms" section), but they also both clearly indicate that not all are psychiatric in nature.  Writing "...may not be exclusively due to..." implies that the symptoms are due to both psychiatric and other causes simultaneously.  And leaving off the info about it being more common among "those complaining of multiple symptoms" really changes the entire meaning of what the sources are saying. --RobinHood70 (talk) 04:23, 25 July 2009 (UTC)
 * Nimnuan finds a little different results from other sources about MUS for the psychiatric comorbidity and they talk about it in thier discussion, why they think it is, they do not say they think symptoms do not have any psychiatric origin like you wrote. "implies that the symptoms are due to both psychiatric and other causes simultaneously." that is right, example it is very hard for seperating "psychiatric" and "organic" in MUS. They are very complicated illnesses and there is not black and white but literature says high psychiatric comorbidity.  RetroS1mone   talk  12:48, 25 July 2009 (UTC)
 * Kroenke review 12830308 "Unexplained or multiple somatic symptoms are strongly associated with coexisting depressive and anxiety disorders. Other predictors of psychiatric co-morbidity include recent stress, lower self-rated health and higher somatic symptom severity, as well as high healthcare utilization, difficult patient encounters as perceived by the physician, and chronic medical disorders. Antidepressants and cognitive-behavioural therapy are both effective for treatment of somatic symptoms, as well as for functional somatic syndromes such as irritable bowel syndrome, fibromyalgia, pain disorders, and chronic headache." RetroS1mone   talk  12:52, 25 July 2009 (UTC)
 * I'm not saying there's no co-morbidity, there quite obviously are in many cases, just that the sources cited don't indicate a strong link in the general case. --RobinHood70 (talk) 20:01, 25 July 2009 (UTC)


 * I added 2 more references on co morbidity, the Chinese large scale study BC it is not just Western result, the meta-analysis of IBS, NUD, CFS, and FM MUS BC it has balance, says it is not only mental disorder. RetroS1mone   talk  03:20, 28 July 2009 (UTC)

MUPS meme continues to spread
Is there a policy that applies when links to separate articles are made covertly? MUPS is linked to the phrase 'unknown cause' in the lead of Interstitial cystitis. Sam Weller (talk) 11:29, 2 August 2009 (UTC)


 * The Policy is WP:UCS. Unknown cause and medically unexplained are synonym and PBS is MUPS from reliable sources. I did not make covert links. RetroS1mone   talk  13:42, 2 August 2009 (UTC)


 * I agree that IC/PBS comes under the MUPS category in at least one source (possibly others - I'm just aware of one in particular). This comes back to the perpetual concern about this article, though.  Is it about the phrase "medically unexplained" or is it about a broader category known as "Medically Unexplained (Physical) Symptoms"?  If it's about the phrase and is synonymous with "unknown cause", then it should be merged into the idiopathic article, which is the term normally used in medicine to describe "unknown cause". --RobinHood70 (talk) 21:24, 2 August 2009 (UTC)


 * There are several issues.


 * If "medically unexplained" and "unknown cause" are synonyms as RetroS1mone suggests there is no reason to link them in the Interstitial cystitis/painful bladder syndrome article. I found 1 MEDRS review that describes Interstitial cystitis/painful bladder syndrome as medically unexplained symptoms. I found 8 MEDRS reviews that describe Interstitial cystitis/painful bladder syndrome as having an unknown cause.        Unknown aetiology is used in at least 3 MEDRS reviews.    Medically unexplained symptoms seems to be little used compared with more common terms used to describe Interstitial cystitis/painful bladder syndrome so I don't believe MUPS should be linked using the logic they are synonyms.


 * RobinHood70 brings up the issue of whether there is a category known as "Medically Unexplained (Physical) Symptoms". It appears there is much confusion about this in MEDRS medical reviews. One review calls MUPS a social and clinical predicament. Another review says Medically unexplained symptoms has been proposed as an alternate name for somatization, somatoform disorders, and functional symptoms.  has a model for (MUPS in caps).  would rather use Physical symptom disorder (PSD) (with the exception of functional somatic syndromes). And  states, "a very wide range of terms is used to describe medically unexplained somatic symptoms." So the question becomes why use or link ill defined terminology to describe symptomatology of illnesses of unknown causation?


 * There is another problem with the way (MUPS) has been introduced into the lead of many of the articles by piping or directly. Per Lead section, "The lead serves both as an introduction to the article, and as a summary of the important aspects of the subject of the article." MUPS isn't even described in the body of the articles as far as I know so it has no busness in the lead. This is a difficult task since MUPS doesn't seem to have an agreed upon usage. MUPS doesn't belong in the lead in the unknown causation illness articles until relevance of the terminology to the article is at least explained in the article. Ward20 (talk) 06:46, 3 August 2009 (UTC)


 * MUPS is symptoms with unknown cause. Period. Full Stop.
 * There is not a Wiki article, Symptoms with unknown cause, i link to a medical term for it which is synonym. When you do not like, pls rename article "Unknown aetiology" or "Unknown cause" and MUPS can be a section in it.
 * Pls discuss change to other pages on other talk pages, and when you disagree on my edits on medical term generaly, pls discuss on medical project or MEDRS. This talk is for MUPS article. Thx. RetroS1mone   talk  13:19, 3 August 2009 (UTC)


 * I'm not sure where you think we're not talking about MUPS, as it's mentioned significantly in every last point above, though there's certainly overlap with IC/PBS, but we can't discuss it in both places at once, so this article was chosen by Sam as the place to discuss it. In light of the fact that this article has been added to a number of pages recently, to me, it makes sense.  Also, as I mentioned, there is an article for the term "idiopathic", and it would make a lot of sense for this article to be a section there, I think, given that that's a more common phrasing for the term "medically unexplained". --RobinHood70 (talk) 17:20, 3 August 2009 (UTC)


 * I brought the issue up on the talk page at WikiProject Medicine, and there's been some interesting replies so far. Meant to mention it here before I left for lunch, but forgot. --RobinHood70 (talk) 19:38, 3 August 2009 (UTC)


 * I left a comment there too since Unexplained symptoms has been directed to Medically unexplained physical symptoms. Ward20 (talk) 21:14, 3 August 2009 (UTC)


 * I ask many times, where is your MEDRS Medically unexplained symptoms does not mean medically unexplained symptoms?? RetroS1mone   talk  03:21, 4 August 2009 (UTC)

(outdent) That's easy: it's in the History and usage section of the article itself. In fact, there's two different sentences that back it up.
 * "MUPS may be synonymous with somatization disorder or psychosomatic illness, where the cause or perception of symptoms is mental in origin, or may overlap these terms or be a 'lower threshold variant' of them."
 * This leaves you with three choices, all of which relate to pscyhological phenomenon - nowhere is "unknown cause" or "medically unexplained" ever mentioned as a possible choice, therefore, it is not synonymous with "unknown cause" or "medically unexplained". You could argue that all three choices use the word "may" therefore it "may not", but that's not the impression the reader is left with, therefore it's misleading unless you state in that sentence that there could also be a physical cause.


 * "Because several definitions of both somatization and MUPS exist, and the usage of both terms is inconsistent in medical literature and practice, MUPS is sometimes used interchangeably with somatization and functional somatic symptoms."
 * Here again, it highlights that the usage is inconsistent and that definitions vary. Given that, it's highly misleading to presume that "unknown cause" or "medically unexplained" were intended to be synonymous with MUPS unless the source itself says that this is so in all cases in which this wording is used (in which case, you should be careful to specify that clearly in any given article).

Essentially, it sets up the basis for an Accidental fallacy by making the link: CFS/Fibromyalgia/MCS/whatever is MUPS, MUPS is some variation of "mental in origin", therefore (whatever condition) is mental in origin. --RobinHood70 (talk) 07:53, 4 August 2009 (UTC)
 * With RobinHood70's explanation, and the talk page discussions at articles and Wikipedia talk:WikiProject Medicine, IMO there is consensus to start correcting the inaccuracies and ambiguities. What is the way to remove the Unexplained symptoms link to Medically unexplained physical symptoms? The various articles can be reviewed on a case by case basis as WhatamIdoing suggested at Wikipedia talk:WikiProject Medicine. Ward20 (talk) 14:05, 4 August 2009 (UTC)
 * I believe it's just a matter of adding a prod tag to the article, using, though given that RetroS1mone may contest it, it might need to go to Articles for deletion instead. --RobinHood70 (talk) 22:56, 5 August 2009 (UTC)


 * Actually it seems that it should be listed here but I wanted to do some other editing for a bit. Ward20 (talk) 23:13, 5 August 2009 (UTC)


 * I asked for a discussion to address the redirect Unexplained symptoms at the redirect discussion. Ward20 (talk) 19:06, 6 August 2009 (UTC)


 * While said logical fallacy is indeed a common problem in CFS discussions, the fact is that some researchers speculate or hypothesize that the symptoms and syndromes labelled as "MUPS" (CFS, IBS, FM etc) are (at least partly) "mental in origin and perception". Of course, they would probably be happy with (or even the source of) the very same ambiguity that you guys are now trying to resolve. - Tekaphor  ( TALK ) 04:17, 8 August 2009 (UTC)


 * I agree that some researchers, psychologists, etc., believe that the various conditions are either partly or entirely mental in origin. I also believe that in some cases, they're probably right.  The unfortunate truth is that there are people out there who are hypochondriacs or malingerers or what have you.  The fallacy arises when it's implied that these conditions are always MUPS, that MUPS is always some variation of "mental in origin", leading the reader into believing that therefore the conditions are always mental in origin.  This is probably the same reasoning behind the WP:SYNTH restriction.  It may not be stated in the article that these conditions are entirely mental in origin, but that's what's implied by making the link between them and the MUPS article, which, as I mentioned, is weighted in favour of the idea that MUPS are entirely mental in origin.


 * I would have to disagree that people are "happy with...ambiguity", however. The fact that there is more than one possible cause for these conditions creates the ambiguity, but I think there are precious few professionals out there who set out with the goal of creating or increasing the ambiguity.  It's simply a case of different, sometimes jaded, views giving rise to different conceptualizations of the various conditions. --RobinHood70 (talk) 07:03, 8 August 2009 (UTC)


 * Different conceptualizations are the key. A psychiatric segment would like to lump all these syndromes together and treat them with CBT or therapy. The molecular and biological pathway scientists would like to split the syndromes into further subgroups and treat more individually. The articles do a terrible job explaining the dichotomy. Ward20 (talk) 12:31, 8 August 2009 (UTC)


 * Yup. The renaming seems to be the result of the discovery of 'central sensitisation' in the late 80's. Once it was proved that pain started with nerves in the body but was overamplified by the spinal cord, and that medically unexplained symptoms could be induced in mice, somatization started looking like bunk, so psychologists did a quick renaming and carried on as before. It'll be a long time before the idea of somatization is finally put to rest. There is some very reputable research on what the normal psychology of chronic pain is (e.g. University of Bath) and the limited extent of the mind to process it (especially at different ages as the neurological immune system changes) so hopefully the idea of psychogenic pain will go the way of the four humours some day soon. J A Treloar 194.74.129.214 (talk) 10:31, 19 June 2018 (UTC)

What about creating separate sections for the different usages? 1. General medicine (randomly MUPS, MUS, UPS, US etc, etc = we don't know). 2. Psychiatry (usually MUPS = somatization disorder = hysteria). 2.i. splitters, and 2.ii lumpers are already there. Cite: an unusually transparent article from the psychiatric perspective. Sam Weller (talk) 16:27, 8 August 2009 (UTC)


 * That sounds like an excellent method of structuring the article. --RobinHood70 (talk) 21:12, 8 August 2009 (UTC)


 * I agree with Sam. I am new to this process and subject so I need to read more of the primary sources. But, I think this demarcation of the different uses will help clarify alot.
 * Let me talk about ME (CFIDS) (which I have) as an example. There is not a consensus about the 'entire picture' of the etiology, but we do know substantial parts of the etiology- many (~1000) unique genes; that there is sudden onset in 75% of cases almost all a viral illness; a link to two retroviruses.
 * In addition, we DO know a great deal about the PATHOPHYSIOLOGY (Neurology, endocrine, immune, etc.). To me, taken together, this means ME is NOT 'MUPS", just like MS or Alzhemiers are not MUPS because (1) ME is not a symptom- it is at least a syndrome and arguably a disease- certainly as much as Alzhemier's Disease is a disease and (2) it is NOT MEDICALLY UNEXPLAINED.
 * I do agree that ME meets the definition of MUPS given in the intro- that there is not a consensus as to cause. But, by far the most frequent use of MUPS is in the context of psychiatry. I have not done an exhaustive review, but in everything I have read by the psychiatrists, there is no discussion of the definition, it is just made abundantly clear that 'MUPS' is used to mean PSYCHOGENIC illness- 'somatization' or something similar, i.e. they are very clearly implying there IS NO medical explanation because IT IS KNOWN THERE IS NO MEDICAL PROBLEM.  This approach is, of course, unsupported by the science.  These psychiatrists (many british) (1) disregard the thousands of articles showing significant underlying physical pathology and (2) USE THEIR OWN FLAWED Oxford/ Sharpe 1991 "CFS" DEFINITION which INCLUDES ALL IDIOPATHIC CHRONIC FATIGUE.  This seems to me to be a conscious attempt to 'create ambiguity' (as someone previously said) and confusion and muddle the science.
 * As for another disease I often see listed by psychiatrists as a MUPS- Chronic Lyme Disease is almost totally medically explained, in my opinion.
 * I think these (or similar) critiques should be given an airing in the article.
 * Sorry if this does not conform to the format or sounds 'biased' but I honestly believe there is a conscious attempt by some scientists to miscast the data and give misimpressions about what is known about etiology and pathophysiology in these diseases and it severely retards the science and understanding of the science. I look forward to discussing with you!Justito (talk) 02:11, 26 December 2009 (UTC)


 * I generally agree. The term and concept of MUPS is problematic. - Tekaphor  ( TALK ) 02:26, 22 February 2010 (UTC)

"The most effective current treatment"
This text was introduced by IP:212.130.131.1 citing "A novel and effective treatment modality for medically unexplained symptoms." (Steele et al 2009) : "The most effective current treatment for some medically unexplained symptoms is a combination of therapeutic approaches tailored to the individual patient. Most MUS patients are in need of psychotherapy, relaxation therapy and physiotherapy under medical supervision. A Combined therapeutic approach which is at least twice as effective as other therapeutic modalities published to date ...". I was able to verify that the article exists, but can someone please verify the content and WP:WEIGHT? - Tekaphor  ( TALK ) 02:26, 22 February 2010 (UTC)


 * I found the abstract but couldn't get farther and couldn't find the article indexed on medline. I think it wise to get the actual wording to verify, "The most effective current treatment". This article may be an opinion piece based on clinical experience would not be a strong reference for the material per WP:MEDASSESS. Ward20 (talk) 06:04, 22 February 2010 (UTC)


 * While the Steele research is interesting, I'm not sure if we should be including it here (and saying it is 'the most effective') as it has zero citations, isn't in medline and is just a primary study. A quick search on google scholar seems to show that CBT is the current most effective treatment. --sciencewatcher (talk) 19:21, 27 May 2011 (UTC)

Some contradictions within this page - suggestions for improvement?
In the opening paragraph, it states " The term does not necessarily imply that a physical cause does not exist, but rather notes that cause(s) for given symptoms are uncertain, unknown or disputed—there is no scientific consensus. "

The History and Usage section below it, however, contradicts this:

"MUPS may be synonymous with somatization disorder[14] or psychosomatic illness, where the cause or perception of symptoms is mental in origin, or may overlap these terms or be a "lower threshold variant" of them.[15] Because several definitions of both somatization and MUPS exist, and the usage of both terms is inconsistent in medical literature and practice, MUPS is sometimes used interchangeably with somatization and functional somatic symptoms,[16] although "somatised mental distress" and "somatisation disorders" (based on symptom counts) may not adequately account for most patients seen with MUPS.[12]

One suggestion to reconcile:

In the opening paragraph, "Strictly speaking, the term itself does not imply that a physical cause does not exist, but rather that cause(s) for given symptoms are uncertain, unknown or disputed. However, in practice, the use of the term usually implies that the cause of the symptoms is believed to be psychological".

Feedback, please?

Wilshica (talk) 04:57, 7 July 2015 (UTC)Wilshica

response/MUPS
Hi Ozzie10aaaa,I like what you've done withe the MUPS wikipedia page, good refs and image. But I hope you won't be offended that I have suggested reverting some of the previous material you deleted. Its important to make clear why a doctor-patient conflict arises in the first place - its to do with the doctor's belief that the symptoms have a psychological cause, and the patient's belief that they are physical in origin I've tried to keep in your new material though, about questioning the doctor's competence. I didn't know what to do with your comment about MUPS leading to a "vegatative state", that's not a widely held belief amongst physician or researchers. Do you mean high morbidity, perhaps?Wilshica (talk) 11:27, 19 July 2015 (UTC)


 * Wilshica there is no problem, that is what we are all here for... the link and wording was actually vegetative symptoms,and the link is Identifying_reliable_sources_(medicine).Thank you for your question (BTW don't you think it might be best to shorten the lead a bit ...should be more compact per Manual_of_Style/Medicine-related_articles)--Ozzie10aaaa (talk) 11:40, 19 July 2015 (UTC)

Hi Ozzie10aaa, Yes, you're right. The lead does need shortening. Another subhead would be good. Not sure what it would be though. Certainly, a "differential diagnosis" section is kinda weird because MUPSs is really no diagnosis at all. What about something like "Definition and Scope"? or "Definition and Description"?

Re the vegetative symptoms, I see what you're saying now. That persons with MUPS can be severely functionally impaired, often unable to work, and in some cases bedbound. This is a good thing to put (not sure where). Here are a couple of good refs: http://dx.doi.org/10.1007/s11136-007-9252-y http://dx.doi.org/10.1016/j.jpsychores.2008.09.018 (this one's a review, so is a stronger reference in wikipedia terms)

I thought your idea of an "Evaluation" section was good too. And the material on peptic ulcers etc. fits there. But the rest of the material that was there is more definitional. Perhaps we could find some additional material? — Preceding unsigned comment added by Wilshica (talk • contribs) 00:19, 20 July 2015 (UTC)
 * agree with you, good (description section sounds OK)...that second reference you have is very good--Ozzie10aaaa (talk) 00:22, 20 July 2015 (UTC)

Ozzie, I noticed you removed the ref for Wilschica's statement about the placebo effect, so it is now unreferenced. I'd suggest either re-adding that citation (Nezu et al, 2001), or removing the unreferenced statement. --sciencewatcher (talk) 05:31, 2 December 2017 (UTC)


 * I've rewrote the text to fix these problems. --sciencewatcher (talk) 20:01, 4 December 2017 (UTC)

External links modified
Hello fellow Wikipedians,

I have just modified one external link on Medically unexplained physical symptoms. Please take a moment to review my edit. If you have any questions, or need the bot to ignore the links, or the page altogether, please visit this simple FaQ for additional information. I made the following changes:
 * Added archive https://web.archive.org/web/20060115221531/http://www.pdhealth.mil/downloads/DHCC_efile.ind.pdf to http://www.pdhealth.mil/downloads/DHCC_efile.ind.pdf

When you have finished reviewing my changes, you may follow the instructions on the template below to fix any issues with the URLs.

Cheers.— InternetArchiveBot  (Report bug) 05:47, 12 January 2018 (UTC)

The place of ME/CFS in this article
Hi @BlenFans, I’m bringing this up here because my edit was reversed, I wanted to say this page’s characterisation of ME/CFS as a MUPS is outdated. The current medical literature ME/CFS is considered as a biological condition without clearly defined aetiology but with consistent findings of abnormalities. You can see the Wikipedia article for ME/CFS itself which has been greatly improved recently, is classified as a good article, and is well on its way to becoming a featured article. (This comment is similar to the one I posted on the FSS page as it is for similar reasons).

Here are some sources anyways:

“Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a chronic, multi-system disease […] studies show neurologic, immunologic, autonomic, and energy metabolism impairments.” Mayo clinic proceedings https://www.mayoclinicproceedings.org/article/S0025-6196(21)00513-9/fulltext#secsectitle0035

‘numerous studies over time have uncovered organic abnormalities in patients with ME/CFS, and the majority of researchers to date classify the disease as organic’ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10819994/

There is much more evidence on the ME/CFS wikipedia page. Due to this evidence I think ME/CFS should be removed from the MUPS wikipedia page, or at the very least there should be an acknowledgment that its status as MUPS is controversial.

Additionally the citation which is used to justify the classification of ME/CFS as MUPS is from 2004, research into ME/CFS has highly advanced since then, and especially since 2017.

Thanks :) (from someone who spends way too much time reading me/cfs research.) YannLK (talk) 18:45, 14 April 2024 (UTC)