Medically unexplained symptoms: continuing challenges for primary care

Integrated care model for patients with functional somatic symptom disorder - a co-produced stakeholder exploration with recommendations for best practice

BACKGROUND

Functional somatic symptoms (FFS) and bodily distress disorders are highly prevalent across all medical settings. Services for these patients are dispersed across the health care system with minimal conceptual and operational integration, and patients do not currently access therapeutic offers in significant numbers due to a mismatch between their and professionals' understanding of the nature of the symptoms. New service models are urgently needed to address patients' needs and to align with advances in aetiological evidence and diagnostic classification systems to overcome the body-mind dichotomy.

METHOD

A panel of clinical experts from different clinical services involved in providing aspects of health care for patients with functional symptoms reviewed the current care provision. This review and the results from a focus group exploration of patients with lived experience of functional symptoms were explored by the multidisciplinary expert group, and the conclusions are summarised as recommendations for best practice.

RESULTS

The mapping exercise and multidisciplinary expert consultation revealed five themes for service improvement and pathway development: time/access, communication, barrier-free care, choice and governance. Service users identified four meta-themes for best practice recommendations: focus on healthcare professional communication and listening skills as well as professional attributes and knowledge base to help patients being both believed and understood in order to accept their condition; systemic and care pathway issues such as stronger emphasis on primary care as the first point of contact for patients, resources to reduce the length of the patient journey from initial assessment to diagnosis and treatment.

CONCLUSION

We propose a novel, integrated care pathway for patients with 'functional somatic disorder', which delivers care according to and working with patients' explanatory beliefs. The therapeutic model should operate based upon an understanding of the embodied nature of patient's complaints and provide flexible access points to the care pathway.

Strategies to improve implementation of collaborative care for functional disorders and persistent somatic symptoms: A qualitative study using a Research World Café design

INTRODUCTION

Persistent somatic symptoms and functional disorders (PSS/FD) are often complex conditions requiring care from multiple disciplines. One way of bringing the different disciplines together is through collaborative care. Little is known about the implementation barriers faced and relevant strategies to tackle the barriers in this field. Therefore, using expert knowledge, we aim to develop realistic strategies for dealing with implementation barriers of collaborative care in PSS/FD.

METHODS

The Research World Café method is a single-session, expert-based method with multiple focus-groups forming and reforming to answer a set of inter-related questions, under the guidance of moderators. Using this method, participants involved in PSS/FD care across different areas of healthcare in the Netherlands developed several realistic strategies for dealing with ten implementation barriers for collaborative care in PSS/FD that were previously identified in a Delphi study. Strategies were grouped into strategy clusters using a card-sorting task.

RESULTS

Thirty-three participants took part, representing ten different disciplines, most commonly physiotherapists, psychologists, and physicians. In total, 54 strategies, identified in response to the ten barriers, were grouped into eight strategy clusters. The strategy clusters were professional education, communication, care coordination, care pathways, joint consults, funding, patient involvement, and prevention.

CONCLUSION

We identified a number of useful strategies for dealing with implementation barriers for collaborative care in PSS/FD. Many strategies provided ways to deal with multiple barriers at once. The effects of applying these strategies in collaborative care in PSS/FD will need testing through implementation studies, as well as in other areas needing multidisciplinary care.

Medically unexplained pain and suicidal ideation among US adults

BACKGROUND

Chronic pain is an established risk factor for suicide. Pain syndromes are complex to diagnose, particularly in cases with limited evidence of injury or pathology. The goal of this study is to assess whether pain of unknown origin (i.e., medically-unexplained pain, MUEP) is more strongly associated with suicide behaviors than pain with a diagnostic explanation.

METHODS

Data comes from the National Comorbidity Survey-Replication, a nationally-representative sample of US adults. Analysis was limited to participants with a lifetime history of any type of chronic pain (n = 3421), which were categorized as having medically-explained pain (MEP, e.g., pain due to a specific health condition or resulting from an injury identified in an x-ray) or MUEP. Logistic regression, using survey procedures, was used to assess the relationship between lifetime MUEP and lifetime history of suicidal ideation and attempts.

RESULTS

Approximately 1 in 10 (11.6 %) adults with chronic pain had MUEP. Those with MUEP reported earlier age of pain onset and more impairment due to health problems. Suicidal ideation was reported by 18.7 % of those with MEP and 28.4 % of those with MUEP. In fully-adjusted models, MUEP was associated with 1.60 times (95 % CI: 1.17-2.18) higher odds of suicidal ideation, and 1.89 (1.25-2.83) higher odds of suicide attempt, compared to MEP.

LIMITATIONS

Cross-sectional analysis; MUEP assessed by self-report.

CONCLUSIONS

Among adults with chronic pain, those with MUEP are more likely to report suicide behaviors. Findings illustrate a role for diagnostic and treatment processes in the relationship between pain and suicide.

Vague sensations. About the background and consequences of discordance between actual and perceived physiological changes

Empirical evidence consistently shows that discordance, also called dissociation or discrepancy, between actual physiological (mainly visceral) events and their perceived counterparts is substantial. On the one hand, we typically do not perceive actual visceral events occurring in our bodies; on the other hand, sometimes we do perceive bodily changes that do not really take place. This narrative review presents the available empirical findings on the discordance, and summarizes possible explanations that approach the phenomenon from the viewpoint of evolution, cognitive development, and predictive processing. Also, the role of top-down factors, such as expectations and experiences is discussed. Finally, practically relevant consequences of the discordance are presented using the examples of mind-body practices, the placebo and nocebo phenomenon, and medically unexplained symptoms. It is concluded that the discordance between actual and perceived body changes can have a negative impact on health, mainly through issues with adherence and other behavioral factors. The existence of actual-perceived discordance should be taught and demonstrated in the elementary and high school, as well as in many areas of higher education.

Quality indicators for collaborative care networks in persistent somatic symptoms and functional disorders: a modified delphi study

BACKGROUND

Care for persistent somatic symptoms and functional disorders (PSS/FD) is often fragmented. Collaborative care networks (CCNs) may improve care quality for PSS/FD. Effectiveness likely depends on their functioning, but we lack a straightforward quality evaluation system. We therefore aimed to develop quality indicators to evaluate CCNs for PSS/FD.

METHOD

Using an online three-round modified Delphi process, an expert panel provided, selected and ranked quality indicators for CCNs in PSS/FD. Recruited experts were diverse healthcare professionals with relevant experience in PSS/FD care in the Netherlands.

RESULTS

The expert panel consisted of 86 professionals representing 15 disciplines, most commonly physiotherapists, psychologists and medical specialists. 58% had more than 10 years experience in PSS/FD care. Round one resulted in 994 quotations, which resulted in 46 unique quality indicators. These were prioritised in round two and ranked in round three by the panel, resulting in a final top ten. The top three indicators were: "shared vision of care for PSS/FD", "pathways tailored to the individual patient", and "sufficiently-experienced caregivers for PSS/FD".

CONCLUSIONS

The identified quality indicators to evaluate CCNs in the field of PSS/FD can be implemented in clinical practice and may be useful in improving services and when assessing effectiveness.

The central role of the Thalamus in psychosis, lessons from neurodegenerative diseases and psychedelics

The PD-DLB psychosis complex found in Parkinson's disease (PD) and Dementia with Lewy Bodies (DLB) includes hallucinations, Somatic Symptom/Functional Disorders, and delusions. These disorders exhibit similar presentation patterns and progression. Mechanisms at the root of these symptoms also share similarities with processes promoting altered states of consciousness found in Rapid Eye Movement sleep, psychiatric disorders, or the intake of psychedelic compounds. We propose that these mechanisms find a crucial driver and trigger in the dysregulated activity of high-order thalamic nuclei set in motion by ThalamoCortical Dysrhythmia (TCD). TCD generates the loss of finely tuned cortico-cortical modulations promoted by the thalamus and unleashes the aberrant activity of the Default Mode Network (DMN). TCD moves in parallel with altered thalamic filtering of external and internal information. The process produces an input overload to the cortex, thereby exacerbating DMN decoupling from task-positive networks. These phenomena alter the brain metastability, creating dreamlike, dissociative, or altered states of consciousness. In support of this hypothesis, mind-altering psychedelic drugs also modulate thalamic-cortical pathways. Understanding the pathophysiological background of these conditions provides a conceptual bridge between neurology and psychiatry, thereby helping to generate a promising and converging area of investigation and therapeutic efforts.

It's not in my head: a qualitative analysis of experiences of discrimination in people with mental health and substance use conditions seeking physical healthcare

Introduction

Clinician bias contributes to lower quality healthcare and poorer health outcomes in people with mental health and substance use conditions (MHSUC). Discrimination can lead to physical conditions being overlooked (diagnostic overshadowing) or substandard treatment being offered to people with MHSUC. This research aimed to utilise experiences of people with MHSUC to identify discrimination by clinicians, including the role of clinician's beliefs and assumptions in physical health service provision.

Methods

We surveyed people with MHSUC who accessed physical healthcare services. Of 354 eligible participants, 253 responded to open-ended questions about experiences of those services. Thematic descriptive analysis of survey responses was completed using existing stigma frameworks and inductive coding.

Results

One dominant theme from survey responses was that diagnostic overshadowing by clinicians was driven by clinician mistrust. Another theme was that clinicians assumed respondent's physical symptoms, including pain, were caused by MHSUC. This influenced decisions not to initiate investigations or treatment. Respondents perceived that clinicians focused on mental health over physical health, contributing to suboptimal care.

Discussion

Discrimination based on MHSUC leads to poor quality care. Health systems and clinicians need to focus quality improvement processes on access to and delivery of equitable physical healthcare to people with MHSUC, address stereotypes about people with MHSUC and improve integration of mental and physical healthcare.

'She thought the same way I that I thought:' a qualitative study of patient-provider concordance among Gulf War Veterans with Gulf War Illness

Objective: Medically unexplained symptoms (MUS), such as chronic fatigue syndrome, irritable bowel syndrome, and Gulf War Illness (GWI), are difficult to treat. Concordance-shared understanding between patient and provider about illness causes, course, and treatment-is an essential component of high-quality care for people with MUS. This qualitative paper focuses on the experiences of United States military Veterans living with GWI who have endured unique healthcare challenges. Methods & Measures: Qualitative interviews were conducted with 31 Veterans with GWI to explore factors that contribute to and detract from concordance with their Veteran Affairs (VA) healthcare providers. In addition to being seen by VA primary care, over half of participants also sought care at a War Related Illness and Injury Study Center, which specializes in post-deployment health. Deductive and inductive codes were used to organize the data, and themes were identified through iterative review of coded data. Results: Major themes associated with patient-provider concordance included validation of illness experiences, perceived provider expertise in GWI/MUS, and trust in providers. Invalidation, low provider expertise, and distrust detracted from concordance. Conclusion: These findings suggest providers can foster concordance with MUS patients by legitimizing patients' experiences, communicating knowledge about MUS, and establishing trust.

Exploring attitudes of healthcare professionals towards those with fibromyalgia: A Q-methodological approach

Fibromyalgia remains a difficult condition to diagnose and treat. Research suggests that this leads to frustrating experiences for service users and healthcare professionals. This has led to negative healthcare professional attitudes towards working with those with fibromyalgia. The research to date reports negative attitudes and predominantly investigates attitudes of primary care physicians. This study explores the attitudes of a range of healthcare professionals towards those diagnosed with fibromyalgia. Using Q-methodology, 27 healthcare professionals completed a sorting task and questionnaire to prioritise statements relating to a range of different attitudes towards service users. All participants significantly loaded onto three factors that explained a total of 64% of the data variance. Factor 1 reflected the attitude 'Service users with fibromyalgia are no different to other service users and I enjoy working with them'. Factor 2 reflected the attitude 'Service users with fibromyalgia are inaccurate informants of their own condition due to lack of understanding of their condition and are not likely to engage in treatments'. Factor 3 reflected the attitude 'Service users with fibromyalgia are trustworthy with a lot of clinical problems [but I lack confidence in specialist skills to support them]'. Contrary to the current literature, there appears to be supportive attitudes from healthcare professionals towards service users diagnosed with fibromyalgia. Increased specialised training, clinical exposure to working with fibromyalgia and reflective practice spaces were identified as elements that could improve healthcare professional attitudes.

What psychological interventions are effective for the management of persistent physical symptoms (PPS)? A systematic review and meta-analysis

OBJECTIVES

Presentation of persistent physical symptoms is associated with increased health care utilization, yet clinical outcomes often remain suboptimal. This systematic review aimed to determine whether psychological interventions are effective for the management of PPS and if so, what are the features of the interventions and at what level of care are they delivered. The review also set out to establish which symptoms in those diagnosed with PPS can be effectively managed with psychological intervention.

METHODS

Studies were included if they clearly reported a psychological intervention, specified the study sample as adults with a diagnosis of persistent physical symptoms, included a comparator and as a minimum an outcome measure of somatic symptoms. Risk of bias was assessed using the EPHPP. Meta-analysis was conducted to estimate the overall effect of interventions on somatic symptoms (the primary outcome), anxiety and depression (secondary outcomes).

RESULTS

Seventeen papers of varying quality indicated that psychological interventions can be effective for the management of somatic symptoms reported by individuals with PPS within a primary care setting. Psychological interventions were also found to be effective at reducing depression symptoms in individuals with PPS in twelve of the included studies. However, the meta-analysis results suggest that the psychological interventions utilized within eleven of the included studies did not significantly impact anxiety symptoms.

CONCLUSIONS

Psychological interventions have some success in managing somatic symptoms in PPS patients within primary care settings although their effects on other psychological symptoms is more mixed. The review highlights the importance of establishing a clearer diagnostic classification to inform treatment trajectories and the need for appropriate training and support within a multi-disciplinary team to enable the provision of such therapies.

Psychosomatic symptoms related to exacerbation of fatigue in patients with medically unexplained symptoms

Background

Medically unexplained symptoms (MUS) are common conditions that cause various somatic complaints and are often avoided in primary care. Fatigue frequently occurs in patients with MUS. However, the somatic and psychiatric symptoms associated with fatigue in patients with MUS are unknown. This study aimed to clarify the intensity of fatigue and the related somatic and psychiatric symptoms in patients with MUS.

Methods

A total of 120 patients with MUS aged 20-64 years who visited the Department of Psychosomatic Medicine, Toho University Medical Center Omori Hospital, between January and March 2021 were considered. The participants' medical conditions were assessed using the Chalder Fatigue Scale (CFS), Somatic Symptom Scale-8 (SSS-8), and Hospital Anxiety and Depression Scale (HADS). We estimated the relationship between CFS, SSS-8 and HADS by using Spearman's rank correlation. Additionally, linear multiple regression analysis with CFS as the objective variable was used to identify symptoms related to fatigue.

Results

Fatigue was significantly associated with all symptoms observed (p < 0.01). Linear multiple regression analysis revealed that "dizziness," "headache," and "Sleep medication" were extracted as relevant somatic symptoms (p < 0.05), independent of anxiety and depression, which were already known to be associated with fatigue in MUS.

Conclusion

The intensity of anxiety, depression, headache, and dizziness were all associated with the intensity of fatigue in MUS patients. On the contrary, sleeping medication was associated with lower levels of fatigue in MUS.

Phantosmia and psychogenic non-epileptic seizures in a patient with burning mouth syndrome suffering from severe depression

Burning mouth syndrome (BMS) is a rare but serious medical condition with important psychiatric comorbidity and specific psychological correlates. Psychopathology related with BMS represents a real challenge for clinical decision-making. In this case, depression is the leading psychiatric diagnosis associated with patient's BMS somatic pain and is driven by anxiety and a dissociative functioning. Facing a complex psychosomatic symptomatology, we offer new clinical perspectives for the screening of psychological traits of BMS. Moreover, we highlight the need to foster interdisciplinarity to improve differential diagnosis and defining an optimal care path. This case report stimulates a reflection on management challenges for the consultation-liaison psychiatry and shows the importance of a person-centred approach when communicating the diagnosis.

Experiences with a structured conversation tool: a qualitative study on feasibility in general practice in Norway

OBJECTIVE

To study the feasibility of a structured conversation tool (ICIT) in Norwegian general practice.

DESIGN AND PARTICIPANTS

A structured conversation tool with elements from Cognitive Behavioral Therapy (CBT) was developed for use at the encounter in general practice to increase patient's self-coping ability and the GPs management and sick leave assessment in patients with MUPS. Eight GPs received training and used the ICIT on 49 patients with MUPS. The physicians were gathered into two focus groups. The interviews were recorded on tape, transcribed, and analyzed with systematic text condensation.

MAIN OUTCOME MEASURES

The aim of our study was to examine any benefit and the feasibility of the ICIT in general practice.

RESULTS

The physicians found the ICIT helpful to sort out, clarify and concretize the patients' issues. They felt less fatigued as patients took on a greater responsibility for their own recovery and reported a greater satisfaction and better management with the patients. A salutogenic approach gave the physicians greater insight into their patients' lives and their issues, opening for new treatment options and aiding in recovery. By focusing on the patient's potential capabilities despite their medical condition, some physicians experienced that patients on sick leave returned to work quicker.

CONCLUSIONS

The GPs in this study reported that the ICIT was helpful in consultations with patients due to unspecific medical conditions and facilitated a sense of competence for the physician. KEY POINTSGPs need communication skill training for integrated treatment and sick leave assessment for patients with Medically Unexplained Physical Symptoms (MUPS).•The GPs experienced that the structured conversation tool was beneficial in structuring, clarifying, and substantiating the patient's problems.•The GPs experienced a greater insight into their patients and their issues, opening new treatment options and aiding in recovery.•The GPs experienced patients' quicker recovery and returns to work by starting immediate treatment using the conversation tool.

Clinical physiologists' experiences of working with people with nonepileptic attack disorder: A qualitative study

OBJECTIVES

To explore the perspectives of clinical physiologists on working with patients with nonepileptic attack disorder (NEAD). Nonepileptic attack disorder is a medically unexplained symptom frequently encountered by clinical physiologists in the field of neurophysiology. Studies in healthcare professionals show that they often find patients with medically unexplained symptoms challenging, uncomfortable, and frustrating to interact with. Clinical physiologists spend a substantial amount of time with patients and are key to the assessment of the condition. It is not known how physiologists experience working with patients with NEAD.

METHODS

Semi-structured interviews were conducted with clinical physiologists who frequently work with these patients. Interviews were recorded, transcribed, and analyzed according to grounded theory methodology.

RESULTS

Twelve participants including current trainees and qualified clinical physiologists working in neurophysiology were interviewed for the study. Participants described the experience of working with people with NEAD as anxiety provoking and unpredictable. The sources of this anxiety were the nature of the psychological aspects of the condition, the need to preserve professional boundaries and a lack of preparedness to manage conversations about distress or the psychological factors impacting the NEAD.

CONCLUSIONS

There is a risk that patient care is compromised by the lack of preparation and skills training of physiologists.

PRACTICE IMPLICATIONS

Physiologists need further training in counseling skills to increase tolerance to emotionally laden content in patient accounts and knowledge of suitable referral routes.

Diversity and molecular network patterns of symptom phenotypes

Symptom phenotypes have continuously been an important clinical entity for clinical diagnosis and management. However, non-specificity of symptom phenotypes for clinical diagnosis is one of the major challenges that need be addressed to advance symptom science and precision health. Network medicine has delivered a successful approach for understanding the underlying mechanisms of complex disease phenotypes, which will also be a useful tool for symptom science. Here, we extracted symptom co-occurrences from clinical textbooks to construct phenotype network of symptoms with clinical co-occurrence and incorporated high-quality symptom-gene associations and protein-protein interactions to explore the molecular network patterns of symptom phenotypes. Furthermore, we adopted established network diversity measure in network medicine to quantify both the phenotypic diversity (i.e., non-specificity) and molecular diversity of symptom phenotypes. The results showed that the clinical diversity of symptom phenotypes could partially be explained by their underlying molecular network diversity (PCC = 0.49, P-value = 2.14E-08). For example, non-specific symptoms, such as chill, vomiting, and amnesia, have both high phenotypic and molecular network diversities. Moreover, we further validated and confirmed the approach of symptom clusters to reduce the non-specificity of symptom phenotypes. Network diversity proposes a useful approach to evaluate the non-specificity of symptom phenotypes and would help elucidate the underlying molecular network mechanisms of symptom phenotypes and thus promotes the advance of symptom science for precision health.

The 'medically unexplained symptoms' syndrome concept and the cognitive-behavioural treatment model

The American Psychiatric Association's, 2013 DSM-5 abandoned the use of the term 'medically unexplained symptoms' for non-neurological disorders. In the UK, treatments for various medical illnesses with unexplained aetiology, such as chronic fatigue syndrome, irritable bowel syndrome and fibromyalgia, continue to fall under an MUS umbrella with cognitive behavioural therapy promoted as a primary therapeutic approach. In this editorial, we comment on whether the MUS concept is a viable diagnostic term, the credibility of the cognitive-behavioural MUS treatment model, the necessity of practitioner training and the validity of evidence of effectiveness in routine practice.

"Because the country, it seems though, has turned their back on me": Experiences of institutional betrayal among veterans living with Gulf War Illness

People living with medically unexplained symptoms (MUS) often have poor quality of life and health outcomes. Many struggle to engage with and trust in healthcare systems. This qualitative study examined how experiences with institutions influence perceptions of medical care for MUS by applying the theoretical framework of institutional betrayal to narratives of U.S. military Veterans living with Gulf War Illness (GWI). Institutional betrayal refers to situations in which the institutions people depend upon for safety and well-being cause them harm. Experiences of institutional betrayal both during active military service and when first seeking treatment appeared to shape perceptions of healthcare in this sample. Veterans expressed the belief that the military failed to protect them from environmental exposures. Veterans' concerns regarding subsequent quality of healthcare were intrinsically linked to a belief that, despite official documentation to the contrary, the predominant paradigm of both the U.S. Department of Defense and the U.S. Department of Veterans Affairs (VA) is that GWI does not exist. Veterans reported that providers are not adequately trained on treatment of GWI and do not believe Veterans' descriptions of their illness. Veterans reported taking up self-advocacy, doing their own research on their condition, and resigning themselves to decrease engagement with VA healthcare or seek non-VA care. The study's findings suggest institutional level factors have a profound impact on perceptions of care and the patient-provider relationship. Future research and policy aimed at improving healthcare for people living with MUS should consider the concept of institutional betrayal.

Investigating Attachment Insecurity and Somatosensory Amplification, and the Mediating Role of Interpersonal Problems

Abstract. Background: Somatosensory amplification involves perceptual sensitivity to and cognitive-affective interpretation of bodily sensations and external stimuli, contributing to heightened experiences of somatic symptoms. However, little is known about somatosensory amplification in relation to vulnerabilities such as attachment insecurity. Aims: The present study investigated the link between attachment insecurity and somatosensory amplification, including the mediating role of dysfunctional interpersonal behaviors. Method: A sample of 245 adult community members completed the Somatosensory Amplification Scale, Generalized Anxiety Disorder Scale, and abbreviated versions of the Experiences in Close Relationships scale and Inventory of Interpersonal Problems. Correlational and regression analyses were used to examine relations among study variables, including a hypothesized parallel mediation model. Results: Somatosensory amplification was significantly associated with attachment anxiety, but not attachment avoidance. Regression analyses, controlling for general anxiety symptoms and gender, found that interpersonal sensitivity (but not aggression or ambivalence) mediated the link between attachment anxiety and somatosensory amplification. Limitations: Study limitations include the use of cross-sectional data and a non-clinical sample. Conclusion: The findings indicate that somatosensory amplification may be related to individuals’ attachment anxiety, through the mediating effect of interpersonal sensitivity problems.

A comparison of emergency department presentations for medically unexplained symptoms in frequent attenders during COVID-19

Medically unexplained symptoms (MUS) are those with no identified organic aetiology. Our emergency department (ED) perceived an increase in MUS frequency during COVID-19. The primary aim was to compare MUS incidence in frequent attenders (FAs) during COVID-19 and a control period.A retrospective list of FA-MUS presenting to our ED from March to June 2019 (control) and March to June 2020 (during COVID-19) was compared. Fisher's exact test was used to compare binomial proportions; this presented as relative risk (RR) with 95% confidence intervals (95%CI).During COVID-19, ED attendances reduced by 32.7%, with a significant increase in the incidence of FA-MUS and FA-MUS ED visits compared to control; RR 1.5 (95%CI 1.1-1.8) p=0.0006, and RR 1.8 (95%CI 1.6-2.0), p<0.0001, respectively.Despite reduced ED attendances during COVID-19, there was a significant increase in the incidence of FA-MUS patients and corresponding ED visits by this cohort. This presents a challenge to ED clinicians who may feel underprepared to manage these patients effectively.

Medically unexplained symptoms: assessment and management

Medically unexplained symptoms or persistent physical symptoms are common, real and are associated with significant distress, loss of functioning and high healthcare costs. History, examination and appropriate investigations are essential to make a diagnosis. Once the diagnosis has been made, exploring the impact of the symptoms helps us to tailor our advice to patients. This paper sets out a practical approach to taking a history, assessment and stepwise management principles.

Barriers and facilitators to the implementation of interventions for medically unexplained symptoms in primary care: A modified Delphi study

OBJECTIVE

Medically Unexplained Symptoms (MUS) are physical symptoms that last for longer than several weeks and for which no (sufficient) somatic explanation can be found. Interventions for treating MUS in primary care are available, but their implementation in daily practice appears difficult. In the current study we aim to explore key barriers and facilitators to the implementation of MUS-interventions in primary care.

METHODS

A three-round modified Delphi study was performed, using the input of 58 experts that are (in)directly involved in the care for patients with MUS (e.g. general practitioners (GPs), GP mental health workers, policy advisors). In the first online questionnaire, we generated ideas about relevant barriers and facilitators on different implementation levels. These ideas were independently coded by two researchers, and reformulated into unique barriers and facilitators. In round two, participants selected the ten most relevant barriers and facilitators from round one, which were ranked on importance in round three.

RESULTS

We identified 42 unique barriers and 57 unique facilitators to the implementation of MUS-interventions. The three highest ranked barriers were all related to time, i.e. too little time for treating complex MUS-patients. The most important facilitator was a positive attitude towards MUS-patients. Results varied somewhat per profession.

CONCLUSION

Key barriers and facilitators to the implementation of MUS-interventions seem to exist on the level of the patient, intervention, professional, organization, and external context. All of these levels should be taken into account in order to increase implementation success of MUS-interventions in primary care.

A Qualitative Study of the Views of Patients With Medically Unexplained Symptoms on The BodyMind Approach®: Employing Embodied Methods and Arts Practices for Self-Management

The arts provide openings for symbolic expression by engaging the sensory experience in the body they become a source of insight through embodied cognition and emotion, enabling meaning-making, and acting as a catalyst for change. This synthesis of sensation and enactive, embodied expression through movement and the arts is capitalized on in The BodyMind Approach^® (TBMA). It is integral to this biopsychosocial, innovative, unique intervention for people suffering medically unexplained symptoms (MUS) applied in primary healthcare. The relevance of embodiment and arts practices in TBMA are discussed in relation to the views of participants in the pursuit of self-management. If widely employed TBMA could have an enormous impact, reach, and significance for patients and global health services. This original pre-clinical trial of qualitative research reports on the perceptions of participant patients with generic MUS, a world-wide issue usually treated by either psychological therapy or physiotherapy. TBMA is not a therapy but a health education program founded upon the concept of an integration of psychological elements with physiological, bodily, and sensory experiences. Thematic analysis of qualitative data sets from open-ended questions in semi-structured interviews and a written questionnaire post intervention is presented. Five aspects which appear to be key to learning self-management were derived from analyzing the data: (1) body with mind connections; (2) importance of facilitation; (3) potential benefits; (4) preparedness for change; (5) self-acceptance/compassion. This article advances the discourse on the nature of self-management for MUS through changing the mind-set and the relationship participants have with their bodily symptom/s through employing embodied methods and arts practices, challenging current, and solely verbal, psychological conceptual frameworks. Rigor lies in the method of data analysis using cross verification of credibility between reported findings and scrutiny by stakeholders. We conclude that facilitated TBMA groups employing embodied methods and arts practices can act as a method for developing the self-management of MUS and improving wellbeing.

Finding the 'right' GP: a qualitative study of the experiences of people with long-COVID

BACKGROUND

An unknown proportion of people who had an apparently mild COVID-19 infection continue to suffer with persistent symptoms, including chest pain, shortness of breath, muscle and joint pains, headaches, cognitive impairment ('brain fog'), and fatigue. Post-acute COVID-19 ('long-COVID') seems to be a multisystem disease, sometimes occurring after a mild acute illness; people struggling with these persistent symptoms refer to themselves as 'long haulers'.

AIM

To explore experiences of people with persisting symptoms following COVID-19 infection, and their views on primary care support received.

DESIGN & SETTING

Qualitative methodology, with semi-structured interviews to explore perspectives of people with persisting symptoms following suspected or confirmed COVID-19 infection. Participants were recruited via social media between July-August 2020.

METHOD

Interviews were conducted by telephone or video call, digitally recorded, and transcribed with consent. Thematic analysis was conducted applying constant comparison techniques. People with experience of persisting symptoms contributed to study design and data analysis.

RESULTS

This article reports analysis of 24 interviews. The main themes include: the ' hard and heavy work ' of enduring and managing symptoms and accessing care; living with uncertainty, helplessness and fear, particularly over whether recovery is possible; the importance of finding the 'right' GP (understanding, empathy, and support needed); and recovery and rehabilitation: what would help?

CONCLUSION

This study will raise awareness among primary care professionals, and commissioners, of long-COVID and the range of symptoms people are experiencing. Patients require their GP to believe their symptoms and to demonstrate empathy and understanding. Ongoing support by primary care professionals during recovery and rehabilitation is crucial.

BMC family practice integrated GP care for patients with persistent physical symptoms: feasibility cluster randomised trial

BACKGROUND

Patients continue to suffer from medically unexplained symptoms otherwise referred to as persistent physical symptoms (PPS). General practitioners (GPs) play a key role in the management of PPS and require further training. Patients are often frustrated with the care they receive. This study aims to assess the acceptability of an 'integrated GP care' approach which consists of offering self-help materials to patients with PPS and offering their GPs training on how to utilise cognitive behavioural skills within their consultations, as well as assessing the feasibility of conducting a future trial in primary care to evaluate its benefit.

METHODS

A feasibility cluster randomised controlled trial was conducted in primary care, South London, UK. GP practices (clusters) were randomly allocated to 'integrated GP care plus treatment as usual' or 'treatment as usual'. Patients with PPS were recruited from participating GP practices before randomisation. Feasibility parameters, process variables and potential outcome measures were collected at pre-randomisation and at 12- and 24-weeks post-randomisation at cluster and individual participant level.

RESULTS

Two thousand nine hundred seventy-eight patients were identified from 18 GP practices. Out of the 424 patients who responded with interest in the study, 164 fully met the eligibility criteria. One hundred sixty-one patients provided baseline data before cluster randomisation and therefore were able to participate in the study. Most feasibility parameters indicated that the intervention was acceptable and a future trial feasible. 50 GPs from 8 GP practices (randomised to intervention) attended the offer of training and provided positive feedback. Scores in GP knowledge and confidence increased post-training. Follow-up rate of patients at 24 weeks was 87%. However estimated effect sizes on potential clinical outcomes were small.

CONCLUSIONS

It was feasible to identify and recruit patients with PPS. Retention rates of participants up to 24 weeks were high. A wide range of health services were used. The intervention was relatively low cost and low risk. This complex intervention should be further developed to improve patients'/GPs' utilisation of audio/visual and training resources before proceeding to a full trial evaluation.

TRIAL REGISTRATION

NCT02444520  (ClinicalTrials.gov).

High pre- and postoperative symptom burden in non-responders to total knee arthroplasty

OBJECTIVES

One in five patients does not improve in pain with walking (non-responders) 12 months after total knee arthroplasty (TKA). This longitudinal study investigated a broad range of symptoms before and after TKA and evaluated possible differences in symptom distress between responders and non-responders with regards to pain with walking after TKA.

METHODS

Prior to TKA surgery, 182 patients completed a demographic questionnaire and the Memorial Symptom Assessment Scale-Short Form (MSAS-SF). The MSAS-SF was repeated 12 months following TKA. Clinical data were extracted from medical records. Patients were categorized as responders or non-responders based on their trajectories of pain with walking assessed prior to surgery, on postoperative day 4, at 6 weeks, and at 3 and 12 months.

RESULTS

Overall, the most distressful preoperative symptoms were pain, lack of energy, difficulty sleeping, feeling drowsy, worrying, feeling bloated, and problems with sexual interest or activity. However, compared with patients classified as responders to TKA, non-responders had higher total symptom distress scores both preoperatively and 12 months postoperatively. Preoperatively, non-responders scored higher than responders on five of the seven most distressing symptoms (i.e., all except difficulty sleeping and feeling bloated), and 12 months postoperatively, non-responders scored higher than responders on six of the seven most distressing symptoms (i.e., all but feeling bloated). In a multivariate analysis, higher preoperative distress scores for pain and problems with sexual interest or activity were significant predictors of non-response to TKA, controlling for other relevant factors.

CONCLUSIONS

Patients' preoperative symptom burden may be a useful indicator of their risk for non-improvement following TKA surgery. Future studies need to evaluate the effect of reducing patients' preoperative symptom burden on TKA outcomes.

Treating medically unexplained symptoms via improving access to psychological therapy (IAPT): major limitations identified

BACKGROUND

Improving Access to Psychological Therapies is a UK Government funded initiative to widen access to psychological treatment for a range of common mental health complaints, such as depression and anxiety. More recently, the service has begun to treat patients with medically unexplained symptoms. This paper reports on a review of treatment protocols and early treatment data for medically unexplained symptoms, specifically the illness myalgic encephalomyelitis/chronic fatigue syndrome.

MAIN TEXT

A series of seven core problems and failings are identified, including an unproven treatment rationale, a weak and contested evidence-base, biases in treatment promotion, exaggeration of recovery claims, under-reporting of drop-out rates, and a significant risk of misdiagnosis and inappropriate treatment.

CONCLUSIONS

There is a pressing need for independent oversight of this service, specifically evaluation of service performance and methods used to collect and report treatment outcomes. This service offers uniform psycho-behavioural therapy that may not meet the needs of many patients with medically unexplained health complaints. Psychotherapy should not become a default when patients' physical symptoms remain unexplained, and patients should be fully informed of the rationale behind psychotherapy, before agreeing to take part. Patients who reject psychotherapy or do not meet selection criteria should be offered appropriate medical and psychological support.

Estimated prevalence of medically unexplained physical symptoms in the medicine outpatient department of a tertiary care hospital in India

PURPOSE

There is a paucity of scientific evidence from the Indian subcontinent regarding the magnitude and burden of Medically Unexplained Physical Symptoms (MUPS). This study aims to fill the evidence gap by assessing the prevalence and pattern of MUPS amongst patients attending the Medicine Out-Patient Department (OPD).

METHODOLOGY

The study assessed all consecutive new patients, presenting to the Medicine OPD of a tertiary care center in India over a period of nine months. All consenting patients, between 18 and 60 years of age, irrespective of their reason for consultation were included for the study. The diagnosis in subjects was established by a combination of clinical history, physical examination, and relevant investigations. A diagnosis of MUPS was made in cases with no demonstrable organic cause, and after agreement in the opinion of two independent physicians. All recruited patients with MUPS were subsequently evaluated on a pre-validated symptom checklist of 23 symptoms.

RESULTS

Out of 976 subjects included, a diagnosis of MUPS was established in 24.6% [95% CI = 21.9-27.3] of the sample. An additional 20.6% met the criteria of persistent MUPS (symptoms >2 months), and 19.7% of subjects had symptom duration of more than three months, meeting the stricter definition for 'persistent MUPS'. Prevalence was significantly higher in females (p = 0.02), and patients of MUPS were significantly younger (p = 0.004) than patients with other diagnoses. MUPS patients on average complained of 13 ± 5 symptoms and sought multiple medical consultations [Median (IQR) = 3 (2 - 6)] in the last one year. Non-specific, general symptoms (94.6%) and various types of pain (93.7%) were the most frequent complaints. Pain symptoms, genitourinary symptoms, palpitation, and nausea were more frequent in females as compared to males.

DISCUSSION

Medically unexplained symptoms are as common in India as in the west and therefore pose a significant burden on the healthcare delivery systems. There is a need to sensitize the medical fraternity and policymakers for this condition to develop effective services.

Hope, disappointment and perseverance: Reflections of people with Myalgic encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) and Multiple Sclerosis participating in biomedical research. A qualitative focus group study

Background

The Clinical Understanding and Research Excellence in ME/CFS group (CureME) at the London School of Hygiene & Tropical Medicine has supported and undertaken studies in immunology, genetics, virology, clinical medicine, epidemiology and disability. It established the UK ME/CFS Biobank (UKMEB), which stores data and samples from three groups: participants with ME/CFS, Multiple Sclerosis (MS) and healthy controls. Patient and public involvement have played a central role from its inception.

Aim

To explore the views of participants with ME/CFS and MS on CureME research findings, dissemination and future biomedical research priorities.

Method

Five ME/CFS and MS focus groups were conducted at two UK sites. Discussions were transcribed and analysed thematically.

Results

A total of 28 UKMEB participants took part: 16 with ME/CFS and 12 with MS. Five themes emerged: (a) Seeking coherence: participants’ reactions to initial research findings; (b) Seeking acceptance: participants explore issues of stigma and validation; (c) Seeking a diagnosis: participants explore issues around diagnosis in their lives; (d) Seeking a better future: participants’ ideas on future research; and (e) Seeking to share understanding: participants’ views on dissemination. Focus groups perceived progress in ME/CFS and MS research in terms of “putting together a jigsaw” of evidence through perseverance and collaboration.

Conclusion

This study provides insight into the emotional, social and practical importance of research to people with MS and ME/CFS, suggesting a range of research topics for the future. Findings should inform biomedical research directions in ME/CFS and MS, adding patients’ voices to a call for a more collaborative research culture.

A life-stress, emotional awareness, and expression interview for primary care patients with medically unexplained symptoms: A randomized controlled trial

OBJECTIVE

Lifetime trauma, relationship adversities, and emotional conflicts are elevated in primary care patients with medically unexplained symptoms (MUS), and these risk factors likely trigger or exacerbate symptoms. Helping patients disclose stressors, increase awareness and expression of inhibited emotions, and link emotions to physical symptoms may improve health. We developed an emotional awareness and expression interview that targets stressful life experiences and conflicts and then tested its effects on primary care patients with MUS.

METHOD

Patients (N = 75) with MUS were recruited at a family medicine clinic and randomized to an interview condition or treatment-as-usual (TAU) control condition. In a single 90-min interview in the clinic, the interviewer elicited disclosure of the patient's stressors, linked them to the patient's symptom history, and encouraged emotional awareness and expression about unresolved relationship trauma or conflict. At baseline and 6-week follow-up, patients completed self-report measures of their physical and psychological health.

RESULTS

Analyses of covariance, controlling for baseline symptoms, compared patients in the interview condition with TAU at 6-week follow-up. Compared with TAU, the interview led to significantly lower pain severity, pain interference, sleep problems, and global psychological symptoms.

CONCLUSIONS

This study provides preliminary evidence for the value of integrating a disclosure and emotional awareness and expression interview into the primary care setting for patients with MUS. (PsycINFO Database Record

'If it's a medical issue I would have covered it by now': learning about fibromyalgia through the hidden curriculum: a qualitative study

BACKGROUND

Fibromyalgia syndrome (FMS) is a long-term condition that affects between 1 and 5% of the general population and lies within the spectrum of medically unexplained symptoms (MUS). FMS can be difficult to diagnose and is usually done so as a diagnosis of exclusion. There is continuing debate regarding its legitimacy excluding other causes of symptoms. It is known that the diagnosis and management of MUS, including FMS, receives little attention in medical curricula and attitudes towards patients with FMS amongst medical professionals and trainees can be negative. The purpose of this study was to investigate how attitudes and perspectives of undergraduate medical students towards FMS are acquired during their training.

METHODS

Qualitative interviews with 21 medical students were conducted to explore their views on FMS, encounters with patients with FMS, and where learning about FMS occurs. Participants were recruited from two English medical schools and the study was approved by two University Ethics committees. Interviews were digitally recorded with consent and data analysed thematically, using principles of constant comparison.

RESULTS

The data were organised within three themes: i) FMS is a complex, poorly understood condition; ii) multiple sources for learning about FMS; and iii) consequences of negative attitudes for patients with FMS.

CONCLUSION

Undergraduate medical students have limited understanding of, and are sceptical over the existence of FMS. These attitudes are influenced by the 'hidden curriculum' and witnessing attitudes and actions of their clinical teachers. Students interpret a lack of formal curriculum teaching around FMS to mean that it is not serious and hence a low priority. Encountering a patient, friend or family member with FMS can increase knowledge and lead to altered perceptions of the condition. Teaching and learning about FMS needs to be consistent to improve knowledge and attitudes of clinicians. Undergraduate students should be exposed to patients with FMS so that they better understand patients with FMS.