Tomas Toft

Symptoms and syndromes of bodily distress: An exploratory study of 978 internal medical, neurological, and primary care patients

Objective: Physical complaints not attributable to verifiable, conventionally defined diseases, i.e., medically unexplained or functional somatic symptoms, are prevalent in all medical settings, but their classification is contested as numerous overlapping diagnoses and syndrome labels have been introduced. This study aims to determine whether functional somatic symptoms cluster into distinct syndromes and diagnostic entities. Methods: The 978 consecutively admitted patients from a neurological department (n = 120), a medical department (n = 157), and from primary care (n = 701) were interviewed using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) diagnostic instrument. Results: Patients complained of a median of five functional somatic symptoms; women of six, men of four (p < .0001). No single symptoms stood out as distinctive for patients with multiple symptoms. Principal component factor analysis identified a cardiopulmonary including autonomic (CP), a musculoskeletal (MS), and a gastrointestinal (GI) symptom group explaining 36.9% of the variance. Latent class analysis showed that the symptom groups are likely to materialize in the same patients, suggesting that they are different manifestations of a common latent phenomenon. Inclusion of a group of five additional general, unspecific symptoms in latent class analysis allowed construction of clinical diagnostic criteria for ‘bodily distress disorder’ dividing patients into three classes: nonbodily distress (n = 589), modest bodily distress (n = 329, prevalence 25.3%, men 20.4%, women 25.6%), and severe bodily distress (n = 60, prevalence 3.3%, men 1.2%, women 4.8%). Conclusion: The study suggests that bodily distress disorder as defined here may unite many of the functional somatic syndromes and some somatoform disorder diagnoses. Bodily distress may be triggered by stress rather than being distinct diseases of noncerebral pathology. SCAN = Schedules for Clinical Assessment in Neuropsychiatry; CP = cardiopulmonary; MS = musculoskeletal; GI = gastrointestinal; CFS = chronic fatigue syndrome; DSM = Diagnostic and Statistical Manual of Mental Disorders; ICD = International Classification of Diseases; SCL = Symptoms Check List; CAGE = cutting down, annoyance by criticism, guilty feeling, and eye-openers; WHO = World Health Organization; STATA = statistical software; IQR = interquartile range; GS = general symptoms; IBS = irritable bowel syndrome.

Mental disorders in primary care: prevalence and co-morbidity among disorders. results from the functional illness in primary care (FIP) study.

BACKGROUNDnPrevalence and co-occurrence of mental disorders is high among patients consulting their family general practitioner (GP) for a new health problem, but data on diagnostics and socio-demographics are sketchy.nnnMETHODnA cross-sectional two-phase epidemiological study. A total of 1785 consecutive patients with new complaints, aged 18-65 years, consulting 28 family practices during March-April 2000 in Aarhus County, Denmark were screened, in the waiting room, for mental and somatic symptoms with SCL-8 and SCL-Somatization questionnaires, for illness worry with Whitely-7 and for alcohol dependency with CAGE. In a stratified random sample of 701 patients, physician interviewers established ICD-10 diagnoses using the SCAN interview. Prevalence was calculated using weighted logistic regression, thus correcting for sample skewness.nnnRESULTSnHalf of the patients fulfilled criteria for an ICD-10 mental disorders and a third of these for more than one group of disorders. Women had higher prevalence of somatization disorder and overall mental disorders than men. Men had higher prevalence of alcohol abuse and hypochondriasis than women. Psychiatric morbidity tended to increase with age. Prevalence of somatoform disorders was 35.9% (95% CI 30.4-41.9), anxiety disorders 164% (95% CI 12.7-20.9), mood disorders 13.5% (95% CI 11.1-16.3), organic mental disorders 3.1% (95% CI 1.6-5.7) and alcohol abuse 2.2% (95% CI 1.5-3.1). Co-morbidities between these groups were highest for anxiety disorders, where 89% also had another mental diagnosis, and lowest for somatoform disorders with 39%.nnnCONCLUSIONSnICD-10 mental disorders are very prevalent in primary care and there is a high co-occurrence between most disorders. Somatoform disorders, however, more often than not exist without other mental disorders.

The patients' illness perceptions and the use of primary health care.

Objective: To investigate if primary care patients’ perceptions of a current health problem were associated with use of health care. Method: One thousand seven hundred eighty-five patients presenting a new health problem to 1 of 38 physicians from 28 general practices in Aarhus County, Denmark. Patients completed a questionnaire on their illness perceptions and emotional distress before the consultation. The physicians completed a questionnaire for each patient on diagnostics and prognostics. Register data on primary health care utilization 3 years before and 2 years after baseline were obtained. Odds ratios were estimated to examine associations between previous health care use and illness perceptions. Linear regression analysis was performed to examine if illness perceptions predicted later health care use. Results: Previous use: Higher use was associated with psychosocial, stress, and lifestyle attributions. Accident/chance attributions were associated with higher use for patients with a chronic disorder but with lower use for patients without a chronic disorder. A strong illness identity (number of self-reported symptoms), illness worry, a long timeline perspective, a belief that the symptoms would have serious consequences, and all emotional distress variables were associated with higher use. Use during follow-up: Infection/lowered immunity attributions were associated with higher use for patients with a chronic disorder, whereas psychosocial and lifestyle attributions were associated with higher use for all patients. Illness worry and all emotional distress variables predicted higher health care use. A strong illness identity, a long timeline perspective, a belief in serious consequences, and stress and accident/chance attributions were among the strongest predictors of health care use in a multivariate model including all variables. Conclusions: Patients’ perceptions of a current health problem are associated with health care use and may offer an obvious starting point for a biopsychosocial approach in primary care. CI = confidence interval; IPQ = Illness Perception Questionnaire; IR = interquartile range; SCL-SOM = the Symptom Check List-Somatization Subscale; DKK = Danish Kroners.

The uncertain consultation and patient satisfaction: the impact of patients' illness perceptions and a randomized controlled trial on the training of physicians' communication skills.

Objective: To identify predictors of patient satisfaction among a range of patient and practitioner variables. In particular, to focus on patients illness perceptions and the impact of a randomized controlled trial on the training of physicians in general communication skills and how to treat patients presenting with poorly defined illness. Methods: A randomized controlled follow-up study conducted in 28 general practices in Aarhus County, Denmark. Half of the physicians were randomized into an educational program on treatment of patients presenting with medically unexplained symptoms (somatization). One thousand seven hundred eighty-five general practice attenders presenting a new health problem completed questionnaires on illness perceptions, physical functioning, and mental distress before the consultation. After the consultation, a questionnaire including relational and communicative domains of patient satisfaction with the current consultation was completed. The physicians completed a questionnaire for each patient on diagnostics and prognostics. Predictors of patient satisfaction were determined by logistic regression. Results: A large number of patient and practitioner variables predicted satisfaction in univariate logistic regression models. Results from a multivariate logistic model showed that the illness perceptions “uncertainty” (patient not knowing what is wrong) and “emotional representations” (the complaint making the patient feel worried, depressed, helpless, afraid, hopeless) predicted dissatisfaction at OR (CI) = 1.8 (1.3–2.4), p < .001 and OR (CI) = 1.5 (1–2.3), p = .03 respectively. Trained physicians were associated with dissatisfaction at OR (CI) 0.7 (0.5–1), p = .06 in the multivariate model. Furthermore, uncertain patients consulting a trained physician were less likely to be dissatisfied OR (CI) = 0.6 (0.3–1), p = .04. Conclusions: A randomized controlled trial on the training of general practitioners communication skills improved patient satisfaction. Illness perceptions predict satisfaction. In particular, patients feeling uncertain and negatively emotionally involved in their health problem were more inclined to being dissatisfied with the consultation. IPQ = Illness Perception Questionnaire; PSCQ-7 = Patient Satisfaction Consultation Questionnaire; TERM = the extended reattribution model; SCL = Symptom Check List; SCL-SOM = SCL-90 somatization subscale.

Training General Practitioners in the Treatment of Functional Somatic Symptoms: Effects on Patient Health in a Cluster-Randomised Controlled Trial (the Functional Illness in Primary Care Study)

Background: Patients with medically unexplained or functional somatic symptoms (FSS) are prevalent in primary care. In this pragmatic cluster-randomised controlled trial we aimed to test the effect of a training programme (The Extended Reattribution and Management model) for general practitioners (GPs) in the treatment of FSS. Methods: 38 participating GPs were randomised to the control group or the training group. The GPs included consecutive 18- to 65-year-old patients presenting during a 3-week period for new health complaints. We assessed a stratified subsample with the psychiatric interview Schedules of Clinical Assessment in Neuropsychiatry. Of 701 patients interviewed, 350 fulfilled the diagnostic criteria for any ICD-10 somatoform disorder (SD) and 111 presented FSS without fulfilling these criteria (sub-threshold SD). Patients completed questionnaires at baseline and after 3, 12 and 24 months. The questionnaires included assessment of health status (36-item Medical Outcomes Study Short Form; SF-36), health anxiety (Whiteley-7) and physical symptoms (Symptom Check List-90, somatization subscale). Results: Patients with SD consulting trained GPs improved more on our primary outcome of physical functioning than patients consulting control GPs at the 3-month follow-up (p = 0.004), but the improvement was not statistically significant at later follow-up. We found no significant differences in improvement between patients with SD and those with sub-threshold SD. Results for other SF-36 subscales, physical symptoms and health anxiety only showed statistically significant differences between the intervention and control groups for patients with SD; patients consulting trained GPs had less improvement in vitality, health anxiety and physical symptoms at 24 months compared with the control group. Conclusions: GP training may accelerate improvement in physical functioning for patients with SD. However, the effect is small and may not be clinically significant.