Improving the Classification of Medically Unexplained Symptoms in Primary Care

Prevalence of DSM-5 somatic symptom disorder in Chinese outpatients from general hospital care

OBJECTIVE

We aimed to explore the prevalence of somatic symptom disorder (SSD) according to DSM-5 criteria in Chinese outpatients from general hospital departments.

METHODS

This multicentre cross-sectional study enrolled 699 patients from outpatient departments, including the neurology, gastroenterology, Traditional Chinese Medicine [TCM] and psychosomatic medicine departments, in five cities in China. The structured clinical interview for DSM-5 (SCID-5) for SSD was administered by trained clinical professionals to diagnose SSD.

RESULTS

SSD was diagnosed in 33.8% (236/697) of all enrolled patients. The prevalence of SSD differed significantly among the departments (χ² = 34.049, df = 2, p ≤0.001). No differences were found between SSD patients and non-SSD patients in terms of gender, residence, marital and living statuses, family income, education, employment status and lifestyle factors. However, patients with SSD reported higher levels of depression, health-related and general anxiety, lower physical and mental quality of life, higher frequency of doctor visits, increased time devoted to physical symptoms and longer duration of somatic symptoms. In a binary linear regression analysis, SSD was significantly associated with an increase in health-related anxiety, time devoted to symptoms and impact of somatic symptoms on daily life. The explained variance was Nagelkerke R² = 0.45.

CONCLUSION

There is a high prevalence of SSD in Chinese general hospital outpatient clinics. The diagnosis is associated with high levels of emotional distress and low quality of life. There is a danger of over-diagnosis if we include the mild and moderate forms of SSD. Future studies are warranted to investigate the prevalence of SSD in inpatient departments and the development of psychological interventions for these patients.

Validity and sensitivity to change of the Somatic Symptom Disorder-B Criteria Scale (SSD-12) in a clinical population

OBJECTIVE

The SSD-12 is a brief self-report questionnaire to measure the psychological criteria of DSM-5 Somatic Symptom Disorder. This study examines its psychometric properties in a German inpatient sample from a psychosomatic rehabilitation setting, and provides evidence to its sensitivity to change.

METHOD

Patients completed the SSD-12 and the Health49-subscale on somatoform complaints before and after receiving inpatient treatment. Therapists evaluated the psychological improvement of their patients at the end of treatment. Effect sizes (ES) and standardized response means (SRM) of pre- and post-SSD-12 mean changes were calculated for subgroups of patients who did or did not improve.

RESULTS

SSD-12 scores at discharge were significantly lower compared to scores at admission for subgroups of patients who improved according to clinicians (t=2976, df=103, p=.004), and for patients who improved according to self-report (t=5.059, df=159, p<.001). Effect sizes of change in SSD-12 scores in the improved subgroups were ES=-0.19 and ES=-0.30, and standardized response means were SRM=-0.29 and SRM=-0.40, respectively.

CONCLUSION

The SSD-12 shows sound psychometric properties and is useful and time-efficient for monitoring psychological burden associated with bothersome somatic symptoms. Its sensitivity to change over time could be documented.

What is the problem with medically unexplained symptoms for GPs? A meta-synthesis of qualitative studies

OBJECTIVE

To gain a deeper understanding of challenges faced by GPs when managing patients with MUS.

METHODS

We used meta-ethnography to synthesize qualitative studies on GPs' perception and management of MUS.

RESULTS

The problem with MUS for GPs is the epistemological incongruence between dominant disease models and the reality of meeting patients suffering from persistent illness. GPs have used flexible approaches to manage the situation, yet patients and doctors have had parallel negative experiences of being stuck, untrustworthy and helpless. In the face of cognitive incongruence, GPs have strived to achieve relational congruence with their patients. This has led to parallel positive experiences of mutual trust and validation. With more experience, some GPs seem to overcome the incongruences, and later studies point towards a reframing of the MUS problem.

CONCLUSION

For GPs, the challenge with MUS is most importantly at an epistemological level. Hence, a full reframing of the problem of MUS for GPs (and for patients) implies broad changes in basic medical knowledge and education.

PRACTICE IMPLICATIONS

Short-term: Improve management of patients with MUS by transferring experience-based, reality-adjusted knowledge from senior GPs to juniors. Long-term: Work towards new models of disease that integrate knowledge from all relevant disciplines.

Sick leave and work disability in primary care patients with recent-onset multiple medically unexplained symptoms and persistent somatoform disorders: a 10-year follow-up of the FIP study

OBJECTIVE

The objective was to explore patient characteristics and 10-year outcome of sick leave and work disability for patients with recent-onset multiple medically unexplained symptoms (MUS) and persistent somatoform disorders (SD).

METHOD

Consecutive patients consulting their family physician (FP) completed a preconsultation questionnaire on symptoms and mental illness (n=1785). The main problem was categorized by the FP after the consultation, and a stratified subsample was examined using a standardized diagnostic interview (n=701). Patients were grouped into three cohorts: recent onset of multiple MUS (n=84); Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, persistent SD (n=183); and reference group with well-defined physical disease according to FP (n=833). Register data on sick leave and disability pension were obtained.

RESULTS

At index consultation, disability pension was received by 8.3% (n=7) in the recent-onset multiple MUS group, 19.1% (n=35) in the SD group and 3.5% (n=29) in the reference group. Both the recent-onset multiple MUS group [hazard ratio (HR)=2.28, 95% confidence interval (CI): 1.14-4.55] and the SD group (HR=3.26, 95% CI:1.93-5.51) had increased risk of new disability pension awards. Furthermore, the SD group had increased risk of sick leave.

CONCLUSIONS

Both recent-onset and persistent MUS have significant long-term impact on patient functioning in regard to working life; this calls for early recognition and adequate management of MUS in primary care.

Towards a clinically useful diagnosis for mild-to-moderate conditions of medically unexplained symptoms in general practice: a mixed methods study

BACKGROUND

Symptoms that cannot be attributed to any known conventionally defined disease are highly prevalent in general practice. Yet, only severe cases are captured by the current diagnostic classifications of medically unexplained symptoms (MUS). This study explores the clinical usefulness of a proposed new diagnostic category for mild-to-moderate conditions of MUS labelled 'multiple symptoms'.

METHODS

A mixed methods approach was used. For two weeks, 20 general practitioners (GPs) classified symptoms presented in consecutive consultations according to the International Classification of Primary Care (ICPC) supplemented with the new diagnostic category 'multiple symptoms'. The GPs' experiences were subsequently explored by focus group interviews. Interview data were analysed according to ethnographic principles.

RESULTS

In 33% of patients, GPs classified symptoms as medically unexplained, but applied the category of 'multiple symptoms' only in 2.8%. The category was described as a useful tool for promoting communication and creating better awareness of patients with MUS; as such, the category was perceived to reduce the risk of unnecessary tests and referrals of these patients. Three main themes were found to affect the clinical usefulness of the diagnostic category of 'multiple symptoms': 1) lack of consensus on categorisation practices, 2) high complexity of patient cases and 3) relational continuity (i.e. continuity in the doctor-patient relationship over time). The first two were seen as barriers to usefulness, the latter as a prerequisite for application. The GPs' diagnostic classifications were found to be informed by the GPs' subjective pre-formed concepts of patients with MUS, which reflected more severe conditions than actually intended by the new category of 'multiple symptoms'.

CONCLUSIONS

The study demonstrated possible clinical benefits of the category of 'multiple symptoms', such as GPs' increased awareness and informational continuity in partnership practices. The use of the category was challenged by the GPs' conceptual understanding of MUS and was applied only to a minority of patients. The study demonstrates a need for addressing these issues if sub-threshold categories for MUS are to be applied in routine care. The category of 'multiple symptoms' may profitably be used in the future as a risk indicator rather than a diagnostic category.

Barriers to the diagnosis of somatoform disorders in primary care: protocol for a systematic review of the current status

BACKGROUND

Somatoform-type disorders and functional medically unexplained symptoms are extremely common in primary care settings. These disorders, however, are consistently underdiagnosed and under-recognised which precludes effective treatment. Given that somatoform symptoms are associated with high impairment, healthcare costs and both physician and patient frustration, it is critical to improve early detection. The first step in improving patient care is to identify the current barriers which obstruct successful diagnosis to enable the design of targeted interventions. We aim to conduct a systematic review to identify the possible physician-, patient- and society-related factors and other practical constraints which may impede successful diagnosis. In the process, we will also be able to recognise the differences in methodological techniques, recommend potential avenues for future research and comment on the literature in this field as a whole.

METHODS/DESIGN

We aim to conduct a systematic review of the relevant peer-reviewed literature published in English or German in the past 10 years in MEDLINE, EMBASE, PsycINFO and the Cochrane Database of Systematic Reviews. Additional studies may be identified from the reference lists of included studies. Title and abstract screening and data extraction from full text manuscripts will be conducted by two independent reviewers. Because we are including a combination of qualitative and quantitative studies, the review will provide a broad understanding of the current situation. Wherever possible, the method and reporting of the review will adhere to the guidelines outlined in the PRISMA statement and bias will be assessed using the Cochrane collaboration's recommendations. We envisage that data will be synthesised using a multilevel (qualitative and quantitative) approach which combines textual narrative and thematic analysis. Barriers will be categorised as modifiable or non-modifiable according to a conceptual framework. The review has been registered in an international registry of systematic reviews PROSPERO (CRD42013002540).

DISCUSSION

We hope that this study will provide an insight into the barriers to diagnosis of somatoform-type disorders and the results can be used to target appropriate interventions to improve care for these patients.

Enhanced care by generalists for functional somatic symptoms and disorders in primary care

BACKGROUND

Patients with medically unexplained or functional somatic symptoms are common in primary care. Previous reviews have reported benefit from specialised interventions such as cognitive behavioural therapy and consultation letters, but there is a need for treatment models which can be applied within the primary care setting. Primary care studies of enhanced care, which includes techniques of reattribution or cognitive behavioural therapy, or both, have shown changes in healthcare professionals' attitudes and behaviour. However, studies of patient outcome have shown variable results and the value of enhanced care on patient outcome remains unclear.

OBJECTIVES

We aimed to assess the clinical effectiveness of enhanced care interventions for adults with functional somatic symptoms in primary care. The intervention should be delivered by professionals providing first contact care and be compared to treatment as usual. The review focused on patient outcomes only.

SEARCH METHODS

We searched the Cochrane Depression, Anxiety and Neurosis Review Group Specialised Register (CCDANCTR-Studies and CCDANCTR-References) (all years to August 2012), together with Ovid searches (to September 2012) on MEDLINE (1950 - ), EMBASE (1980 - ) and PsycINFO (1806 - ). Earlier searches of the Database of Abstracts of Reviews of Effectiveness (DARE), CINAHL, PSYNDEX, SIGLE, and LILACS were conducted in April 2010, and the Cochrane Central Register of Controlled Trials (CENTRAL) in October 2009. No language restrictions were applied. Electronic searches were supplemented by handsearches of relevant conference proceedings (2004 to 2012), reference lists (2011) and contact with authors of included studies and experts in the field (2011).

SELECTION CRITERIA

We limited our literature search to randomised controlled trials (RCTs), primary care, and adults with functional somatic symptoms. Subsequently we selected studies including all of the following: 1) a trial arm with treatment as usual; 2) an intervention using a structured treatment model which draws on explanations for symptoms in broad bio-psycho-social terms or encourages patients to develop additional strategies for dealing with their physical symptoms, or both; 3) delivery of the intervention by primary care professionals providing first contact care; and 4) assessment of patient outcome.

DATA COLLECTION AND ANALYSIS

Two authors independently screened identified study abstracts. Disagreements about trial selections were resolved by a third review author. Data from selected publications were independently extracted and risk of bias assessed by two of three authors, avoiding investigators reviewing their own studies. We contacted authors from included studies to obtain missing information. We used continuous outcomes converted to standardised mean differences (SMDs) and based analyses on changes from baseline to follow-up, adjusted for clustering.

MAIN RESULTS

We included seven studies from the literature search, but only six provided sufficient data for analyses. Included studies were European, cluster RCTs with adult participants seeing their usual doctor (in total 233 general practitioners and 1787 participants). Methodological quality was only moderate as studies had no blinding of healthcare professionals and several studies had a risk of recruitment and attrition bias. Studies were heterogeneous with regard to selection of patient populations and intensity of interventions. Outcomes relating to physical or general health (physical symptoms, quality of life) showed substantial heterogeneity between studies (I(2) > 70%) and post hoc analysis suggested that benefit was confined to more intensive interventions; thus we did not calculate a pooled effect. Outcomes relating to mental health showed less heterogeneity and we conducted meta-analyses, which found non-significant overall effect sizes with SMDs for changes at 6 to 24 months follow-up: mental health (3 studies) SMD -0.04 (95% CI -0.18 to 0.10), illness worry (3 studies) SMD 0.09 (95% CI -0.04 to 0.22), depression (4 studies) SMD 0.07 (95% CI -0.05 to 0.20) and anxiety (2 studies) SMD -0.07 (95% CI -0.38 to 0.25). Effects on sick leave could not be estimated. Three studies of patient satisfaction with care all showed positive but non-significant effects, and measures were too heterogeneous to allow meta-analysis. Results on healthcare utilisation were inconclusive. We analysed study discontinuation and found that both short term and long term discontinuation occurred more often in patients allocated to the intervention group, RR of 1.25 (95% CI 1.08 to 1.46) at 12 to 24 months.

AUTHORS' CONCLUSIONS

Current evidence does not answer the question whether enhanced care delivered by front line primary care professionals has an effect or not on the outcome of patients with functional somatic symptoms. Enhanced care may have an effect when delivered per protocol to well-defined groups of patients with functional disorders, but this needs further investigation. Attention should be paid to difficulties including limited consultation time, lack of skills, the need for a degree of diagnostic openness, and patient resistance towards psychosomatic attributions. There is some indication from this and other reviews that more intensive interventions are more successful in changing patient outcomes.

Descriptive and predictive validity of somatic attributions in patients with somatoform disorders: a systematic review of quantitative research

OBJECTIVE

Research on hypochondriasis and other somatoform disorders (SFD) has provided evidence that patients with SFD tend to attribute their symptoms to organic dysfunctions or disease. However, recent studies appear to discredit this. There is no systematic evidence on whether patients with SFD predominantly rely on somatic attributions, despite calls to include somatic attributions as a positive criterion of somatic symptom disorder (SSD) in the upcoming Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

METHODS

This study is a systematic review of quantitative studies which assess the descriptive and predictive validity of somatic attribution in SFD. The literature search was restricted to studies with patients who met the DSM-IV criteria for SFD.

RESULTS

Somatic attribution style in SFD has acceptable descriptive but insufficient predictive validity. This confirms that the overlap between somatic and psychological attributions is often substantial. Attribution style can discriminate between SFD patients with and without comorbidity.

CONCLUSION

A somatic attribution style does not qualify as a positive criterion in SSD. However, there is an urgent need for further research on causal illness perceptions in the full spectrum of medically unexplained symptoms in order to confirm this result. Given its high prevalence, research on psychological attribution style is warranted. Re-attribution does not provide a framework sophisticated enough to address the needs of patients in primary care.

Diagnosing somatisation disorder (P75) in routine general practice using the International Classification of Primary Care

OBJECTIVE

(i) To analyze general practitioners' diagnosis of somatisation disorder (P75) using the International Classification of Primary Care (ICPC)-2-E in routine general practice. (ii) To validate the distinctiveness of the ICD-10 to ICPC-2 conversion rule which maps ICD-10 dissociative/conversion disorder (F44) as well as half of the somatoform categories (F45.0-2) to P75 and codes the other half of these disorders (F45.3-9), including autonomic organ dysfunctions and pain syndromes, as symptom diagnoses plus a psychosocial code in a multiaxial manner.

METHODS

Cross-sectional analysis of routine data from a German research database comprising the electronic patient records of 32 general practitioners from 22 practices. For each P75 patient, control subjects matched for age, gender, and practice were selected from the 2007 yearly contact group (YCG) without a P75 diagnosis using a propensity-score algorithm that resulted in eight controls per P75 patient.

RESULTS

Of the 49,423 patients in the YCG, P75 was diagnosed in 0.6% (302) and F45.3-9 in 1.8% (883) of cases; overall, somatisation syndromes were diagnosed in 2.4% of patients. The P75 coding pattern coincided with typical characteristics of severe, persistent medically unexplained symptoms (MUS). F45.3-9 was found to indicate moderate MUS that otherwise showed little clinical difference from P75. Pain syndromes exhibited an unspecific coding pattern. Mild and moderate MUS were predominantly recorded as symptom diagnoses. Psychosocial codes were rarely documented.

CONCLUSIONS

ICPC-2 P75 was mainly diagnosed in cases of severe MUS. Multiaxial coding appears to be too complicated for routine primary care. Instead of splitting P75 and F45.3-9 diagnoses, it is proposed that the whole MUS spectrum should be conceptualized as a continuum model comprising categorizations of uncomplicated (mild) and complicated (moderate and severe) courses. Psychosocial factors require more attention.

Illness explanations among patients with medically unexplained symptoms: different idioms for different contexts

Patients with medically unexplained symptoms (MUS) are often considered to be strictly confined to thinking about their symptoms as having only a physical etiology. However, several studies have shown, that the patients also apply other explanations for their sufferings. The aim of this study is to analyse the social construction of illness explanations among patients with MUS, and to illustrate the use of explanatory idioms as being dependent on space, time and setting, legitimizing each idiom. The study is based on repeated, semi-structured, qualitative interviews with nine informants during a period of 1.5 years. A thematic content analysis was performed on a pragmatic and phenomenological basis. We found, that patients with MUS employ at least four different explanatory idioms defined as: (1) the symptomatic idiom; (2) the personal idiom; (3) the social idiom; and (4) the moral idiom. All idioms play an important role in the process of creating meaning in the patients' everyday life. The symptomatic idiom is mainly used at clinical consultations in primary care, but it is not the only idiom of significance for the patients. Simultaneously other idioms exist and gradually become important for especially patients with MUS due to the lack of valid diagnoses and treatment opportunities. Clinical settings, however, call for the employment of the symptomatic idiom and a discrepancy is found between the general practitioners' notion of the bio-psycho-social model and the patients' everyday life idioms.

Functional illness in primary care: dysfunction versus disease

BACKGROUND

The Biopsychosocial Model aims to integrate the biological, psychological and social components of illness, but integration is difficult in practice, particularly when patients consult with medically unexplained physical symptoms or functional illness.

DISCUSSION

This Biopsychosocial Model was developed from General Systems Theory, which describes nature as a dynamic order of interacting parts and processes, from molecular to societal. Despite such conceptual progress, the biological, psychological, social and spiritual components of illness are seldom managed as an integrated whole in conventional medical practice. This is because the biomedical model can be easier to use, clinicians often have difficulty relinquishing a disease-centred approach to diagnosis, and either dismiss illness when pathology has been excluded, or explain all undifferentiated illness in terms of psychosocial factors. By contrast, traditional and complementary treatment systems describe reversible functional disturbances, and appear better at integrating the different components of illness. Conventional medicine retains the advantage of scientific method and an expanding evidence base, but needs to more effectively integrate psychosocial factors into assessment and management, notably of 'functional' illness. As an aid to integration, pathology characterised by structural change in tissues and organs is contrasted with dysfunction arising from disordered physiology or psychology that may occur independent of pathological change.

SUMMARY

We propose a classification of illness that includes orthogonal dimensions of pathology and dysfunction to support a broadly based clinical approach to patients; adoption of which may lead to fewer inappropriate investigations and secondary care referrals and greater use of cognitive behavioural techniques, particularly when managing functional illness.

Recent developments in the understanding and management of functional somatic symptoms in primary care

PURPOSE OF REVIEW

Medically unexplained or functional somatic symptoms are prevalent in primary care, but general practitioners commonly find them difficult to treat. We focus on the conceptual issues and treatment from a primary care perspective, although the field is difficult to review because of the inconsistency and multiplicity of terminology used by different authors and specialties.

RECENT FINDINGS

The training of general practitioners in management techniques has been hampered by an obsolete theoretical framework and outdated diagnostic systems. Epidemiological studies, however, indicate that valid, empirically based diagnostic criteria for functional disorders may be developed. Management studies in primary care have shown disappointing effects on patient outcome, but a lot may be gained by making the training programmes more sophisticated. Recently, stepped care approaches have been introduced but they need scientific evaluation.

SUMMARY

There is an immediate need for a common language and a theoretical framework of understanding of functional symptoms and disorders across medical specialties, clinically and scientifically. Any names that presuppose a mind-body dualism (such as somatization, medically unexplained) ought to be abolished. The overall ambition for treatment is to offer patients with functional somatic symptoms the same quality of professional healthcare as we offer any other patient.