Frequent attenders without organic disease in a gastroenterology clinic. Patient characteristics and health care use

Health Status and Clinical Diagnoses of 3000 UK Gulf War Veterans

Up to June 2001, 3000 British veterans of the Gulf War had sought advice from a special medical assessment programme established because of an alleged Gulf War syndrome. After assessment those attending were classified as completely well, well with symptoms, well with incidental diagnoses treated or controlled, or unwell (physically or mentally). Mental illness was confirmed by a psychiatrist. The first 2000 attenders have been reported previously. The present paper summarizes findings in all 3000.

2252 (75%) of those attending were judged ‘well’, of whom 303 were symptom-free. Medical diagnoses were those to be expected in such an age-group (mean age 34 years, range 21–63). No novel or unusual condition was found. In 604 of the 748 unwell veterans, a substantial element of the illness was psychiatric, the most common condition being post-traumatic stress disorder.

The healthcare requirements of the Gulf veterans seen in this programme can therefore be met by standard National Health Service provision.

[Would the Screening of Common Mental Disorders in Primary-Care Health Services Hyper-Frequent Patients Be Useful?]

Hyper-frequentation in health services is a problem for patients, their families and the institutions. This study is aimed at determining the frequency and characteristics of common mental disorders in hyper-frequent patients showing vague symptoms and signs at a primary healthcare service during the year 2007 in the city of Cali (Colombia).

METHODOLOGY

Cross sectional. The most frequent mental disorders in hyper-frequent patients were detected through a telephone interview which included several modules of the PRIME MD instrument.

RESULTS

In general, healthcare service hyper-frequenters are working women, 38,7-year old in average. Basically, the consultation is due to cephalalgia but they also exhibit a high prevalence of common mental disorders (somatization, depression and anxiety) not easily diagnosed by physicians in primary care. Expenses for additional health activities generated by these patients are attributed basically to medical consultation and required procedures.

CONCLUSION

Considering hyper-frequenters in health care services as a risk group in terms of common mental disorders involves screening as an efficient strategy to prevent abuse in service use and to improve satisfaction with the attention received.

Long-term physical health consequences of childhood sexual abuse: a meta-analytic review

OBJECTIVE

The purpose of the present article was to systematically review the literature investigating the long-term physical health consequences of childhood sexual abuse (CSA).

METHODS

Literature searches yielded 31 studies comparing individuals with and without a history of CSA on six health outcomes: general health, gastrointestinal (GI) health, gynecologic or reproductive health, pain, cardiopulmonary symptoms, and obesity. Exploratory subgroup analyses were conducted to identify potential methodological moderators.

RESULTS

Results suggested that a history of CSA was associated with small to moderate group differences on almost all health outcomes assessed, such that individuals with a history of CSA reported more complaints for each health outcome. Suggestive trends in moderating variables of study design and methodology are presented.

CONCLUSIONS

Results highlight the long-term physical health consequences of CSA and identify potential moderators to aid in the design of future research.

Childhood abuse and treatment response in patients with irritable bowel syndrome: a post-hoc analysis of a 12-week, randomized, double-blind, placebo-controlled trial of paroxetine controlled release

OBJECTIVE

Although irritable bowel syndrome (IBS) is frequently comorbid with childhood trauma, information on the clinical implications of this comorbidity is limited. We investigated whether a history of abuse was associated with response to treatment in a double blind, randomized, placebo controlled trial of paroxetine controlled release (CR) in IBS.

METHODS

Seventy-two IBS subjects were randomized to receive paroxetine CR (dose 12.5-50 mg/day) or placebo for 12 weeks. Subject selection was independent of abuse history. Sixty-one subjects completed the Sexual and Physical Abuse Questionnaire about their childhood abuse history. IBS symptoms were recorded using the Interactive Voice Response System (IVRS). Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Perceived Stress Scale (PSS) and Clinical Global Impression (CGI) were also measured. The primary outcome was treatment response defined as > or =25% reduction in composite pain scores (CPS) on the IVRS from randomization to end of treatment.

RESULTS

The rate of abuse history was 50.8% (n = 31/61). Baseline demographic clinical characteristics (CPS, BDI, BAI, PSS, CGI scores) were not associated with abuse history. After 12 weeks of treatment, subjects with abuse history showed significantly higher CPS (t = 2.422, P = 0.018) than subjects without a history and less mean change of CPS (t = 3.506, P = 0.001). In a logistic regression analysis, history of abuse did not predict treatment response as measured by > or =25% reduction in CPS (OR = 0.481, CI = 0.164-1.406, P = 0.181), while the drug status (paroxetine CR) was significantly associated with treatment response as defined by a CGI improvement score of 1-2 (OR = 12.121, CI = 2.923-50.271, P = 0.001). Abuse history did not predict CGI-I (Fisher's exact, P = 0.500) improvements during the trial.

CONCLUSIONS

History of abuse did not appear to have any significant clinical correlates at baseline and did not predict treatment response. Further studies are needed to confirm whether SSRIs are effective in IBS patients irrespective of their abuse history.

Mapping the road from childhood trauma to adult somatization: the role of attachment

OBJECTIVE

This study tested whether insecure attachment mediates the link between childhood trauma and adult somatization.

METHODS

A community sample of 101 couples completed self-report measures, including the Relationship Scales Questionnaire, the Childhood Trauma Questionnaire, the Somatic Symptom Inventory, the Beck Depression Inventory, and the Conflict Tactics Scale.

RESULTS

Childhood trauma was associated with higher levels of somatization and insecure attachment. Insecure attachment style was also associated with higher levels of somatization. Controlling for age, income, and recent intimate partner violence, analyses showed that fearful attachment fully mediated the link between childhood trauma and somatization for women. For men, there was no such mediation, but both childhood trauma and insecure attachment styles made independent contributions to predicting levels of somatization.

CONCLUSIONS

Findings are consistent with the hypothesis that, for women, childhood trauma influences adult levels of somatization by fostering insecure adult attachment. For men, findings suggest that trauma and attachment are both important independent predictors of adult somatization. Study results support the idea that childhood trauma shapes patients' styles of relating to others in times of need, and these styles, in turn, influence the somatization process and how patients respond to providers. Screening for attachment style may provide information that could allow health care providers to tailor treatment more effectively.

Reported sexual abuse predicts impaired functioning but a good response to psychological treatments in patients with severe irritable bowel syndrome

OBJECTIVE

We assessed the effect of reported sexual abuse on symptom severity and health-related quality of life in patients with severe irritable bowel syndrome (IBS) undergoing psychological treatments.

METHODS

IBS patients entering a treatment trial who reported prior sexual abuse were compared with the remainder in terms of symptom severity and health-related quality of life (SF-36) at trial entry and 15 months later. Analyses used ANCOVA with age, sex, marital status, and treatment group as covariates. We assessed possible mediators using multiple regression analysis.

RESULTS

Of 257 patients with severe IBS, 31 (12.1%) reported a history of rape and 28 (10.9%) reported forced, unwanted touching. People who reported abuse were more impaired than the remainder on the SF-36 scales for pain (adjusted p = .023) and physical function (p = .029); these relationships followed a "dose-response" relationship and were mediated by SCL-90 somatization score. At 15 months follow-up, the associations between reported abuse and SF-36 scores were lost because people with reported abuse, especially rape, improved more than the remainder when treated with psychotherapy or paroxetine (selective serotonin reuptake inhibitor antidepressant); this improvement was mediated by change in SCL-90 somatization score.

CONCLUSIONS

In severe IBS, the association between self-reported sexual abuse and impaired functioning is mediated by a general tendency to report numerous bodily symptoms. A reported history of abuse is associated with a marked improvement following psychological treatment.

Illness-related parenting in mothers with functional gastrointestinal symptoms

OBJECTIVE

Social learning has been identified as a factor that increases vulnerability to the development of irritable bowel syndrome (IBS). This study aimed to distinguish between child-mediated and parent-mediated modes of transmission of illness behavior. The reporting of infants' symptoms and treatment seeking for these symptoms, by mothers, was examined over the period during which infants were aged 0 to 18 months. Thus childrens' imitation of excessive maternal illness behavior could be ruled out as a possible cause of differences in treatment seeking.

METHODS

Questionnaire data from the Avon Longitudinal Study of Parents and Children (ALSPAC) were analyzed, comparing illness-related parenting in 73 mothers who reported taking medication for functional bowel symptoms (mostly IBS) with parenting in 154 mothers who reported past or current stomach ulcers (SU).

RESULTS

There were no significant differences between the groups in the reported incidence of infants' symptoms. However, mothers with bowel symptoms had taken their infants to the doctor for a greater number of conditions than mothers reporting SU. This difference was not due to increased treatment seeking for gastrointestinal symptoms.

CONCLUSIONS

Mothers with functional bowel symptoms are more likely to seek treatment when their infants experience symptoms, providing evidence of early social reinforcement of illness behavior. Such reinforcement may increase the child's vulnerability to a range of functional disorders, including IBS.

Do childhood adversity and recent social stress predict health care use in patients presenting with upper abdominal or chest pain?

OBJECTIVE

A comprehensive model of health care use by patients with functional gastrointestinal disorders has not been fully tested. This study aimed to establish whether reported childhood and/or recent adversity are independent predictors of health care use when all other relevant factors are also included in the model.

MATERIALS AND METHODS

Consecutive new patients with upper abdominal or chest pain presenting to a secondary/tertiary clinic were assessed using the Childhood Experience of Care and Abuse and Life Events and Difficulties Schedules. They completed the Hospital Anxiety and Depression and Health Anxiety Questionnaires. Outcome was total number of health care visits recorded in hospital and general practice (GP) records over 18 months.

RESULTS

One hundred fifty-one patients were included (65% response rate). Health care visits were most frequent in unmarried (p < 0.0005), females (p < 0.0005), and those lacking social support (p = 0.012). In multiple regression analysis to predict number of health care visits, reported sexual abuse (p = 0.042) and death of a sibling during childhood (p = 0.026) were also independent predictors, together with SF36 subscale scores for physical function, health perception, and mental health (35% of variance explained). Childhood adversity predicted health care use in patients with functional gastrointestinal disorders and recent social stress did so in patients with demonstrated pathological findings.

CONCLUSION

After adjustment for demographic, physical, and psychological factors, childhood adversity, especially in severe form, is an independent predictor of health care use in patients with upper functional gastrointestinal disorders. The same was not true for patients consulting for demonstrable pathological abnormalities, for whom ongoing social stress was an independent predictor.

Abuse, dissociation, and somatization in irritable bowel syndrome: towards an explanatory model

This study tested a preliminary model of the role of dissociation and somatization in linking abuse to irritable bowel syndrome (IBS). Outpatients with IBS (N = 64) or bowel symptoms explained by physical disease (N = 61) completed questionnaires to assess recollections of abuse as children or adults and current dissociation, somatization, and emotional distress. By comparison with physically diseased patients, patients with IBS recalled more sexual abuse as children and adults, more physical abuse as children, and more psychological abuse as adults. They were more anxious and depressed, and somatized and dissociated more. Analyses indicated a causal chain linking, in turn, abuse, dissociation, somatization, and IBS. The results are consistent with a model in which childhood abuse is linked to IBS because it causes a tendency to dissociate, and because dissociation causes a general increase in physical symptoms. Future research should identify factors that explain why a generally increased level of physical symptoms should, in some patients, lead specifically to IBS.

Psychiatry, psychotherapy and gastroenterology -- bringing it all together

In this review, some aspects of functional gastrointestinal disorders are described, with particular reference to psychiatric and psychological features. Seven syndromes or conditions, which may present not uncommonly in a gastroenterology clinic, are identified and clarified. Thereafter, the roles of a psychiatrist and other mental health professionals (psychotherapists, psychologists) within gastroenterology are described, with particular reference to what an integrated service may offer.

Perceived vulnerability to illness in individuals with irritable bowel syndrome

OBJECTIVE

To determine whether individuals with irritable bowel syndrome (IBS) differ from other individuals in their perceived lifetime risk of an unrelated medical condition.

METHOD

A questionnaire was used to assess worry about deep vein thrombosis (DVT) and perceived future risk of developing the condition in individuals with IBS and controls following a media scare concerning DVT.

RESULTS

Individuals with IBS reported higher perceived lifetime risk of DVT than did healthy controls or individuals with asthma. Current physical symptoms, exposure to information about DVT and the illness attitudes measured could not entirely account for the higher perceived health risk among individuals with IBS.

CONCLUSIONS

A perception of enhanced personal vulnerability to illness appears to be present in individuals with IBS, although it is possible that this perception is related to higher levels of negative affect amongst this group. Whilst a perception of enhanced vulnerability to illness is likely to contribute to IBS-related illness behaviour, it does not appear to be specific to reasoning about IBS and is also apparent when individuals consider an unrelated health issue.

Health status and clinical diagnoses of 3000 UK Gulf War veterans

Up to June 2001, 3000 British veterans of the Gulf War had sought advice from a special medical assessment programme established because of an alleged Gulf War syndrome. After assessment those attending were classified as completely well, well with symptoms, well with incidental diagnoses treated or controlled, or unwell (physically or mentally). Mental illness was confirmed by a psychiatrist. The first 2000 attenders have been reported previously. The present paper summarizes findings in all 3000. 2252 (75%) of those attending were judged "well", of whom 303 were symptom-free. Medical diagnoses were those to be expected in such an age-group (mean age 34 years, range 21-63). No novel or unusual condition was found. In 604 of the 748 unwell veterans, a substantial element of the illness was psychiatric, the most common condition being post-traumatic stress disorder. The healthcare requirements of the Gulf veterans seen in this programme can therefore be met by standard National Health Service provision.

Sexual abuse, physical abuse, chronic fatigue, and chronic fatigue syndrome: a community-based study

Using a randomly selected community-based sample, this investigation examined whether histories of childhood sexual, physical, and death threat abuse predicted adulthood outcomes of specific medical and psychiatric conditions involving chronic fatigue. This study also tested prior suggestions that most individuals with chronic fatigue syndrome report a past history of interpersonal abuse. Multinomial logistic regression was used to examine the relationship between abuse history and chronic fatigue group outcomes while controlling for the effects of sociodemographics. Compared with healthy controls, childhood sexual abuse was significantly more likely to be associated with outcomes of idiopathic chronic fatigue, chronic fatigue explained by a psychiatric condition, and chronic fatigue explained by a medical condition. None of the abuse history types were significant predictors of chronic fatigue syndrome. A closer examination of individuals in the chronic fatigue syndrome group revealed that significantly fewer individuals with CFS reported abuse as compared with those who did not. The implications of these findings are discussed.

Screening for high utilizing somatizing patients using a prediction rule derived from the management information system of an HMO: a preliminary study

BACKGROUND

Somatization is a common, costly problem with great morbidity, but there has been no effective screening method to identify these patients and target them for treatment.

OBJECTIVES

We tested a hypothesis that we could identify high utilizing somatizing patients from a management information system (MIS) by total number of visits and what we termed "somatization potential," the percentage of visits for which ICD-9 primary diagnosis codes represented disorders in the musculoskeletal, nervous, or gastrointestinal systems or ill-defined complaints.

METHODS

We identified 883 high users from the MIS of a large staff model HMO as those having six or more visits during the year studied (65th percentile). A physician rater, without knowledge of hypotheses and predictors, then reviewed the medical records of these patients and identified somatizing patients (n = 122) and nonsomatizing patients (n = 761). In two-thirds of the population (the derivation set), we used logistic regression to refine our hypothesis and identify predictors of somatization available from the MIS: demographic data, all medical encounters, and primary diagnoses made by usual care physicians (ICD-9 codes). We then tested our prediction model in the remaining one-third of the population (the validation set) to validate its usefulness.

RESULTS

The derivation set contained the following significant correlates of somatization: gender, total number of visits, and percent of visits with somatization potential. The c-statistic, equivalent to the area under the ROC curve, was 0.90. In the validation set, the explanatory power was less with a still impressive c-statistic of 0.78. A predicted probability of 0.04 identified almost all somatizers, whereas a predicted probability of 0.40 identified about half of all somatizers but produced few false positives.

CONCLUSIONS

We have developed and validated a prediction model from the MIS that helps to distinguish chronic somatizing patients from other high utilizing patients. Our method requires corroboration but carries the promise of providing clinicians and health plan directors with an inexpensive, simple approach for identifying the common somatizing patient and, in turn, targeting them for treatment. The screener does not require clinicians' time.

Medically unexplained symptoms in frequent attenders of secondary health care: retrospective cohort study

OBJECTIVE

To estimate the prevalence of medically unexplained symptoms in patients who most frequently attend outpatient services.

DESIGN

Retrospective cohort study over three years with review of case notes.

SETTING

Secondary care services in the South Thames (West) NHS region.

PARTICIPANTS

Outpatient attenders with new appointments in 1993.

MAIN OUTCOME MEASURES

Number of outpatient appointments, and number of consultation episodes for medically unexplained conditions.

RESULTS

Medical records of 361 of 400 sampled frequent attenders were examined, and 971 consultation episodes were recorded. Ninety seven (27%) had one or more consultation episodes in which the condition was medically unexplained; 208 (21%) of the 971 consultation episodes were medically unexplained. Abdominal pain, chest pain, headache, and back pain were commonly found to be medically unexplained.

CONCLUSIONS

Medically unexplained symptoms present in most hospital specialties and account for a considerable proportion of consultations by frequent attenders in secondary care.

Psychiatric status, somatisation, and health care utilization of frequent attenders at the emergency department: a comparison with routine attenders

Seventy-seven frequent attenders at an emergency department (ED) in an inner-city hospital in the UK (defined as seven or more visits in the previous 12 months) were compared with 182 patients who were attending the same department on a routine basis. Patients completed the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) and the Short Form (SF)-36. Information was obtained on 64% of the frequent attenders and 45% underwent a detailed psychiatric assessment. Of the frequent attenders, 45% had psychiatric disorder and 49% had some form of an alcohol-related disorder. Compared with routine attenders, frequent attenders reported lower health status, had more psychiatric disorder (odds ratio: OR=8.2, 95% confidence interval: CI=3.8--18.1), had more general hospital admissions (OR=19.9, 95% CI=8.3--47.8), more psychiatric admissions (OR=167.5, 95% CI=9.5--2959.0), and more GP visits (95% CI for difference=-10.2 to -5.7). There was no evidence that frequent attenders had more somatisation than routine attenders. Specific treatment and management strategies need to be developed for this group of patients, although a substantial proportion may be difficult to engage in the treatment process.

A survey of frequent attenders at a gastroenterology clinic

OBJECTIVE

To examine a group of patients satisfying criteria for "frequent attending" as part of an audit of an outpatient gastroenterology service, and to note the prevalence of those with no conspicuous organic disease to account for their symptomatology.

METHODS

We used the hospital computer (Oxford Patient Administration System, OXPAS) to identify 2530 consecutive patients who were given an appointment to attend the gastroenterology clinic during an 11-month period. Patients designated "frequent attenders" had their notes flagged before the clinic attendance and were examined in more detail. A frequent attender was defined as a patient who had attended any hospital outpatient clinic in the three Oxford general hospitals on four or more occasions in the previous 12 months. The gastroenterologist then interviewed the patients satisfying these criteria and indicated whether he/she was satisfied that there was no relevant organic disease to account for the symptoms.

RESULTS

Of the total 2530 patients, 762 (30%) satisfied our criteria for frequent attendance (FA). Of these, 452 (59%) had organic disease, 128 (17%) either did not attend or cancelled and 159 (21%) had no relevant organic disease. The diagnosis was uncertain in 23 patients (3%). Of patients satisfying our criteria for frequent attending, approximately 20-25% had no established gastroenterological disease.

CONCLUSIONS

Frequent attenders present formidable management problems for the gastroenterologist. If they can be identified by computer before the outpatient visit then assessment and management might be more appropriately supervised in designated clinics by more experienced gastroenterology staff.

"Wheelchair" patients with nonorganic disease: a psychological inquiry

We studied ten patients referred from the neurology service with severe disability associated with the use of a wheelchair, but with no organic disorder to account for their disabilities. All patients were assessed using rating scales as well as a standardized psychiatric interview (SCID), and all medical and psychiatric case notes were examined. We also interviewed key carers for their views on the information and assistance the patients had received. All but two of the ten patients were women, and the mean age was 45.4 years (SD=5.4). All had current diagnoses of conversion or somatoform disorders and six had previous episodes of major depression. Most patients expressed beliefs about their illness that were not consistent with the medical facts, and only two of the carers were satisfied with explanations they had been given by doctors. The results suggest that requests for psychiatric help once patients have become grossly disabled are unlikely to lead to recovery. The psychiatrist, however, can help the primary care doctor to formulate a plan of management aimed at preventing further deterioration.