Explaining medically unexplained symptoms

Social Factors of Health-Seeking Behavior: On Medical Treatment for Elders With Dementia in Oaxaca, Mexico

This article presents data on family caregiving for elders with dementia in Oaxaca, Mexico. Drawing on a year of ethnographic research, this article explores how caregivers engage in health-seeking behaviors and how they choose between biomedical and traditional medical alternatives. While caregivers are primarily concerned to maintain elders’ health, decisions about which medical providers to (not) consult invoke broader social factors that go beyond their relationships with elders, and concern socioeconomic realms of power, as well as broader ideals concerning local tradition and its maintenance in the contemporary world.

Illness perceptions of youths with functional disorders and their parents: An interpretative phenomenological analysis study

BACKGROUND

Functional disorders, defined as disorders with no clear medical explanation, are common and impose a significant burden on youths, their families, healthcare services and society as a whole. Currently, the literature describes resistance among patients and their families towards psychological symptom explanations and treatments. More knowledge about the thoughts and understandings of youths with functional disorders and their parents is needed. The aim of this study was to explore the illness perceptions of youths with severe functional disorders and their parents.

METHODS

A qualitative interview study using interpretative phenomenological analyses. The study included 11 youths aged 11-15 years with functional disorders and their parents, where interviews were performed at the point of referral from a somatic to a psychiatric treatment setting.

RESULTS

Analyses identified three main themes. Themes 1(Ascribing identity to the disorder) and 2 (Monocausal explanations) explore key elements of the participants' illness perceptions, and theme 3 (Mutable illness perceptions) explores how illness perceptions are influenced by experiences from healthcare encounters.

CONCLUSIONS

The label 'functional disorder' was poorly integrated in the illness perceptions of the youths and their parents. Participants used a monocausal and typically physical explanation rather than a multicausal biopsychosocial explanation for their symptoms.

Lyme Disease and the Epistemic Tensions of "Medically Unexplained Illnesses"

In the US, disagreement over the biological basis of "chronic Lyme disease" has resulted in the institutionalization of two standards of care: "mainstream" and "Lyme-literate." For mainstream physicians, chronic Lyme disease is a "medically unexplained illness" that presents with an abundance of "symptoms" in the absence of diagnostic "signs." For Lyme-literate physicians, and complementary and alternative medicine practitioners more generally, symptoms alone provide sufficient evidence for medical explanation. Drawing upon ethnographic research among mainstream and Lyme-literate physicians, I suggest that medically unexplained illness is not a biomedical anomaly but an intrinsic feature of biomedicine.

Careful expressions of social aspects: How local professionals in high school settings, municipal services, and general practice communicate care to youth presenting persistent bodily complaints

Persistent health complaints pose communicative dilemmas in care encounters, adversely affecting patient experiences and pathways. Little is known about the impact and role of professionals in encounters with young people with incipient, debilitating, and persistent symptoms. This study aims to explore communicative dilemmas and the role of language in care provided by local professionals in high school settings, municipal services, and general practice to young people presenting persistent bodily complaints. The study is based on in-depth individual interviews conducted from April to July 2016 with 12 professionals identified and selected during anthropological multi-sited fieldwork in a Norwegian community. We identify two modalities of what we have chosen to call 'careful expression', used as strategies across professions to overcome communicative dilemmas. Professionals reflexively and pragmatically negotiated with the powers of language to influence illness experience and to enact empowered young subjects. These insights may prove relevant for future studies of care encounters while also indicating a critical attitude to institutional logics that affect care responses.

Functional symptoms in dermatology: Part 1

Functional - or somatoform - symptoms are those that arise with no proven organic pathology. Also known as 'medically unexplained' symptoms, they can present in any medical speciality, including dermatology. Mucocutaneous pain syndromes and functional pruritus are two examples of functional disorders encountered by dermatologists. Patients presenting with somatoform symptoms have paradoxically complex and often subjectively severe symptomatology, yet minimal abnormalities on clinical examination or investigation. Such disparity can be frustrating and distressing for patients and clinicians alike, and there are many pitfalls regarding overinvestigation and misleading communication. However, with an honest and open approach - sometimes requiring collaboration with psychological services - management of functional symptoms can be effective, and patients can be successfully rehabilitated.

Common therapeutic strategies in psychological treatments for medically unexplained somatic symptoms

Objective: Medically unexplained somatic symptoms (MUSS) represent a frequent complaint in health care services. While psychological treatments have demonstrated some effect in patients with MUSS, further progress may be achieved by a synthesis of clinical strategies used in diverse treatment models. The aim of this study was to identify clinical strategies shared across multiple psychological treatments intended for the treatment of adult patients with MUSS. Method: Descriptions of psychological treatments for patients with MUSS were searched in the PsycINFO, PsycARTICLES, and Medline databases and manually. N = 135 resources met inclusion criteria and were subjected to qualitative analysis. Results: Similarities across treatments were captured in 8 broad categories and 18 subcategories that covered aspects of the therapeutic relationship, specific skills (bodily, emotional, and relational) for patients to develop, search for the meaning of symptoms, and the orientation on life beyond symptoms. Conclusions: Despite the differences in technique, it was possible to identify common therapeutic strategies in psychological treatments for patients with MUSS. These overarching treatment strategies, many of which have already obtained empirical support, may inspire further research and the development of comprehensive treatments with enhanced efficacy. Limitations of the present study include the lack of focus on specific syndromes.

Hospitalized Patients with Medically Unexplained Physical Symptoms: Clinical Context and Economic Costs of Healthcare Management

Medically Unexplained Physical Symptoms (MUPS) are physical symptoms without a medical explanation. This study collected data from hospitalized patients presenting MUPS, aiming to draw a clinical and socio-demographic profile of patients with MUPS, to explore psychopathological correlations of Somatic Symptoms Disorder (SSD) diagnosis, and to estimate economic costs related to hospital management for MUPS. The cross-sectional study consisted in the evaluation of data referring to hospitalized patients admitted between 2008 and 2018 in a teaching hospital in Northern Italy. A total of 273 patients presenting MUPS have been hospitalized. The sample showed a prevalence of female, married and employed patients. The most frequent wards involved are Neurology, Internal Medicine and Short Unit Stay. The most common symptoms found are headache, pain, syncope and vertigo. There is no evidence that a history of medical disease is associated with a diagnosis of SSD. A personality disorder diagnosis in patients with MUPS was associated with increased probability of having a diagnosis of SSD. A marginally significant positive association emerged with anxiety disorders, but not with depressive disorder. The overall estimated cost of hospitalization for patients with MUPS is 475'409.73 €. The study provides the investigation of a large number of patients with MUPS and a financial estimate of related hospitalization costs.

[Functional somatic syndromes: A comprehensive cognitive model]

Functional somatic syndromes are frequent in general and specialized medicine practices. Several treatments can be useful. However, the treatment program is often hampered by patients' reluctance to acknowledge the diagnosis because of erroneous lay representations. Recent advances in cognitive science offer a new understanding of the pathophysiology of functional somatic disorders, making this diagnosis more acceptable for patients and caregivers. Simply explained with practical examples, the Bayesian model in particular provides some insights into the underlying cognitive mechanisms of functional somatic syndromes and their treatments. Advantages of this approach are twofold: it is consistent with current scientific knowledge and it can facilitate the physician-patient relationship.

Subacute fatigue in primary care - two sides of the story

OBJECTIVES

Fatigue is a common symptom in primary care. Chronic fatigue research highlights the value of preventing chronicity, but little research has investigated the early, subacute stage of the fatigue trajectory (<3 months). We aimed to examine patient and general practitioner (GP) perspectives of subacute fatigue in primary care: (1) to gain a better understanding of fatigue during this stage and (2) to explore how management could be improved.

DESIGN

A qualitative study design was used. In-depth, semi-structured telephone interviews were conducted with 14 patients and 14 GPs (non-dyadic), recruited from 19 primary care practices.

METHODS

Interview transcripts were thematically analysed. Initially, patient and GP accounts were analysed separately, before themes were merged to identify shared and independent perspectives.

RESULTS

Three main themes were identified. Within these, subthemes from patients', GPs', or shared patient/GP perspectives emerged. The main themes encompassed the following: (1) Change from normal - the impact of fatigue; (2) The challenges of managing fatigue; and (3) The consultation GPs' knowledge was often not reflected in patients' accounts, even for those reporting positive experiences, suggesting knowledge was not effectively translated.

CONCLUSIONS

Some findings, such as impact, mirror those described in chronic fatigue. New insights into early-stage fatigue management also arose, including mismatches in patient and GP perceptions on negative tests and not re-presenting. These highlight the need for better communication and shared understanding. GPs should pre-emptively present a biopsychosocial model of fatigue and keep communication channels open, particularly in the light of negative physiological tests. Statement of contribution What is already known on this subject? Patients with chronic fatigue retrospectively report lack of understanding from GPs in early stage of illness. Little research has investigated the early stages of the fatigue trajectory. What does this study add? Consequences of an episode of subacute fatigue are similar to those reported for CFS. There is discordance between GPs' positive view of negative tests and patients' need for explanation of symptoms. The length of appointments is a significant barrier for creating shared understanding.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Childhood trauma and somatic symptoms among psychiatric outpatients: Investigating the role of shame and guilt

Previous research suggests a link between experiences of childhood maltreatment and adult somatic symptom distress. Contributing mechanisms, however, are not yet well understood. It is possible that shame and guilt may function as mediators in the relationship between childhood trauma and adult somatic distress. The present study was developed to investigate the relationship between childhood maltreatment and adult somatic distress, including the potential mediating role of shame and guilt, among psychiatric outpatients. Using data from a sample of 99 Canadian psychiatric outpatients, mediation models with shame and guilt as parallel mediators were evaluated for relationships between childhood emotional abuse, sexual abuse, emotional neglect, and somatic symptoms. Controlling for current depressive symptoms, a significant indirect effect was found for the relationship between emotional abuse and shame, but not guilt, in contributing to somatic symptoms. A similar result was obtained regarding the mediating role of shame in the relationship between emotional neglect and somatic symptoms. Mediation was non-significant regarding childhood sexual abuse, which was directly related to somatic distress after controlling for depressive symptoms. The findings provide further evidence of the link between childhood trauma and somatic symptom distress, with shame as a mechanism for the effects of emotional abuse and neglect.

Epistemological and methodological paradoxes: secondary care specialists and their challenges working with adolescents with medically unexplained symptoms

Background

Early adolescence is considered a critical period for the development of chronic and recurrent medically unexplained symptoms (MUS), and referrals and system-initiated patient trajectories often lead to an excess of examinations and hospitalizations in the cross-section between mental and somatic specialist care for this group of patients. Dimensions of the relationship and communication between clinician and patient are shown in primary care studies to be decisive for subsequent illness pathways, often creating adverse effects, but knowledge on clinical communication in specialist care is still scarce.

Methods

This study explores communicative challenges specific to clinical encounters between health professionals and adolescent patients in specialist care, as presented through interviews and focus group data with highly experienced specialists working in adolescent and child services at a Norwegian university hospital.

Results

The results are presented in a conceptual model describing the epistemological and methodological paradoxes inherent in the clinical uncertainty of MUS. Within these paradoxes, the professionals try to solve the dilemmas by being creative in their communication strategies; applying metaphors and other rhetorical devices to explain complex ideas; creating clinical prototypes as a way to explain symptoms and guide them in clinical action; relying on principles from patient-centered care involving empathy; and trying to balance expertise and humility.

Conclusion

The challenges in communication arise as a result of opposing discourses on biomedicine, family, health and adolescence that create dilemmas in everyday clinical work. By moving away from a positivist and biomedical framework towards an interpretive paradigm, where culturally derived and historically situated interpretations are used to understand the social life-world of the patient, one can create a more humane health service in accordance with ideals of patient-centered care.

Personality and Affect When the Central Nervous System is Sensitized: An Analysis of Central Sensitization Syndromes in a Substance Use Disorder Population

Functional somatic syndromes, or more recently termed central sensitivity syndromes (CSS), comprise a significant portion of the chronic pain population. Although it is evident that personality is intricately related to the pain experience, it has not been widely studied. This article examines the impact of CSS on the clinical presentation of individuals presenting to treatment for a substance use disorder (SUD), with an emphasis on personality and emotional functioning. We examined personality profiles of individuals presenting to treatment with SUD between three groups: those with a CSS (n = 30), non-CSS chronic pain (n = 79), and no pain (n = 232). Based on previous research and a psychodynamic conceptualization of CSS, we hypothesized that predictors of the presence of a CSS in this sample would be higher rates of overall anxiety, traumatic stress, perfectionistic traits, and a need for interpersonal closeness. Logistic regression analyses did not support our hypothesis. Exploratory analyses indicated which personality traits most strongly predicted the presence of CSS. We discuss these findings using descriptive psychopathology literature, with recommendations for future research.

Myalgic encephalomyelitis/chronic fatigue syndrome and the biopsychosocial model: a review of patient harm and distress in the medical encounter

Objective: Despite the growing evidence of physiological and cellular abnormalities in myalgic encephalomyelitis (ME)/chronic fatigue syndrome (CFS), there has been a strong impetus to tackle the illness utilizing a biopsychosocial model. However, many sufferers of this disabling condition report distress and dissatisfaction following medical encounters. This review seeks to account for this discord.Methods: A narrative review methodology is employed to synthesize the evidence for potential iatrogenesis.Results: We identify seven potential modalities of iatrogenesis or harm reported by patients:difficulties in reaching an acceptable diagnosis;misdiagnosis, including of other medical and psychological conditions;difficulties in accessing the sick role, medical care and social support;high levels of patient dissatisfaction with the quality of medical care;negative responses to controversial therapies (cognitive behavioral therapy and graded exercise therapy);challenges to the patient narrative and experience;psychological harm (individual and collective distress).Conclusion: The biopsychosocial framework currently applied to ME/CFS is too narrow in focus and fails to adequately incorporate the patient narrative. Misdiagnosis, conflict, and harm are observable outcomes where doctors' and patients' perspectives remain incongruent. Biopsychosocial practices should be scrutinized for potential harms. Clinicians should consider adopting alternative patient-centred approaches.Implications for rehabilitationPatients with ME/CFS may report or experience one or more of the modalities of harms and distress identified in this review.It is important health and rehabilitation professionals seek to avoid and minimize harms when treating or assisting ME/CFS patients.There are conflicting models of ME/CFS; we highlight two divergent models, a biopsychosocial model and a biomedical model that is preferred by patients.The 'biopsychosocial framework' applied in clinical practice promotes treatments such as cognitive behavioral therapy and exercise therapy, however, the evidence for their success is contested and many patients reject the notion their illness is perpetuated by dysfunctional beliefs, personality traits, or behaviors.Health professionals may avoid conflict and harm causation in ME/CFS by adopting more concordant 'patient-centred' approaches that give greater prominence to the patient narrative and experience of illness.

Patients' experiences of living with medically unexplained symptoms (MUS): a qualitative study

BACKGROUND

Patients with medically unexplained symptoms (MUS) are common in primary care, and pose a communicative and therapeutic challenge to GPs. Although much has been written about GPs' frustration and difficulties while dealing with these patients, research presenting the patients' perspectives on MUS still seems to be scarce. Existing studies have demonstrated the patients' desire to make sense of symptoms, addressed the necessity for appropriate and acceptable explanation of MUS, and revealed stigmatization of patients with symptoms of mental origin. Treatment in primary care should focus on the patient's most essential needs and concerns. The objective of this paper is to explore Polish patients' perspectives on living with MUS.

METHODS

A qualitative content analysis of 20 filmed, semi-structured interviews with patients presenting MUS (8 men and 12 women, aged 18 to 57) was conducted. All patients were diagnosed with distinctive somatoform disorders (F45), and presented the symptoms for at least 2 years. The interviews were transcribed verbatim and analysed independently by two researchers.

RESULTS

Four major themes emerged: (1) experiences of symptoms; (2) explanations for symptoms; (3) coping; (4) expectations about healthcare. Within the first theme, the patients identified the following sub-themes: persistence of symptoms or variability, and negative emotions. Patients who observed that their symptoms had changed over time were better disposed to accept the existence of a relationship between the symptoms and the mind. The second theme embraced the following sub-themes: (1) personal explanations; (2) social explanations; (3) somatic explanations. The most effective coping strategies the patients mentioned included: the rationalization of the symptoms, self-development and ignoring the symptoms. The majority of our respondents had no expectations from the healthcare system, and stated they did not use medical services; instead, they admitted to visiting psychologists or psychiatrists privately.

CONCLUSION

Patients with MUS have their own experiences of illness. They undertake attempts to interpret their symptoms and learn to live with them. The role of the GP in this process is significant, especially when access to psychological help is restricted. Management of patients with MUS in the Polish healthcare system can be improved, if access to psychologists and psychotherapists is facilitated and increased financial resources are allocated for primary care. Patients with MUS can benefit from a video/filmed consultation with a follow-up analysis with their GP.

Development and evaluation of diversity-oriented competence training for the treatment of depressive disorders

Studies in Europe indicate that some ethnic minorities have higher rates of mental disorders and less favorable treatment outcomes than their counterparts from majority groups. To date, efforts regarding training to reduce disparities have mainly focused on ethnocultural competences of therapists, with less attention paid to other aspects of diversity, such as sex/gender and socioeconomic status. In this study, we aim to determine the effectiveness of a population-specific, diversity-oriented competence training designed to increase therapists' competencies to integrate aspects of diversity features in clinical assessment, diagnosis, and treatment of depressive disorders in Turkish- and Moroccan-Dutch patients. A group of 40 therapists were location-based assigned to either training or a control condition (no training). Self-reported diversity competence, a knowledge test, and therapists' satisfaction with training were used to monitor the training and to measure competence levels at baseline, post-training, and three-month follow-up. Attitude-awareness and knowledge components of the self-reported diversity competence and test-measured knowledge increased in the training condition. Most gains remained stable at follow-up except test-measured knowledge after controlling for percentage of ethnic minority patients in caseload. There were no changes regarding therapists' self-reported skills. Therapists expressed medium-high satisfaction with the training, acknowledging the relevance of diversity competence for their daily practice. Future training must ensure better adjustment to therapists' pre-existing knowledge and be followed by long-term efforts to maintain competence levels and enhance competence transfer within teams.

Assessing explanatory models and health beliefs: An essential but overlooked competency for clinicians

Explanatory models of illness – the way people perceive, interpret and respond to it – are mediated not only by the illness itself, but also by cultural and social contexts. This article discusses recent evidence showing how the exploration of explanatory models can help to shape treatment and outcomes for some of the most common categories of mental illness, and presents case studies illustrating dilemmas clinicians face when their explanatory models differ from those of their patients. It concludes with recommendations on how a culturally sensitive clinical approach based on the exploration of explanatory models during assessment and treatment can be used as an effective way of dealing with the complexity of patients' and families' needs.

Learning Objectives

• Appreciate the use of explanatory models in clinical practice

• Understand the relevance of explanatory models in relation to specific diagnostic categories of mental illness

• Recognise that dilemmas may arise if the explanatory models of the clinician and the patient differ, and be able to manage this tension

A CBT-based approach to medically unexplained symptoms

This article discusses a cognitive–behavioural therapy (CBT) approach to the treatment of medically unexplained symptoms that is based on the ‘five areas’ model of CBT. We describe a typical course of therapy and some of the common problems encountered during treatment. Emphasis is placed on the practical management of these conditions, and the focus is on symptoms as opposed to cause. We believe that this approach is widely applicable and could be used in a large range of settings to tackle these debilitating conditions. In writing this article we intended to provide an overview of patients with medically unexplained symptoms. The article would be of interest to staff within liaison psychiatry departments looking to set up a medically unexplained symptoms service and general psychiatry teams who may have contact with patients presenting with somatic symptoms. Psychiatric teams without access to a liaison department may also find this article interesting.

Medically unexplained symptoms in primary care

Adult patients with medically unexplained symptoms (somatisation) in primary care are numerous and make disproportionately high demands on health services. Most of these individuals are open to the suggestion that their illness reflects psychological needs. Empowering explanations from doctors can enable patient and doctor to work collaboratively in managing the problem and can reduce healthcare contacts. Parental medically unexplained symptoms, sexual and physical abuse in childhood and childhood neglect are associated with a greater risk of medically unexplained symptoms in adulthood. The overall prognosis for the majority of primary care patients with medically unexplained symptoms is very good. The two most common approaches to dealing with medically unexplained symptoms in primary care are stepped-care approaches and teaching general practitioners new skills to manage consultations more effectively.

Doctor-patient relationship and quality of life in Irritable Bowel Syndrome: an exploratory study of the potential mediating role of illness perceptions and acceptance

Irritable Bowel Syndrome (IBS) is a functional gastrointestinal disorder characterised by unpredictable bowel symptoms. These can be difficult to manage, consequently impacting quality of life (QoL). In addition, a strained doctor-patient relationship is independently reported in the qualitative literature. Given the doctor is often the first port of call for people with IBS, a difficult relationship may influence subsequent IBS management. Research suggests illness perceptions are important in determining IBS outcomes in therapy; however, their association with doctor-patient relationship and QoL is yet to be investigated. This exploratory study aimed to investigate the association between these constructs in IBS, as well as potential mediation by illness perceptions. Online questionnaires measuring doctor-patient relationship, illness perceptions, acceptance and QoL, were completed by 167 participants who reported an IBS diagnosis (144 female, mean age = 44.22 years, SD = 15.91 years). Bootstrapped pathway analysis was used to model the relationship and mediation effects. There was a significant positive correlation between patient-doctor relationship and QoL, r = .258, n = 167, p = .001. There was a significant indirect effect between doctor-patient relationship and QoL through illness coherence and acceptance (bootstrapped estimate = .058, 95%CI Lower-Upper = .02, .095, p = .002). No other indirect effects were observed in combination with good fit indices for the other illness perceptions. Findings suggest a doctor-patient relationship which fosters mutual understanding and helps patients make sense of symptoms, increases their ability to manage their IBS in a psychologically flexible manner, subsequently helping them maintain their QoL.

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

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

Association Between Patient Review of Systems Score and Somatization

Importance

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

Objectives

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

Design, Setting, and Participants

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

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

Epistemic injustice in healthcare encounters: evidence from chronic fatigue syndrome

Chronic fatigue syndrome or myalgic encephalomyelitis (CFS/ME) remains a controversial illness category. This paper surveys the state of knowledge and attitudes about this illness and proposes that epistemic concerns about the testimonial credibility of patients can be articulated using Miranda Fricker's concept of epistemic injustice. While there is consensus within mainstream medical guidelines that there is no known cause of CFS/ME, there is continued debate about how best to conceive of CFS/ME, including disagreement about how to interpret clinical studies of treatments. Against this background, robust qualitative and quantitative research from a range of countries has found that many doctors (and medical students) display uncertainty about whether CFS/ME is real, which may result in delays in diagnosis and treatment for patients. Strikingly, qualitative research evinces that patients with CFS/ME often experience suspicion by healthcare professionals, and many patients vocally oppose the effectiveness, and the conceptualisation, of their illness as psychologically treatable. We address the intersection of these issues and healthcare ethics, and claim that this state of affairs can be explained as a case of epistemic injustice (2007). We find evidence that healthcare consultations are fora where patients with CFS/ME may be particularly vulnerable to epistemic injustice. We argue that the (often unintentional) marginalisation of many patients is a professional failure that may lead to further ethical and practical consequences both for progressive research into CFS/ME, and for ethical care and delivery of current treatments among individuals suffering from this debilitating illness.

The association between multiple chemical sensitivity and mental illness: Evidence from a nationally representative sample of Canadians

OBJECTIVE

The goal of the present study was to investigate the association between multiple chemical sensitivity (MCS) and major depressive disorder (MDD), generalized anxiety disorder (GAD), MDD and GAD comorbidity (MDD+GAD), severe distress, and positive mental wellbeing.

METHODS

This cross-sectional investigation was carried out using the 2012 Canadian Community Health Survey - Mental Health Component. The study population consisted of 21,977 individuals aged 20 and older, from Canada's ten provinces. Odds ratios were computed using multinomial logistic regression to calculate estimates of the association between MCS and mental illness. All analyses were weighted to take into account the complex survey design.

RESULTS

Individuals with MCS had 2.37 (1.55, 3.64) times greater odds of MDD, 3.09 (1.80, 5.30) times greater odds of MDD+GAD, and 2.60 (1.67, 4.07) times greater odds of severe distress. No association between MCS and GAD was observed. A sex difference was observed with males with MCS having lower odds of positive mental wellbeing, whereas no association was observed in females.

CONCLUSIONS

The present study findings supported an association between MCS and mental illness. The causal mechanism supporting this association remains unclear.

Moving on: the BodyMind ApproachTM for medically unexplained symptoms

Purpose

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

Design/methodology/approach

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

Findings

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

Research limitations/implications

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

Practical implications

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

Social implications

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

Originality/value

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

Adult attachment insecurity is positively associated with medically unexplained chronic pain

BACKGROUND

Attachment insecurity (i.e. anxiety in relationships and/or discomfort in close relationships) is associated with self-reports of physical symptoms, medically unexplained symptoms and health conditions involving pain. Medically unexplained chronic pain (MUCP) may represent a particularly severe form of symptom reporting that is also characteristic of individuals with insecure attachment. This study investigated relationships between adult attachment style ratings and past-year MUCP in a sample of the general U.S. population and the ability of attachment style ratings to account for variance in past-year MUCP beyond that accounted for by potential confounders.

METHOD

Data from the National Comorbidity Survey Replication (N = 5645) were used. Attachment was assessed with an interview-administered version of a commonly used self-report measure of secure, anxious and avoidant attachment. MUCP was assessed with a brief interview. Depressive and anxiety disorders were included as covariates and were assessed with a fully structured interview based on DSM-IV criteria.

RESULTS

The past-year prevalence of MUCP was 2.45% (95% CI = 2.07-2.83). The two insecure attachment styles (i.e. anxious and avoidant) were positively associated with MUCP. These associations remained statistically significant after adjusting for demographic variables and depressive and anxiety disorders. When the two insecure attachment styles were considered together, only avoidant attachment remained significantly associated with MUCP.

CONCLUSION

Attachment insecurity ratings were positively associated with past-year MUCP and remained so after statistically adjusting for depressive and anxiety disorders. Further research aimed at understanding the mechanism(s) responsible for the association between attachment insecurity and MUCP is warranted.

SIGNIFICANCE

Consistent with earlier research regarding transient physical symptoms, medically unexplained chronic pain was associated with attachment insecurity. Understanding the mechanisms responsible for this association could guide treatment innovations.

Diabetes and the Motivated Patient: Understanding Perlocutionary Effect in Health Communication

Health care providers (HCP) understand the importance of keeping patients motivated but may be unaware how their words may have unintended negative effects upon their patient's lives. People with diabetes report being told by their HCP that they are "cured" or that they are praised for strides made in weight loss and/or lowered blood glucose, and interpret these messages in unexpected ways. For this paper, we focus upon one case to illustrate the depth and nuance of the patient-provider communication as it emerged within a larger interview-based ethnographic study. Audio-recorded interviews and transcriptions were analyzed discursively. Discourse analysis reveals the ways ideology affects how the patient responds to HCP's utterances and how this affects diabetes self-care. Findings indicate significant perlocutionary effects upon health outcomes, varying both positively and/or negatively. This study points to the importance of carefully considering the power of words and whenever possible knowing the patient's ideological orientation to their world. HCPs should be explicit and deliberate with their communication. Sensitization to the various ways patients hear and react to messages in a clinical setting may lead to improved health outcomes, especially for those with chronic health conditions such as diabetes mellitus.

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.

Psychological profile of individuals presenting with chronic cough

Chronic refractory cough (CRC) is a common problem in respiratory clinics. Adverse effects on quality of life are documented in the literature, but relatively little is known about the underlying psychological factors in this patient population. We aimed to investigate the association of psychological factors with chronic cough, comparing CRC to explained cough and non-cough groups. 67 patients attending a specialist cough clinic (CRC, n=25; explained cough, n=42) and 22 non-cough individuals participated. All participants completed the Hospital Anxiety & Depression Scale, Big Five Inventory (Personality), Chalder Fatigue Scale and Patient Health Questionnaire-15. Cough patients also completed the Illness Perception Questionnaire-Revised. Appropriate statistical analyses were used to compare participant groups. Chronic refractory coughers displayed significantly higher levels of anxiety, depression, fatigue and somatic physical symptoms than non-cough participants. Compared to explained coughers, there were higher depression and fatigue scores and significantly more negative illness representations (specifically, strong beliefs regarding negative consequences, lower illness coherence and higher emotional representations). "Explained" coughers reported significantly increased fatigue and somatic symptoms in comparison to non-coughers. The prevalence of fatigue, low mood, negative illness beliefs and increased physical symptom reporting should be considered in consultations and in developing novel interventions for CRC patients.

Group supervision for healthcare professionals within primary care for patients with psychosomatic health problems: a pilot intervention study

BACKGROUND

In primary health care, efficacious treatment strategies are lacking for these patients, although the most prominent symptoms accounting for consultation in primary care often cannot be related to any biological causes.

AIM

The aim was to explore whether group supervision from a specific phenomenological theory of psychosomatics could provide healthcare professionals treating patients with psychosomatic health issues within primary care a deeper understanding of these conditions and stimulate profession-specific treatment strategies. Our research questions were as follows: (i) What is the healthcare professionals' understanding of psychosomatics before and after the intervention? (ii) What are the treatment strategies for this group of patients before and after the intervention?

METHODS

The study was an explorative qualitative intervention pilot study. The six participants from a primary healthcare setting in a medium-sized city in Sweden participated in the study. A supervision group was formed, based on a mix of professions, age, gender and years of clinical experience. Supervision consisted of one 75-minutes meeting every month during the course of 6 months. Participants were interviewed before and after the supervision intervention.

FINDINGS

The study showed two distinct categories emerged from the data. One category of healthcare professionals espoused a psycho-educative approach, while the other lacked a cohesive approach. The supervision improved the second category of healthcare professionals' understanding of psychosomatics. The psycho-educative group did not change their understanding of psychosomatics, although they felt strengthened in their approach by the supervision. Profession-specific strategies were not developed.

IMPLICATIONS

This pilot study indicates that a relatively short supervision intervention can aid clinicians in their clinical encounters with these patients; however, further research is necessary to ascertain the value of the specific phenomenologically based supervision intervention.

The causal explanatory functions of medical diagnoses

Diagnoses in medicine are often taken to serve as explanations of patients' symptoms and signs. This article examines how they do so. I begin by arguing that although some instances of diagnostic explanation can be formulated as covering law arguments, they are explanatory neither in virtue of their argumentative structures nor in virtue of general regularities between diagnoses and clinical presentations. I then consider the theory that medical diagnoses explain symptoms and signs by identifying their actual causes in particular cases. While I take this to be largely correct, I argue that for a diagnosis to function as a satisfactory causal explanation of a patient's symptoms and signs, it also needs to be supplemented by understanding the mechanisms by which the identified cause produces the symptoms and signs. This mechanistic understanding comes not from the diagnosis itself, but rather from the theoretical framework within which the physician operates.

A taxonomy of explanations in a general practitioner clinic for patients with persistent "medically unexplained" physical symptoms

OBJECTIVE

To develop a taxonomy of explanations for patients with persistent physical symptoms.

METHODS

We analysed doctors' explanations from two studies of a moderately-intensive consultation intervention for patients with multiple, often "medically-unexplained," physical symptoms. We used a constant comparative method to develop a taxonomy which was then applied to all verbatim explanations.

RESULTS

We analysed 138 explanations provided by five general practitioners to 38 patients. The taxonomy comprised explanation types and explanation components. Three explanation types described the overall structure of the explanations: Rational Adaptive, Automatic Adaptive, and Complex. These differed in terms of who or what was given agency within the explanation. Three explanation components described the content of the explanation: Facts - generic statements about normal or dysfunctional processes; Causes - person-specific statements about proximal or distal causes for symptoms; Mechanisms - processes by which symptoms arise or persist in the individual. Most explanations conformed to one type and contained several components.

CONCLUSIONS

This novel taxonomy for classifying clinical explanations permits detailed classification of explanation types and content. Explanation types appear to carry different implications of agency.

PRACTICE IMPLICATIONS

The taxonomy is suitable for examining explanations and developing prototype explanatory scripts in both training and research settings.

Negotiating explanations: doctor-patient communication with patients with medically unexplained symptoms-a qualitative analysis

BACKGROUND

Patients with medically unexplained physical symptoms (MUPS) seek explanations for their symptoms, but often find general practitioners (GPs) unable to deliver these. Different methods of explaining MUPS have been proposed. Little is known about how communication evolves around these explanations.

OBJECTIVE

To examine the dialogue between GPs and patients related to explanations in a community-based clinic for MUPS. We categorized dialogue types and dialogue outcomes.

METHODS

Patients were ≥18 years with inclusion criteria for moderate MUPS: ≥2 referrals to specialists, ≥1 functional syndrome/symptoms, ≥10 on the Patient Health Questionnaire-15 and GP's judgement that symptoms were unexplained. We analysed transcripts of 112 audio-recorded consultations (39 patients and 5 GPs) from two studies on the Symptoms Clinic Intervention, a consultation intervention for MUPS in primary care. We used constant comparative analysis to code and classify dialogue types and outcomes.

RESULTS

We extracted 115 explanation sequences. We identified four dialogue types, differing in the extent to which the GP or patient controlled the dialogue. We categorized eight outcomes of the sequences, ranging from acceptance to rejection by the patient. The most common outcome was holding (conversation suspended in an unresolved state), followed by acceptance. Few explanations were rejected by the patient. Co-created explanations by patient and GP were most likely to be accepted.

CONCLUSION

We developed a classification of dialogue types and outcomes in relation to explanations offered by GPs for MUPS patients. While it requires further validation, it provides a framework, which can be used for teaching, evaluation of practice and research.

Symptoms and the body: Taking the inferential leap

The relationship between the conscious experience of physical symptoms and indicators of objective physiological dysfunction is highly variable and depends on characteristics of the person, the context and their interaction. This relationship often breaks down entirely in the case of "medically unexplained" or functional somatic symptoms, violating the basic assumption in medicine that physical symptoms have physiological causes. In this paper, we describe the prevailing theoretical approach to this problem and review the evidence pertaining to it. We then use the framework of predictive coding to propose a new and more comprehensive model of the body-symptom relationship that integrates existing concepts within a unifying framework that addresses many of the shortcomings of current theory. We describe the conditions under which a close correspondence between the experience of symptoms and objective physiology might be expected, and when they are likely to diverge. We conclude by exploring some theoretical and clinical implications of this new account.

Organic vs. functional neurological disorders: The role of childhood psychological trauma

Although the relationship between psychological trauma and medically unexplained symptoms (MUS) is well established, this relationship is less well understood in people with medically unexplained neurological symptoms. In the present study, we set out to compare people with functional neurological disorders, and organic neurological disorders, in terms of childhood and adulthood traumatic events, traumatic stress, emotional dysregulation and symptoms of depression and anxiety. We have hypothesised that those with functional neurological disorders would be more likely to report childhood and adulthood traumatic life events, traumatic symptomatology, emotional dysregulation and symptoms of anxiety and depression, compared to those with organic neurological disorders. Sample consisted of a consecutive series of people with functional neurological disorders and with organic neurological disorders (n=82) recruited from a hospital in Scotland. Participants completed measures of life events, traumatic stress, emotional regulation, anxiety and depression. The two groups were found to significantly differ in relation to all measures, with the MUS group being more likely to report childhood and adulthood life events, more severe emotional dysregulation, traumatic stress and symptoms of anxiety and stress. Logistic regression analysis revealed that exposure to childhood traumatic life events, specifically childhood sexual abuse, and childhood physical neglect, were the only factors which were significantly associated with membership of the medically unexplained neurological symptoms group. Although further research is required to confirm our findings, our results suggest that identifying and addressing the impact of childhood trauma, may alleviate distress and aid recovery from functional neurological disorders.

An exploratory study of the experience of fibromyalgia diagnosis in South Africa

Within the conceptual framework of 'medically-ill-defined' conditions, this article focuses on the experiences of 'diagnosis' through a narrative analysis of fibromyalgia (a chronic musculoskeletal pain disorder) in South Africa. In-depth interviews were used to collect narratives from 15 participants. The findings show how the contested and confusing experience of fibromyalgia diagnosis can be understood, by viewing the interactions that patients have with their practitioners, families, peers and colleagues. The currency of fibromyalgia as a diagnosis and the inequalities present in the South African health care system characterise the experiences of symptom recognition, diagnosis and treatment. The analysis reveals how those living with fibromyalgia search for diagnosis, and struggle to maintain legitimacy for their experience in the complex constellation of porous symptoms that appear infrequently. The findings of this study confirm the existing evidence that shows fibromyalgia to be a challenging illness experience, which is attributed to the lack of clarity and legitimacy, and high contestation that surrounds the condition. Additionally, this study presents the ways that limited access to diagnosis and treatment for fibromyalgia in the South African context shapes this specific illness experience, and the value of using narrative approaches to gain insight into how people live with hidden and poorly understood conditions in this environment.

Open Trial of Integrated Primary Care Consultation for Medically Unexplained Symptoms

Within primary care settings, patients with medically unexplained symptoms (MUS) are common, often present with comorbid psychopathology, and have high rates of healthcare utilization. Despite increased healthcare utilization, these patients often have poor outcomes that frustrate patients and providers alike. A behavioral consultation intervention for primary care patients with MUS (n = 10) was developed and assessed. All participants completed all intervention and assessment sessions and rated the intervention favorably. Participants self-report scores revealed statistically significant improvements from baseline to 3-month follow-up on physical functioning, mental functioning, and physical symptoms. Notwithstanding the limitations of open trial designs, these findings demonstrate high feasibility for a behavioral health consultation treatment model for patients with MUS and highlight the need for further research.

A global measure of sickness behaviour: Development of the Sickness Questionnaire

Symptoms after inflammatory activation, so-called sickness behaviour, overlap with trans-diagnostic complaints. As no self-report questionnaire to assess sickness behaviour exists, we aimed to develop such an instrument, the Sickness Questionnaire. Items responsive to experimentally induced inflammatory activation (randomized double-blind study endotoxin (0.6 ng/kg) versus placebo, n = 52) were selected and the statistical properties were examined in 172 primary care patients. A principal component analysis indicated a one-factor solution (Cronbach's alpha = .86). This 10-item scale correlated with depression ( β = .41, p < .001), anxiety ( β = .36, p < .001), self-rated health ( β = .28, p < .001) and a single item of feeling sick ( β = .55, p < .001). The results support the adequacy of Sickness Questionnaire as a brief assessment instrument of perceived sickness behaviour.

Nonepileptic seizures in the pediatric population: A qualitative study of patient and family experiences

OBJECTIVE

The objective of this study was to characterize the experience of nonepileptic seizures (NES) in young people (0-19years) and their families, referred to a UK specialist (tertiary) pediatric hospital. The topics investigated include: accessing healthcare, how the diagnosis was first explained, impact on home life and school, coping strategies, and ideas about naming and causes.

METHODS

Ten young people with NES and 29 family members took part in focus groups and telephone interviews. The data generated were analyzed qualitatively with thematic analysis.

RESULTS

Six themes were identified from participant experiences: upset and afraid, missing out, feeling misunderstood, confusion and uncertainty, less than epilepsy, and making sense and moving on. Participants described severe disruption to multiple domains of functioning at home, educationally, and in social activities. Young people felt guilty but also overprotected, while family members felt that they were failing as parents. The journey to diagnosis and treatment was seen as unnecessarily tortuous, with access to care and treatment pathways poorly defined. Participants described feeling that a wide variety of professionals did not believe their experiences, showed pejorative attitudes, and left them feeling isolated and marginalized. The young people and family members found NES a difficult disorder to understand and sometimes could not differentiate it from epilepsy. Epilepsy was used as a benchmark for several comparisons, including highlighting the lack of support for and information about NES. Families disliked being told that it was "good news" that their child did not have epilepsy and questioned if their child should be present during initial diagnostic discussions. Participants described stressful situations as a common trigger for NES. Young people showed ambivalence towards the need to understand the condition or the choice of name used for it, whereas family members considered this crucial for achieving recovery.

CONCLUSIONS

Young people and families who live with NES experience considerable distress and impairment. Pathways to diagnosis need to be streamlined, and better integration of pediatric, mental health, and educational services is required. The use of the "good news" story to discuss the diagnosis with families should be reconsidered, as families seem to interpret this as indicating that there is no effective treatment. Educational resources and support groups for young people and families are needed. Greater understanding of experiences may allow investigation of the pathogenic mechanism and inform possible management approaches. Training of health professionals in communicating with young people and families with NES must be improved.

Establishing a psychosomatic clinic in a low resource setting: Process, challenges, and opportunities

BACKGROUND

Specialty psychosomatic clinics are a felt need in low- and middle-income countries, but its benefits and challenges have not been reported so far.

AIMS

To describe the process, challenges, and opportunities that we encountered in setting up a specialty psychosomatic clinic at a government medical college in South India.

METHODS

The biweekly psychosomatic clinic was located in the Department of Psychiatry and manned by a multimodal team. Structured questionnaires were used to evaluate all patients. All psychiatric diagnoses were made as per International Classification of Diseases-10, clinical descriptions and diagnostic guidelines. Management comprised both pharmacotherapy and psychotherapeutic interventions.

RESULTS

A total of 72 patients registered for services in the 1(st) year of the clinic. The mean age of the sample was 36.6 years (range 14-60 years). A median of 2 years and 19 visits to various care providers had elapsed before their visit to the clinic. The index contact was a general practitioner in the majority of cases though an overwhelming majority (95.6%) had also sought specialist care. The most common diagnostic cluster was the somatoform group of disorders (50.0%). Antidepressants were the most commonly prescribed medications (70.6%).

CONCLUSION

The specialty psychosomatic clinic provided better opportunities for a more comprehensive evaluation of people with medically unexplained symptoms and better resident training and focused inter-disciplinary research. It describes a scalable model that can be replicated in similar resource constrained settings.

Managing Medically Unexplained Symptoms in Primary Care: A Narrative Review and Treatment Recommendations

Medically unexplained symptoms (MUS) are persistent physical symptoms in the absence of identifiable disease. MUS present a major challenge for primary care providers (PCPs) because complex symptom presentations, strained patient-physician relationships, and treatment-resistant symptoms can challenge a PCP's sense of competency. This review is intended to help PCPs understand the burden and theoretical context of MUS and to provide concise recommendations for managing MUS within primary care settings. Based on a narrative review of the literature, these recommendations emphasize in particular the importance of co-creating plausible explanations for MUS, understanding the pitfalls of consultations involving MUS, and developing multimodal treatment plans.

Endometriosis and fertility: women's accounts of healthcare

STUDY QUESTION

What do women with endometriosis recall being told about their fertility by their healthcare providers?

SUMMARY ANSWER

Women recalled being given varied information and advice, and gave examples of empathic and individualized care from doctors but also reported opportunities for enhancing clinical practice.

WHAT IS KNOWN ALREADY

There is evidence of an association between endometriosis and infertility. However, the strength of this association and the mechanisms that underlie it are not yet known nor are the implications for optimum healthcare.

STUDY DESIGN, SIZE, DURATION

This study used in-depth cross-sectional qualitative research methods.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women aged at least 18 years who lived in Victoria, Australia, and who had been surgically diagnosed with endometriosis were invited to participate in in-depth interviews about their experience of endometriosis. Twenty-six women of diverse backgrounds and experiences of endometriosis were interviewed from January to September 2014. Interviews were transcribed and analysed thematically using a data-driven approach.

MAIN RESULTS AND THE ROLE OF CHANCE

All women encountered medical professionals who were aware of the association between endometriosis and infertility, and who were proactive in ensuring fertility was addressed within endometriosis care. Women recalled being given varied, often conflicting, information about the consequences for their fertility of an endometriosis diagnosis. While some recounted positive experiences with the way their doctor communicated with them about endometriosis and fertility, all women reported adverse experiences such as receiving insufficient or inappropriate information or having their doctor prioritize their fertility over other aspects of their care, including quality of life and symptom relief, without first consulting them.

LIMITATIONS, REASONS FOR CAUTION

The perspectives of the women's doctors were not sought. The findings may not translate to settings that differ from a predominantly Anglo-Saxon country with both universal public and private healthcare systems.

WIDER IMPLICATIONS OF THE FINDINGS

Women's fertility needs and priorities differ for many reasons; there can be no 'one size fits all' approach to care. Women may benefit most from endometriosis care in which they are first asked about their fertility needs and preferences and in which medical uncertainty is acknowledged.

STUDY FUNDING/COMPETING INTERESTS

K.Y. receives a scholarship from the National Health and Medical Research Council and Australian Rotary Health. J.F. is supported by a Monash Professional Fellowship and the Jean Hailes Professional Fellowship which is funded by Perpetual Trustees Pty Ltd. The authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

Not applicable.

Which somatic symptoms are associated with an unfavorable course in Chinese patients with major depressive disorder?

INTRODUCTION

This was an analysis of the impact of somatic symptoms on the severity and course of depression in Chinese patients treated for an acute episode of major depressive disorder (MDD).

METHODS

Data were extracted from a 3-month prospective observational study which enrolled 909 patients with MDD in psychiatric care settings; this analysis focused on the Chinese patients (n=300). Depression severity was assessed using the Clinical Global Impression of Severity (CGI-S) and 17-item Hamilton Depression Rating Scale (HAMD-17); somatic symptoms were assessed using the patient-rated 28-item Somatic Symptom Inventory (SSI). Cluster analysis using baseline SSI scores grouped patients into three clusters with no/mild, moderate, or severe somatic symptoms. Four SSI factors (pain, autonomic symptoms, energy, and central nervous system) were defined, and regression analyses identified which factors were associated with remission at 3 months.

RESULTS

More than 70% of the patients had moderate or severe somatic symptoms. Baseline depression severity (HAMD-17 and CGI-S scores) was associated with more severe somatic symptoms. Remission rates differed between clusters of patients: 84.1%, 72.0%, and 55.3% for no/mild, moderate, and severe somatic symptoms, respectively (P=0.0034). Pain symptoms were the somatic symptoms more strongly associated with lower remission rates at 3 months.

DISCUSSION

Somatic symptoms are associated with greater clinical severity and lower remission rates. Among somatic symptoms, pain symptoms have the greatest prognostic value and should be taken into account when treating patients with depression.

Shift, Interrupted: Strategies for Managing Difficult Patients Including Those with Personality Disorders and Somatic Symptoms in the Emergency Department

Difficult patients are often those who present with a mix of physical and psychiatric symptoms, and seem refractory to usual treatments or reassurance. such patients can include those with personality disorders, those with somatization symptoms; they can come across as entitled, drug-seeking, manipulative, or simply draining to the provider. Such patients are often frequent visitors to Emergency Departments. Other reasons for difficult encounters could be rooted in provider bias or countertransference, rather than sole patient factors. Emergency providers need to have high awareness of these possibilities, and be prepared to manage such situations, otherwise workup can be sub-standard and dangerous medical mistakes can be made.