Preamble

Narrative Medicine Interpretation Models and the Empowering Mechanism of Narrative Thinking in General Practice Clinics

Abstract

Narrative medicine, as a humanistic medical model that integrates clinical practice with narrative competence, provides a new perspective for improving the doctor-patient relationship and enhancing the quality of medical services. This study explores the interpretation models of narrative medicine within the context of Chinese general practice clinics and analyzes the empowering mechanisms of narrative thinking in the diagnostic and therapeutic process. By examining the core elements of "attention, representation, and affiliation," this paper elucidates how general practitioners can utilize narrative tools to bridge the gap between "disease" (the biological condition) and "illness" (the lived experience). The research suggests that narrative thinking not only optimizes clinical decision-making but also fosters empathy and professional identity among general practitioners, ultimately achieving a holistic approach to patient care.

1. Introduction

In the contemporary medical landscape, the transition from a purely biomedical model to a biopsychosocial model has become a global consensus. General practice, characterized by its comprehensive, continuous, and person-centered nature, serves as the frontline of this transition. However, the increasing technicality of modern medicine often leads to the "de-personalization" of patients, where the focus shifts from the person to the pathology. Narrative medicine, a discipline proposed by Rita Charon, emphasizes the ability to acknowledge, absorb, interpret, and be moved by the stories of illness. In the specific environment of the general practice clinic, narrative medicine offers a framework to restore the humanistic essence of medicine.

2. The Narrative Medicine Interpretation Model in General Practice

The application of narrative medicine in general practice clinics is not merely an addition of communication skills but a fundamental shift in the clinical interpretation model. This model is built upon three core pillars:

2.1 Attention: Deep Listening and Presence

In the general practice clinic, "attention" refers to the practitioner's ability to focus entirely on the patient's verbal and non-verbal cues. Unlike the rapid-fire questioning typical of specialized clinics, narrative attention requires a "radical listening" approach. This allows the physician to perceive the patient's underlying anxieties, social context, and personal expectations, which are often obscured by physical symptoms.

2.2 Representation: Constructing the Illness Narrative

Representation is the process by which the physician translates the patient's raw experience into a coherent narrative. In general practice, this involves moving beyond the standardized "chief complaint"

1.528000 广东省佛山市，南方医科大学顺德医院叙事医学研究中心

Study on the Empowerment of Narrative Medicine for the Quality of Life of Patients with Medically Unexplained Symptoms

ZHANG Xiaolin
Shunde Hospital, Southern Medical University, Foshan 528000, China
Southern Hospital, Southern Medical University, Guangzhou 510000, China

ZHANG Peng
Associate Chief Physician

Abstract

"Medically Unexplained Symptoms" (MUS) have emerged as a significant public health concern. Traditional biomedical interpretations of MUS often fail to address the numerous dilemmas faced by individuals experiencing these symptoms, leading to prominent clinical issues such as overdiagnosis and overtreatment. Drawing upon the interpretive framework of narrative medicine, this paper proposes that the vast majority of individuals with MUS suffer from "narrative closure"—specifically of the traumatic, skeptical, or geriatric types—or "interpersonal narrative rupture." Only general practitioners or specialists equipped with narrative thinking can effectively reduce the overtreatment of MUS and its associated negative effects while simultaneously improving patients' quality of life.

By establishing a robust narrative connection with individuals suffering from MUS, clinicians can guide patients toward active narrative regulation. This process assists patients in achieving transformative growth of the "narrative self," thereby mitigating the impact of symptoms on their quality of life. This article calls for the construction of a comprehensive narrative medicine system within general practice to enhance the professional narrative competence of general practitioners. By integrating scales for narrative rupture and narrative closure into the diagnostic and therapeutic process for MUS, clinicians can effectively improve their capacity for narrative diagnosis, patient education, and narrative healing when addressing medically unexplained symptoms.

Keywords: Narrative Medicine; Medically Unexplained Symptoms; Clinical Narrative Thinking; Whole-Person Healing

Introduction

Medically Unexplained Symptoms (MUS) represent a complex challenge where patients present with persistent physical complaints that do not align with known organic pathology after adequate medical investigation. In clinical practice, the limitations of the traditional biomedical model often lead to a cycle of over-testing and ineffective treatments, which can exacerbate patient anxiety and diminish their quality of life.

The Narrative Interpretation of MUS

From the perspective of narrative medicine, MUS can be understood not merely as a physiological failure, but as a crisis of the patient's life story. Most individuals presenting with MUS can be categorized into specific states of narrative dysfunction:

1. Narrative Closure: This occurs when a patient's life story becomes stagnant or fixed. We identify three primary subtypes:
   • Traumatic Narrative Closure: Where past trauma halts the progression of the individual's life story, manifesting as physical symptoms.
   • Skeptical Narrative Closure: Where doubt regarding the medical system or the self prevents the formation of a coherent healing narrative.
   • Geriatric Narrative Closure: Often seen in elderly patients who perceive their life story as nearing its end, leading to a focus on somatic decline.
2. Interpersonal Narrative Rupture: This refers to a breakdown in the communicative bond between the patient and their social or medical environment. When a patient feels their "story" is not being heard or validated by clinicians, the resulting rupture can manifest as intensified physical distress.

The Role of Narrative Thinking in Clinical Practice

To address these challenges, it is essential for general practitioners and specialists to develop "narrative thinking." This involves moving beyond the mere collection of clinical data to actively listening to and interpreting the patient's lived experience. By establishing a "narrative connection," the physician acts as a co-author in the patient's journey toward health.

Clinicians should guide patients through "narrative regulation," helping them reframe their symptoms within a broader, more meaningful life context. This approach facilitates the growth of the "narrative self," allowing patients to move past their symptoms and achieve a higher quality of life, even in the absence of a definitive biomedical cure.

Conclusion and Recommendations

This study advocates for the systematic integration of narrative medicine into the general practice framework. Specifically, we recommend:

• Enhancing Narrative Competence: Training programs for general practitioners should focus on narrative skills to improve diagnostic accuracy and patient rapport.
• Implementing Assessment Tools: Incorporating standardized scales to measure narrative closure and narrative rupture during the MUS diagnostic process.
• Promoting Narrative Healing: Shifting the clinical focus from purely symptomatic relief to "whole-person healing" through narrative education and intervention.

By empowering both physicians and patients through the principles of narrative medicine, the medical community can better address the complexities of MUS, reduce the burden of overtreatment, and significantly improve patient outcomes.

Abstract

Medically unexplained symptoms（MUS）have become an important public health issue. The biomedical interpretation of MUS cannot solve lots of dilemma faced by MUS individuals，and the problems of overdiagnosis and overtreatment are clinically prominent. Starting from the explanatory model of MUS based on narrative medicine，this article proposes that the vast majority of patients with MUS suffer from traumatic，suspicious，professional or elderly narrative foreclosures or interpersonal narrative disruption. Only general practitioners or specialists with narrative thinking can reduce overdiagnosis and its negative effects，and improve patients life quality. Healthcare professionals may actively guide patients to carry out narrative adjustment and narrative mediation on the basis of establishing a good narrative connection with persons with MUS，so as to help them achieve leapfrog growth in their narrating self and reduce the impact of symptoms on their quality of life. The article calls for establishing a system of narrative medicine to improve the professional narrative competencies of general practitioners and integrate narrative scales for narrative disconnectedness as well as narrative foreclosure into the process of holistic diagnosis and healing for MUS，in order to effectively improve their capabilities of narrative diagnosis，narrative patient education and narrative healing in dealing with MUS.

Key words Narrative medicine；Medically unexplained symptoms；Clinicians narrative competencies；Holistic healing YANG X L，ZHANG P. Study on the empowerment of narrative medicine to the life quality of the patients with undifferentiated disease［J］. Chinese General Practice，2025.［Epub ahead of print］ Editorial Office of Chinese General Practice. This is an open access article under the CC BY-NC-ND 4.0 license.

The development of modern medicine—marked by the emergence of imaging technology, genetic testing, and biotechnology—means that diseases can be predicted, diagnosed, treated, and managed more effectively than in any previous era of medical history. Paradoxically, however, a vast array of diseases, pains, and discomforts still fall into the category of "medically unexplained." Medicine remains poorly understood regarding these conditions, let alone their prevention and management.

These "medically unexplained symptoms" (MUS) or "medically unexplained physical symptoms" (MUPS) have become a significant public health issue. In clinical practice, physicians frequently encounter patients who present with a wide variety of discomforts that remain without a clear diagnosis even after detailed examinations. While domestic scholars in China often refer to such clinical problems as "undifferentiated diseases," the term MUS is more commonly adopted internationally. As a descriptive term, MUS encompasses somatization disorders, hypochondriasis, persistent pain, and mood disorders, as well as functional syndromes such as fibromyalgia and chronic fatigue syndrome. MUS is one of the most common issues encountered across clinical disciplines, particularly in general practice. It is often described using terms such as non-specific symptoms, persistent physical symptoms, functional symptoms, autonomic dysfunction, or neurosis. MUS can be viewed as a continuous spectrum ranging from self-limiting symptoms to recurrent or persistent symptoms and symptom disorders. Research has also found that MUS falls within the scope of persistent physical symptoms (PPS).

These unexplained diseases share common characteristics: physical symptoms lack corresponding pathological manifestations, yet if the patient's narrative of their illness experience is authentic, their functional impairment may also be real. Medical science prioritizes visualization and evidence. If existing examinations or scans fail to reveal the presence of a disease or tangible abnormalities (such as nodules, tumors, enlargement, effusion, fibroids, or ulcers), patients with these conditions may feel a loss of presence and a sense that no one is listening. Many are subjected to constant doubt and denial by others because "a patient's pain only exists once acknowledged by a doctor; the patient's self-report does not count." Without medically recognized, visible pathological evidence, patients are left in a "gray zone questioned by medicine." Medical terminology has "constructed a hierarchy of patients, where those at the top have clear evidence to prove their illness and are thus accepted by the medical field, while those unable to prove their illness reside at the bottom, suffering from medical skepticism." MUS patients may appear in any specialty clinic, but they most frequently seek help from general practitioners, neurologists, and specialists in pain management, cardiology, gynecology, and gastroenterology. Statistics show that diagnosing and treating MUS patients has become a primary task for many internists, especially in primary care and general practice clinics; more than one-third of patients referred to hospital outpatient clinics are classified as MUS patients. Existing literature indicates that research on MUS primarily focuses on diagnostic reliability, patient mental health, the benefits of psychotherapeutic interventions, demographic and social characteristics, and factors influencing the doctor-patient relationship. Overall, international literature regarding MUS has been steadily increasing in recent years.

Western literature has categorized explanatory models for MUS into various theories, including somatic amplification, sensitization, susceptibility and immune system sensitization, endocrine disorders, signal filtering, illness behavior, autonomic nervous system dysfunction, abnormal proprioception, and cognitive-behavioral therapy models. Compared to the increasing international attention on MUS, domestic Chinese literature remains relatively sparse, with few studies moving beyond the biomedical framework or single-disease explanatory models.

In fact, MUS is closely related to a patient's cognition of their illness, family circumstances, emotional regulation abilities, lifestyle habits, personality traits, and the quality of their interpersonal connections. Within the framework of Chinese narrative medicine, clinicians and the public can fundamentally transform their understanding of MUS and improve the quality of life for these patients.

Narrative medicine theory suggests that the rise in MUS patients is directly related to two trends in modern medicine: an over-reliance on objective evidence and a neglect of the patient's subjective experience of illness. Clinicians who possess only evidence-based thinking rely primarily on pharmaceuticals and surgery as their means of treatment. However, individuals with MUS are difficult to cure through these external means, leading to frequent conflicts and disputes between doctors and patients. Consequently, many doctors tend to avoid such patients. Due to the inability to reach a consensus with their physicians, MUS patients also report generally low levels of satisfaction with their medical encounters.

Using narrative medicine as a framework, this paper proposes a new explanatory model. Specifically, the fundamental reason individuals are troubled by MUS is that they are trapped in a certain life story or state of being. Their internal energy cannot escape the constraints and entanglements of this state, and they exist in a state of fractured interpersonal narrative connection with relevant individuals. This prolonged state of "narrative closure" severely hinders the growth of the narrative self. The vast majority of MUS patients experience different types of narrative closure, such as traumatic, skeptical, or geriatric types. The narrative medicine explanatory model for MUS can guide healthcare workers to realize that they deal with specific suffering in their daily practice rather than abstract health. It encourages a focus on the person in pain rather than just the physical symptoms. This model guides clinicians back to the original intention of medicine: relieving human suffering. Only in this way can the quality of life for MUS patients be truly enhanced.

1 MUS

A Narrative Medicine Interpretation of Medically Unexplained Symptoms (MUS)

In the era of evidence-based medicine, clinicians tend to explain diseases based on their pathophysiological foundations. Taking cardiovascular disease as an example, evidence-based thinking leads clinicians to understand these conditions through a framework of risk-based interpretation, placing cardiovascular diseases—which should be attributed to multiple causes—under a single explanatory architecture. The success of "psycho-cardiology" clinics serves as a footnote to this perspective. Particularly with the application of antibiotics, chemotherapy, and genetic technology, modern medicine has become more urgent in its external pursuit of "cure," while neglecting the patient's internal need for "care." However, this reductionist interpretation model not only triggers a sense of existential frustration in patients during their medical journey but also brings a serious sense of professional frustration to doctors. Patients seek medical consultation repeatedly without receiving rational or effective diagnosis and treatment. They undergo expensive, repetitive invasive tests and imaging examinations across multiple hospitals, which not only increases the psychosomatic and economic pressure on MUS individuals and their families but also consumes vast amounts of social medical resources. As the number of MUS patients grows, failure to break this vicious cycle will lead to a severe crisis for society, medical institutions, physicians, and patients alike.

The emergence of narrative medicine provides a vital opportunity to achieve a virtuous cycle of narrative care and holistic healing for MUS individuals. From the dimension of the individual's narrative self-growth and the developmental mechanisms of disease, narrative medicine proposes an interpretative model completely different from the biomedical reductionist approach to MUS. The philosophy of narrative medicine suggests that three causes induce MUS: (1) the individual's narrative self fails to reach the maturity required for their current life stage, rendering them unable to actively adjust their life state; (2) the individual is in a long-term state of ruptured interpersonal narrative connection; and (3) narrative closure leads to the stagnation of narrative self-growth. This interpretative model, co-constructed by the physician and the MUS individual through narrative interaction, is the model most likely to be accepted by the patient and to exert an empowering effect.

MUS represents a liminal state or a "gray zone" between health and disease. Within the context of narrative medicine, MUS often acts as a messenger in a patient's life, signaling that there is a problem with their life state that requires active adjustment.

This messenger intends for the individual to use the warning brought by these symptoms to initiate active narrative integration, better perceive and understand their own life state, make corresponding narrative adjustments, and achieve narrative self-growth. When individuals troubled by MUS lack awareness of narrative regulation and instead blindly pursue drugs and surgery to solve the problem, they miss the optimal window for intervention and eventually enter a true state of disease. Conversely, timely and effective narrative regulation or narrative care from others can enable them to return from the gray zone to the "kingdom of health."

A patient's MUS often appears following major trauma (such as childhood abuse, war trauma, or disaster-related trauma) or significant life events (bereavement, romantic breakups, unemployment, disability, business failure, or marital breakdown). It may also occur during major life transitions where the individual experiences excessive pressure, strained interpersonal relationships, or other significant adjustments. MUS patients can only receive correct diagnosis, treatment, and care within a physician's framework of narrative thinking. For the patient, only by using the suffering of symptoms as an opportunity—and through self-narrative regulation combined with narrative intervention from physicians, family, and friends—can they restart a stagnant life narrative process, cultivate their capacity for narrative regulation, and achieve leapfrog growth of the narrative self. Only then can symptoms be alleviated or eliminated.

MUS occurs frequently among children, adolescents, and women. Traditional Chinese Medical literature mentions that widows, unmarried women, young boys, and those who are frustrated in their ambitions must "divert their emotions and be good at self-explanation" rather than relying entirely on the power of herbs and medicine. If a physician only knows how to respond with medication, they will treat these people as "difficult cases" and their symptoms as "intractable diseases." In reality, such patients require the "power of the tongue" (communication). Explained through narrative medicine, children and adolescents are in the early stages of narrative self-development, and their capacity for self-narrative regulation is very weak.

Furthermore, there are gender differences in narrative needs. When encountering difficulties, crises, setbacks, or frustrations, women have a greater need for narrative regulation, whereas men tend toward instrumental regulation. If a woman lacks effective narrative care within her family, workplace, or social relationships, she becomes more susceptible to MUS.

It can be said that narrative medicine provides a more nuanced and considerate approach to health management for minors and women. The philosophy of narrative medicine suggests that many MUS patients suffer from "narrative closure" due to trauma, professional stress, doubt, or aging. Conditions such as atypical chest pain in cardiology, irritable bowel syndrome (IBS) in gastroenterology, fibromyalgia in rheumatology, chronic neck and back pain in orthopedics, psychogenic non-epileptic seizures (PNES) in neurology, and chronic pelvic pain in gynecology are highly likely to be triggered by narrative closure. Some individuals diagnosed with epilepsy are often told to undergo at least two years of drug treatment, yet medication and physical therapy clearly struggle to be effective. The MUS population is often over-medicalized, being treated for diseases that do not fundamentally exist. The evidence-based mindset causes both physicians and MUS individuals to completely overlook the fact that the true path to healing lies in re-stimulating the individual's internal narrative regulation capacity, predicated on repairing narrative connections with significant others.

Building a narrative community with healthcare providers and family members is the foundational condition for moving beyond the distress of MUS, whether the patient is suffering from narrative closure due to trauma or a singular identity. Dr. Varella, an oncologist and bestselling author, has proposed that when emotions and feelings are hidden or suppressed, it can lead to unexplained pain such as gastritis, gastric ulcers, and lumbar spinal pain. Over time, these issues may even deteriorate into cancer. Finding a confidant to share one's story of pain can dissolve adverse symptoms. It can be argued that MUS is primarily associated with poor subjective narrative regulation and hindered narrative self-growth; interpersonal narrative connection is the most powerful prescription for these problems. Patients with these types of symptoms can be followed long-term by general practitioners (GPs) who can comprehensively grasp major life events before and after the onset of illness. By working closely with various specialists and applying narrative concepts, GPs can lead patients out of the predicament of their symptoms and help them understand their life stories from a more holistic perspective.

MUS severely impacts an individual's quality of life, impairing their work capacity, social behavior, ability to concentrate, daily performance, and sleep quality. Many authoritative medical experts believe that internal distress is often transformed into physical symptoms. There is a close relationship between unexplained pain in specific regions and life circumstances and the complex emotions they trigger: excessive worry and stress can cause headaches and neck/shoulder pain; individuals lacking emotional support often experience upper back pain, while financial pressure can trigger lower back pain; hand pain may stem from an inability to establish friendly or intimate interpersonal connections; falling into self-blame or an unwillingness to forgive others can lead to neck pain; being trapped by past trauma may result in ankle pain; and the pressure of facing major future decisions can trigger hip pain. Pain even haunts the young.

Under the narrative medicine interpretation model, chronic pain, chronic fatigue syndrome, and other MUS symptoms in individuals—especially young people—are often directly related to a narrative self-maturity that is insufficient to handle the demands of their life stage. It is linked to an avoidant rather than proactive attitude toward certain life events, which prevents the enhancement of narrative regulation skills. When narrative self-maturity does not match the current life stage, even a seemingly minor event may be perceived as a major traumatic incident. When such trauma occurs, "Broca's area" in the left brain, responsible for language, may shut down. The function of telling the traumatic story can only be reopened when the individual perceives kindness, warmth, and a narrative connection from another person.

The following is a case of a general practitioner with narrative thinking conducting a narrative consultation for an MUS patient to improve her condition: Ms. Cen, aged 45, presented with throat discomfort that seriously affected her normal life. She had visited the otolaryngology departments of several hospitals, but no clear diagnosis was made, and medication failed to improve her symptoms. When Ms. Cen arrived at the general practice clinic of Dr. Zhang, who is trained in narrative medicine, Dr. Zhang did not start the consultation by focusing directly on the disease or symptoms. Instead, observing Ms. Cen's furrowed brow and that she appeared older than her 45 years, he asked about her family situation. It turned out that Ms. Cen's husband had passed away in a car accident years ago, and she had struggled alone to raise her daughter.

Upon further inquiry, Dr. Zhang learned that Ms. Cen's daughter was thirteen years old and had just entered adolescence. She argued about everything, and her rebellious behavior left Ms. Cen feeling deeply frustrated and discouraged. Ms. Cen could not win arguments with her daughter and worried that her daughter was too headstrong; she feared that if anything happened to her, leaving her daughter alone to face this complex world, the consequences would be unthinkable.

After listening to Ms. Cen's story, Dr. Zhang said: "You are younger than I am, yet you have endured so much bitterness; it really hasn't been easy. Moreover, you have suffering that you cannot speak of, and no one truly understands your pain. No wonder your throat always feels like something is pressing against it!" Hearing the doctor's words, Ms. Cen burst into tears. For the first time, she realized that her physical symptoms were intertwined with her emotions, mental burdens, and life experiences. Dr. Zhang further explained that being in a long-term state of ruptured narrative connection causes the body's muscles to tighten unconsciously.

If the muscles of her upper esophagus remained in a state of continuous tension, it could lead to the symptoms of throat discomfort. Continuing to arrange examinations, such as CT scans, would have a minimal probability of finding abnormalities; instead, it would prolong her worry and anxiety, which would be harmful rather than helpful to her condition. The doctor's explanation touched Ms. Cen, allowing her to view her physical problems through a broader lens rather than keeping her attention entirely locked on the symptom of throat discomfort.

Beyond otolaryngology, ophthalmology and audiology also encounter patients with unexplained loss of vision or hearing. Without narrative thinking, clinicians often dismiss self-reported blindness or deafness that lacks a clear evidence-based diagnosis as "imaginary illnesses." In fact, these MUS cases are as real as actual blindness or deafness, involving a sudden and total loss of sight or hearing. The following is a famous clinical case:

Yvonne was a supermarket employee. While she was stocking items in a refrigerator, a colleague accidentally sprayed glass cleaner into her face. She tried to wash her eyes and left work early to rest at home. However, when she woke up the next day, she found her vision was extremely blurred.

Within 48 hours, her condition worsened to the point where she could not distinguish between day and night. After six months of seeking medical help, doctors still found no organic issues with her eyes. Nevertheless, according to her own account, her vision remained shrouded in darkness, and the lack of a clear diagnosis added to her panic and anxiety. Later, when she met a doctor who included inquiries about her life circumstances during the consultation, Yvonne seemed to gain a new perspective on her symptoms. After working hard to balance the relationships between her job, her children, and her overbearing husband, and learning to cope with various frustrations, her vision gradually returned.

In this case, it can be said that the strengthening of her narrative self-maturity allowed her to break free from the influence of her symptoms and return to a normal life. Additionally, other MUS individuals, such as those with psychogenic non-epileptic seizures (PNES), often have experienced major traumatic events—such as sexual abuse, physical abuse, or the loss of a loved one—that are difficult to accept or move past through self-narrative regulation alone. Camilla, a lawyer in London, once exhibited epileptic symptoms, including convulsions and loss of bodily control. Under the guidance of a physician with narrative thinking, Camilla realized that her seizures might be related to the death of her young son; realizing this helped her gradually recover. In summary, compared to patients with diagnosable physical diseases, MUS individuals suffering from symptoms like blindness, fatigue, epilepsy, or paralysis rooted in trauma and life dilemmas often endure even more unbearable pain. When clinicians can interpret symptoms through narrative medicine, allowing patients to truly see and understand their life circumstances and engage in reflection and empowerment, individuals can successfully rid themselves of their symptoms.

2 医者叙事思维与

Holistic Diagnosis and Treatment of Patients

With social progress and development, the pace of life has accelerated and social competition has intensified, leading to a trend where patients with Medically Unexplained Symptoms (MUS) are becoming younger, and the overall prevalence is increasing annually. The vast majority of MUS patients do not show significant improvement after conventional medical treatment. This is because the root of MUS symptoms lies in a crisis of the "narrative self" and a serious breakdown in the capacity for self-narrative regulation. Consequently, these symptoms cannot be alleviated through medication or surgery; achieving holistic healing depends on the clinician's clinical narrative thinking. Narrative thinking refers to a form of practical wisdom characterized by the ability to shift perspectives to perceive the life situations of oneself and others. it involves actively utilizing accumulated narrative capital to provide individualized responses, reflections, and empowerment. It stands as a mode of thinking complementary to scientific, evidence-based, and technical thinking.

Clinical narrative thinking is an interpersonal interaction in which clinicians apply narrative logic to patient education, disease notification, clinical diagnosis, treatment, and decision-making. When facing an increasing number of MUS patients, clinicians must first realize that establishing an interpersonal narrative relationship—rather than a purely evidence-based doctor-patient relationship—is the essential foundation for the effective management of individual MUS symptoms. Therefore, hospitals should prioritize the cultivation of narrative thinking among medical staff and create a safe narrative space that encourages patients to share their life stories and experiences. Based on the critical non-biomedical information obtained during narrative interaction, doctors should use the language of the patient's "life world" to provide specific explanations for the causes of symptoms, thereby guiding them toward new strategies for self-symptom management and self-narrative care.

Clinician Narrative Thinking and Professional Narrative Closure

Human beings are composed of multiple identities and play different roles in various contexts. However, those experiencing "professional narrative closure" confine themselves solely to their professional identity. They derive their entire sense of satisfaction from external evaluations of their professional status, deny the existence of other identities, and are unwilling to extend their life stories into realms such as personal life, family, or romance. Such individuals invest the vast majority of their energy and resources into external matters that yield quick feedback or benefits. This single-identity narrative closure is detrimental to health. Only by being adept at switching identities and establishing narrative connections with oneself, family, colleagues, workplace clients, and society can one achieve both success and health.

For those in a state of closure, MUS often serves as a wake-up call. Without encountering specific life events and receiving guidance from those with life wisdom to stimulate internal reflection and insight, it is difficult for such individuals to change their rigid life trajectories.

Dr. Xiao Zhou, a 28-year-old physician working in Zhuhai, felt an inexplicable sense of malaise, characterized by daytime fatigue and headaches, and nighttime insomnia and irritability. She constantly suspected something was wrong with her body. However, it had been less than three months since her comprehensive annual physical examination. To confirm her health status, she underwent various tests at the hospital; all data and imaging reports were normal, resulting in no definitive diagnosis. Nevertheless, her subjective symptoms worsened, and she eventually consulted a psychiatrist at her own hospital. Since she did not know the psychiatrist personally, she identified herself as a colleague. The doctor immediately administered a scale and informed her that the result indicated moderate depression. She was prescribed two medications: a sleep aid and an antipsychotic/antidepressant.

After the consultation, Xiao Zhou did not feel as though she had truly been "treated." This reflects the current state of many psychiatric departments in China, where even this specialty—which should be the least reliant on rigid evidence-based protocols—has become overly "evidence-based." Psychiatrists often stop listening to patients' illness experiences and instead use an absolute biomedical cognitive framework to interpret and respond to disease. As a doctor herself, Xiao Zhou found this approach incomprehensible and did not take the prescribed medication. Later, she drove over an hour to Shunde to see another doctor who was rumored to have successfully treated many similar patients. After asking about her recent work situation, this doctor posed two questions: "Are you married?" and "Have your immediate relatives, such as parents or siblings, experienced any major life events?" The doctor also prescribed medication but advised that it was only for temporary symptom relief and should not be taken long-term. To escape her current state, the doctor emphasized, the most important thing was to rediscover herself.

On the drive back, these two questions lingered in her mind. At 28, she was still single, and marriage had never been on her agenda. Among her four siblings, an older sister had committed suicide last year after being diagnosed with stage III ovarian cancer, and a younger brother had recently been diagnosed with diabetes. Due to her busy clinical schedule, she had only faced these events briefly and had not taken the time to fully confront these family tragedies or accompany her family members. She realized that since graduating from medical school, she had been passively caught in a whirlwind of medical affairs, constantly busy, and had avoided or missed too much. These unaddressed issues were still affecting her subconsciously.

Upon returning to the hospital, Xiao Zhou arranged her department's work and took a few days off to return to her hometown. Gathering with her siblings, she learned that her sister had been in an unhappy marriage. Because their parents were deceased and Xiao Zhou was working elsewhere, the sister had no one to connect with and faced the breakdown of her marriage and the cancer diagnosis alone, leading her to feel that life was not worth living. Xiao Zhou realized that if she did not change her own state of being, she might be the next to suffer a serious illness. Subsequently, she repaired her intimate connections with her family and established daily narrative links with her siblings and their children. Outside of work, she also learned to engage in timely self-narrative regulation. Within three weeks, her symptoms were significantly relieved. Not only did she return to work with more energy, but her colleagues also noticed her improved state. Furthermore, she began to apply narrative thinking in her interactions with patients.

Between the two doctors, one only knew how to prescribe medication based on scale data, while the other—through two questions that did not require immediate answers—triggered a narrative integration of her life. This allowed her to recognize and adjust her life state, achieving symptom relief and the growth of her narrative self. This case demonstrates that to improve the holistic healing of MUS patients, psychiatrists must break free from the constraints of the biomedical model and actively establish narrative connections for intervention. Furthermore, in specialties where MUS patients most frequently seek help—such as general practice, neurology, gastroenterology, cardiology, and psychiatry—doctors should possess clinical narrative thinking. Within the "narrative community" built with the patient, they should provide narrative care and guide the patient toward the growth of their narrative self.

Clinician Narrative Thinking and Traumatic Narrative Closure

The concept of life-health narratives suggests that if individuals experience bereavement, bullying, mental abuse, neglect, or witness conflict and violence during infancy and childhood, these traumatic experiences often affect more than just the psychological level. They can severely impact physiological manifestations, leading to chronic disease symptoms or medically unexplained symptoms in adolescence or adulthood. These experiences are termed "Adverse Childhood Experiences" (ACEs) or "Early Adverse Life Events" (EALs). Such traumatic experiences increase the likelihood of suffering from medically unexplained Functional Neurological Symptoms (FNS) and are significantly correlated with the severity of Functional Somatic Syndromes (FSS) such as fibromyalgia, chronic fatigue syndrome, somatoform disorders, and irritable bowel syndrome. Research has found a positive correlation between unexplained functional abdominal pain in childhood, chronic pain in adulthood, and adverse parenting styles (low care and high protection), as well as direct links to conditions like chronic pelvic pain syndrome in women. In the context of narrative medicine, these findings are strongly associated with weak parent-child narrative connections and a lack of narrative care awareness. These adverse family narrative ecologies likely increase the risk of chronic pain in children later in life. Therefore, in addition to receiving narrative care and guidance from clinicians, there is a need for more parents to transform their parenting styles, pay attention to subtle changes in their children, and establish intimate narrative connections to create a better family narrative ecology and prevent the occurrence of MUS.

In 2020, shortly after the Life and Health Narrative Center opened, several parents brought children aged 8 to 10, and even teenagers, who were still bedwetting. In the modern medical context, bedwetting is often medicalized as a disease—a problem to be solved through examinations, prescriptions, and injections. However, despite visiting many hospitals and undergoing various tests, no issues were found. This increased parental anxiety, leading to more frequent doctor visits in the hope of finding a diagnosis and a pharmacological solution.

[TABLE:1] [FIGURE:1] Chinese General Practice https

However, the vast majority of bedwetting issues in children are not physiological; they are not problems of the brain or the urinary system. These cases of non-physiological bedwetting are often rooted in the adverse parenting styles of caregivers or traumatic experiences in early childhood that did not receive positive attention or effective care. At the Narrative Center, we conduct long-term communication with both children and parents, listening to their family stories surrounding the bedwetting. We found that these children often lived in single-parent families, were separated from their parents for long periods, experienced the sudden death of a loved one, or had moved to a strange place. Some children were even beaten or scolded by parents or grandparents because of their bedwetting. Extensive research by the Narrative Center has found that parental conflict or divorce, sudden death or injury of relatives, long-term separation from parents, moving to unfamiliar environments, being frightened at night, and punishment or shaming by parents are all factors that cause or exacerbate bedwetting or trap children in a state of narrative closure.

Furthermore, fibromyalgia—a common MUS symptom in adults—often emerges after an individual experiences an unbearable, high-stress event. These stressful events include car accidents, surgery, childbirth, physical overload due to overwork, long-term stress, psychological trauma, or histories of abuse or sexual assault.

Clinician Narrative Thinking and Hypochondriacal Narrative Closure

In the context of narrative medicine, practitioners find that MUS individuals often feel troubled by multiple symptoms rather than just one, leading to extreme panic. For those with hypochondriacal narrative closure, these symptoms often undergo a process of "somatosensory amplification." When individuals encounter events in their life course that they cannot cope with, the weakness of the narrative self prevents the physical stress response from dissipating, causing it to manifest as persistent symptoms. Once a physical sensation arises, the individual focuses almost all their attention on it.

They develop certain cognitions and attributions that further amplify the perception of these bodily signals. This amplification leads to a vicious cycle where symptoms are continuously reinforced by the individual's doubts. Consequently, MUS individuals experience a series of more severe and destructive physical sensations.

Ms. Huang, a retiree, visited a general practice clinic due to five years of unexplained chest tightness, dizziness, and migratory headaches. Over several years, she had sought treatment at multiple renowned Grade A tertiary hospitals, undergoing numerous comprehensive examinations and evaluations in departments such as neurology, rheumatology, respiratory medicine, cardiology, and psychiatry.

However, no clear abnormal indicators were found, making a definitive diagnosis impossible. Despite nearly five years of empirical drug treatment, her weight continued to decline progressively. Consequently, she worried she had a serious illness, and her subjective symptoms became more numerous and severe, leaving her anxious and unable to eat or sleep. Through patient guidance from a general practitioner, Ms. Huang "opened up" and narrated her marriage and life history. It was revealed that she and her husband had been in a long-term cold war; after their child was born, they had lived without a sexual relationship for over 20 years. In her family of origin, her father’s volatile temper had made her timid and afraid to express her feelings and emotions. Finally, she expressed to the doctor that although she had visited so many hospitals, no doctor had ever seriously listened to her story; they only issued test orders and psychological assessment forms before prescribing medication. Speaking out made her feel an immediate sense of relief. She vowed to work on changing her life situation and to persuade her husband to attend a consultation, striving to live a better life. After several follow-up visits, Ms. Huang's headaches disappeared, and her other symptoms were significantly alleviated.

From the cases above, the most critical steps in leading patients out of the predicament of MUS are "acknowledging the suffering that MUS brings to the individual" and "being willing to listen and guide the subject to share their traumatic story." If doctors only focus on symptoms without exploring the stories and deep-seated reasons behind them, it is difficult to truly understand the patients' concerns, let alone cure them. Many doctors consulted by such MUS individuals are left puzzled and can only attempt to treat superficial symptoms. This "treats the branches" rather than the "root," missing the best opportunity for the growth of the MUS individual's narrative self. Some clinicians, fearing they will be perceived as incompetent if they cannot provide a diagnosis, force themselves to give far-fetched diagnoses, which results in misdiagnosis, over-diagnosis, and over-treatment.

3 结语

To efficiently manage the increasing number of patients with Medically Unexplained Symptoms (MUS), a fundamental measure in current medical practice is to conduct assessments of narrative competence among general practitioners and specialists. Such assessments guide clinicians to recognize the essential value of professional narrative ability and narrative thinking in achieving holistic healing. Furthermore, integrating the Narrative Closure Scale into the diagnostic and therapeutic process for MUS can help patients become aware of their own life narrative styles and conditions, thereby guiding them to actively engage in the integration and regulation of their life stories. In a sense, narrative integration is a process of harmonization; through review and reflection, discordant and difficult-to-explain stories are integrated into a coherent and harmonious overarching life narrative. In other words, the progression of every individual's life narrative is a continuous process of tuning from discordance toward harmony. Each instance of narrative integration serves the purpose of achieving leapfrog growth for the subject's narrative self.

Positive interpersonal narrative connections possess an inherent capacity to alleviate pain and suffering. In contrast to the suffering caused by narrative rupture, clinicians who embrace the concept of narrative integration can produce pain-resistant effects by guiding patients to repair their life stories. Narrative medicine allows clinicians to discover a deeper power of connection rooted in shared human experience. Once this interpersonal connection is established, a healing relationship can be formed. This not only facilitates an understanding of the patient's suffering to help achieve holistic healing but also assists both parties in constructing a complete self through narrative interaction. Many patients have transformed their life states through narrative care and narrative intervention by clinicians; as the patient's quality of life improves, the overall medical quality of the hospital is enhanced accordingly.

Currently, compared to research on other diseases for which clear evidence can be found, the holistic diagnosis and treatment of MUS has not yet formed a mature system. There is also a lack of corresponding clinical elective and compulsory curriculum construction. Consequently, neither general practitioners nor specialists in other fields possess systematic narrative thinking, leading to a deficiency in their ability to identify and respond to MUS. Therefore, in response to the current situation of MUS,

the focus of work over the next three years should be placed on continuing education and training regarding clinicians' professional narrative competence. Building upon evidence-based thinking, it is essential to improve clinicians' narrative thinking and holistic diagnostic levels. A comprehensive model should be employed to address the difficult symptoms troubling MUS patients and alleviate their suffering. MUS calls for more humanized medical services; therefore, it is necessary to conduct research that keeps pace with the times, actively using the current socio-narrative ecological status of MUS as an entry point to study stress and coping mechanisms from a multi-dimensional perspective.

Author Contributions: Yang Xiaolin proposed the research ideas, was responsible for drafting and revising the paper, and constructed the theoretical system of narrative medicine, taking overall responsibility for the manuscript. Zhang Peng provided, analyzed, and organized the cases, constructed the theoretical system of general practice, and participated in the writing and revision of the paper.

The authors declare no conflicts of interest.

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