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

The Importance of Early Diagnosis of Somatic Symptom Disorder: A Case Report

A somatic symptom disorder (SSD) diagnosis is made when a person places emphasis on physical symptoms such as pain, exhaustion, or shortness of breath so much that it causes significant suffering and/or functional issues. The individual's thoughts, sentiments, and activities are an overstated reaction to such symptoms. Regardless of whether the physical symptoms are connected to a diagnosable medical condition, the person experiences symptoms and believes they are ill. When a person exhibits symptoms that satisfy the diagnostic standards of an SSD, the disease should be identified. However, due to the disorder's frequent co-occurrence, particularly with anxiety and depressive disorders, support for these concurrent diagnoses should be sought. Cognitive-behavioral therapy, mindfulness-based therapy, and medication are all examples of effective treatments for SSD. It has been demonstrated that tricyclic antidepressants or selective serotonin reuptake inhibitors (SSRIs) aid in treating symptoms. The authors describe the case of an eight-year-old boy with complaints of abdominal pain that were unexplained by various tests. The pain lasted 10 years and was episodic (each episode lasted around 10 days; one particular episode lasted approximately six months). Multiple investigations were conducted, but no physiological reason for his symptoms was discovered. His evaluation was conducted by an interdisciplinary team that included neurologists, psychiatrists, surgeons, and doctors. The underlying cause was subsequently determined to be SSD. As people with SSD present to general practitioners and the emergency room rather than psychiatric facilities, this incident serves as a sobering reminder of the need to advocate for an accurate diagnosis of this condition.

Does workplace telepressure get under the skin? Protocol for an ambulatory assessment study on wellbeing and health-related physiological, experiential, and behavioral concomitants of workplace telepressure

BACKGROUND

The daily working life of many employees requires the use of modern information and communication technology (ICT) devices such as computers, tablets, and smartphones. The double-edged nature of digital work environments has been increasingly highlighted. Benefits such as increased flexibility come at a personal cost. One of the potential downsides is workplace telepressure, i.e., the experience of urge and preoccupation to quickly reply to work-related messages and demands using ICT. There is initial - mainly survey-based-evidence that workplace telepressure may have negative effects on a variety of wellbeing and health outcomes.

AIMS AND HYPOTHESES

Adopting the Effort-Recovery Model and the concept of allostatic load as theoretical frameworks, the present study aims to investigate the hypothesis that workplace telepressure is significantly associated with increased "wear and tear", in the form of more psychosomatic complaints, worse sleep quality (self-reported and actigraphy-based), worse mood, and biological alterations (lower cardiac vagal tone, lower anabolic balance defined as the ratio of salivary dehydroepiandrosterone to salivary cortisol, and higher salivary alpha-amylase). Additionally, the study aims to investigate the hypothesis that connection to work defined as work-related workload and work-related perseverative cognition plays a significant role in the mediation of these relationships.

METHODS

To test our hypotheses, we will conduct an ambulatory assessment study with a convenience sample of 120 healthy workers regularly using ICTs for job communication. For one week, participants will be asked to complete electronic diaries assessing their level of workplace telepressure, psychosomatic complaints, sleep quality, mood, work-related workload, and work-related perseverative cognition. They will also continuously wear the Bittium Faros 180L ECG monitor, the wrist-worn actigraph MotionWatch 8, and perform saliva sampling five times per day.

DISCUSSION

This study will be the most comprehensive ambulatory investigation of workplace telepressure and its psychophysiological concomitants to date and constitutes an important step towards understanding how high levels of workplace telepressure may lead in the long term to secondary alterations (e.g., hypertension, chronic inflammation) and disease (e.g., heart disease). The findings of this study are also anticipated to contribute to guiding the development and implementation of interventions, programs, and policies relevant to employees' digital wellbeing.

Functional neurological disorder: Clinical manifestations and comorbidities; an online survey

Functional Neurological Disorder (FND) is common and is often accompanied by multiple comorbid symptoms and conditions. There have been no large-scale studies exploring the change of its clinical manifestations and comorbidities. We used an online survey to assess FND patient characteristics, changes to fatigue, sleep and pain and comorbid symptoms and diagnoses, as well as treatment strategies. The survey was shared via the charities FND Action and FND Hope. 527 participants were included in the analysis. Most (97.3%) reported experiencing more than one core FND symptom. Many respondents reported associated pain (78.1%), fatigue (78.0%) and sleep disturbances (46.7%) before FND diagnosis which often increased thereafter. Rates of obesity were higher (36.9%) than in the general population. Obesity was associated with increased pain, fatigue and sleep difficulties. There was frequent weight gain after diagnosis. 50.0% of participants reported having other diagnoses prior to FND, while in 43.3% new comorbidities arise after FND diagnosis. Many respondents reported being dissatisfied with their care, expressing a wish for further follow-up from mental health (32.7%) and/or neurological services (44.3%). This large online survey further supports the phenotypic complexity of FND. High rates of pain, fatigue and sleep disturbance exist before diagnosis but monitoring for change is worthwhile. Our study identified major gaps in service provision; we highlight the importance of an open mind regarding change in symptoms; this could aid the early identification and management of co-morbidities, including obesity and migraine, which possibly have a negative impact on FND.

Characteristics of 110 Patients With Functional Visual Loss

PURPOSE

Functional visual loss (FVL) is characterized by complaints of visual impairment without evidence of an organic cause. Physicians are often reluctant to diagnose FVL; thus, little is known about health care utilization in patients with FVL.

DESIGN

Retrospective case series.

METHODS

A total of 110 patients seen at 2 university-affiliated neuro-ophthalmology practices who were diagnosed with FVL were included. Medical records were evaluated, and data were collected on demographics, clinical presentation, ophthalmologic examination, neuroimaging, ancillary tests, and other health care provider visits and treatments.

RESULTS

More than 70% of patients with FVL were women with a mean age of 37 ± 15 years. The presenting complaint in 71.8% (79/110) of participants was decreased vision, which was bilateral in >50% of cases. Close to half (53/110) endorsed at least 1 coexisting psychiatric or neurologic diagnosis. The mean number of different medical specialists seen before neuro-ophthalmic consultation was 3.7 ± 2.6, and the average number of health care visits was 4.6 ± 4.4. Each patient had 2.2 ± 1.8 neuroimaging studies performed. Fifteen percent of patients underwent unnecessary treatments, including receiving steroids, visual therapy, and prisms.

CONCLUSIONS

Patients with FVL typically see at least 3 different health care providers across 4 different visits and undergo at least 2 neuroimaging studies before having neuro-ophthalmic consultation. To avoid this undue burden on patients and the health care system, clinicians should refer patients with suspected FVL to a neuro-ophthalmologist to confirm the diagnosis of FVL and appropriately counsel the patient.

Non-Cardiac Chest Pain as a Persistent Physical Symptom: Psychological Distress and Workability

Non-Cardiac Chest Pain (NCCP) is persistent chest pain in the absence of identifiable cardiac pathology. Some NCCP cases meet criteria for Persistent Physical Symptoms (PPS), where the symptoms are both persistent and distressing/disabling. This study aimed to identify patients that might need specialist treatment for PPS by examining cases of NCCP that meet PPS criteria. We analysed data from 285 chest pain patients that had received an NCCP diagnosis after attending an emergency cardiac department. We compared NCCP patients who did and did not meet the additional criteria for heart-related PPS and hypothesised that the groups would differ in terms of psychological variables and workability. We determined that NCCP patients who meet PPS criteria were more likely than other NCCP patients to be inactive or unable to work, reported more general anxiety and anxiety about their health, were more depressed, ruminated more, and, importantly, had a higher number of other PPS. A high proportion of NCCP patients meet PPS criteria, and they are similar to other PPS patients in terms of comorbidity and disability. This highlights the importance of focusing psychological interventions for this subgroup on the interplay between the range of physical and psychological symptoms present.

Categorical interoception: the role of disease context and individual differences in habitual symptom reporting

OBJECTIVE

Symptom reports correspond less to physiological dysfunction in persons with high levels of symptoms in daily life and in patients with functional somatic symptoms, suggesting poor symptom perception. In this study, we investigated whether interoception was impacted by the meaning of the context and by habitual symptom reporting.

METHODS

Eight inspiratory resistances that were equidistant in intensity were administered to healthy women (N = 124) varying in habitual symptom reporting. One group was asked to categorise them as benign sensations vs. as bodily symptoms that could suggest a disease (disease context group). Another group was asked to categorise them as low- vs. high-intensity sensations (neutral context group).

MAIN OUTCOME

Perceived differences in intensity within- vs. between-category and unpleasantness, categorisation threshold, and the reliability of categorising each stimulus were examined in relation to context (disease, neutral) and symptom reporting levels in daily life.

RESULTS

Context (neutral vs. disease) impacted intensity and unpleasantness perception. Processing of respiratory interoceptive stimulation was more detailed, elaborate, and cautious when categorising stimuli as signalling health or disease vs. as low- or high-intensity. Individual differences in habitual symptoms had no effect.

CONCLUSION

The pattern of results suggests that these categorisation effects indicate flexible, context-sensitive interoceptive processing, which may characterise healthy individuals.

Prevalence of medically unexplained symptoms in adults who are high users of healthcare services and magnitude of associated costs: a systematic review

INTRODUCTION

Medically unexplained symptoms (MUS) is a common clinical syndrome in primary and secondary healthcare service. Outcomes for patients with persistent MUS include increased disability, poorer quality of life and higher healthcare costs. The aim of this systematic review was to determine the prevalence of MUS in patients who are high users of healthcare or high-cost patients in comparison with routine users and the magnitude of associated costs.

DESIGN

A systematic review of the available literature.

DATA SOURCES AND ELIGIBILITY CRITERIA

The following electronic databases were systematically searched without language restriction from inception to June 2018 and updated on 22 October 2021: MEDLINE, PsycINFO, EMBASE, CINAHL and PROSPERO. Inclusion criteria included studies investigating adults aged ≥18 years, who were high healthcare users or accrued high healthcare costs, in which the prevalence and/or associated costs of MUS was quantified. Two reviewers independently extracted information on study characteristics, exposure and outcomes.

RESULTS

From 5622 identified publications, 25 studies from 9 countries involving 31 650 patients were selected for inclusion. Due to high risk of bias in many studies and heterogeneity between studies, results are described narratively. There were wide variations in prevalence estimates for MUS in high users of healthcare (2.9%-76%), but MUS was more prevalent in high use groups compared with low use groups in all but one of the 12 studies that included a comparator group. Only three studies investigated healthcare costs associated with MUS, and all three reported greater healthcare costs associated with MUS.

CONCLUSION

MUS has been found to be more prevalent in high use healthcare populations than comparator groups, but the magnitude of difference is difficult to estimate due to considerable heterogeneity between studies and potential for bias. Future studies should prioritise a standardised approach to this research area, with agreed definitions of MUS and high healthcare use.

PROSPERO REGISTRATION NUMBER

CRD42018100388.

Parallel use of primary and secondary healthcare by frequent attenders in occupational health and their work disability: a longitudinal study in Finland

OBJECTIVES

To investigate occupational health frequent attenders' (FAs) use of other healthcare sector services and whether parallel use affects their likelihood to receive a disability pension.

DESIGN

Longitudinal study combining routine medical record data with register data.

SETTING

Primary care in Finland is provided through three parallel healthcare sectors, all available to the working population. Additionally, patients can be referred to secondary care. This study combines medical record data from a nationwide occupational healthcare provider, with healthcare attendance data from private care and from public primary and secondary care attendance, sociodemographic data and disability pension decisions.

PARTICIPANTS

Patients between 18 and 68 years of age who used occupational health primary care at least once during the study years 2014-2016 were included. The total study population was 59 650 patients. They were divided into three groups (occasional and persistent FAs and non-FAs) for analysis.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was FAs parallel use of private care and public primary and secondary care. The secondary outcome was work disability pension granted to FAs who used several healthcare sectors.

RESULTS

Both FA groups were more likely to use other healthcare service sectors more than non-FAs did. Persistent FAs were likely to use public secondary care services in particular (OR 4.31 95% CI 3.46 to 5.36). FAs using all healthcare sectors were also more likely to receive a disability pension than those FAs using only occupational health services (OR 4.53 (95% CI 1.54 to 13.34). This association was strengthened by attendance in public secondary care.

CONCLUSIONS

FAs using several healthcare sectors in parallel have an increased likelihood to receive a disability pension. There is need for care coordination to ensure adequate measures for work ability support.

The Effect of Internet-Delivered Cognitive Behavioral Therapy Versus Psychoeducation Only on Psychological Distress in Patients With Noncardiac Chest Pain: Randomized Controlled Trial

Background

Patients with recurrent episodes of noncardiac chest pain (NCCP) experience cardiac anxiety as they misinterpret the pain to be cardiac related and avoid physical activity that they think could threaten their lives. Psychological interventions, such as internet-delivered cognitive behavioral therapy (iCBT), targeting anxiety can be a feasible solution by supporting patients to learn how to perceive and handle their chest pain.

Objective

This study aims to evaluate the effects of a nurse-led iCBT program on cardiac anxiety and other patient-reported outcomes in patients with NCCP.

Methods

Patients with at least two health care consultations because of NCCP during the past 6 months, and who were experiencing cardiac anxiety (Cardiac Anxiety Questionnaire score ≥24), were randomized into 5 weeks of iCBT (n=54) or psychoeducation (n=55). Patients were aged 54 (SD 17) years versus 57 (SD 16) years and were mainly women (32/54, 59% vs 35/55, 64%). The iCBT program comprised psychoeducation, mindfulness, and exposure to physical activity, with weekly homework assignments. The primary outcome was cardiac anxiety. The secondary outcomes were fear of bodily sensations, depressive symptoms, health-related quality of life, and chest pain frequency. Intention-to-treat analysis was applied, and the patients were followed up for 3 months. Mixed model analysis was used to determine between-group differences in primary and secondary outcomes.

Results

No significant differences were found between the iCBT and psychoeducation groups regarding cardiac anxiety or any of the secondary outcomes in terms of the interaction effect of time and group over the 3-month follow-up. iCBT demonstrated a small effect size on cardiac anxiety (Cohen d=0.31). In the iCBT group, 36% (16/44) of patients reported a positive reliable change score (≥11 points on the Cardiac Anxiety Questionnaire), and thus an improvement in cardiac anxiety, compared with 27% of (13/48) patients in the psychoeducation group. Within-group analysis showed further significant improvement in cardiac anxiety (P=.04) at the 3-month follow-up compared with the 5-week follow-up in the iCBT group but not in the psychoeducation group.

Conclusions

iCBT was not superior to psychoeducation in decreasing cardiac anxiety in patients with NCCP. However, iCBT tends to have better long-term effects on psychological distress, including cardiac anxiety, health-related quality of life, and NCCP frequency than psychoeducation. The effects need to be followed up to draw more reliable conclusions.

Trial Registration

ClinicalTrials.gov NCT03336112; https://www.clinicaltrials.gov/ct2/show/NCT03336112

Epidemiology and organisation of care in medically unexplained symptoms: A systematic review with a focus on cultural diversity and migrants

BACKGROUND

Since the pathophysiology of medically unexplained symptoms (MUS) remains unclear, healthcare providers often struggle with these patients, especially with a different ethnic and/or cultural background. These challenges are insufficiently addressed in their training and in the organisation of care.

AIM

To improve healthcare provider-patient interaction focused on MUS patients in general and in ethnic minorities and refugees in particular through a systematic review of syndromal definitions and epidemiology and organisation of care of MUS patients.

METHODS

Screening of PubMed, Web of Science, Cinahl and Cochrane Library on the keywords 'Medical unexplained (physical) symptoms (MUPS)', 'Somatoform disorder', 'Functional syndrome', 'Diversity', 'Migrants', 'Ethnicity', 'Care models', 'Medical education', 'Communication skills', 'Health literacy'.

RESULTS

Different case definitions result in markedly different epidemiological estimates for MUS patients. Nevertheless, they are prevalent in a wide range of healthcare settings. Literature offers evidence of the effectiveness of structural frameworks in approaching MUS patients. Organisation of MUS care needs to transcend different levels of care: specialist tertiary and secondary care and primary care involving different qualifications of caregivers need to be aligned.

CONCLUSION

The systematic review identified significant gaps and shortcomings in organisation of care. These need to be addressed in order to improve outcomes.

Characteristics and economic burden of frequent attenders with medically unexplained symptoms in primary care in Israel

Background

Frequent Attenders with Medically Unexplained Symptoms (FA/MUS) are common in primary care, though challenging to identify and treat.

Objectives

This study sought to compare FA/MUS to FA with organic illnesses (FA/OI) and the general clinic population (Non-FA) to understand their demographic characteristics and healthcare utilisation patterns.

Methods

For this retrospective, observational study, Electronic Medical Records (EMR) were obtained from Clalit Health Services, regarding the population of a sizeable primary care clinic in Be’er-Sheva, Israel. Electronic medical records were screened to identify the top 5% of FA. FA were stratified based on whether they had OI. FA without OI were then corroborated as having MUS by their physicians. Demographics, healthcare utilisation and costs were analysed for FA/OI, FA/MUS and Non-FA.

Results

Out of 594 FA, 305 (53.6%) were FA/OI and 264 (46.4%) were FA/MUS. FA/OI were older (69.1 vs. 56.4 years, p<.001) and costlier (ILS27693 vs. ILS9075, p<.001) than FA/MUS. Average costs for FA/MUS were over four times higher than Non-FA (ILS9075 vs. ILS2035, p<.001). The largest disparities between FA/OI and FA/MUS were in hospitalisations (ILS6998 vs. ILS2033) and surgical procedures (ILS8143 vs. ILS3175). Regarding laboratory tests, differences were smaller between groups of FA but significantly different between FA and Non-FA.

Conclusion

FA/MUS are more costly than Non-FA and exhibit unique healthcare utilisation and costs patterns. FA/OI had more severe illnesses necessitating hospitalisations and surgical interventions, while FA/MUS had more investigations and tests, attempting to find an explanation for their symptoms.

"I'm So Tired": Fatigue as a Persistent Physical Symptom among Working People Experiencing Exhaustion Disorder

Fatigue is widespread in the population, particularly among working people. Exhaustion disorder (ED), a clinical manifestation of burnout, is common, but, after treatment, about one-third still experience fatigue and other physical symptoms. We propose that in some instances, fatigue as a persistent physical symptom (PPS) might be a more appropriate formulation of ED patients' fatigue problems, and we suggest that ED patients who meet fatigue PPS criteria will differ from other ED patients in terms of psychological distress, non-fatigue PPSs and functional impairment. Questionnaires were sent to 10,956 members of a trade union of which 2479 (22.6%) responded. Of 1090 participants who met criteria for ED, 106 (9.7%) met criteria for fatigue as a PPS. Participants who met fatigue PPS criteria scored on average higher on measures of depression, anxiety and functional impairment and were more likely to have clinically significant scores. Moreover, they had 27 times higher odds of meeting other PPS subtypes and reported more non-fatigue PPS subtypes, suggesting a more complex health problem. Specific evidence-based interventions are available for both ED and PPSs, and therefore, it is crucial to accurately formulate the fatigue problem reported by patients to provide appropriate treatment.

A typology of clinical conditions

In the philosophy of medicine, great attention has been paid to defining disease, yet less attention has been paid to the classification of clinical conditions. These include conditions that look like diseases but are not; conditions that are diseases but that (currently) have no diagnostic criteria; and other types, including those relating to risk for disease. I present a typology of clinical conditions by examining factors important for characterizing clinical conditions. By attending to the types of clinical conditions possible on the basis of these key factors (symptomaticity, dysfunction, and the meeting of diagnostic criteria), I draw attention to how diseases and other clinical conditions as currently classified can be better categorized, highlighting the issues pertaining to certain typology categories. Through detailed analysis of a wide variety of clinical examples, including Alzheimer disease as a test case, I show how nosology, research, and decisions about diagnostic criteria should include normative as well as naturalistically describable factors.

An introduction to the assessment and management of psychodermatological disorders

Psychodermatology is an emerging field at the interface between psychiatry, psychology and dermatology. There is a strong bidirectional relationship between a number of dermatological disorders and psychiatric disorders. This article provides an overview of psychiatric disorders with dermatological symptoms, and dermatological disorders with secondary psychophysiological consequences. The principles of management and our insights into establishing a psychodermatology service in the UK are discussed.

Theoretical and clinical disease and the biostatistical theory

Although concepts of disease have received much scrutiny, the benefits of distinguishing between theoretical and clinical disease-and what is meant by those terms-may not be as readily apparent. One way of characterizing the distinction between theoretical and clinical conceptions of disease is by relying on Boorse's biostatistical theory (BST) for a conception of theoretical disease. Clinical disease could then be defined as theoretical disease that is diagnosed. Explicating this distinction provides a useful extension of the BST. The benefits of this approach are clearly and non-normatively demarcating disease from non-disease, while allowing for values and purpose to determine what criteria are used in clinical practice to represent a disease's underlying dysfunction. Through discussion of a variety of medical conditions, including polycystic ovary syndrome and type 2 diabetes mellitus, I explore how the relationship between BST-based theoretical and clinical disease could make sense of various features of clinical practice and medical theory. It could do this by lending focus to a nuanced understanding of the pathophysiological defects present in disease and the means by which they are assessed. This could contribute to making sense of revised nosologies and diagnostic criteria.

Effects of a work stress intervention on healthcare use and treatment compared to treatment as usual: a randomised controlled trial in Swedish primary healthcare

BACKGROUND

Work stress is an increasing burden in society. Identifying early symptoms of work stress in primary healthcare (PHC) could result in earlier and better-targeted care. The Work Stress Questionnaire (WSQ) was developed in PHC for this task. We aimed to evaluate whether the use of the WSQ, in combination with physicians' feedback, resulted in differences in healthcare visits and treatment compared to treatment as usual (TAU) in patients reporting high stress. Our hypothesis was that patients receiving the intervention would generate more visits to rehabilitation providers during follow-up compared to TAU.

METHODS

A two-armed randomised controlled trial was conducted at seven primary healthcare centres (PHCCs) in Region Västra Götaland, Sweden. One group received the WSQ intervention, and the controls received TAU. Employed, not sick-listed persons aged 18-64 years who sought care for mental or physical health complaints at the PHCCs participated. Register data on healthcare visits and treatments 12 months prior to inclusion and 12 months after were obtained and analysed with Fisher's exact test together with questionnaire data (WSQ and background features).

RESULTS

A total of 271 participants were included in the study, 132 intervention and 139 controls. Visits to psychologists/psychotherapists were higher among intervention participants with high stress (20%, n = 87) during follow-up compared to corresponding controls (7%, n = 97) (p < 0.05). Collaborative care measures were more common among the stressed intervention participants (23%) post-inclusion compared to the stressed controls (11%) (p < 0.05). The amount of received cognitive behavioural therapy (CBT) was higher among the stressed intervention group (16%) than among controls (10%) during follow-up.

CONCLUSIONS

The intervention group that used the WSQ with physicians' feedback had an increased number of rehabilitative measures and treatment more in line with established guidelines compared to treatment as usual. Findings of the study indicate that the WSQ can assist in identifying work stress in primary healthcare and contribute to physicians' recommendations of suitable rehabilitative measures at an earlier stage compared to treatment as usual.

TRIAL REGISTRATION

ClinicalTrials.gov. Identifier: NCT02480855 . Registered 20 May 2015.

Interrelationships between symptom burden and health functioning and health care utilization among veterans with persistent physical symptoms

Background

Between 10 and 50% of primary care patients present with persistent physical symptoms (PPS). Patients with PPS tend to utilize excessive or inappropriate health care services, while being stuck in a deleterious cycle of inactivity, deconditioning, and further worsening of symptoms and disability. Since military deployment (relative to non-deployment) is associated with greater likelihood of PPS, we examined the interrelationships of health care utilization, symptom burden and functioning among a sample of recently deployed Veterans with new onset persistent physical symptoms.

Methods

This study analyzed a cohort of 790 U.S. soldiers who recently returned from deployment to Iraq or Afghanistan. Data for this analysis were obtained at pre- and post-deployment. We used moderation analyses to evaluate interactions between physical symptom burden and physical and mental health functioning and four types of health care utilization one-year after deployment, after adjusting for key baseline measures.

Results

Moderation analyses revealed significant triple interactions between physical symptom burden and health functioning and: primary care (F = 3.63 [2, 303], R²Δ = .02, p = 0.03), specialty care (F = 6.81 [2, 303] R²Δ =0.03, p < .001), allied therapy care (F = 3.76 [2, 302], R²Δ = .02, p = 0.02), but not mental health care (F = 1.82 [1, 303], R²Δ = .01, p = .16), one-year after deployment.

Conclusions

Among U.S. Veterans with newly emerging persistent physical symptoms one-year after deployment, increased physical symptom burden coupled with decreased physical and increased mental health functioning was associated with increased medical care use in the year after deployment. These findings support whole health initiatives aimed at improving health function/well-being, rather than merely symptom alleviation.

Association between fatigue, pain, digestive problems, and sleep disturbances and individuals' health-related quality of life: a nationwide survey in South Korea

Background

Physical symptoms such as fatigue, pain, digestive problems, and sleep disturbances are chief reasons individuals seek primary care, as they affect health-related quality of life. We investigated the associations between various combinations of these common symptoms and individuals’ health-related quality of life.

Methods

This large-scale survey study of 1100 Koreans aged ≥19 years was conducted in 2017 using multi-stage stratified sampling based on region, sex, and age. Data were collected using questionnaires administered face-to-face; then, a linear regression analysis was performed to assess how the symptoms were related to participants’ health-related quality of life. Complex symptoms were defined as co-occurrence of two or more of the four symptoms—fatigue, pain, digestive problems, and sleep disturbances.

Results

The most frequently observed stand-alone symptom was fatigue, while the most common combination was fatigue and pain. When examined individually, fatigue, digestive problems, and sleep disturbances were closely associated with mental health-related quality of life, and pain was associated with physical health-related quality of life. Complex symptoms were also related to health-related quality of life. Lower physical health-related quality of life was strongly associated when fatigue and pain or all four symptoms were co-occurring, and the lowest mental health-related quality of life was seen when all four symptoms were present, after adjusting for all variables.

Conclusions

Symptoms can be present in various combinations and are significantly associated with health-related quality of life. Extra attention should be given to patterns accompanying fatigue and pain and to those involving more symptoms. This elucidated the characteristics of symptoms that affect the health-related quality of life of South Korean adults.

Somatic Symptom Perception and Interoception

Abstract. Models of chronic somatic symptoms assume that abnormalities in interoception are related to the development and maintenance of symptom distress. Different models, however, disagree on the exact nature of the assumed abnormality: cognitive-behavioral models stress a hypervigilant cognitive style (predicting higher interoceptive accuracy) whereas predictive processing models assume a less detailed sensory processing (predicting lower interoceptive accuracy). This study aimed at testing the relationship between interoception and symptom perception. Using structural equation modeling, associations between cardiac interoception and symptom perception were tested in a sample of students ( n = 316) and a second heterogeneous sample ( n = 340, including 63 patients with either pathological health anxiety or a somatoform disorder according to DSM-IV). Stronger sensory symptom perceptions in the cardiorespiratory system were associated with lower interoceptive accuracy in sample 2. The findings are more in line with the predictive processing approach, suggesting less detailed and more biased interoception being associated with chronic somatic symptom distress.

Multiple physical symptoms and individual characteristics - A cross-sectional study of the general population

OBJECTIVE

Multiple physical symptoms not attributable to known organic disease are common in all medical fields and associated with major personal and social consequences. This study investigated multiple physical symptoms according to the construct of bodily distress syndrome (BDS) and associated individual characteristics in the general adult population.

METHODS

A nationwide, population-based study of 100,000 randomly selected individuals aged 20 years and older, conducted in 2012. A web-based questionnaire formed the basis of the study and was combined with Danish national registry data on socioeconomic factors and medication and healthcare use.

RESULTS

49,706 individuals completed the questionnaire. After exclusion of women indicating pregnancy, respondents reporting chronic disease and respondents over 65 years of age, 23,331 remained for analysis. Of these 23,331 individuals, 15.5% fulfilled the criteria for BDS. BDS positives were more often younger (20-40 years) and female. Self-rated health and self-reported functional capacity were impaired among these individuals. Fulfilling the BDS criteria was significantly associated with current or former smoking, overweight and obesity, low educational level and income, and unemployment. Moreover, individuals with BDS were more often from ethnic minorities and had higher use of healthcare and medication.

CONCLUSION

Multiple physical symptoms, as captured by the concept of BDS, are common in the general adult population, especially among younger women. Fulfilling the BDS criteria is associated with substantial negative impact on self-perceived health and socioeconomic parameters. Fulfilling BDS criteria is positively associated with health risk behaviors (smoking, overweight and obesity) and higher use of healthcare and medication.

Medically unexplained physical symptoms in patients visiting the emergency department: an international multicentre retrospective study

OBJECTIVE

The objective of this study was to assess the incidence and characteristics of patients presenting with physical symptoms that remain medically unexplained at the emergency department (ED).

PATIENTS AND METHODS

A retrospective chart study was carried out in three hospitals in The Netherlands and Belgium. All patients (age > 18 years) visiting the ED in 4 selected weeks in 2013 at the Erasmus University Medical Center (Erasmus MC) in Rotterdam, The Netherlands, and 1 selected week in 2013 at the Haaglanden Medical Center, Westeinde HMC in The Hague, The Netherlands, and the University Hospital Ghent (UZG), Belgium, were included. Descriptive statistics were used for data analysis.

RESULTS

A total of 2869 patients (Erasmus MC 1674, HMC 691, UZG 504) were included. Medically unexplained physical symptoms in the emergency department (EDMUPS) were present in 13.4% of all ED visits (Erasmus MC 12.5%, HMC 18.7%, UZG 9.1%). No EDMUPS were identified in trauma patients. When excluding trauma patients, EDMUPS were present in 18.5% (Erasmus MC 16.8%, HMC 26.5%, UZG 13.3%) of the visits. The characteristics of patients with and without EDMUPS differed significantly; patients with EDMUPS were more often younger, female, self-referred, frequent visitors, were prescribed less medication and more often had a psychiatric disease. Dutch and Belgian Hospital differed in the distribution of patients in triage categories and in the incidence of psychiatric illnesses.

CONCLUSION

Physical symptoms remain unexplained in a significant number of patients at the time of ED assessment.

Somatic symptom disorder: a diagnostic dilemma

Somatic symptom disorder (SSD) is a diagnosis that was introduced with publication of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) in 2013. It eliminated the diagnoses of somatisation disorder, undifferentiated somatoform disorder, hypochondriasis and pain disorder; most of the patients who previously received these diagnoses are now diagnosed in DSM-5 with SSD. The main feature of this disorder is a patient's concern with physical symptoms for which no biological cause is found. It requires psychiatric assessment to exclude comorbid psychiatric disease. Failure to recognise this disorder may lead the unwary physician or surgeon to embark on investigations or diagnostic procedures which may result in iatrogenic complications. It also poses a significant financial burden on the healthcare service. Patients with non-specific abdominal pain have a poor symptomatic prognosis with continuing use of medical services. Proven treatments include cognitive behavioural therapy, mindfulness therapy and pharmacological treatment using selective serotonin reuptake inhibitors or tricyclic antidepressants. The authors describe the case of a 31-year-old woman with an emotionally unstable personality disorder and comorbid disease presenting to the emergency department with a 3-week history of left-sided abdominal and leg pain. Despite a plethora of investigations, no organic cause for her pain was found. She was reviewed by the multidisciplinary team including surgeons, physicians, neurologists and psychiatrists. A diagnosis of somatoform symptom disorder was subsequently rendered. As patients with SSD will present to general practice and the emergency department rather than psychiatric settings, this case provides a cautionary reminder of furthering the need for appropriate recognition of this condition.

Does early identification of work-related stress, combined with feedback at GP-consultation, prevent sick leave in the following 12 months? a randomized controlled trial in primary health care

Background

Experiencing work-related stress constitutes an obvious risk for becoming sick-listed. In primary health care, no established method to early identify, advise and treat people with work-related stress exists. The aim was to evaluate if the use of the Work Stress Questionnaire (WSQ) brief intervention, including feedback from the general practitioner (GP), had an impact on the level of sickness absence.

Method/design

In total 271 (intervention group, n = 132, control group, n = 139) non-sick-listed employed women and men, aged 18 to 64 years, who had mental and physical health complaints and sought care at primary health care centers participated in this two-armed randomized controlled trial. The main outcomes were the number of registered sick leave days and episodes, and time to first sick leave during the 12-months follow-up. The intervention included early identification of work-related stress by the WSQ, GP awareness supported by a brief training session, patients’ self-reflection by WSQ completion, GP feedback at consultation, and initiation of preventive measures.

Results

The mean days registered for the WSQ intervention group and the control group were 39 and 45 gross days respectively, and 31 and 39 net days respectively (ns). No statistical significant difference for the number of sick leave episodes or time to first day of sick leave episode were found between the groups.

Conclusions

The WSQ brief intervention combined with feedback and suggestions of measures at patient–GP-consultation was not proven effective in preventing sick leave in the following 12 months compared to treatment as usual. More research is needed on methods to early identify, advise and treat people with work-related stress in primary health care, and on how and when GPs and other professionals in primary health care can be trained to understand this risk of sick leave due to work-related stress, on how to prevent it, and on how to advise and treat employees at risk.

Trial registration

ClinicalTrials.gov. Identifier: NCT02480855. Registered 20 May 2015.

Hyperexcitability of Cortical Oscillations in Patients with Somatoform Pain Disorder: A Resting-State EEG Study

Patients with somatoform pain disorder (SPD) suffer from somatic pain that cannot be fully explained by specific somatic pathology. While the pain experience requires the integration of sensory and contextual processes, the cortical oscillations have been suggested to play a crucial role in pain processing and integration. The present study is aimed at identifying the abnormalities of spontaneous cortical oscillations among patients with SPD, thus for a better understanding of the ongoing brain states in these patients. Spontaneous electroencephalography data during a resting state with eyes open were recorded from SPD patients and healthy controls, and their cortical oscillations as well as functional connectivity were compared using both electrode-level and source-level analysis. Compared with healthy controls, SPD patients exhibited greater resting-state alpha oscillations (8.5-12.5 Hz) at the parietal region, as reflected by both electrode-level spectral power density and exact low-resolution brain electromagnetic tomography (eLORETA) cortical current density. A significant correlation between parietal alpha oscillation and somatization severity was observed in SPD patients, after accounting for the influence of anxiety and depression. Functional connectivity analysis further revealed a greater frontoparietal connectivity of the resting-state alpha oscillations in SPD patients, which was indexed by the coherence between pairs of electrodes and the linear connectivity between pairs of eLORETA cortical sources. The enhanced resting-state alpha oscillation in SPD patients could be relevant with attenuated sensory information gating and excessive integration of pain-related information, while the enhanced frontoparietal connectivity could be reflecting their sustained attention to bodily sensations and hypervigilance to somatic sensations.

Prevalence of medically unexplained symptoms in adults who are high users of health care services: a systematic review and meta-analysis protocol

INTRODUCTION

Medically unexplained symptoms (MUS) are common in primary-care and secondary-care settings. Persistent symptoms of MUS are associated with a variety of poor outcomes including increased disability, poor quality of life and high healthcare costs. The aim of this systematic review is to review the relevant literature to determine the prevalence of MUS in patients who are high users of healthcare and/or who accrue high healthcare costs.

METHODS AND ANALYSIS

This review will include studies with cases that are either high users of general healthcare or are patients who accrue high healthcare costs, aged ≥18 years and where a recognised measure of MUS, either a standardised clinical interview or questionnaire, was employed. The following citation databases MEDLINE, PsycINFO, EMBASE, CINAHL, PROSPERO and the Cochrane library will be systematically searched from inception to 30 June 2018. The Cochrane library was included because of the significant proportion of non-observational studies currently published in the database. The prevalence of MUS and associated disorders along with the costs or use of healthcare associated with the presence of MUS will be estimated with 95% CI. If possible, study results will be pooled into a meta-analysis. However, if heterogeneity is high, data analysis will be presented descriptively.

ETHICS AND DISSEMINATION

Ethical approval is not required for this systematic review since only data from existing studies will be used. Results of this review will be disseminated in peer-reviewed publications and at national and international conferences.

PROSPERO REGISTRATION NUMBER

CRD42018100388.

Deficient head motor control in functional dizziness: Experimental evidence of central sensory-motor dysfunction in persistent physical symptoms

Understanding the mechanisms of symptoms that are insufficiently explained by organic dysfunction remains challenging. Recently, it has been proposed that such "functional symptoms" are based on erroneous sensory processing in the central nervous system (CNS), with internal expectations dominating sensory inputs. In a pilot study, we used a head motor control set-up to assess the interplay between sensory input and expectation on the example of patients with functional dizziness. Eight patients and 11 age-matched healthy controls performed large active eye-head gaze shifts towards visual targets in the natural situation and with the head moment of inertia 3.3-fold increased. The latter induces head oscillations and the expected sensory outcome of the movement, estimated in the CNS, does not match the actual sensory input. Head oscillations were assessed in patients and in healthy subjects and compared to prior results from patients with organic disease (vestibular loss and cerebellar ataxia). Head oscillations in patients with functional dizziness were different from those of healthy subjects (F(1,17)=27.26, P<0.001, partial η²=0.62), and similar to those of patients with cerebellar ataxia, and with vestibular loss (F(2,19)=0.56, P=0.58). Even in the natural, unweighted, condition, head oscillations were higher in functional dizziness patients than in healthy subjects (P=0.001). Since an extensive work-up failed to demonstrate any explanatory peripheral vestibular, motor, or cerebellar organic dysfunction, these motor control deficits are a first indication of erroneous interplay between expectations and sensory input in the CNS that could account for persistent physical symptoms.

Frequent attenders in general medical practice in Italy: a preliminary report on clinical variables related to low functioning

BACKGROUND

Frequent attenders (FAs), defined as patients reporting a disproportionate number of visits to general practitioners (GPs), may represent up to one-third of GP patients responsible for a high burden of care not always justified by the severity of the medical condition. The aim of this study was to explore sociodemographic and clinical characteristics of FAs of GP in Italy with particular attention to functional impairment.

METHODS

A total sample of 75 FAs (defined as individuals who had consulted GPs 15 times or more during 2015) of GPs of three primary care centers (Pisa, Livorno, and Lucca) in Italy were enrolled and assessed by sociodemographic scale, Structured Clinical Interview for DSM-5 (SCID-5), global functioning (Global Assessment of Functioning [GAF]), illness behavior and perceived health (Illness Behavior Inventory), and somatic comorbidity (Cumulative Illness Rating Scale).

RESULTS

Most of the sample were females, middle aged, married, or cohabiting, with low levels of education. One-third of FAs was low functioning (LF; GAF score <70), with no differences in the sociodemographic variables. Approximately 70.3% of the patients reported a current SCID diagnosis, in particular, major depressive disorder, somatic symptom disorders, and panic disorder, all being more frequent in LF patients. Half of the patients were taking a psychopharmacological therapy, mostly benzodiazepines (BDZs).

CONCLUSION

Most FAs were female with current medical disorders, and LF. All claimed to be worried about their own health and perceived themselves as more impaired also regarding the health perception and social role. LF patients were, or had been more likely to be under psychopharmacological treatment. FAs seem to constitute a special population that should be carefully evaluated for mental disorders and appropriate treatment.

The association of psychological factors and healthcare use with the discrepancy between subjective and objective respiratory-health complaints in the general population

BACKGROUND

We examined the prevalence of self-perceived respiratory symptoms (SRS) in the absence of any objective findings of respiratory pathology, and the association of such prevalence with psychological factors and healthcare use in the general population.

METHODS

The study was conducted among a nationally representative sample of Finnish adults (BRIF8901). Respiratory functioning was measured by a spirometry test. Structured questionnaires were used to measure SRS, physician visits and psychological factors of alexithymia, sense of coherence, illness worry and common mental disorders. Individuals with a diagnosed respiratory disease or a severe psychiatric disorder, determined in a diagnostic interview, were excluded, giving a sample comprising 4544 participants.

RESULTS

Twenty-six per cent of the general population and 36% of those with no diagnosed severe psychiatric disorder or respiratory disease experienced SRS despite a normal spirometry result. Psychological factors were associated with SRS (0.0001 &lt; p &lt; 0.032), and on the number of physician visit explaining 42.7% of the difference in visits between individuals with and without SRS, respectively. Illness worry was associated most strongly with SRS [odds ratio (OR) 1.29, 95% confidence interval (CI) 1.19-1.41, p &lt; 0.0001] and higher numbers of physician visits (OR 1.35, CI 1.32-1.38, p &lt; 0.00001), even after several adjustments.

CONCLUSIONS

Respiratory symptoms without objective findings are common in the general population. The study results underline the role of psychological factors in the reporting of respiratory symptoms and the associated medical burden, thereby indicating the functional nature of the symptomatology.

Different Strokes for Different Folks: The BodyMind Approach as a Learning Tool for Patients With Medically Unexplained Symptoms to Self-Manage

Medically unexplained symptoms (MUS) are common and costly in both primary and secondary health care. It is gradually being acknowledged that there needs to be a variety of interventions for patients with MUS to meet the needs of different groups of patients with such chronic long-term symptoms. The proposed intervention described herewith is called The BodyMind Approach (TBMA) and promotes learning for self-management through establishing a dynamic and continuous process of emotional self-regulation. The problem is the mismatch between the patient's mind-set and profile and current interventions. This theoretical article, based on practice-based evidence, takes forward the idea that different approaches (other than cognitive behavioural therapy) are required for people with MUS. The mind-set and characteristics of patients with MUS are reflected upon to shape the rationale and design of this novel approach. Improving services for this population in primary care is crucial to prevent the iterative spiraling downward of frequent general practitioner (GP) visits, hospital appointments, and accident and emergency attendance (A&E), all of which are common for these patients. The approach derives from embodied psychotherapy (authentic movement in dance movement psychotherapy) and adult models of learning for self-management. It has been developed from research and practice-based evidence. In this article the problem of MUS in primary care is introduced and the importance of the reluctance of patients to accept a psychological/mental health referral in the first instance is drawn out. A description of the theoretical underpinnings and philosophy of the proposed alternative to current interventions is then presented related to the design, delivery, facilitation, and educational content of the program. The unique intervention is also described to give the reader a flavor.

Internists' dilemmas in their interactions with chronically ill patients; A comparison of their interaction strategies and dilemmas in two different medical contexts

Background

Internists appear to define productive interactions, key concept of the Chronic Care Model, as goal-directed, catalyzed by achieving rapport, and depending on the medical context: i.e. medically explained symptoms (MES) or medically unexplained symptoms (MUS).

Objective

To explore internists’ interaction strategy discourses in the context of MES and MUS.

Methods

We interviewed twenty internists working in a Dutch academic hospital, identified relevant text fragments in the interview transcripts and analyzed the data based on a discourse analysis approach.

Results

We identified four interaction strategy discourses: relating, structuring, exploring, and influencing. Each was characterized by a dilemma: relating by ‘creating nearness versus keeping distance’; structuring by ‘giving space versus taking control’; exploring by ‘asking for physical versus psychosocial causes’; and influencing by ‘taking responsibility versus accepting a patient’s choice. The balance sought in these dilemmas depended on whether the patient’s symptoms were medically explained or unexplained (MES or MUS). Towards MUS the internists tended to maintain greater distance, take more control, ask more cautiously questions related to psychosocial causes, and take less responsibility for shared decision making.

Discussion and conclusions

Adopting a basic distinction between MES and MUS, the internists in our study appeared to seek a different balance in each of four rather fundamental clinical dilemmas. Balancing these dilemmas seemed more difficult regarding MUS where the internists seemed more distancing and controlling, and tended to draw on their medical expertise. Moving in this direction is counterproductive and in contradiction to guidelines which emphasize that MUS patients warrant emotional support requiring a shift towards interpersonal, empathic communication.

Motor Retraining (MoRe) for Functional Movement Disorders: Outcomes From a 1-Week Multidisciplinary Rehabilitation Program

BACKGROUND

Functional movement disorders (FMDs) are conditions of abnormal motor control thought to be caused by psychological factors. These disorders are commonly seen in neurologic practice, and prognosis is often poor. No consensus treatment guidelines have been established; however, the role of physical therapy in addition to psychotherapy has increasingly been recognized. This study reports patient outcomes from a multidisciplinary FMD treatment program using motor retraining (MoRe) strategies.

OBJECTIVE

To assess outcomes of FMD patients undergoing a multidisciplinary treatment program and determine factors predictive of treatment success.

DESIGN

Retrospective chart review.

SETTING

University-affiliated rehabilitation institute.

PATIENTS

Thirty-two consecutive FMD patients admitted to the MoRe program from July 2014-July 2016.

INTERVENTION

Patients participated in a 1-week, multidisciplinary inpatient treatment program with daily physical, occupational, speech therapy, and psychotherapy interventions.

MAIN OUTCOME MEASUREMENTS

Primary outcome measures were changes in the patient-rated Clinical Global Impression Scale (CGI) and the physician-rated Psychogenic Movement Disorder Rating Scale (PMDRS) based on review of standardized patient videos. Measurements were taken as part of the clinical evaluation of the program.

RESULTS

Twenty-four of the 32 patients were female with a mean age of 49.1 (±14.2) years and mean symptom duration of 7.4 (±10.8) years. Most common movement phenomenologies were abnormal gait (31.2%), hyperkinetic movements (31.2%), and dystonia (31.2%). At discharge, 86.7% of patients reported symptom improvement on the CGI, and self-reported improvement was maintained in 69.2% at the 6-month follow-up. PMDRS scores improved by 59.1% from baseline to discharge. Longer duration of symptoms, history of abuse, and comorbid psychiatric disorders were not significant predictors of treatment outcomes.

CONCLUSIONS

The majority of FMD patients experienced improvement from a 1-week multidisciplinary inpatient rehabilitation program. Treatment outcomes were not negatively correlated with longer disease duration or psychiatric comorbidities. The results from our study are encouraging, although further long-term prospective randomized studies are needed.

LEVEL OF EVIDENCE

III.

Medically unexplained physical symptoms in patients attending a medical outpatient clinic in a tertiary hospital in North India

OBJECTIVE

Medically unexplained physical symptoms (MUPS) are commonly seen across health care settings. Earlier studies have focussed on prevalence, cost-utilization and burden. Data from India is scarce. Patients with persistent MUPS have more impairment and psychological distress. This study was designed to assess psychological morbidity, health anxiety (HA), somatic symptom load, disability, quality of life (QOL) in patients with persistent MUPS presenting to a general medical outpatient service and compare it with patients with medically explained physical symptoms (MEPS).

METHODS

The study was conducted in the outpatient service of the Department of Internal Medicine in a tertiary hospital in North India. Persistent MUPS was defined as physical symptoms of at least 3 months duration leading to dysfunction and with no identifiable medical cause. 70 patients with persistent MUPS and MEPS each were recruited. Psychiatric morbidity was assessed using the Mini International Neuropsychiatric interview, somatic symptom load with Patient Health Questionniare-15 (PHQ-15), HA with Whiteley Index, disability with WHODAS 2.0 and QOL with WHOQOL-Bref.

RESULTS

Both the groups were comparable on socio-demography and length of symptoms. Prevalence of psychiatric disorders and HA was significantly greater in MUPS. Patients with persistent MUPS had significantly more health care utilization, number and burden of somatic symptoms, greater disability and worse QOL.

CONCLUSIONS

Patients with persistent MUPS have a different profile when compared to MEPS. There is a need to screen and identify patients with MUPS and manage them keeping in mind the psychological factors and chronic nature and number of symptoms.

The four week time frame for somatic symptom questionnaires reflects subjective symptom burden best

OBJECTIVE

Various questionnaires are available to assess somatic symptom burden, however their assessment time frames vary largely. The aim of this study was to investigate the most relevant assessment time frame for somatic symptoms by relating somatic symptom burden, with varying time frames, to quality of life (QoL) and health anxiety as indicators for clinical relevance of symptoms.

METHODS

This study was performed in data derived from a convenience sample of 3477 participants (age: 48.0 (SD 14.1), 66.4% female) of the Dutch research platform HowNutsAreTheDutch. Symptom burden was assessed using all items from the Patient Health Questionnaire-15 (PHQ-15) and 6 items of the Symptom Checklist-90 SOM (SCL-90 SOM). Five versions of the questionnaire were constructed, which evaluated symptom burden during the past 24h, 1week, 2weeks, 4weeks, and 3months.

RESULTS

Symptom burden significantly increased with each step increase in time frame until 4weeks, with no further increase when comparing 4weeks and 3months. The time frame of 4weeks provided the strongest associations between somatic symptom burden and health anxiety (B=1.635; 95%CI: 1.368 to 1.938; p≤0.001). This was also true when analysing the association between QoL and the symptom groups of musculoskeletal (B=-1.54; 95%CI: -1.93 to -1.16;p≤0.001) and gastrointestinal symptoms (B=-0.71; 95%CI: -0.96 to -0.47;p≤0.001).

CONCLUSION

An assessment time frame of 4weeks for somatic symptom questionnaires reflects clinically relevant somatic symptom burden in terms of QoL and health anxiety best, followed by the 3months' time frame.

How do hospital doctors manage patients with medically unexplained symptoms: a qualitative study of physicians

Objective Medically unexplained symptoms are a common presentation in medical practice and are associated with significant morbidity and high levels of service use. Most research exploring the attitudes and training of doctors in treating patients with unexplained symptoms has been conducted in primary care. This study aims to explore the ways in which doctors working in secondary care approach and manage patients with medically unexplained symptoms. Design A qualitative study using in-depth interviews and thematic analysis. Setting Three hospitals in the North Thames area. Participants Twenty consultant and training-grade physicians working in cardiology, gastroenterology, rheumatology and neurology. Main outcome measure Physicians' approach to patients with medically unexplained symptoms and their views on managing these patients. Results There was considerable variation in how the physicians approached patients who presented with medically unexplained symptoms. Investigations were often ordered without a clear rationale and the explanations given to patients when results of investigations were normal were highly variable, both within and across specialties. The doctor's level of experience appeared to be a more important factor in their investigation and management strategies than their medical specialty. Physicians reported little or no formal training in how to manage such presentations, with no apparent consistency in how they had developed their approach. Doctors described learning from their own experience and from senior role models. Organisational barriers were identified to the effective management of these patients, particularly in terms of continuity of care. Conclusions Given the importance of this topic, there is a need for serious consideration as to how the management of patients with medically unexplained symptoms is included in medical training and in the planning and delivery of services.

Implementing a Psychotherapy Service for Medically Unexplained Symptoms in a Primary Care Setting

Medically unexplained symptoms (MUS) are known to be costly, complex to manage and inadequately addressed in primary care settings. In many cases, there are unresolved psychological and emotional processes underlying these symptoms, leaving traditional medical approaches insufficient. This paper details the implementation of an evidence-based, emotion-focused psychotherapy service for MUS across two family medicine clinics. The theory and evidence-base for using Intensive Short-Term Dynamic Psychotherapy (ISTDP) with MUS is presented along with the key service components of assessment, treatment, education and research. Preliminary outcome indicators showed diverse benefits. Patients reported significantly decreased somatic symptoms in the Patient Health Questionnaire-15 (d = 0.4). A statistically significant (23%) decrease in family physicians’ visits was found in the 6 months after attending the MUS service compared to the 6 months prior. Both patients and primary care clinicians reported a high degree of satisfaction with the service. Whilst further research is needed, these findings suggest that a direct psychology service maintained within the family practice clinic may assist patient and clinician function while reducing healthcare utilization. Challenges and further service developments are discussed, including the potential benefits of re-branding the service to become a ‘Primary Care Psychological Consultation and Treatment Service’.

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.

Identifying patients with chronic widespread pain in primary care

Supplemental Digital Content is Available in the Text.

Patients with chronic widespread pain may regularly consult in primary care for regional pain without being recognized as having a generalized condition.

Chronic widespread pain (CWP) is common in the general population. It is unclear how people reporting this problem present in primary care; they may regularly consult for regional pains without being recognized as having a generalized condition. Our objectives were to determine the prevalence of people consulting in primary care for musculoskeletal conditions in different body regions on different occasions (recurrent regional pain consultation), the proportion with diagnosed generalized pain and survey-reported widespread pain, and if they have features characteristic of CWP. Phase 1 used electronic records from 12 general practices in North Staffordshire (Consultations in Primary Care Archive) from 2005 to 2009. Phase 2 used linked self-reported health and primary health care data from 8286 people aged >50 years in 8 general practices (North Staffordshire Osteoarthritis Project) between 2002 and 2005. In Phase 1, 11% of registered patients fulfilled criteria for recurrent regional pain consultation. Three-quarters had no recorded CWP-related generalized pain condition (eg, fibromyalgia). In Phase 2, 53% of recurrent regional pain consulters had survey-reported widespread pain and 88% had consulted for somatic symptoms. Self-reported general health was worse in recurrent regional pain consulters than in single-region consulters and poorest in those who also reported persistent widespread pain. Recurrent regional pain consulters are a heterogeneous group of frequent consulters sharing features with CWP (eg, somatic symptoms) but including those less severely affected. They lie on the spectrum of polysymptomatic distress characteristic of CWP and represent a group whose needs may be better met by earlier diagnosis of multisite pain.

"ABC"-The Awareness-Body-Chart: A new tool assessing body awareness

Background

Despite the importance of body awareness for health and well-being there is still a lack of valid assessment tools to scan proper body awareness. To respond to the limitations of questionnaires (reading/interpretation problems) the Awareness-Body-Chart (ABC) was designed to assess body awareness by colouring 51 regions according to their awareness. The objective of this study was to investigate the psychometric characteristics of the ABC.

Methods

In a questionnaire-study, 106 students in Graz (79 females, 27 males, age median 21 (IQR 20–23) years) filled in the ABC, furthermore a German body awareness questionnaire „KEKS”, and the Beck Depression Inventory II. Factor structure, internal consistency, and retest reliability of the ABC were investigated. Correlations of the ABC with the KEKS and the Beck Depression Inventory II and comparisons of subgroups were conducted.

Results

Through factor analyses, 14 factors with clear assignments to body parts could be categorized: cranium, face, cervical/lumbar region, chest/abdomen, back, shoulder, upper arm, lower arm/elbow, hand, genital area, thigh/hip, knee, lower leg, and foot. The 14 body parts and the total score showed acceptable to high Cronbach’s alphas (α = .64 - .97). The test-retest reliability showed values between ρ = .71 and ρ = .96. The correlation of the ABC and KEKS (r = .66, p < .001) confirmed validity. Further indications of validity could be seen in comparisons of subgroups and in correlations with the Beck Depression Inventory II.

Conclusion

The ABC proved good psychometric properties with acceptable to high internal consistency, acceptable to high retest reliability and high construct validity. It is an easy-to-use tool for clinical settings and research. The ABC opens new insights into body awareness-patterns of various subgroups.

Hospitalization due to acute exacerbation of chronic pain: An intervention study in a university hospital

BACKGROUND AND AIMS

Hospitalization as a result of acute exacerbation of complex chronic pain is a largely hidden problem, as patients are often admitted to hospital under a variety of specialities, and there is frequently no overarching inpatient chronic pain service dedicated to their management. Our institution had established an inpatient acute pain service overseen by pain physicians and staffed by specialist nurses that was intended to focus on the management of perioperative pain. We soon observed an increasing number of nurse-to-nurse referrals of non-surgical inpatients admitted with chronic pain. Some of these patients had seemingly intractable and highly complex pain problems, and consequently we initiated twice-weekly attending physician-led inpatient pain rounds to coordinate their management. From these referrals, we identified a cohort of 20 patients who were frequently hospitalized for long periods with exacerbations of chronic pain. We sought to establish whether the introduction of the physician-led inpatient pain ward round reduced the number and duration of hospitalizations, and costs of treatment.

METHODS

We undertook a retrospective, observational, intervention cohort study. We recorded acute Emergency Department (ED) attendances, hospital admissions, and duration and costs of hospitalization of the cohort of 20 patients in the year before and year after introduction of the inpatient pain service.

RESULTS

The patients' mean age was 38.2 years (±standard deviation 13.8 years, range 18-68 years); 13 were women (65.0%). The mode number of ED attendances was 4 (range 2-15) pre-intervention, and 3 (range 0-9) afterwards (p=0.116). The mode bed occupancy was 32 days (range 9-170 days) pre-intervention and 19 days (range 0-115 days) afterwards (p=0.215). The total cost of treating the cohort over the 2-year study period was £733,010 (US$1.12m), comprising £429,479 (US$656,291) of bed costs and £303,531 (US$463,828) of investigation costs. The intervention did not achieve significant improvements in the total costs, bed costs or investigation costs.

CONCLUSIONS

Despite our attending physician-led intervention, the frequency, duration and very substantial costs of hospitalization of the cohort were not significantly reduced, suggesting that other strategies need to be identified to help these complex and vulnerable patients.

IMPLICATIONS

Frequent hospitalization with acute exacerbation of chronic pain is a largely hidden problem that has very substantial implications for patients, their carers and healthcare providers. Chronic pain services tend to focus on outpatient management. Breaking the cycle of frequent and recurrent hospitalization using multidisciplinary chronic pain management techniques has the potential to improve patients' quality of life and reduce hospital costs. Nonetheless, the complexity of these patients' chronic pain problems should not be underestimated and in some cases are very challenging to treat.

Association Between Patient Review of Systems Score and Somatization

Importance

Somatization is a condition in which psychological distress is manifested by medically unexplained symptoms, and it is prevalent in all medical specialties, including otolaryngology. Recognition of somatization can be difficult, and there are limited methods available.

Objectives

To determine whether patients with somatization respond differently to the review of systems (ROS) portion of the patient interview and whether the ROS can be used to identify patients with somatization.

Design, Setting, and Participants

A retrospective review of medical records of 2120 consecutive consultations of English- or Spanish-speaking patients aged 18 to 89 years who presented to the otolaryngology clinic from January 1, 2014, to November 10, 2015, was conducted to compare how the ROS of patients with chief complaints associated with somatization (group B: globus sensation, dizziness, and tinnitus) differs from those with symptoms more often associated with objective findings (group A: nasal obstruction, hoarseness, and hearing loss); a total of 605 patients were included. Objective clinical findings after physical examination and related testing were reviewed and classified as either significant, marginal, or absent. Current or past psychiatric comorbidities were also examined.

Main Outcomes and Measures

Number of affirmative responses on a standardized, 69-point ROS was recorded as a ROS score (ROSS). Objective clinical findings, symptoms, and psychiatric comorbidities were recorded.

Results

Of the 605 patients included in the analysis, 346 (57.2%) were women, and the mean (SD) age was 51.6 (15.7) years. Among patients with medically unexplained symptoms (median, 11; range, 0-39), the ROSS was higher compared with those with objective clinical findings (median, 6; range, 0-31) (median difference, 4; 95% CI, 3 to 6). Group A (hoarseness, nasal obstruction, and hearing loss: median ROSS, 6, range, 0-41) exhibited lower ROSS than group B (dizziness, globus sensation, and tinnitus: median ROSS, 9; range, 0-39) (median difference, -2; 95% CI -3 to -1). Psychiatric comorbidity (median, 10; range, 0-41) was associated with higher ROSS than patients without psychiatric comorbidity (median, 5.5; range, 0 to 36) (median difference, 5; 95% CI, 3 to 6).

Conclusions and Relevance

The manner in which patients respond to a standardized ROS differs in those with medically unexplained symptoms and in those with psychiatric disease. The ROS offers information beyond the actual systems review, and may be useful in the identification of somatization.

The biopsychosocial model of illness: a model whose time has come

The biopsychosocial model outlined in Engel’s classic Science paper four decades ago emerged from dissatisfaction with the biomedical model of illness, which remains the dominant healthcare model. Engel’s call to arms for a biopsychosocial model has been taken up in several healthcare fields, but it has not been accepted in the more economically dominant and politically powerful acute medical and surgical domains. It is widely used in research into complex healthcare interventions, it is the basis of the World Health Organisation’s International Classification of Functioning (WHO ICF), it is used clinically, and it is used to structure clinical guidelines. Critically, it is now generally accepted that illness and health are the result of an interaction between biological, psychological, and social factors. Despite the evidence supporting its validity and utility, the biopsychosocial model has had little influence on the larger scale organization and funding of healthcare provision. With chronic diseases now accounting for most morbidity and many deaths in Western countries, healthcare systems designed around acute biomedical care models are struggling to improve patient-reported outcomes and reduce healthcare costs. Consequently, there is now a greater need to apply the biopsychological model to healthcare management. The increasing proportion of healthcare resource devoted to chronic disorders and the accompanying need to improve patient outcomes requires action; better understanding and employment of the biopsychosocial model by those charged with healthcare funding could help improve healthcare outcome while also controlling costs.

Cognitive Behavior Therapy for Medically Unexplained Symptoms: A Systematic Review and Meta-analysis of Published Controlled Trials

Medically unexplained symptoms (MUS) commonly present across the board in medical specialties and are often challenging to treat. Our objective was to assess the efficacy for cognitive-behavior therapy (CBT) in MUS. Electronic search of databases was carried out for published controlled trials in English language peer-reviewed journals from inception till August 2016. Effect sizes for the trials were computed using standardized mean difference, and I² test was used to assess sample heterogeneity. Pooled mean effect sizes were derived using a random-effects model. Critical appraisal of studies was done using the Cochrane risk of bias assessment tool. A total of 11 trials involving 1235 subjects were included in the study. Ten trials used standard CBT techniques while one studied the efficacy of mindfulness-based CBT technique. The control arms were treatment as usual in five trials, augmented care in four and waitlisted controls in two trials. The pooled mean effect size for CBT was 0.388 (range 0.055-0.806, 95% confidence intervals 0.316-0.461). The I² value was 0 using a random effects model indicating low heterogeneity among studies. Risk of bias was noted in many included studies. Egger plot intercept indicated potential publication bias. CBT was superior to the waiting list, treatment as usual or enhanced usual care with moderate effect sizes in the treatment of MUS. These findings are impacted by the limited number of studies in this area and questionable methodological rigor of included studies.

Moving on: the BodyMind ApproachTM for medically unexplained symptoms

Purpose

The purpose of this paper is to summarise practice-based evidence from an analysis of outcomes from a county-wide pilot study of a specialised primary care clinic employing an original approach for patients with medically unexplained symptoms (MUS). Conditions with persistent bodily symptoms for which tests and scans come back negative are termed MUS. Patients are generic, high health-utilising and for most there is no effective current treatment pathway. The solution is a proven service based on proof of concept, cost-effectiveness and market research studies together with practice-based evidence from early adopters. The research was transferred from a university into a real-world primary care clinical service which has been delivering in two clinical commissioning groups in a large county in England.

Design/methodology/approach

Clinical data calculated as reliable change from the various clinics were aggregated as practice-based evidence pre- and post-intervention via standardised measurements on anxiety, depression, symptom distress, functioning/activity, and wellbeing. It is not a research paper.

Findings

At post-course the following percentages of people report reliable improvement when compared to pre-course: reductions in symptom distress 63 per cent (39/62), anxiety 42 per cent (13/31) and depression 35 per cent (11/31); increases in activity levels 58 per cent (18/31) and wellbeing 55 per cent (17/31) and 70 per cent felt that they had enough help to go forward resulting in the self-management of their symptoms which decreases the need to visit the GP or hospital.

Research limitations/implications

Without a full clinical trial the outcomes must be interpreted with caution. There may be a possible Hawthorne or observer effect.

Practical implications

Despite the small numbers who received this intervention, preliminary observations suggest it might offer a feasible alternative for many patients with MUS who reject, or try and find unsatisfying, cognitive behaviour therapy.

Social implications

Many patients suffering MUS feel isolated and that they are the only one for whom their doctor cannot find an organic cause for their condition. The facilitated group has a beneficial effect on this problem, for example they feel a sense of belonging and sharing of their story.

Originality/value

The BodyMind Approach is an original intervention mirroring the new wave of research in neuroscience and philosophy which prides embodiment perspectives over solely cognitive ones preferred in the “talking” therapies. There is a sea change in thinking about processes and models for supporting people with mental ill-health where the need to include the lived body experience is paramount to transformation.

Survivorship of severe medically unexplained symptoms in palliative care

OBJECTIVES

Patients who articulate their psychological distress primarily through physical symptoms (referred to as medically unexplained symptoms (MUS)) pose a challenge to the skills of most clinicians, including palliative care physicians. The philosophical underpinnings of palliative care with a stated focus on symptom management and care of the person in their psychosociospiritual context lend itself to the care of these patients. The aim of this study was to investigate the characteristics to improve identification of this patient group within palliative care.

METHODS

Here, we report a case series of 6 patients with severe MUS who were referred to palliative care. We use illustrative case vignettes, examine clinical and demographic characteristics and review the perspectives of the multidisciplinary team to identify the common threads.

RESULTS

This case series highlights the complexities and challenges that are inherent in providing assessment and care for patients with MUS that present to palliative care. Characteristics that were identified included the clustering of 'trigger' symptoms, backgrounds of multiple chronic illnesses and relationship dysfunction. Patient outcomes in this group were universally poor, including the death of 2 patients.

CONCLUSIONS

Knowledge of this patient group is vital given the likely increase in prevalence of MUS as palliative care broadens its focus earlier in the trajectory of illness. The strengths of palliative care, including psychosociospiritual assessment, multidisciplinary input and communication skills holds the potential to accurately identify patients with MUS and allow the opportunity for specialist psychiatric input with the hope of improving outcomes for patients and their families.

Clinical practitioners' views on the management of patients with medically unexplained physical symptoms (MUPS): a qualitative study

OBJECTIVES

By identifying strategies that practicing physicians use in managing patients with medically unexplained physical symptoms (MUPS), we present an interim practical management guide (IPMG) that clinical practitioners may find useful in their clinical practices and that may help guide future research.

DESIGN

A qualitative research study based on interview data from practicing physicians with experience in dealing with MUPS and known to the physician members of the research team. A parallel exploration of patient experiences was carried out simultaneously and is reported elsewhere.

SETTING

2 urban centres in 2 different Canadian provinces in a healthcare system where family physicians provide the majority of primary care and self-referral to specialists rarely occurs.

PARTICIPANTS

The physician members of the research team invited practicing family and specialty physicians to participate in the study.

RESULTS

We characterise the care of patients with MUPS in terms of a 4-part framework: (1) the challenge of diagnosis; (2) the challenge of management/treatment; (3) the importance of communication and (4) the importance of the therapeutic relationship.

CONCLUSIONS

On the basis of the details in the different parts of the framework, we propose an IPMG that practitioners may find useful to facilitate the clinical care of patients with MUPS. The guide can be readily implemented into the practice of any physician who cares for patients with MUPS.

Early identification in primary health care of people at risk for sick leave due to work-related stress - study protocol of a randomized controlled trial (RCT)

BACKGROUND

Early identification of persons at risk of sickness absence due to work-related stress is a crucial problem for society in general, and primary health care in particular. Tho date, no established method to do this exists. This project's aim is to evaluate whether systematic early identification of work-related stress can prevent sickness absence. This paper presents the study design, procedure and outcome measurements, as well as allocation and baseline characteristics of the study population.

METHOD/DESIGN

The study is a two-armed randomized controlled trial with follow-up at 3, 6 and 12 months. Non-sick-listed employed women and men, aged 18 to 64 years, who had mental and physical health complaints and sought care at primary health care centers (PHCC) were eligible to participate. At baseline work-related stress was measured by the Work Stress Questionnaire (WSQ), combined with feedback at consultation, at PHCC. The preventive intervention included early identification of work-related stress by the WSQ, GP training in the use of WSQ, GP feedback at consultation and finding suitable preventive measures. A process evaluation was used to explore how to facilitate future implementation and structural use of the WSQ at the PHCC. The primary outcome to compare the preventive sick leave intervention by the general practitioner (GP) versus treatment as usual is sick leave data obtained from the Swedish Social Insurance Agency register.

DISCUSSION

Early screening for sick leave due to work-related stress makes it possible not only to identify those at risk for sick leave, but also to put focus on the patient's specific work-related stress problems, which can be helpful in finding suitable preventive measures. This study investigates if use of the WSQ by GPs at PHCCs, combined with feedback at consultation, prevents future sickness absence.

TRIAL REGISTRATION

ClinicalTrials.gov. Identifier: NCT02480855 . Registered 20 May 2015.