Tim olde Hartman

Medically unexplained symptoms, somatisation disorder and hypochondriasis: course and prognosis. A systematic review.

OBJECTIVE To study the course of medically unexplained symptoms (MUS), somatisation disorder, and hypochondriasis, and related prognostic factors. Knowledge of prognostic factors in patients presenting persistent MUS might improve our understanding of the naturalistic course and the identification of patients with a high risk of a chronic course. METHODS A comprehensive search of Medline, PsycInfo, CINAHL, and EMBASE was performed to select studies focusing on patients with MUS, somatisation disorder, and hypochondriasis, and assessing prognostic factors. Studies focusing on patients with single-symptom unexplained disorder or distinctive functional somatic syndromes were excluded. A best-evidence synthesis for the interpretation of results was used. RESULTS Only six studies on MUS, six studies on hypochondriasis, and one study on abridged somatisation could be included. Approximately 50% to 75% of the patients with MUS improve, whereas 10% to 30% of patients with MUS deteriorate. In patients with hypochondriasis, recovery rates vary between 30% and 50%. In studies on MUS and hypochondriasis, we found some evidence that the number of somatic symptoms at baseline influences the course of these conditions. Furthermore, the seriousness of the condition at baseline seemed to influence the prognosis. Comorbid anxiety and depression do not seem to predict the course of hypochondriasis. CONCLUSIONS Due to the limited numbers of studies and their high heterogeneity, there is a lack of rigorous empirical evidence to identify relevant prognostic factors in patients presenting persistent MUS. However, it seems that a more serious condition at baseline is associated with a worse outcome.

The reassuring value of diagnostic tests: A systematic review

OBJECTIVE This review is a narrative synthesis of the RCTs which studied the efficacy of using diagnostic tests to reassure patients. METHODS We searched for RCTs that examined the level of reassurance after diagnostic testing in outpatients. We used PubMed, Psychinfo, Cochrane Central, Ongoing Trials Database and Scopus. RESULTS We found 5 randomized controlled trials that included 1544 patients. The trials used different diagnostic tests (ECG, radiography of lumbar spine, MR brain scan, laboratory tests, MR of lumbar spine) for different complaints (e.g. chest pain, low back pain and headache). Four out of 5 RCTs did not find a significant reassuring value of the diagnostic tests. One study reported a reassuring effect at 3 months which had disappeared after one year. CONCLUSION Despite the sparse and heterogeneous studies, the results point in the direction of diagnostic tests making hardly any contribution to the level of reassurance. We recommend further studies on the use of diagnostic tests and other strategies to reassure the patient. PRACTICE IMPLICATIONS A clear explanation and watchful waiting can make additional diagnostic testing unnecessary. If diagnostic tests are used, it is important to provide adequate pre-test information about normal test results.

Experts' opinions on the management of medically unexplained symptoms in primary care. A qualitative analysis of narrative reviews and scientific editorials

BACKGROUND The feasibility as well as the suitability of several therapies for medically unexplained symptoms (MUS) in primary care applied by the family physician (FP) appeared to be low. FPs need effective and acceptable strategies to manage these functionally impaired patients. OBJECTIVE To review important and effective elements in the treatment of patients with MUS in primary care according to experts in MUS research. METHODS We performed a systematic search of narrative reviews and scientific editorials in Medline and PsycINFO and triangulated our findings by conducting a focus group with MUS experts. RESULTS We included 7 scientific editorials and 23 narrative reviews. According to MUS experts, the most important elements in the treatment of MUS are creating a safe therapeutic environment, generic interventions (such as motivational interviewing, giving tangible explanations, reassurance and regularly scheduled appointments) and specific interventions (such as cognitive approaches and pharmacotherapy). Furthermore, MUS experts indicate that a multi-component approach in which these three important elements are combined are most helpful for patients with MUS. In contrast to most specific interventions, opinions of MUS experts regarding generic interventions and creating a safe therapeutic relationship seem to be more based on theory and experience than on quantitative research. CONCLUSIONS MUS experts highlight the importance of generic interventions and doctor-patient communication and relationship. However, studies showing the effectiveness of these elements in the management of MUS in primary care is still scarce. Research as well as medical practice should focus more on these non-specific aspects of the medical consultation.

Mindfulness-based cognitive therapy for patients with medically unexplained symptoms: A cost-effectiveness study

OBJECTIVE Our aim was to assess cost-effectiveness of mindfulness-based cognitive therapy (MBCT) compared with enhanced usual care (EUC) in treating patients with persistent medically unexplained symptoms(MUS). METHODS A full economic evaluation with a one year time horizon was performed from a societal perspective. Costs were assessed by prospective cost diaries. Health-related Quality of Life was measured using SF-6D. Outcomes were costs per Quality-Adjusted Life Year (QALY). Bootstrap simulations were performed to obtain mean costs, QALY scores and incremental cost-effectiveness ratios (ICERs). RESULTS MBCT participants (n=55) had lower hospital costs and higher mental health care costs than patients who received EUC (n=41). Mean bootstrapped costs for MBCT were €6269, and €5617 for EUC (95% uncertainty interval for difference: -€1576; €2955). QALYs were 0.674 for MBCT and 0.663 for EUC. MBCT was on average more effective and more costly than EUC, resulting in an ICER of €56,637 per QALY gained. At a willingness to pay of €80,000 per QALY, the probability that MBCT is cost-effective is 57%. CONCLUSION Total costs were not statistically significantly different between MBCT and EUC. However, MBCT seemed to cause a shift in the use of health care resources as mental health care costs were higher and hospital care costs lower in the MBCT condition. Due to the higher drop-out in the EUC condition the cost-effectiveness of MBCT might have been underestimated. The shift in health care use might lead to more effective care for patients with persistent MUS. The longer-term impact of MBCT for patients with persistent MUS needs to be further studied.

Do unexplained symptoms predict anxiety or depression? Ten-year data from a practice-based research network

BACKGROUND Unexplained symptoms are associated with depression and anxiety. This association is largely based on cross-sectional research of symptoms experienced by patients but not of symptoms presented to the GP. AIM To investigate whether unexplained symptoms as presented to the GP predict mental disorders. DESIGN AND SETTING Cross-sectional and longitudinal analysis of data from a practice-based research network of GPs, the Transition Project, in the Netherlands. METHOD All data about contacts between patients (n = 16,000) and GPs (n = 10) from 1997 to 2008 were used. The relation between unexplained symptoms episodes and depression and anxiety was calculated and compared with the relation between somatic symptoms episodes and depression and anxiety. The predictive value of unexplained symptoms episodes for depression and anxiety was determined. RESULTS All somatoform symptom episodes and most somatic symptom episodes are significantly associated with depression and anxiety. Presenting two or more symptoms episodes gives a five-fold increase of the risk of anxiety or depression. The positive predictive value of all symptom episodes for anxiety and depression was very limited. There was little difference between somatoform and somatic symptom episodes with respect to the prediction of anxiety or depression. CONCLUSION Somatoform symptom episodes have a statistically significant relation with anxiety and depression. The same was true for somatic symptom episodes. Despite the significant odds ratios, the predictive value of symptom episodes for anxiety and depression is low. Consequently, screening for these mental health problems in patients presenting unexplained symptom episodes is not justified in primary care.

Explaining symptoms after negative tests : towards a rational explanation

Christopher Burton, Peter Lucassen, Aase Aamland and Tim Olde Hartman Division of Applied Health Sciences, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen AB25 2ZD, UK Department of Primary & Community Care, Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands Research Unit for General Practice, Unit Health, Bergen, Norway Corresponding author: Christopher Burton. Email: c.burton@abdn.ac.uk

Medically unexplained symptoms: evidence, guidelines, and beyond

Medically unexplained symptoms (MUS) are frequently presented in primary care.1 In about 25–50% of all symptoms presented in primary health care, no support for an underlying physical disease can be found. MUS are a heterogeneous group of symptoms and can involve almost all types of symptoms that patients present to their GP. Functional somatic syndromes, such as irritable bowel syndrome (IBS), fibromyalgia, and chronic fatigue syndrome (CFS), as well as symptoms stemming from a specific somatic disease that are more severe, more persistent, or limit functioning to a greater extent than expected, based on (objective) disease parameters, are also referred to as MUS. MUS represent a spectrum of severity from mild via moderate to severe, characterised by an increased number and duration of symptoms and functional limitations. Most of the time MUS are transient and self-limiting, but sometimes MUS persist, resulting in extensive investigations and referrals and unnecessary healthcare costs. Therefore, early recognition of MUS is of paramount importance. Although only 2.5% of the patients in general practice meet criteria for persistent or severe MUS (such multiple symptoms that persist for longer than 3 months resulting in severe functional limitations), GPs experience many difficulties in caring for these patients.2 For that reason the Dutch College of General Practitioners decided to publish the evidence-based primary care guideline on MUS, which provides …

Prodromal symptoms and early detection of Parkinson’s disease in general practice: a nested case-control study

BACKGROUND Timely diagnosis of Parkinsons disease (PD), facilitating early intervention, depends largely on the GPs awareness of early symptomatology. For general practice, it is unknown which prodromal symptoms (symptoms preceding the typical motor symptoms of PD) demand the GPs alertness. OBJECTIVE To assess prodromal symptoms that should alert the GP to the possibility of PD in primary care patients. METHODS A nested case-control study was carried out in a population of approximately 12000 patients registered in the Continuous Morbidity Registration database affiliated with the University of Nijmegen in the Netherlands. The database pools subject data from four primary care practices. The subjects comprised all 86 patients diagnosed with PD between 1972 and 2007, and 78 controls, matched by sex, age, socioeconomic status and primary care practice. The primary measures of outcome were the prodromal symptoms presenting in the two years prior to the diagnosis of PD. The number (and type) of referrals and diagnostic tests were also assessed. RESULTS In the two-year period prior to diagnosis, PD patients more often presented with functional somatic symptoms, constipation, hyperhidrosis and sleep disorders than controls. Patients also more frequently experienced more than one prodromal symptom and were more often referred within the primary care team or to a medical specialist. CONCLUSIONS Prodromal symptoms of PD are encountered in general practice. GPs should be alert when patients present with multiple prodromal symptoms in a two-year period, especially considering the benefits of early intervention, and the future possibilities for disease-modifying therapy.

Why the ‘reason for encounter’ should be incorporated in the analysis of outcome of care

In the traditional medical model, the diagnosis takes a central stage in the delineation of treatment and care. The diagnosis as the determinant of the response to patients1 has been the general line of medical education,2 is at the core of most evidence-based guidelines and protocols,3 and shapes the payment of physicians’ performance.4 Since its renaissance in the 1960s, general practice has questioned the narrow focus on the diagnosis as the single determinant of professional performance and pursued a person-centred, holistic approach of health care;5,6 diseases do not come in isolation but occur in the context of an individual with the disease, and it is to this broader context that health care has to respond. Yet, despite the growing international support of people at the centre of health care, professional performance is mainly regulated and awarded in relation to the diagnosis, disregarding the broader individual and social context of diseases, even in countries with a long and strong primary care tradition.3,7 Person-centredness should be part of every consultation. Clarifying the patient perspective parallel to the health problem can be a practical way of achieving this. In this article we call on the discipline of general practice to clarify patients’ perspectives in a systematic way, in patient care and research. We argue that patients’ reasons to seek medical care reflect their personal needs and expectations, and we illustrate how the use of the International Classification of Primary Care (ICPC)8 can help better understand the process and outcome of care. ICPC was a major step in the development of health informatics for primary care, by incorporating different aspects alongside the classification of health problems.9 For this …

“Medically unexplained” symptoms and symptom disorders in primary care: prognosis-based recognition and classification

BackgroundMany patients consult their GP because they experience bodily symptoms. In a substantial proportion of cases, the clinical picture does not meet the existing diagnostic criteria for diseases or disorders. This may be because symptoms are recent and evolving or because symptoms are persistent but, either by their character or the negative results of clinical investigation cannot be attributed to disease: so-called “medically unexplained symptoms” (MUS).MUS are inconsistently recognised, diagnosed and managed in primary care. The specialist classification systems for MUS pose several problems in a primary care setting. The systems generally require great certainty about presence or absence of physical disease, they tend to be mind-body dualistic, and they view symptoms from a narrow specialty determined perspective. We need a new classification of MUS in primary care; a classification that better supports clinical decision-making, creates clearer communication and provides scientific underpinning of research to ensure effective interventions.DiscussionWe propose a classification of symptoms that places greater emphasis on prognostic factors. Prognosis-based classification aims to categorise the patient’s risk of ongoing symptoms, complications, increased healthcare use or disability because of the symptoms. Current evidence suggests several factors which may be used: symptom characteristics such as: number, multi-system pattern, frequency, severity. Other factors are: concurrent mental disorders, psychological features and demographic data. We discuss how these characteristics may be used to classify symptoms into three groups: self-limiting symptoms, recurrent and persistent symptoms, and symptom disorders. The middle group is especially relevant in primary care; as these patients generally have reduced quality of life but often go unrecognised and are at risk of iatrogenic harm. The presented characteristics do not contain immediately obvious cut-points, and the assessment of prognosis depends on a combination of several factors.ConclusionThree criteria (multiple symptoms, multiple systems, multiple times) may support the classification into good, intermediate and poor prognosis when dealing with symptoms in primary care. The proposed new classification specifically targets the patient population in primary care and may provide a rational framework for decision-making in clinical practice and for epidemiologic and clinical research of symptoms.