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

The PROSPECTS study: design of a prospective cohort study on prognosis and perpetuating factors of medically unexplained physical symptoms (MUPS)

OBJECTIVE

This paper describes the rationale and methodology of the PROSPECTS study, a study which aims to assess the course and prognosis of medically unexplained physical symptoms (MUPS), in terms of symptom severity and physical and social functioning. Additionally, it aims to identify different course types and to determine which factors are associated with these course types. Based on these factors, one or more prediction models will be developed.

METHODS

This study is a prospective, multicenter longitudinal cohort study with 1 baseline and 4 follow-up measurements during a 3 year period. 450 MUPS patients (age 18-70 years) will be included, divided over a primary care group, recruited in general practices, and a secondary/tertiary care group, recruited in specialized MUPS care programs.

MAIN STUDY PARAMETERS/ENDPOINTS

Primary outcome measures are severity of symptoms and degree of functional impairment. Secondary outcome measures are health care consumption and level of depressive symptoms and anxiety. Potential predictors are based on current theoretical models describing the perpetuation of MUPS and include somatic, psychological and social factors. Latent Class Growth Mixture Modeling will be used to identify distinct course types. Logistic regression analysis will be used to identify risk factors associated with these course types. Finally, one or more multivariate prediction models for the course of MUPS will be developed and tested.

CONCLUSION

The PROSPECTS study aims to enhance our insight into the course of MUPS, thus contributing to better recognition of future patients at risk for persistent MUPS.

Relationship between alexithymia and coping strategies in patients with somatoform disorder

PURPOSE

A multidimensional intervention integrating alexithymia, negative affect, and type of coping strategy is needed for the effective treatment of somatoform disorder; however, few studies have applied this approach to the three different dimensions of alexithymia in patients with somatoform disorder. The purpose of this study was to determine the relationship between type of coping strategy and three different dimensions of alexithymia expressed in patients.

PATIENTS AND METHODS

A total of 196 patients with somatoform disorder completed the 20-item Toronto Alexithymia Scale, the Zung Self-Rating Depression Scale, the Spielberger State-Trait Anxiety Inventory, the Somatosensory Amplification Scale, and the Lazarus Stress Coping Inventory. The relationships between alexithymia (Toronto Alexithymia Scale - 20 score and subscales), demographic variables, and psychological inventory scores were analyzed using Pearson's correlation coefficients and stepwise multiple regression analysis.

RESULTS

The mean Toronto Alexithymia Scale - 20 total score (56.1±10.57) was positively correlated with the number of physical symptoms as well as with psychopathology scores (Self-Rating Depression Scale, State-Trait Anxiety Inventory trait, state, and Somatosensory Amplification Scale), but negatively correlated with planful problem solving, confrontive coping, seeking social support, and positive reappraisal coping scores. With respect to coping strategy, multiple regression analyses revealed that "difficulty in identifying feelings" was positively associated with an escape-avoidance strategy, "difficulty in describing feelings" was negatively associated with a seeking social support strategy, and "externally oriented thinking" was negatively associated with a confrontive coping strategy.

CONCLUSION

Alexithymia was strongly associated with the number of somatic symptoms and negative affect. Patients with high "difficulty in describing feelings" tend to rely less on seeking social support, and patients with high "externally oriented thinking" tend to rely less on confrontive coping strategies. The coping skills intervention implemented should differ across individuals and should be based on the alexithymia dimension of each patient.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Health anxiety disorders in older adults: conceptualizing complex conditions in late life

Health anxiety disorders (e.g., hypochondriasis) are prevalent but understudied in older adults. Existing research suggests that severe health anxiety has a late age of onset, perhaps because of comorbidity with physical health conditions that are more likely to occur with aging. Despite being under diagnosed in later life due to a lack of age-appropriate diagnostic criteria, significant positive associations with age suggest that health anxiety disorders are more prevalent in older than younger adults. Preliminary research also highlights the complexity of these disorders in older adults and the potential importance of medical morbidity as a risk factor. This review explores the complexities of health anxiety disorders in later life with a focus on understanding defining features, prevalence rates, correlates, assessment, diagnosis, and treatment. We offer a theoretical model of the development of severe health anxiety among older adults to encourage further research on this important and under-studied topic.

Post-graduate education for medical specialists focused on patients with medically unexplained physical symptoms; development of a communication skills training programme

OBJECTIVE

Stepwise description of the development of a post-graduate communication skills training programme for medical specialists focused on patients with medically unexplained physical symptoms (MUPS) to improve specialist interaction with MUPS patients.

METHODS

Using the 'intervention mapping approach' we accomplished a needs assessment (literature study and pilot) to formulate intervention objectives and identify methods and techniques for a MUPS-focused communication skills training programme for medical specialists.

RESULTS

A 14-h training programme which consists of experiential learning, role-play and feedback. Using skills from Cognitive Behavioural Therapy, medical specialists are stimulated to explore interrelating factors that reinforce symptoms, to reassure patients effectively and to provide plausible and understandable explanations for MUPS. Dealing with complex referrals and informing GPs properly are also practiced.

CONCLUSION

By applying the 'intervention mapping approach' we were able to create a feasible and promising intervention to improve specialist interaction with MUPS patients. Intervention effects are currently being assessed in a randomized controlled trial.

PRACTICE IMPLICATIONS

If the RCT demonstrates sufficient effectiveness and efficiency of the MUPS focused communication skills training programme for medical specialists the intervention could be embedded in post-graduate education of medical specialists and residents.

GP perspectives of irritable bowel syndrome--an accepted illness, but management deviates from guidelines: a qualitative study

Background

The estimated prevalence of irritable bowel syndrome (IBS) is 10%. Up to one third of patients develop chronic symptoms, which impact on everyday functioning and psychological wellbeing. Guidelines suggest an increased role for primary care in the management of patients with IBS, and referral for psychological interventions. Literature reports dissatisfaction and frustration experienced by both patients with IBS and healthcare professionals. The aim of this study was to explore the perspectives of general practitioners (GPs) in relation to the diagnosis and management of IBS and their views on the potential use of a risk assessment tool to aid management decisions for patients with IBS in primary care.

Methods

This was a qualitative study using face-to-face semi-structured interviews with GPs in North West England. Interviews were fully transcribed and data analyzed using constant comparison across interviews. Tensions between GP accounts and the NICE guideline for the management of IBS were highlighted.

Results

GPs described IBS as a diagnosis of exclusion and the process as tentative and iterative, with delay in adding a Read code to the patient record until they were confident of the diagnosis. Whilst GPs accepted there was a link between IBS and psychological symptoms they suggested that the majority of patients could be managed within primary care without referral for psychological interventions, in conflict with the NICE guideline. They did not feel that a risk assessment tool for patients with IBS would be helpful.

Conclusions

This study highlights the tensions between evidence recognizing the need to identify patients whose symptoms may become chronic and offer pro-active care, including referral for psychological therapies, and the perspectives of GPs managing patients in every-day clinical practice. The reluctance of GPs to refer patients for evidence-based psychological treatments may have implications for commissioning services and patient care.

Specific collaborative group intervention for patients with medically unexplained symptoms in general practice: a cluster randomized controlled trial

BACKGROUND

Patients with medically unexplained symptoms (MUS) are frequent in primary care and substantially impaired in their quality of life (QoL). Specific training of general practitioners (GPs) alone did not demonstrate sustained improvement at later follow-up in current reviews. We evaluated a collaborative group intervention.

METHODS

We conducted a cluster randomized controlled trial. Thirty-five GPs recruited 304 MUS patients (intervention group: 170; control group: 134). All GPs were trained in diagnosis and management of MUS (control condition). Eighteen randomly selected intervention GPs participated in training for a specific collaborative group intervention. They conducted 10 weekly group sessions and 2 booster meetings in their practices, together with a psychosomatic specialist. Six and 12 months after baseline, QoL was assessed with the Short-Form 36. The primary outcome was the physical composite score (PCS), and the secondary outcome was the mental composite score (MCS).

RESULTS

At 12 months, intention-to-treat analyses showed a significant between-group effect for the MCS (p = 0.023) but not for the PCS (p = 0.674). This effect was preceded by a significant reduction of somatic symptom severity (15-item somatic symptom severity scale of the Patient Health Questionnaire, PHQ-15) at 6 months (p = 0.008) that lacked significance at 12 months (p = 0.078). As additional between-group effects at 12 months, per-protocol analyses showed less health anxiety (Whiteley-7; p = 0.038) and less psychosocial distress (PHQ; p = 0.024); GP visits were significantly (p = 0.042) reduced in the intervention group.

CONCLUSIONS

Compared to pure GP training, collaborative group intervention achieved a progressive, clinically meaningful improvement in mental but not physical QoL. It could bridge gaps between general practice and mental health care.

Overview of data-synthesis in systematic reviews of studies on outcome prediction models

Background

Many prognostic models have been developed. Different types of models, i.e. prognostic factor and outcome prediction studies, serve different purposes, which should be reflected in how the results are summarized in reviews. Therefore we set out to investigate how authors of reviews synthesize and report the results of primary outcome prediction studies.

Methods

Outcome prediction reviews published in MEDLINE between October 2005 and March 2011 were eligible and 127 Systematic reviews with the aim to summarize outcome prediction studies written in English were identified for inclusion.

Characteristics of the reviews and the primary studies that were included were independently assessed by 2 review authors, using standardized forms.

Results

After consensus meetings a total of 50 systematic reviews that met the inclusion criteria were included. The type of primary studies included (prognostic factor or outcome prediction) was unclear in two-thirds of the reviews. A minority of the reviews reported univariable or multivariable point estimates and measures of dispersion from the primary studies. Moreover, the variables considered for outcome prediction model development were often not reported, or were unclear. In most reviews there was no information about model performance. Quantitative analysis was performed in 10 reviews, and 49 reviews assessed the primary studies qualitatively. In both analyses types a range of different methods was used to present the results of the outcome prediction studies.

Conclusions

Different methods are applied to synthesize primary study results but quantitative analysis is rarely performed. The description of its objectives and of the primary studies is suboptimal and performance parameters of the outcome prediction models are rarely mentioned. The poor reporting and the wide variety of data synthesis strategies are prone to influence the conclusions of outcome prediction reviews. Therefore, there is much room for improvement in reviews of outcome prediction studies.

Multiple symptoms and medically unexplained symptoms--closely related concepts in general practitioners' evaluations. A linked doctor-patient study

OBJECTIVES

Symptoms for which doctors cannot find a clear medical explanation, medically unexplained symptoms (MUS), represent a challenge in medical practice. Recent proposals to define this phenomenon are based on patients' symptom count, without distinguishing between medically explained and unexplained symptoms. We describe how general practitioners (GPs) evaluate multiple and medically unexplained symptoms, and how these dimensions are interconnected. Furthermore, we explore how the number of patient-reported symptoms is associated with the two axes.

METHODS

A multi-centre, doctor-patient-linked cross-sectional study in general practice. GPs rated consecutive patients along two 11 point ordinal scales assessing multiple (Multi-scale) and medically unexplained symptoms (MUS-scale). Patients completed a questionnaire addressing 38 symptoms experienced during the previous week and 866 linked questionnaires were available for analysis.

RESULTS

GPs used the whole range of the scales, rating only a minority of the patients as "0 (not at all)". The two scales were highly correlated (r=0.80), with a quadratically weighted kappa of 0.73, reflecting substantial agreement between the scales. MUS-scores were highest in middle age. There was a tendency that Multi-scores increased with age and that correlations between the scales decreased with age, in both sexes, although partly non-significant. The number of patient-reported symptoms was moderately correlated with the two scales.

CONCLUSION

Multisymptomatology captures MUS as a continuous construct to a great degree in GPs' clinical evaluations, although the two cannot be regarded as the same phenomenon. Patient-reported symptoms seem to be a less valid proxy for MUS.

How patients and family physicians communicate about persistent medically unexplained symptoms. A qualitative study of video-recorded consultations

OBJECTIVE

To study doctor-patient interaction styles in consultations with patients presenting persistent medically unexplained symptoms (MUS) and to study on which stages of the consultation patients and doctors focus within the available time.

METHODS

exploratory, qualitative analysis of transcripts of 20 videotaped consultations between family physicians (FP) and persistent MUS patients.

RESULTS

Patients presented many symptoms in a rather unstructured way. However, FPs hardly used structuring techniques such as agenda setting and summarizing. Patients with persistent MUS got much opportunity to tell their story, but the reasons for encounter, their beliefs and concerns were not discussed in a structured manner. Although consultations were focused on these issues, mostly patients themselves initiated discussion of their ideas, concerns and expectations. FPs' extensive explanations of the origin of the symptoms often did not take patients' beliefs and concerns into account.

CONCLUSIONS

Due to patients' multiple symptom presentation and the absence of FPs' structuring techniques, consultations of persistent MUS patients proceed rather unfocused. However, patients got ample opportunity to tell their story.

PRACTICE IMPLICATIONS

Persistent MUS patients might benefit from structured consultations focused on the exploration of the reason for encounter.

Somatic symptoms in consultation-liaison psychiatry

In medically ill patients the term 'somatic symptoms' is used to understand those symptoms which cannot be fully understood in the light of existing medical illness(es). These include a number of physical symptoms and also certain clinical syndromes such as irritable bowel syndrome, fibromyalgia, and chronic fatigue syndrome among others. However, it is increasingly recognized that such patients have larger degrees of psychological morbidities, especially depressive and anxiety disorders, and have disproportionately elevated rates of medical care utilization, including outpatient visits, hospitalizations and total healthcare costs. In view of this psychological morbidity, significant distress and functional impairment, the role of the consultation-liaison psychiatrist is prominent in the management of these patients. A consultation-liaison (CL) psychiatrist is expected to be part of the primary care team to manage patient with unexplained SS, and at the same time is expected to guide colleagues to practice a patient-centred approach to improve the outcome of patients with such symptoms. The clinical work of a CL psychiatrist involves evaluation of patients with medically unexplained symptoms for probable psychiatric disorders and treatment of psychiatric morbidity and also management of patients without psychiatric morbidity. Management strategies include reattribution, cognitive behaviour therapy and antidepressants, with each strategy showing varying degrees of success.

Hospitalization for physical illness and risk of subsequent suicide: a population study

OBJECTIVE

To examine suicide risk in relation to physical illness across a broad range of illnesses, including hospitalization history, specific organ or system illness and comorbidity.

DESIGN

A nested case-control study.

SETTING

Data were retrieved from five Danish national registers.

SUBJECTS

On the basis of the entire population of Denmark, this study included 27 262 suicide cases, and 468 007 live controls matched for sex and date of birth.

MAIN OUTCOME MEASURES

Risk of suicide was assessed using conditional logistic regression.

RESULTS

In the study population, 63.5% of suicide cases and 44.5% of comparison controls had a history of hospitalization for physical illness. A physical illness significantly increased the risk of subsequent suicide (incidence rate ratios 2.13, 95% CI 2.07-2.18) with a substantially greater effect in women than in men (P < 0.01). The elevated risk increased progressively with frequency and recency of hospitalization and was significant for diseases occurring in all organs or systems of the body. Comorbidity involving several organs or systems increased the risk substantially. The associated estimates were to some extent reduced but remained highly significant after adjustment for psychiatric history and socio-economic status. Taking into account both prevalence and adjusted effect size, physical illness accounted for 24.4%, 21.0% and 32.3% of population attributable risk for suicide in total, male and female populations, respectively.

CONCLUSIONS

Physical illness constitutes a significant risk factor for suicide independent of psychiatric and socio-economic factors. Clinicians treating physically ill patients should be aware of the risk, especially amongst those with multiple or recent hospitalizations, or multiple comorbidities.

Prevalence of somatoform disorders and medically unexplained symptoms in old age populations in comparison with younger age groups: a systematic review

OBJECTIVE

To review current knowledge regarding the prevalence of somatization problems in later life by level of caseness (somatoform disorders and medically unexplained symptoms, MUS) and to compare these rates with those in middle-aged and younger age groups.

METHOD

A systematic search of the literature published from 1966 onwards was conducted in the Pubmed and EMBASE databases.

RESULTS

Overall 8 articles, describing a total of 7 cohorts, provided data of at least one prevalence rate for somatoform disorders or MUS for the middle-aged (50-65 years) or older age (≥65 years) group. Prevalence rates for somatoform disorders in the general population range from 11 to 21% in younger, 10 to 20% in the middle-aged, and 1.5 to 13% in the older age groups. Prevalence rates for MUS show wider ranges, of respectively 1.6-70%, 2.4-87%, and 4.6-18%, in the younger, middle, and older age groups, which could be explained by the use of different instruments as well as lack of consensus in defining MUS.

CONCLUSION

Somatoform disorders and MUS are common in later life, although the available data suggest that prevalence rates decline after the age of 65 years. More systematic research with special focus on the older population is needed to understand this age-related decline in prevalence rates.

Construct validity and descriptive validity of somatoform disorders in light of proposed changes for the DSM-5

OBJECTIVE

Current diagnostic criteria for somatoform disorders demand revisions due to their insufficient clinical as well as scientific usability. Various psychological and behavioral characteristics have been considered for the proposed new category Somatic Symptom Disorder (SSD). With this study, we were able to jointly assess the validity of these variables in an inpatient sample.

METHODS

Using a cross-sectional design, we investigated N=456 patients suffering from somatoform disorder, anxiety, or depression. Within one week after admission to the hospital, informed consent was obtained and afterwards, a diagnostic interview and a battery of self-report questionnaires were administered. Logistic regression analyses were performed to determine which variables significantly add to construct and descriptive validity.

RESULTS

Several features, such as somatic symptom severity, health worries, health habits, a self-concept of being weak, and symptom attribution, predicted physical health status in somatization. Overall, our model explained about 50% of the total variance. Furthermore, in comparison with anxious and depressed patients, health anxiety, body scanning, and a self-concept of bodily weakness were specific for DSM-IV somatoform disorders and the proposed SSD.

CONCLUSIONS

The present study supports the inclusion of psychological and behavioral characteristics in the DSM-5 diagnostic criteria for somatoform disorders. Based on our results, we make suggestions for a slight modification of criterion B to enhance construct validity of the Somatic Symptom Disorder.

Symptom load and functional status: results from the Ullensaker population study

Background

There is evidence to support that the number of self-reported symptoms is a strong predictor of health outcomes. In studies examining the link between symptoms and functional status, focus has traditionally been on individual symptoms or specific groups of symptoms. We aim to identify associations between the number of self-reported symptoms and functional status.

Methods

A questionnaire was sent to people in seven age groups (N = 3227) in Ullensaker municipality in Southern Norway. The Standardised Nordic Questionnaire and the Subjective Health Complaints Inventory were used to record 10 musculoskeletal symptoms and 13 non-musculoskeletal symptoms, respectively. Four COOP-WONCA charts were used to measure functional status.

Results

We found a strong linear association between the number of self-reported symptoms and functional status. The number of symptoms explained 39.2% of the variance in functional status after adjusting for the effects of age and sex. Including individual symptoms instead of only the number of symptoms made little difference to the effect of musculoskeletal pain but affected the influence of non-muscular symptoms. Including even minor problems captured substantially more of the variance in functional status than including only serious problems.

Conclusions

The strong association between the number of symptoms and functional status, irrespective of type of symptom, might indicate that the symptoms share some common characteristics. The simple act of counting symptoms may provide an approach to study the relationships between health and function in population studies and might be valuable in research on medically unexplained conditions.

Health care use by patients with somatoform disorders: a register-based follow-up study

OBJECTIVE

Studies have shown a greater use of medical than mental health services in patients with somatoform disorders. However, not many studies are based on structured interviews and include the entire somatoform spectrum of diagnoses. We conducted a register-based case-control study to investigate medical care use prior to and three years after diagnosis in patients with somatoform disorders.

METHODS

We included 380 patients with somatoform diagnoses (SCID-NP for DSM-IIIR) in a case-control study and compared them with 174 patients with anxiety disorders and 5540 controls from the background population. Data from the Danish National Registers were used to assess health care use in both primary and secondary care.

RESULTS

Somatoform patients incurred 2.11 (2.09-2.12) times the primary care visits of controls. They had 3.12 (3.08-3.16) times as many somatic bed-days than controls and 3.94 (3.91-3.97) as many psychiatric bed-days. Primary care use remained stable 3 years after diagnosis (p = 0.14) and the award of disability pension (p = 0.82). However, the number of somatic admissions decreased from 5.64 to 2.76 (p = 0.0004) 3 years after diagnosis. Somatization had an independent effect on health care use when controlling for psychiatric comorbidity.

CONCLUSIONS

Patients with somatoform disorders make significantly greater use of health care services than do controls and patients with anxiety. Somatoform patients made more use of psychiatric services than expected. The use of somatic health care was independent of psychiatric comorbidity. Primary care use and disability pension award were not influenced by proper diagnosing of somatoform disorders whereas number of somatic admissions were halved.

Emerging themes in the revision of the classification of somatoform disorders

The somatoform disorders, as currently defined in DSM-IV and ICD-10, have been criticized for their complexity and poor clinical utility. In this paper we consider these criticisms as well as the conceptual question of whether there is sufficient evidence for classifying them as mental and behavioural disorders. The review suggests that, as currently defined, somatoform disorders do not fulfil a recently articulated set of criteria for mental and behavioural disorders. In particular, the disorders are not defined according to positive psychological and behavioural disorders and evidence is sparse to support their classification as different and distinct diagnoses. Any revision of the disorders should not be based on 'medically unexplained' symptoms. Rather, the relevant diagnoses should include a combination of bothersome somatic symptoms with several other psychological features including beliefs about somatic symptoms and evidence of marked concerns about health and illness. Finally, the review presents a set of proposals for the revision of these disorders, by the Somatic Disorders and Dissociative Disorders Working Group of the WHO International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders, which attempt to take account of the criticisms and current understanding of somatic experiences.

Non-specific, functional, and somatoform bodily complaints

BACKGROUND

4-10% of the general population and 20% of primary care patients have what are called "non-specific, functional, and somatoform bodily complaints." These often take a chronic course, markedly impair the sufferers' quality of life, and give rise to high costs. They can be made worse by inappropriate behavior on the physician's part.

METHODS

The new S3 guideline was formulated by representatives of 29 medical and psychological specialty societies and one patient representative. They analyzed more than 4000 publications retrieved by a systematic literature search and held two online Delphi rounds and three consensus conferences.

RESULTS

Because of the breadth of the topic, the available evidence varied in quality depending on the particular subject addressed and was often only of moderate quality. A strong consensus was reached on most subjects. In the new guideline, it is recommended that physicians should establish a therapeutic alliance with the patient, adopt a symptom/coping-oriented attitude, and avoid stigmatizing comments. A biopsychosocial diagnostic evaluation, combined with sensitive discussion of signs of psychosocial stress, enables the early recognition of problems of this type, as well as of comorbid conditions, while lowering the risk of iatrogenic somatization. For mild, uncomplicated courses, the establishment of a biopsychosocial explanatory model and physical/social activation are recommended. More severe, complicated courses call for collaborative, coordinated management, including regular appointments (as opposed to ad-hoc appointments whenever the patient feels worse), graded activation, and psychotherapy; the latter may involve cognitive behavioral therapy or a psychodynamic-interpersonal or hypnotherapeutic/imaginative approach. The comprehensive treatment plan may be multimodal, potentially including body-oriented/non-verbal therapies, relaxation training, and time-limited pharmacotherapy.

CONCLUSION

A thorough, simultaneous biopsychosocial diagnostic assessment enables the early recognition of non-specific, functional, and somatoform bodily complaints. The appropriate treatment depends on the severity of the condition. Effective treatment requires the patient's active cooperation and the collaboration of all treating health professionals under the overall management of the patient's primary-care physician.

Physical functioning in older persons with somatoform disorders: a pilot study

OBJECTIVES

The primary objective of this study was to systematically examine the physical functioning of older persons with somatoform disorders, as this has never been carried out before. Second, we wanted to test our hypothesis that higher somatic disease burden in patients with somatoform disorders is associated with a higher level of somatisation.

DESIGN AND SETTING

Observational study of patients referred for medically unexplained symptoms (MUS) to our outpatient mental health center for older adults. The patients were offered a standardized, multidisciplinary diagnostic procedure, including a comprehensive geriatric assessment. Inter-rater reliability between two geriatricians assessing the contribution of somatic pathology to the main somatic symptom was assessed.

PARTICIPANTS

A total of 37 patients referred for MUS (mean age 75 ± 6 years).

MEASUREMENTS

Timed up and go test (TUG) and hand grip strength were used as measures for frailty; the Cumulative Index Rating Scale for Geriatrics (CIRS-G) sum score and severity index measured the burden of cumulative somatic morbidity. The Groningen Activity Rating Scale (GARS) measured functional status. The Whitely Index was used as measure for somatisation.

RESULTS

Patients' main symptom could be completely explained by a somatic disease in 3/37 (8%) patients (kappa between geriatricians = 0.72). A total of 32 patients met the criterion for a Somatoform Disorder according to DSM-IV-TR criteria, but somatic comorbidity partially explained the main symptom in 15/32 patients. These patients were older (P = .049), had more somatic comorbidity (P = .049), a slower gait speed (TUG, P = .035), a lower hand grip strength (P = .050), and a lower functional status (P = .30) compared with the 17 patients without any explanation for their main somatic symptom. In contrast to our hypothesis, a higher level of somatisation was associated with less somatic disease burden.

CONCLUSION

Geriatric assessment has an important added value in older patients referred with medically unexplained symptoms because in half of these patients, symptoms can be partially or fully explicable following careful assessment of comorbidity and frailty.

Utilisation of search filters in systematic reviews of prognosis questions

BACKGROUND

Search filters are designed to increase efficiency of information retrieval and can be particularly useful in limiting the large numbers of articles retrieved for systematic reviews (SRs). Existing published prognosis search filters (or hedges) have lower sensitivity and precision values than their therapy counterparts.

OBJECTIVES

Taking into account the relatively poor performance of prognosis filters, this study seeks to identify which methods of limiting search results to prognostic studies are most often used by SR teams.

METHODS

One hundred and three SRs of prognostic studies published in 2009 and indexed in MEDLINE were retrieved. Each review's search strategy was reviewed and prognosis-related search terms were extracted.

RESULTS

Forty-seven of 103 studies used prognosis-related terms to limit the search. Six SRs of 103 did not specify their search terms, and the remaining 50 SRs used content terms only (no terms related to methodology or prognosis). Of the 47 strategies using prognosis-related terms, only six used a published filter. Many SRs used few or poorly selected prognosis-related search terms which are unlikely to provide the sensitivity generally sought for SRs.

CONCLUSIONS

Published prognosis search filters are used in only a small minority of prognosis SRs.

Estimating the prevalence of medically unexplained symptoms from primary care records

OBJECTIVES

To develop models to estimate the likely prevalence of medically unexplained symptoms (MUS) and severe MUS in a primary care practice from existing patient electronic records collected in the previous 2 years for secondary prevention and commissioning of psychological treatment.

STUDY DESIGN

Cross-sectional survey comparing general practitioners' (GPs) assessment of the presence or absence of MUS and severe MUS with clinical, demographic and service use variables associated with MUS or functional somatic syndromes from previous research in the patient's routine electronic record over the previous 2 years.

METHODS

Seventeen GPs from eight practices identified cases of MUS and severe MUS in 828 consecutive consulters in primary care. Models of variables associated with MUS and severe MUS were constructed using multivariate multilevel logistic regression. The predictive validity of the final models was tested, comparing predicted with observed data and expected prevalence rates from the literature.

RESULTS

Models to predict MUS and severe MUS had areas under the receiver operating characteristic curve of 0.70 [95% confidence interval (CI) 0.65-0.74] and 0.76 (95% CI 0.70-0.82), respectively. Both models showed adequate goodness of fit with observed data, and had good predictive validity compared with the expected prevalence of MUS, severe MUS, and anxiety or depression.

CONCLUSION

Models to predict the prevalence of MUS and severe MUS from routine practice records for commissioning purposes were successfully developed, but they require independent validation before general use. The sensitivity of these models was too low for use in clinical screening.

Clinical findings and pain symptoms as potential risk factors for chronic TMD: descriptive data and empirically identified domains from the OPPERA case-control study

Clinical characteristics might be associated with temporomandibular disorders (TMD) because they are antecedent risk factors that increase the likelihood of a healthy person developing the condition or because they represent signs or symptoms of either subclinical or overt TMD. In this baseline case-control study of the multisite Orofacial Pain: Prospective Evaluation and Risk Assessment (OPPERA) project, 1,633 controls and 185 cases with chronic, painful TMD completed questionnaires and received clinical examinations. Odds ratios measuring association between each clinical factor and TMD were computed, with adjustment for study-site as well as age, sex, and race/ethnicity. Compared to controls, TMD cases reported more trauma, greater parafunction, more headaches and other pain disorders, more functional limitation in using the jaw, more nonpain symptoms in the facial area, more temporomandibular joint noises and jaw locking, more neural or sensory medical conditions, and worse overall medical status. They also exhibited on examination reduced jaw mobility, more joint noises, and a greater number of painful masticatory, cervical, and body muscles upon palpation. The results indicated that TMD cases differ substantially from controls across almost all variables assessed. Future analyses of follow-up data will determine whether these clinical characteristics predict increased risk for developing first-onset pain-related TMD PERSPECTIVE: Clinical findings from OPPERA's baseline case-control study indicate significant differences between chronic TMD cases and controls with respect to trauma history, parafunction, other pain disorders, health status, and clinical examination data. Future analyses will examine their contribution to TMD onset.

Depression and sickness behavior are Janus-faced responses to shared inflammatory pathways

It is of considerable translational importance whether depression is a form or a consequence of sickness behavior. Sickness behavior is a behavioral complex induced by infections and immune trauma and mediated by pro-inflammatory cytokines. It is an adaptive response that enhances recovery by conserving energy to combat acute inflammation. There are considerable phenomenological similarities between sickness behavior and depression, for example, behavioral inhibition, anorexia and weight loss, and melancholic (anhedonia), physio-somatic (fatigue, hyperalgesia, malaise), anxiety and neurocognitive symptoms. In clinical depression, however, a transition occurs to sensitization of immuno-inflammatory pathways, progressive damage by oxidative and nitrosative stress to lipids, proteins, and DNA, and autoimmune responses directed against self-epitopes. The latter mechanisms are the substrate of a neuroprogressive process, whereby multiple depressive episodes cause neural tissue damage and consequent functional and cognitive sequelae. Thus, shared immuno-inflammatory pathways underpin the physiology of sickness behavior and the pathophysiology of clinical depression explaining their partially overlapping phenomenology. Inflammation may provoke a Janus-faced response with a good, acute side, generating protective inflammation through sickness behavior and a bad, chronic side, for example, clinical depression, a lifelong disorder with positive feedback loops between (neuro)inflammation and (neuro)degenerative processes following less well defined triggers.

A randomized clinical trial of mindfulness-based cognitive therapy versus unrestricted services for health anxiety (hypochondriasis)

Objective: The efficacy and acceptability of existing psychological interventions for health anxiety (hypochondriasis) are limited. In the current study, the authors aimed to assess the impact of mindfulness-based cognitive therapy (MBCT) on health anxiety by comparing the impact of MBCT in addition to usual services (unrestricted services) with unrestricted services (US) alone. Method: The 74 participants were randomized to either MBCT in addition to US (n = 36) or US alone (n = 38). Participants were assessed prior to intervention (MBCT or US), immediately following the intervention, and 1 year postintervention. In addition to independent assessments of diagnostic status, standardized self-report measures and assessor ratings of severity and distress associated with the diagnosis of hypochondriasis were used. Results: In the intention-to-treat (ITT) analysis (N = 74), MBCT participants had significantly lower health anxiety than US participants, both immediately following the intervention (Cohen's d = 0.48) and at 1-year follow-up (d = 0.48). The per-protocol (PP) analysis (n = 68) between groups effect size was d = 0.49 at postintervention and d = 0.62 at 1-year follow-up. Mediational analysis showed that change in mindfulness mediated the group changes in health anxiety symptoms. Significantly fewer participants allocated to MBCT than to US met criteria for the diagnosis of hypochondriasis, both immediately following the intervention period (ITT 50.0% vs. 78.9%; PP 47.1% vs. 78.4%) and at 1-year follow-up (ITT 36.1% vs. 76.3%; PP 28.1% vs. 75.0%). Conclusions: MBCT may be a useful addition to usual services for patients with health anxiety.

Reasons for encounter and symptom diagnoses: a superior description of patients' problems in contrast to medically unexplained symptoms (MUS)

This is a review of the literature on the role of symptoms in family practice, with a focus on the diagnostic approach in family medicine (FM). We found two, contrasting, approaches to reducing symptoms presented by patients in primary care, especially those which do not immediately allow the definition of a disease-label diagnosis. Years of research into 'medically unexplained symptoms' (MUS) has failed to support an international body of knowledge and cannot convincingly support the philosophy on which the reduction itself is based. This review supports the approach of researching reasons for encounter as they present to the family doctor, without artificial mind-body metaphors. The medical model is shown to be an incomplete reduction of FM, and the concept of MUS fails to improve this situation. A new model based on a substantial paradigm shift is needed. That model should be the biopsychosocial model, reflected in the philosophical concepts of the International Classification of Primary Care and the value of the patient's 'reason for encounter'. There is more to life than medicine may diagnose, and FM should strive to move closer to the lives of our patients than the medical model alone could allow.

The epidemiology of multiple somatic symptoms

BACKGROUND

The risk factors for a high total somatic symptom count are unclear; and it is not known whether total somatic symptoms count is a predictor of impaired health status.

METHOD

A prospective population-based cohort study in North West England. Randomly sampled residents (1443 participants; 58% response) completed questionnaires to determine number of somatic symptoms (SSI), health status and a wide range of risk factors; 741 completed questionnaires 1 year later. We used logistic regression to identify risk factors for high SSI at follow-up and for persistently high SSI. We used ANCOVAR and multiple regression to assess whether baseline SSI predicted health status at follow-up.

RESULTS

Twenty-one percent of participants scored over 25 on the Somatic Symptom Inventory (SSI) at baseline and 14% at both baseline and follow-up. Risk factors for a persistent high SSI were: fewer than 12 years of education, separated, widowed or divorced status, reported psychological abuse during childhood, co-existing medical illnesses, anxiety and depression. In multivariate analysis baseline SSI predicted health status (SF12 physical component score and health-related quality of life (EuroQol)) 12 months later. Persistent high SSI was a clinically meaningful predictor of these outcomes.

CONCLUSIONS

Our data support a biopsychosocial approach to somatic symptoms rather than the dualistic approach of identifying "medically unexplained" symptoms. The risk factors for total somatic symptom count were those associated with psychiatric disorders including physical illness. A persistent high somatic symptom count provides a readily measured dimension of importance in epidemiology as a predictor of health status.

Hypochondriacal delusion in an elderly woman recovers quickly with electroconvulsive therapy

A 72-year-old woman without any medical and psychiatric history, suffered from nausea, pain in the epigastria and constipation for over a year. She eventually lost 20 kilograms despite nightly drip-feeding. Extensive additional tests did not reveal any clues for her complaints. She remained convinced that her symptoms were a side-effect of anti-fungal medication she used. She was diagnosed with hypochondria. In the course of time her ideas about her somatic symptoms became delusional and she was diagnosed with a hypochondriacal delusion as part of melancholia, without depressed mood or loss of interest or pleasure as prominent features. It is important to recognize melancholia as soon as possible by continually evaluating other symptoms of depression. This may enable to avoid repetitive and exhaustive somatic examinations, which are not indicated, and to start effective treatment. In our patient electroconvulsive therapy resulted in a fast and complete recovery.

A strong association between non-musculoskeletal symptoms and musculoskeletal pain symptoms: results from a population study

BACKGROUND

There is a lack of knowledge about the pattern of symptom reporting in the general population as most research focuses on specific diseases or symptoms. The number of musculoskeletal pain sites is a strong predictor for disability pensioning and, hence, is considered to be an important dimension in symptom reporting. The simple method of counting symptoms might also be applicable to non-musculoskeletal symptoms, rendering further dimensions in describing individual and public health. In a general population, we aimed to explore the association between self-reported non-musculoskeletal symptoms and the number of pain sites.

METHODS

With a cross-sectional design, the Standardised Nordic Questionnaire and the Subjective Health Complaints Inventory were used to record pain at ten different body sites and 13 non-musculoskeletal symptoms, respectively, among seven age groups in Ullensaker, Norway (n = 3,227).

RESULTS

Results showed a strong, almost linear relationship between the number of non-musculoskeletal symptoms and the number of pain sites (r = 0.55). The number and type of non-musculoskeletal symptoms had an almost equal explanatory power in the number of pain sites reported (27.1% vs. 28.2%).

CONCLUSION

The linear association between the number of non-musculoskeletal and musculoskeletal symptoms might indicate that the symptoms share common characteristics and even common underlying causal factors. The total burden of symptoms as determined by the number of symptoms reported might be an interesting generic indicator of health and well-being, as well as present and future functioning. Research on symptom reporting might also be an alternative pathway to describe and, possibly, understand the medically unexplained multisymptom conditions.

A follow-up study of patients with medically unexplained symptoms referred to a liaison psychiatry service

OBJECTIVE

The principal objective was to describe general hospital use and mortality in a group of patients with medically unexplained symptoms referred to a liaison psychiatry service.

METHOD

Cases were identified from patients with medically unexplained symptoms referred to a liaison psychiatry service between 1998 and 2005. We also identified a control group of patients, matched for age, sex, and date of referral, referred for other reasons to the same service. Follow-up information was obtained from the New Zealand Health Information Service national minimum data set from 1998 to 2006. Finally we compared hospital use in people with medically unexplained symptoms with national data on average length of stay in New Zealand hospitals.

RESULTS

Over 9 years 153 patients referred for medically unexplained symptoms spent nearly 14,000 days in hospital. They also had statistically significant greater numbers of general hospital admissions and fewer deaths compared to patients referred to liaison psychiatry for other reasons. Patients with medically unexplained symptoms spent 41% spent longer in hospital on each admission (5.5 days) compared to the New Zealand average length of stay in general hospitals (3.9 days). After referral to liaison psychiatry patients who were frequently admitted with medically unexplained symptoms experienced a statistically significant decrease in the number of admissions and length of stay per year.

CONCLUSIONS

Patients referred to a liaison psychiatry service with medically unexplained symptoms use substantial amounts of health service resources. They also have a lower mortality and are admitted to hospital more often than a matched control group.

Prevalence of health anxiety problems in medical clinics

OBJECTIVES

To determine the prevalence of significant health anxiety (hypochondriasis) in patients aged 16-75 in cardiology, respiratory medicine, neurological, endocrine and gastrointestinal clinics in general hospitals in London, Middlesex and North Nottinghamshire.

METHOD

The Health Anxiety Inventory (HAI) (short form) was administered to patients attending the five clinics over a 21 month period and all those who scored 20 or more invited to take part in a further assessment for a randomised controlled trial.

RESULTS

Of 43,205 patients attending the clinics 28,991 (67.1%) were assessed and of these, after exclusion of ineligible patients 5747 (19.8%) had significant health anxiety. 444 subsequently agreed to take part in a randomised controlled trial of treatment. The prevalence levels varied by clinic with neurology (24.7%) having the highest prevalence followed by respiratory medicine (20.9%), gastroenterology (19.5%), cardiology (19.1%), and endocrinology (17.5%).

CONCLUSION

Abnormal health anxiety is common and a significant problem in those attending medical clinics and deserves greater awareness.

[Medically unexplained and somatoform complaints and disorders in the elderly: a systematic review of the literature]

OBJECTIVE

To provide a systematic overview of the research concerning the frequency of medically unexplained, somatoform complaints and disorders in the elderly, their risk factors, comorbidity, course, management in primary and secondary care, and psychotherapy.

METHOD

We evaluated 248 clinical and randomized trials, reviews, meta-analyses and practice guidelines for adult samples identified from "PubMed" and "PsycInfo" using the search terms "somatoform" OR "medically unexplained" OR "somatization" OR "somatisation" in combination with other terms for their relevance for the elderly. Other relevant trials were identified from the references from these publications.

RESULTS

Medically unexplained, somatoform complaints and disorders occur in older persons and are more frequent in elderly women than in elderly men. Although many studies found no increased frequency of somatoform complaints in the elderly, based on present research we cannot draw final conclusions concerning the frequency of somatoform disorders and complaints in the elderly, and we cannot give evidence based recommendations for their treatment in primary and secondary care and psychotherapy.

DISCUSSION

This situation results from the special problems encountered in the diagnosis of somatoform complaints and disorders in the elderly, from problems in conceptualisation also found in younger adults, and from the lack of research concerning treatment focussed solely on the old and very old.

Course and prediction of somatoform disorder and medically unexplained symptoms in primary care

THEORY/OBJECTIVE: Somatoform disorder (SFD) is associated with considerable psychosocial impairment. However, only a few studies have dealt with the course of this clinical subgroup. Therefore, the objective was to identify predictors for the various courses of SFD and medically unexplained symptoms (MUS).

METHOD

We screened 620 consecutive patients in primary care using the Patient Health Questionnaire (PHQ-15). Afterwards, 308 patients were studied in more detail using a diagnostic interview and a set of questionnaires. One year later, we were able to interview 277 participants a second time.

RESULT

After 1 year, 48.8% of the respondents had a remitted SFD. The following variables proved to be significant predictors of MUS: current depressive episode, negative life events, number of MUS at baseline, attributional style, autonomic sensations and catastrophizing cognitions. The course of SFD could be predicted through current depressive or anxiety disorder, negative life events, functional disability and attributional style.

CONCLUSION

Somatoform disorder has a favorable course. The predictors of the courses of SFD and MUS we found can be integrated into previous explanatory models. The coping with MUS or SFD can be seen as a mediating factor.

Long-term follow-up of hypochondriasis after selective serotonin reuptake inhibitor treatment

BACKGROUND

: There is paucity of knowledge on the long-term outcome of hypochondriasis, with even less knowledge about the effect of treatment with a selective serotonin reuptake inhibitor (SSRI).

METHODS

: This prospective follow-up study included 58 patients with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) hypochondriasis who had participated in a trial of SSRI treatment 4 to 16 years earlier (mean ± SD = 8.6 ± 4.5 years).

RESULTS

: Information was obtained on 79.3% (n = 46) of the original group. At follow-up, 40% of the patients continued to meet full DSM-IV criteria for hypochondriasis. Persistence of hypochondriasis was individually predicted by longer duration of prior hypochondriasis (P = 0.003), history of childhood physical punishment (P = 0.01), and less usage of SSRIs during the interval period (P = 0.02). Remission status was not significantly predicted by demographic characteristics, baseline hypochondriasis severity, or psychiatric comorbidity.

CONCLUSIONS

: A substantial proportion of patients with hypochondriasis who receive treatment with SSRIs achieve remission over the long term. Interim SSRI use may be a factor contributing to better prognosis.

Consultation letters for medically unexplained physical symptoms in primary care

BACKGROUND

In primary care between 10% and 35% of all visits concern patients with medically unexplained physical symptoms (MUPS). MUPS are associated with high medical consumption, significant disabilities and psychiatric morbidity.

OBJECTIVES

To assess the effectiveness of consultation letters (CLs) to assist primary care physicians or occupational health physicians in the treatment of patients with MUPS and diagnostic subgroups.

SEARCH STRATEGY

We searched for randomized controlled trials (RCTs) on the Cochrane Collaboration Depression, Anxiety and Neurosis Group Controlled Trials Registers, the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 2, 2009), MEDLINE  (1966-2009), MEDLINE In Process (2009-08-17), EMBASE (1974-2009), PSYCINFO (1980-2009) and CINAHL (1982-2009). We screened the references lists of selected studies and consulted experts in the field to identify any additional, eligible RCTs.

SELECTION CRITERIA

RCTs of CLs for patients with MUPS being treated in primary care settings.

DATA COLLECTION AND ANALYSIS

Two authors independently screened the abstracts of the studies identified through the searches and independently assessed the risk of bias of the included studies. We resolved any disagreement by discussion with a third review author. We assessed heterogeneity and, where a number of studies reported the same outcomes, pooled results in a meta-analysis.

MAIN RESULTS

We included six RCTs, with a total of 449 patients. In four studies (267 patients) the CL intervention resulted in reduced medical costs (in two studies the outcomes could be pooled: MD -352.55 US Dollars (95% CI -522.32 to -182.78)) and improved physical functioning (three studies, MD 5.71 (95% CI 4.11 to 7.31)). In two studies (182 patients) the intervention was a joint consultation with a psychiatrist in presence of the physician, and resulted in reduced severity of somatization symptoms, reduced medical consumption and improved social functioning.

AUTHORS' CONCLUSIONS

There is limited evidence that a CL is effective in terms of medical costs and improvement of physical functioning for patients with MUPS in primary care. The results are even less pronounced in patients with clinically less severe, but more meaningful, forms of MUPS and the results vary for other patient-related outcomes. All studies, except one, were performed in the United States and therefore the results can not be generalized directly to countries with other healthcare systems. Furthermore all studies were small and of only moderate quality. There is very limited evidence that a joint consultation with the patient by a psychiatrist in the presence of the physician, together with the provision of a CL, reduces severity of somatization symptoms and medical consumption.

Mindfulness-based cognitive therapy for hypochondriasis, or severe health anxiety: a pilot study

In spite of the existence of evidence-based treatments for hypochondriasis, or severe health anxiety, recovery rates are low and morbidity is high. Therefore, more treatment options are needed for this prevalent condition. Mindfulness-based cognitive therapy (MBCT) interventions have been gaining research and clinical attention for the treatment of mood, and more recently anxiety disorders. A small, uncontrolled pilot study of an 8-week group MBCT intervention for hypochondriasis was conducted. Ten subjects (five females and five males) with a mean age of 35.6 (range=25-59) recruited from an academic community health network met criteria and completed the study. There were significant improvements in measures of health anxiety, disease-related thoughts, somatic symptoms, and mindfulness at the end of treatment, and these benefits were sustained at 3-month follow-up. Participants evidenced high treatment satisfaction, with no drop-outs or adverse events. These findings provide the basis for a larger, more rigorous, controlled trial of this promising treatment approach.

The contribution of high levels of somatic symptom severity to sickness absence duration, disability and discharge

INTRODUCTION

The primary objectives were to compare the duration of sickness absence in employees with high levels of somatic symptom severity (HLSSS) with employees with lower levels of somatic symptom severity, and to establish the long-term outcomes concerning return to work (RTW), disability and discharge. Secondary objective was to evaluate determinants of the duration of sickness absence in employees with HLSSS.

METHODS

489 sick-listed employees registered with five Occupational Health Physician (OHP) group practices were included in this study. We measured their baseline scores for somatic symptoms severity, depressive disorders, anxiety disorders, health anxiety, distress and functional impairment. The OHPs filled in a questionnaire on their diagnosis. A prospective 2-year follow-up was carried out to assess the long-term outcomes concerning sickness absence, and retrospective information was gathered with regard to sickness absence during the 12 months before the employees were sick-listed.

RESULTS

The median duration of sickness absence was 78 days longer for employees with HLSSS. They more often remained disabled and were discharged more often, especially due to problems in the relationship between the employer and the employee. HLSSS, health anxiety and older age contributed to a longer duration of sickness absence of employees.

CONCLUSION

High levels of somatic symptom severity are a determinant of prolonged sickness absence, enduring disabilities and health-related job loss. Occupational health physicians should identify employees who are at risk and adhere to guidelines for medically unexplained somatic symptoms.

Towards positive diagnostic criteria: a systematic review of somatoform disorder diagnoses and suggestions for future classification

OBJECTIVES

The classification of somatoform disorders is currently being revised in order to improve its validity for the DSM-V and ICD-11. In this article, we compare the validity and clinical utility of current and several new diagnostic proposals of those somatoform disorders that focus on medically unexplained somatic symptoms.

METHODS

We searched the Medline, PsycInfo, and Cochrane databases, as well as relevant reference lists. We included review papers and original articles on the subject of somatoform classification in general, subtypes of validity of the diagnoses, or single diagnostic criteria.

RESULTS

Of all diagnostic proposals, only complex somatic symptom disorder and the Conceptual Issues in Somatoform and Similar Disorders (CISSD) example criteria reflect all dimensions of current biopsychosocial models of somatization (construct validity) and go beyond somatic symptom counts by including psychological and behavioral symptoms that are specific to somatization (descriptive validity). Predictive validity of most of the diagnostic proposals has not yet been investigated. However, the number of somatic symptoms has been found to be a strong predictor of disability. Some evidence indicates that psychological symptoms can predict disease course and treatment outcome (e.g., therapeutic modification of catastrophizing is associated with positive outcome). Lengthy symptom lists, the requirement of lifetime symptom report (as in abridged somatization), complicated symptom patterns (as in current somatization disorder), and imprecise definitions of diagnostic procedures (e.g., missing symptom threshold in complex somatic symptom disorder) reduce clinical utility.

CONCLUSION

Results from the reviewed studies suggest that, of all current and new diagnostic suggestions, complex somatic symptom disorder and the CISSD definition appear to have advantages regarding validity and clinical utility. The integration of psychological and behavioral criteria could enhance construct and descriptive validity, and confers prospectively relevant treatment implications. The incorporation of a dimensional approach that reflects both somatic and psychological symptom severity also has the potential to improve predictive validity and clinical utility.

The course of newly presented unexplained complaints in general practice patients: a prospective cohort study

OBJECTIVE

Newly presented unexplained complaints (UCs) are common in general practice. Factors influencing the transition of newly presented into persistent UCs have been scarcely investigated. We studied the number and the nature of diagnoses made over time, as well as factors associated with UCs becoming persistent. Finally, we longitudinally studied factors associated with quality of life (QoL).

METHODS

Prospective cohort study in general practice of patients presenting with a new UC. Data sources were case record forms, patient questionnaires and electronic medical registries at inclusion, 1, 6 and 12 months. Presence of complaints and diagnoses made over time were documented. Potential risk factors were assessed in mixed-effect logistic and linear regression models.

RESULTS

Sixty-three GPs included 444 patients (73% women; median age 42) with unexplained fatigue (70%), abdominal complaints (14%) and musculoskeletal complaints (16%). At 12 months, 43% of the patients suffered from their initial complaints. Fifty-seven percent of the UCs remained unexplained. UCs had (non-life-threatening) somatic origins in 18% of the patients. QoL was often poor at presentation and tended to remain poor. Being a male [odds ratio (OR) 0.6; 95% confidence interval (CI) 0.4-0.8] and GPs' being more certain about the absence of serious disease (OR 0.9; 95% CI 0.8-0.9) were the strongest predictors of a diminished probability that the complaints would still be present and unexplained after 12 months. The strongest determinants of complaint persistence [regardless of (un)explicability] were duration of complaints >4 weeks before presentation (OR 2.6; 95% CI 1.6-4.3), musculoskeletal complaint at baseline (OR 2.3; 1.2-4.5), while the passage of time acted positively (OR 0.8 per month; 95% CI 0.78-0.84). Musculoskeletal complaints, compared to fatigue, decreased QoL on the physical domain (4.6 points; 2.6-6.7), while presence of psychosocial factors decreased mental QoL (5.0; 3.1-6.9).

CONCLUSION

One year after initial presentation, a large proportion of newly presented UCs remained unexplained and unresolved. We identified determinants that GPs might want to consider in the early detection of patients at risk of UC persistence and/or low QoL.

Explanation and relations. How do general practitioners deal with patients with persistent medically unexplained symptoms: a focus group study

Background

Persistent presentation of medically unexplained symptoms (MUS) is troublesome for general practitioners (GPs) and causes pressure on the doctor-patient relationship. As a consequence, GPs face the problem of establishing an ongoing, preferably effective relationship with these patients. This study aims at exploring GPs' perceptions about explaining MUS to patients and about how relationships with these patients evolve over time in daily practice.

Methods

A qualitative approach, interviewing a purposive sample of twenty-two Dutch GPs within five focus groups. Data were analyzed according to the principles of constant comparative analysis.

Results

GPs recognise the importance of an adequate explanation of the diagnosis of MUS but often feel incapable of being able to explain it clearly to their patients. GPs therefore indicate that they try to reassure patients in non-specific ways, for example by telling patients that there is no disease, by using metaphors and by normalizing the symptoms. When patients keep returning with MUS, GPs report the importance of maintaining the doctor-patient relationship. GPs describe three different models to do this; mutual alliance characterized by ritual care (e.g. regular physical examination, regular doctor visits) with approval of the patient and the doctor, ambivalent alliance characterized by ritual care without approval of the doctor and non-alliance characterized by cutting off all reasons for encounter in which symptoms are not of somatic origin.

Conclusion

GPs feel difficulties in explaining the symptoms. GPs report that, when patients keep presenting with MUS, they focus on maintaining the doctor-patient relationship by using ritual care. In this care they meticulously balance between maintaining a good doctor-patient relationship and the prevention of unintended consequences of unnecessary interventions.