Explaining medically unexplained symptoms

Communicating about the experience of pain and fatigue in disability

PURPOSE

To examine the experiences of people with chronic disabling conditions as they communicate with health care providers about pain and fatigue.

METHOD

Twenty-three adults with a variety of chronic disabling conditions participated in 5 focus groups. The following issues were raised: tell me about your pain/fatigue; what things go along with pain/fatigue? how do you talk about pain/fatigue with your health care provider (HCP)? What should your HCP know that they do not ask you about?

RESULTS

Results of qualitative analysis suggested two major themes. The first theme was labeled "Putting it in words" and suggests that both pain and fatigue are described in many ways, including the dimensions of type, intensity, level of interference and temporal aspects. Participants reported difficulty with responding to a single question that asked them to assign a number to their level of pain or fatigue. The second theme was labeled, "Let's talk about it" and suggested that participants wanted HCPs "to listen and believe me when I describe my experience". They wanted to be asked about how pain or fatigue interferes with life and about compensatory strategies rather than being asked to rate symptom intensity. Participants wished to be viewed as experts and to be actively involved in decisions about their health care.

CONCLUSIONS

Pain and fatigue were viewed as having many facets that are associated in complex ways with other aspects of the health/disability condition. From the participants' perspective, assignment of a pain intensity rating does not represent the complexity of their pain experience. Suggestions are provided for HCPs when communicating about pain and fatigue with people with chronic conditions.

Psychobehavioral predictors of somatoform disorders in patients with suspected allergies

OBJECTIVE

To explore a combination of health-related psychobehavioral features as potential positive criteria for somatoform disorders (SFD). Currently, SFD can only be diagnosed in the absence of sufficient organic symptom explanation, resulting in low criterion validity and delay of appropriate therapy.

METHODS

Cross sectionally, we studied various psychobehavioral characteristics of 197 inpatients with suspected allergies. At the beginning of the medical work-up, patients were interviewed and completed a set of self-rating questionnaires (Illness Perception Questionnaire-Revised, Whiteley Index-7, Cognitions About Body And Health Questionnaire, Scale for the Assessment of Illness Questionnaire, Health Attitude Survey, Reassurance Questionnaire, and Patient Health Questionnaire). Organic explicability of the presenting symptoms was assessed by allergists at the end of the work-up. Forty-eight patients with SFD were compared with 149 patients without SFD, and predictive models were set up. To control for effects of the work-up situation, we also investigated 47 patients with an established diagnosis of hymenoptera venom allergy.

RESULTS

In the work-up group, various self-reported psychobehavioral features discriminated patients with SFD from patients without SFD. In logistic regression analysis, self-reported dissatisfaction with medical care, disease conviction, reduced symptom controllability, and reduced body scanning independently predicted SFD. A predictive model based on these psychobehavioral characteristics had high sensitivity and specificity (area under the curve = 0.86, 95% Confidence Interval = 0.79-0.93; p < .001), which was comparable to the Patient Health Questionnaire-15, an established SFD screening tool assessing somatization.

CONCLUSIONS

Psychobehavioral characteristics in patients with SFD cannot solely be attributed to the uncertainty of a work-up situation. Their predictive value is comparable to that of the traditional measuring of symptom number and severity; hence, they should be considered as SFD positive criteria in Diagnostic and Statistic Manual of Mental Disorders, 5th Edition.

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

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

Validation of the Depression and Somatic Symptoms Scale by comparison with the Short Form 36 scale among psychiatric outpatients with major depressive disorder

BACKGROUND

The Depression and Somatic Symptoms Scale (DSSS) is a self-administered scale developed for monitoring both depression and somatic symptoms. The aims of this study were to establish the criterion-related validity of the DSSS by testing the correlation between the DSSS and the Short Form 36 (SF-36) scale and to compare the ability of the DSSS and two other scales in predicting the outcome of the SF-36.

METHODS

The study enrolled 135 outpatients with a major depressive episode, 95 of whom received treatment for 1 month. Four scales were administered and evaluated: the DSSS, the SF-36, the Hospital Anxiety and Depression Scale, and the Hamilton Depression Rating Scale. Pearson correlation was used to test correlations among scales. Multiple linear regressions were used to find the scales most effective in predicting the SF-36.

RESULTS

The three scales were significantly correlated with most of the SF-36 subscales. The depression and somatic subscales of the DSSS significantly correlated with the mental and physical subscales of the SF-36, respectively. The DSSS and the Hospital Anxiety and Depression Scale were better able to predict physical and mental subscales of the SF-36, respectively. The Hamilton Depression Rating Scale had a good ability to predict functional impairment.

CONCLUSIONS

Psychometric scales with appropriate somatic symptoms might be more compatible with both physical and mental dimensions of the SF-36. DSSS proved to be a valid scale for monitoring both depression and somatic symptoms in patients with depression. Future studies should test whether the DSSS is better at predicting the treatment and prognosis of depression than conventional scales for depression.

Applicability of 15-item Geriatric Depression Scale to detect depression in elderly medical outpatients

Elder depressives approach physicians for their medical problems, but the detection of their depression is poor. This study aimed to explore the screening for depressive symptoms using a 15-item Geriatric Depression Scale (GDS) in medical clinics. The study was carried out in outpatient setting of geriatric clinic of tertiary care hospital using the Hindi version of GDS-15. Out of 100 eligible older medical clinic patients, 22% of participants scored high on the GDS (≥5) and 18% were definitely having a depressive disorder as per ICD10. The sensitivity of the GDS instrument was 100% and specificity 94%. This study confirmed that a brief screening instrument like the GDS helps physicians to identify and diagnose depression in the medical settings. The need of the hour is to train health personnel involved in geriatric care regarding identifying, diagnosing and managing depression in medical clinics.

Psychiatric issues in chronic pain

Chronic pain requires comprehensive care. While interdisciplinary approaches are recommended, the role of psychiatrists is often misunderstood. Psychiatrists should be involved with the care of patients with chronic pain as early as possible to maximize outcome. Psychiatrists offer an expertise that specifically addresses important deficiencies in the care of patients with chronic pain: 1) the lack of a detailed formulation, 2) the lumping of all psychopathology, and 3) the failure to effectively use psychopharmacologic treatments. This review provides a framework for formulating the diagnoses and treatments of patients with chronic pain.

The effect of concurrent pain on the management of patients with depression: an analysis of NHS healthcare resource utilisation using the GPRD database

INTRODUCTION

Patients with depression frequently report painful physical symptoms. However, there are scant data from the UK concerning differences in primary and secondary care resource use between depressed patients with and without pain treated in general practice.

METHODS

Patients with depression codes were identified from the General Practice Research Database (GPRD) excluding those with psychoses. The observation period was 1st January 2000-31st December 2006. Patients were further categorised into three groups: (i) no painful physical symptom codes ever in the observation period (NO PAIN); (ii) patients with no other diagnostic or test codes 30 days either side of a pain code (PAIN MINUS DIAGNOSIS) and (iii) patients with pain codes and other diagnostic codes (PAIN PLUS DIAGNOSIS). Rates of general practitioner (GP) visits, antidepressant and concomitant prescribing and switching, secondary care referrals and diagnostic tests were reported per group with 95% confidence limits (CI).

RESULTS

A total of 145,784 patients with depression aged 18-50 years were selected. Of these, 48,615 (33.3%) were classed as NO PAIN, the remaining 66.6% having pain. PAIN MINUS DIAGNOSIS patients constituted 5654 (5.8%) of those with pain. PAIN MINUS DIAGNOSIS and PAIN PLUS DIAGNOSIS had a significantly higher rate of GP visits than NO PAIN patients, 10.37 (95% CI 10.23, 10.52); 11.15 (11.11,11.20) and 7.04 (7.00, 7.08) respectively. Inter and intraclass drug switching was high with 13% of PAIN MINUS DIAGNOSIS and 14% of PAIN PLUS DIAGNOSIS patients having three or more switches compared with 7% of NO PAIN patients. Referral rates to secondary care were significantly higher in both pain groups compared with patients with no pain. Diagnostic testing was significantly greater in PAIN MINUS DIAGNOSIS and PAIN PLUS DIAGNOSIS groups than NO PAIN patients for all test types, with X-rays being the most common test; 3.85 (3.69,4.00); 2.77 (2.74,2.80); 0.91 (0.89, 0.94) respectively.

CONCLUSION

Patients in general practice diagnosed with depression and concurrent painful physical symptoms have higher resource use in primary and secondary care.

[Vague and diffuse symptoms in biomedicine: a review of the literature]

The purpose of this study is to chart academic output on vague and diffuse symptoms in biomedicine. As methodological tool, we conducted a bibliographic study through the Internet ranging from 1990 to 2005. Forty papers were selected and five major theme areas were established for the survey: the nomenclatures assigned to vague and diffuse symptoms; their definitions; the relevance of the theme being addressed; the criteria used to diagnose vague and diffuse symptoms; and the therapeutic actions adopted. The discussion of the findings identifies many biomedical difficulties in dealing with sufferers from undefined complaints, including: diversity and lack of conceptual precision in the use of the nomenclature; physicians who are poorly prepared to deal with these patients; demand considered as a psychic disorder; difficulties in establishing diagnostic criteria and poor use of treatment resources. This leads to the conclusion that the biomedical model behind these difficulties has few tools for dealing with the singularities of human suffering and its experiential phenomenological dimension.

Symptoms beyond diagnosis--a case study

The aim of this paper was to discuss how words for symptoms relate to experience and to find out how seriously ill patients two years after diagnosis and treatment articulated suffering. Nine patients who have had a cancer tumour of the central nervous system were interviewed in their homes and the findings were interpreted in a hermeneutic process. Bodily, obstructive, emotive and metaphorical expressions of symptoms appeared. The transformed life situation involved inability to perform everyday tasks and a feeling of frustration of needs and desires. The words for symptoms conveyed individual embodied experience connected to a discourse of shared meanings. The relationship between individuality and culture means that words for symptoms are created and understood in a process between patient and listener, between discourse, culture and history.

Depression, anxiety, stress, social interaction and health-related quality of life in men and women with unexplained chest pain

Background

Unexplained chest pain (UCP) is a common reason for emergency hospital admission and generates considerable health-care costs for society. Even though prior research indicates that psychological problems and impaired quality of life are common among UCP patients, there is lack of knowledge comparing UCP patients with a reference group from the general population. The aim of this study was to analyse differences between men and women with UCP and a reference group in terms of psychosocial factors as depression, anxiety, stress, social interaction and health-related quality of life (HRQOL).

Methods

A self-administered questionnaire about psychosocial factors was completed by 127 men and 104 women with acute UCP admitted consecutively to the Emergency Department (ED) or as in-patients on a medical ward. A reference group from the general population, 490 men and 579 women, participants in the INTERGENE study and free of clinical heart disease, were selected.

Results

The UCP patients were more likely to be immigrants, have a sedentary lifestyle, report stress at work and have symptoms of depression and trait-anxiety compared with the reference group. After adjustment for differences in age, smoking, hypertension and diabetes, these factors were still significantly more common among patients with UCP. In a stepwise multivariate model with mutual adjustment for psychosocial factors, being an immigrant was associated with a more than twofold risk in both sexes. Stress at work was associated with an almost fourfold increase in risk among men, whereas there was no independent impact for women. In contrast, depression only emerged as an independent risk factor in women. Trait-anxiety and a low level of social interaction were not independently associated with risk in either men or women. Patients with UCP were two to five times more likely to have low scores for HRQOL.

Conclusion

Both men and women with UCP had higher depression scores than referents, but an independent association was only found in women. Among men, perceived stress at work emerged as the only psychosocial variable significantly associated with UCP.

Unexplained and underpowered: the relationship between psychosomatic disorders and interpersonal abuse -- a critical review

Although it is commonly accepted that interpersonal violence (IntPV) leads to adverse health consequences, the available data are far from decisive. To test the hypothesized link, the authors devised an evidence-based strategy to determine the data quality in studies purporting to link IntPV and some medically unexplained disorders in women (irritable bowel syndrome, chronic pelvic pain, fibromyalgia/chronic fatigue, and other chronic pain syndromes). English language studies with control groups of unaffected women were assessed for the quality of their methodologies. The number of studies, together with the consistency of their findings in each domain, was collated to determine the overall weight of evidence regarding the link for each condition. The quantity and quality of research in each clinical area proved to be sparse. In general, most research was limited to small, convenience samples, with insufficient attention to the design of control groups and to sample size. The evidence currently available regarding irritable bowel syndrome, fibromyalgia/chronic fatigue, chronic pelvic pain, and other chronic pain syndromes does not allow for any firm conclusion regarding their link to IntPV. More research - paying particular regard to the methodological concerns identified here - is required in order to generate any definitive conclusions.

Cultural models and somatic syndromes

OBJECTIVES

To review the relevance of cultural models in the generation and amplification of somatic symptoms and syndromes.

METHODS

Based on a selective review of literature, we examine evidence that cultural and personal explanatory models can contribute to the pathogenesis, symptomatology, and chronicity of medically unexplained symptoms and functional somatic syndromes.

RESULTS

In the contemporary world, culture involves flows of information, roles, and institutions that offer individuals multiple models for understanding illness. Cultural models include 1) explanatory models, which make causal attributions and impute specific mechanisms or processes of pathophysiology; 2) prototypes, which are salient images or exemplars drawn from personal experience, family, friends, mass media, and popular culture that are used to reason analogically about one's own condition; and 3) implicit models and procedural knowledge that may be difficult to articulate because they are embedded in body practices and ways of experiencing distress. Symptom attributions and explanations can participate in vicious circles of symptom amplification that give rise to culture-specific varieties of panic disorder, hypochondriacal worry, and medically unexplained symptoms.

CONCLUSIONS

Clinical research using the methods of experimental cognitive and social psychology as well as community-based ethnographic and ecological research are needed to advance our understanding of the impact of personal and cultural models on somatic distress. Nevertheless, the current state of knowledge on social and cultural dimensions of somatic syndromes suggests a typology of forms of psychosomatic and sociosomatic looping that has implications for the nosology of somatoform disorders.

Influence of cultural and social factors on the epidemiology of idiopathic somatic complaints and syndromes

OBJECTIVE

To review international research on somatic presentations often seen together with or attributed to psychopathology. For conceptual clarity, we refer to these presentations as "idiopathic somatic complaints and syndromes" (ISCS). This review will also pose specific questions on cultural issues affecting these somatic manifestations.

METHOD

Selective review of the international literature dealing with the phenomenology, epidemiology, and cultural profile of ISCS focusing on papers published in refereed journals and written in English.

RESULTS

Major problems with much of the previous research in this area are the use of different definitions and ascertainment procedures. As currently conceptualized in the literature, ISCS are universal and seem closely related to psychological issues (stress) and psychopathological conditions such as depression worldwide. Although there are many similarities regarding the form and content of these somatic presentations across cultures, there is some evidence for cultural patterning of symptoms. Unfortunately, current classifications for ISCS are unsatisfactory.

CONCLUSIONS

We outline specific recommendations for conducting future research and for improving the classification of ISCS of presumed psychological origin or import in future nosologies.

Reluctance to disclose difficult diagnoses: a narrative review comparing communication by psychiatrists and oncologists

INTRODUCTION

National guidance in most medical specialties supports the full and open disclosure of diagnoses to patients.

RESULTS

Surveys show that most patients want to know their diagnosis, whether it is medical or psychiatric, and a substantial proportion want to know detailed prognostic information. In the past, oncologists have been criticised for failing to reveal a diagnosis of cancer to patients in a sensitive and timely manner. Over the last 30 years, there is evidence that this practice has improved. Yet, clinicians still have difficulty when the diagnosis is not certain, when the prognosis is unfavourable, and when relatives request "not to tell." All of these influences are present in mental health settings.

DISCUSSION

Psychiatrists and general practitioners may be equally reluctant to reveal difficult diagnoses and prognoses of conditions such as schizophrenia and dementia. The reluctance to reveal a difficult diagnosis may be a routine, but little acknowledged the aspect of medical care that should be incorporated into undergraduate and postgraduate education and openly discussed during peer group supervision.

The cognitive behavioural model of medically unexplained symptoms: A theoretical and empirical review

The article is a narrative review of the theoretical standing and empirical evidence for the cognitive behavioural model of medically unexplained symptoms (MUS) in general and for chronic fatigue syndrome (CFS) and irritable bowel syndrome (IBS) in particular. A literature search of Medline and Psychinfo from 1966 to the present day was conducted using MUS and related terms as search terms. All relevant articles were reviewed. The search was then limited in stages, by cognitive behavioural therapy (CBT), condition, treatment and type of trial. Evidence was found for genetic, neurological, psychophysiological, immunological, personality, attentional, attributional, affective, behavioural, social and inter-personal factors in the onset and maintenance of MUS. The evidence for the contribution of individual factors, and their autopoietic interaction in MUS (as hypothesised by the cognitive behavioural model) is examined. The evidence from the treatment trials of cognitive behavioural therapy for MUS, CFS and IBS is reviewed as an experimental test of the cognitive behavioural models. We conclude that a broadly conceptualized cognitive behavioural model of MUS suggests a novel and plausible mechanism of symptom generation and has heuristic value. We offer suggestions for further research.

Gulf War Illness: lessons from medically unexplained symptoms

Service in the Persian Gulf in 1991 is associated with increased reporting of symptoms and distress in a proportion of those who served there. Yet despite clear evidence of an increase in symptom burden and a decrease in well being, exhaustive clinical and laboratory based scientific research has failed to document many reproducible biomedical abnormalities in this group. Likewise, there has been no evidence of an increase in disease related mortality. Formal psychiatric disorders are twice as common in Gulf War veterans, as might be expected in the aftermath of any conflict, but this too is insufficient to explain the ill-health observed. Many service personnel who returned unwell believe that they have Gulf War Syndrome, and that their ill-health is due to exposures that they encountered in theatre. Research on multiple exposures to date has not generated a plausible aetiological mechanism for veterans' ill-health. Even if medical research has failed to provide a satisfactory explanation, it remains the case that many of those affected continue to be unwell and disabled some 15 years after returning from combat. For this reason, it is time that more attention is given to developing effective interventions to relieve their ill-health and distress. In this review we discuss the importance of the wider social context, individual illness beliefs and attributions and go on to outline a model of continuing ill-health in Gulf veterans. The review concludes with some suggestions for future research priorities, in particular the need for further qualitative studies to further our understanding of the illness, in order that better treatments may be developed.

Trauma and medically unexplained symptoms towards an integration of cognitive and neuro-biological accounts

Medically unexplained symptoms (MUS) are frequently associated with a history of traumatization. The first purpose of the present review paper was to investigate systematically the evidence for such relation in a subset of clinical samples with MUS presenting with functional somatization: chronic pelvic pain, irritable bowel syndrome and conversion and somatization disorder. The second purpose was to critically review three dominant models explaining the relation between trauma and MUS (i.e. dissociation, conversion and hierarchical cognitive models). The latter model in particular adequately accounts for the non-volitional and non-intentional character of MUS and explains how traumata can affect the development of MUS without assuming that previous trauma is a necessary prerequisite of MUS. The cognitive model, however, lacks integration with current neurobiological findings, indicative of central stress-and central nervous system alterations in MUS. The final purpose of the present paper was, therefore, to review current neurobiological studies focused on trauma and MUS and to formulate a research agenda to integrate these neurobiological developments with cognitive models for MUS.

Primary care consultations about medically unexplained symptoms: patient presentations and doctor responses that influence the probability of somatic intervention

OBJECTIVE

In primary care, many consultations about physical symptoms that the doctor thinks are not explained by physical disease nevertheless lead to somatic interventions. Our objective was to test the predictions that somatic intervention becomes more likely a) when doctors provide simple reassurance rather than detailed symptom explanations and do not help patients discuss psychosocial problems and b) when patients try to engage doctors by extending their symptom presentation.

METHODS

Consultations of 420 patients presenting physical symptoms that the doctor considered unexplained by physical disease were audio-recorded, transcribed, and coded. Analysis modeled the probability of somatic intervention as a function of the quantity of specific types of speech by patients (symptomatic and psychosocial presentations) and doctors (normalization, physical explanations, psychosocial discussion).

RESULTS

Somatic intervention was associated with the duration of consultation. Controlling for duration, it was, as predicted, associated positively with symptom presentations and inversely with patients' and doctors' psychosocial talk. The relationship with doctors' psychosocial talk was accounted for by patients' psychosocial talk. Contrary to predictions, doctors' normalization was inversely associated with somatic intervention and physical explanations had no effect.

CONCLUSION

Somatic intervention did not result from the demands of patients. Instead, it became more likely as patients complained about their symptoms. Facilitating patients' psychosocial talk has the potential to divert consultations about medically unexplained symptoms from somatic interventions. To understand why such consultations often lead to somatic interventions, we must understand why patients progressively extend their symptom presentations and why doctors, in turn, apparently respond to this by providing somatic intervention.

Dysfunctional cognitions in idiopathic environmental intolerances (IEI)—An integrative psychiatric perspective

Idiopathic environmental intolerances (IEI) - formerly multiple chemical sensitivities (MCS) - are characterized by diffuse symptoms reported after exposure to low doses of everyday chemicals. Previous theories about the origin of IEI have emphasized either biological or psychological factors, neglecting a probable interplay. Many have suggested classifying IEI as a somatoform or an anxiety disorder, irrespective of some incongruities. By focusing on dysfunctional cognitions we discuss obvious parallels of IEI with somatoform disorders, and also indicate overlaps with anxiety and delusional disorders. To propose a hypothetical psycho-neurobiological basis of IEI, recent evidence about cortically represented symptoms in the absence of peripheral stimuli is briefly summarized. We conclude that IEI can serve as an illustrative example for the impact of cognitive, representational processes in symptom generation.

Patients with persistent medically unexplained symptoms in general practice: characteristics and quality of care

Background

Medically unexplained physical symptoms (MUPS) are common in general practice (GP), and are even more problematic as they become persistent. The present study examines the relationship between persistent MUPS in general practice on the one hand and quality of life, social conditions, and coping on the other hand. Additionally, it is examined how patients with persistent MUPS evaluate the quality of GP-care.

Methods

Data were used from a representative survey of morbidity in Dutch general practice, in which data from the electronic medical records were extracted. A random sample of patients participated in an extensive health interview and completed self-reported measures on social isolation, coping and the quality of GP-care. Patients with persistent MUPS (N = 192) were compared with general practice patients not meeting the criteria for persistent MUPS (N = 7.314), and with a group of patients that visited the GP in comparable rates for medical diagnoses (N = 2.265). Multiple logistic regression analyses were used to control for relevant socio-demographic variables and chronic diseases.

Results

After adjustment for demographics and chronic diseases, patients with persistent MUPS reported more psychological distress, more functional impairment, more social isolation, and they evaluated the quality of GP-care less positive than the other two patient groups. Although the majority of MUPS patients were positive about the quality of GP-care, they more often felt that they were not taken seriously or not involved in treatment decisions, and more often reported that the GP did not take sufficient time. The three groups did not differ with respect to the statement that the GP unnecessarily explains physical problems as psychological ones.

Conclusion

Strengthening MUPS patients' social network and encouraging social activities may be a meaningful intervention in which the GP may play a stimulating role. To further improve MUPS patients' satisfaction with GP-care, GPs may pay extra attention to taking sufficient time when treating MUPS patients, taking the problems seriously, and involving them in treatment decisions.

Use of health care services for psychological distress by immigrants in an urban multicultural milieu

OBJECTIVE

Research in the United States tends to attribute low rates of use of mental health services by immigrants to economic barriers. The purpose of our study was to examine this issue in the context of Canada's universal health care system.

METHODS

A survey of the catchment area of a comprehensive clinic in Montreal interviewed random samples of 924 Canadian-born individuals and 776 immigrants born in the Caribbean (n = 264), Vietnam (n = 234), or the Philippines (n = 278) to assess their health care use for somatic symptoms, psychological distress, and recent life events.

RESULTS

Overall rates of use of medical services in the past year were similar in immigrant (78.5%) and nonimmigrant (76.5%) groups. Rates of use of health care services for psychological distress were significantly lower among immigrants (5.5% compared with 14.7%, P < 0.001). This difference was attributable both to a lower rate of use of specialty mental health services by immigrants (2.5% compared with 11.7%, P < 0.001) and to differential use of medical services for psychological distress (3.5% compared with 5.8%, P = 0.02). When level of psychological distress was controlled, Vietnamese and Filipino immigrants were one-third as likely as Canadian-born residents to make use of mental health services. The lower rate of use by immigrants could not be explained by differences in sociodemographics, somatic or psychological symptoms, length of stay in Canada, or use of alternative sources of help.

CONCLUSION

Immigrant status is associated with lower rates of use of mental health services, even with universal health insurance. This lower rate of use likely reflects cultural and linguistic barriers to care.

Physical ill health and risk of psychosis

Patients with psychosis have been found to suffer from physical illnesses more commonly than the general population. In this report, self-reported physical ill health and its correlates among subjects with and without vulnerability to psychosis in a sample of first-degree relatives, help-seekers and controls were investigated. Perceived physical health was statistically significantly poorer among subjects with minor symptoms on the Structured Interview for Prodromal Symptoms and those vulnerable to psychosis than among those without symptoms measured by 13 somatoform symptom sum scores of the Symptom Checklist-90. Those at current risk of psychosis had a significantly higher mean sum score on the 13 somatic items (mean=21.1) than others (mean=9.6). Having physical symptoms or a self-reported physician-diagnosed illness was significantly associated with vulnerability to psychosis (odds ratio=3.05). The subjects with a mood disorder (odds ratio=4.33) had significantly more commonly physician-diagnosed illnesses than those who had no diagnosis or any other diagnosis. Physical ill health seems to be common among those vulnerable to psychosis.

Outcome and impact of mental disorders in primary care at 5 years

OBJECTIVE

To assess 5-year mental disorder recognition rates and determine the natural history of mental disorders in primary care.

METHODS

A prospective cohort of adults presenting to a primary care walk-in clinic with a physical symptom were evaluated at baseline (n = 500) and at 5 years (n = 387) for mental disorders with the Primary Care Evaluation of Mental Disorders (PRIME-MD). Additional measures included functional status (Medical Outcomes Study SF-6; MOS-SF6), Patient Health Questionnaire-15, Satisfaction (Rand-9), unmet expectations, and symptom outcome. Patients self-reported whether their disorder was diagnosed or treated at the 5-year follow-up.

RESULTS

At baseline, 29% of patients had a mental disorder (major depression: 8.4%, minor depression 10.4%, Panic disorder 1.4%, generalized anxiety disorder 2%, anxiety not otherwise specified (NOS) 11.4%); of these patients, 26% had more than one mental disorder. Over 5 years, 33% were recognized. Threshold disorders were more likely to be recognized (major depression 56%, panic 100%, generalized anxiety disorder 88%) than subthreshold disorders (minor depression 20%, anxiety NOS 25%). Correlates of recognition included having a threshold or multiple disorders; recognition was associated with greater likelihood of persistence. Most patients with subthreshold disorders at baseline had no disorder at 5 years and few progressed to threshold disorders (minor to major depression 12%, anxiety NOS to generalized anxiety or panic 8%).

CONCLUSIONS

Mental disorders are common and their recognition and treatment remain low. Subthreshold disorders have a better prognosis. Patients with threshold or multiple disorders, worse functioning or persistence of their disorder were more likely to be diagnosed.

Management of functional somatic syndromes

Although functional somatic syndromes (FSS) show substantial overlap, treatment research is mostly confined to single syndromes, with a lack of valid and generally accepted diagnostic criteria across medical specialties. Here, we review management for the full variety of FSS, drawn from systematic reviews and meta-analyses since 2001, and give recommendations for a stepped care approach that differentiates between uncomplicated and complicated FSS. Non-pharmacological treatments involving active participation of patients, such as exercise and psychotherapy, seem to be more effective than those that involve passive physical measures, including injections and operations. Pharmacological agents with CNS action seem to be more consistently effective than drugs aiming at restoration of peripheral physiological dysfunction. A balance between biomedical, organ-oriented, and cognitive interpersonal approaches is most appropriate at this truly psychosomatic interface. In view of the iatrogenic component in the maintenance of FSS, doctor-centred interventions and close observation of the doctor-patient relationship are of particular importance.

Alexithymia, somatization and negative affect in a community sample

Whilst alexithymia has been consistently linked to somatization, two prominent theoretical models lead to opposite predictions as to which of two proposed typologies of alexithymia will be particularly associated with somatic symptom reporting. In the present study, participants were recruited from a cross-section of the general adult population (n=301), and asked to complete a battery of self-report questionnaires which assessed alexithymia, somatization and negative affect. Collapsed across the whole sample, specific facets of alexithymia (enhanced fantasy life and difficulty identifying emotions) were significantly associated with somatization, and these pathways were perfectly mediated by negative affectivity. Further, type II alexithymia (impairment in the cognitive but not the affective dimension of alexithymia) was more predictive of somatization relative to type I alexithymia (impairment in both the cognitive and affective dimensions of alexithymia) and non-alexithymia (unimpaired in the cognitive and affective dimensions of alexithymia). The theoretical and clinical implications of these results are discussed.

Evidence-based nursing: effects of a structured nursing program for the health promotion of Korean women with Hwa-Byung

The objectives of this study were to develop a culturally tailored nursing program for patients with Hwa-Byung (HB) and to test the effects of the nursing intervention. The structured nursing intervention program was based on a transcultural theoretical framework in which patients with HB received therapies consisting of music therapy, drama, and group therapy. Hwa-Byung is a culture-bound syndrome, literally translated as anger syndrome, attributed to the suppression of anger. Individuals experience a decrease in quality of life as a result of insufficient treatment. Current health care programs do not meet the needs of these individuals, who still need nursing interventions. A culturally tailored therapy is effective and appropriate for patients with illnesses related to their cultural background. Evidence-based nursing is a crucial approach in verifying the effects of nursing care and in enhancing the body of knowledge on nursing science. A nonequivalent, nonsynchronized, and controlled study design was applied to experimental and control groups of an even number of women. The nursing program was generally effective in the mental health condition test; the mental health condition of the experimental group was significantly more improved as compared with that of the control group. The program was particularly effective in the categories of somatization, depression, psychoticism, and hostility. The data indicate that the mental health of patients with HB could be improved with the use of nursing intervention programs. Nurses need to understand the cultural background of patients and provide culture-sensitive interventions for effective patient-oriented care.

Course and predictors of medically unexplained pain symptoms in the general population

OBJECTIVE

The objective of this study was to explore the course and the predictors of clinically significant medically unexplained pain symptoms (MUS-pain) within the 6 months preceding the interviews at baseline and on follow-up in the general population.

METHODS

A Norwegian general population study of 605 persons interviewed with the Composite International Diagnostic Interview Somatoform Section was conducted in 1989/1990 (baseline), and 421 persons (69.6% response rate; 242 women and 179 men) were reinterviewed in 2000/2001 (follow-up). Cases of recent MUS-pain compared with those at baseline were assessed on follow-up. Four blockwise logistic regression analyses were undertaken to find predictors (such as stressful life events, living alone, depression and anxiety, and physical morbidity) for recent MUS-pain in 2001.

RESULTS

A small "stable" group of recent MUS-pain sufferers (8% of all reinterviewed and 33.6% of those with recent MUS-pain at baseline) was evident. In this group almost all were women. In addition to female gender being a significant (P<.05) marker of recent MUS-pain (which gives a twofold-higher risk compared with men), only depression--not the occurrence of prior recent MUS-pain--remained a significant (P<.05) predictor in the final model, increasing the likelihood of having recent MUS-pain by threefold.

CONCLUSION

The prognosis of MUS-pain is relatively good, except for a small group (mainly women) that is prone to chronicity. Clinicians should examine for depression when confronted with MUS-pain patients and should be aware of the twofold-higher risk in women for persistent MUS-pain over a long time.

Rethinking depression: an ethnographic study of the experiences of depression among Chinese

Relative to studies of patients in the West, little research has focused on the lived experiences of patients with mental illness in non-Western societies. The current understanding of the phenomenology of depression and other psychiatric disorders is almost entirely based on studies of Western populations. The objective of the present study was to examine the experiences of depressive disorders among contemporary Chinese in Guangzhou (Canton), China. A total of 40 patients who had significant depressive symptoms were recruited using quota sampling from the outpatient department of a regional mental health service. The depressive experiences of participants were examined by open-ended, in-depth, ethnographic interviews. The interviews were taped, transcribed, and translated. Content analysis was conducted on both the Chinese and English transcripts. A total of six categories of affective experiences were identified among the participants. Indigenous affective lexicons, embodied emotional experiences, implicit sadness, preverbal pain, distress of social disharmony, and centrality of sleeplessness were regularly observed among the informants. Our findings suggest that psychiatric textbooks and diagnostic systems do not cover the full range of depressive symptoms experienced among contemporary Chinese. More studies are needed to examine how depression is differentially experienced globally--a crucial step in making professional diagnosis, treatment, and research more broadly applicable across cultures.

Somatic symptoms in depression

Both painful and nonpainful somatic symptoms essentially characterize clinical states of depressive mood. So far, this well-established psychopathological knowledge has been appreciated only insufficiently by the official diagnostic sys-terms of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IVTR) and the ICD-10 Classification of Mental and Behavioral Disorders. Clinical Descriptions and Diagnostic Guidelines (ICD-10). From a perspective of primary care services, this unmet diagnostic need is deplorable, as the main mode of presenting a depression is by reporting somatic symptoms. This somatic form of presentation, however, significantly contributes to low rates of recognition in primary care. A diagnostic challenge may be seen in the differentiation of a depression with prevailing somatic symptoms from anxiety, somatoform disorders, and medical conditions. When somatic symptoms, particularly painful physical conditions, accompany the already debilitating psychiatric and behavioral symptoms of depression, the course of the illness may be more severe, implying a higher risk of early relapse, chronicity suicide, or mortality due to other natural causes, the economic burden increases considerably, the functional status may be hampered heavily, and health-related quality of life may be lowered dramatically. The neurobiological underpinnings of somatic symptoms in depression may guide more promising treatment approaches.

Predictors of fatigue in rescue workers and residents in the aftermath of an aviation disaster: a longitudinal study

OBJECTIVES

Although medically unexplained physical symptoms such as fatigue are frequently observed after exposure to trauma, the vast majority of health outcomes studies in trauma and disaster research relates to the psychological and psychiatric problems met by victims. The objectives of this study were to investigate the prevalence of (persistent) fatigue in the aftermath of a disaster and to analyze the predictive value of sociodemographic and various health-related variables for fatigue among both rescue workers and residents.

METHODS

A total of 1951 rescue workers and 753 residents involved in the Bijlmermeer aviation disaster participated in this study. Follow-up data were gathered in 70% of randomly selected rescue workers and 53% of the residents. Multiple regression analyses, multivariate logistic regression analyses, and crosslagged panel analyses examined sociodemographic variables and self-report measures for psychopathology, posttraumatic stress reactions, quality of life, somatosensory amplification, health anxiety, and tendency to be reassured by a physician as predictors of fatigue at baseline and fatigue from baseline to 13 to 28 months follow up.

RESULTS

Elevated levels of fatigue are common after involvement in a disaster in rescue workers (20.6%) and residents (45.4%). Higher levels of psychopathology, lower quality of life, and the tendency to be less reassured were multivariate predictors of both elevated and persistent fatigue. Tendency to be reassured was the most important causal factor for fatigue.

CONCLUSIONS

These results suggest that early identification, adequate reassurance, and treatment of individuals at risk may be worthwhile to prevent chronic fatigue.

Why do primary care physicians propose medical care to patients with medically unexplained symptoms? A new method of sequence analysis to test theories of patient pressure

OBJECTIVE

We test predictions from contrasting theories that primary care physicians offer medical care to patients with medically unexplained symptoms in response to a) patients' attribution of symptoms to disease and demand for treatment or b) their progressive elaboration of their symptoms in the attempt to engage their physicians.

METHODS

Primary care physicians identified consecutive patients who consulted with symptoms that the physician considered unexplained by physical disease. Four hundred twenty consultations with 36 physicians were audio recorded and transcribed, and physician and patient speech was coded turn by turn. Hierarchical logistic regression analysis modeled the probability of the physician proposing medical care as a function of the quantity of patients' speech of specific kinds that preceded it.

RESULTS

Whether physicians proposed medical care was unrelated to patients' attributions to disease or demands for treatment. Proposals of explicitly somatic responses (drugs, investigation or specialist referral) became more likely after patients had elaborated their symptoms and less likely after patients indicated psychosocial difficulties. Proposals of a further primary care consultation were responses simply to lengthening consultation.

CONCLUSIONS

The findings are incompatible with the influential assumption that physicians offer medical care to patients with unexplained symptoms because the patients demand treatment for a physical disease. Instead, the reason why many of these patients receive high levels of medical care should be sought by investigating the motivations behind physicians' responses to patients' symptom presentation.

The potentially somatizing effect of clinical consultation

Many patients who present physical symptoms that their doctors cannot explain by physical disease have persisting symptoms and impairment. An influential view has been that such symptoms are the somatization of emotional distress, but there has also been concern that medical practice contributes to shaping these presentations. Analysis of patients' accounts indicate that they approach these consultations with a sense of being the expert on the nature and reality of their symptoms and, in primary care at least, they seek convincing explanations, engagement, and support. They often describe doctors as doubting that their symptoms are real and as not taking their symptoms seriously. Observational research has demonstrated that patients presenting idiopathic symptoms in primary care generally provide cues to their need for explanation or to psychosocial difficulties. Their doctors tend to provide simple reassurance rather than detailed explanations, and often disregard psychosocial cues. Patients seem to intensify their presentation in consequence, elaborating and extending their accounts of their symptoms, perhaps in the effort to engage their doctors and demonstrate the reality of their symptoms. When doctors propose physical investigation and treatment in response to such escalating presentation, they thereby inadvertently somatize patients' psychological presentation. Consultations, therefore, have elements of contest, whereby patients seek engagement from doctors who seek to disengage. Although provision of a medical label, such as a functional diagnosis, can legitimize patients' complaints and avoid contest, this is at the risk of indicating that medicine can take responsibility for managing the symptoms. More collaborative relationships rely on doctors recognizing patients' authority in knowing about their symptoms, and providing tangible explanations that make sense to the patient and allow them to tolerate or manage the symptoms. Researchers need to study how doctors can best achieve these aims within routine consultations.

Beyond the 'new cross-cultural psychiatry': cultural biology, discursive psychology and the ironies of globalization

The 'new cross-cultural psychiatry' heralded by Kleinman in 1977 promised a revitalized tradition that gave due respect to cultural difference and did not export psychiatric theories that were themselves culture bound. In the ensuing years, the view of culture within anthropology has continued to change, along with our understanding of the relationship of biological processes to cultural diversity, and the global political economic contexts in which mental health care is delivered. This article considers the implications of these new notions of culture, biology and the context of practice for theory in cultural psychiatry. The future of cultural psychiatry lies in advancing a broad perspective that: (a) is inherently multidisciplinary (involving psychiatric epidemiology, medical anthropology and sociology, cognitive science and social psychology), breaking down the nature/culture dichotomy with an integrative view of culture as a core feature of human biology, while remaining alert to cultural constructions of biological theory; (b) attends to psychological processes but understands these as not exclusively located within the individual but as including discursive processes that are fundamentally social; and (c) critically examines the interaction of both local and global systems of knowledge and power. Globalization has brought with it many ironies for cultural psychiatry: Transnational migrations have resulted in cultural hybridization at the same time as ethnicity has become more salient; the call for evidence-based medicine has been used to limit the impact of cultural research; and cultural psychiatry itself has been co-opted by pharmaceutical companies to inform marketing campaigns to promote conventional treatments for new populations. Cultural psychiatry must address these ironies to develop the self-critical awareness and flexibility needed to deliver humane care in shifting contexts.

Abnormal illness behaviour: physiological, psychological and social dimensions of coping with distress

PURPOSE OF REVIEW

Pilowsky introduced the term 'abnormal illness behaviour' to characterize syndromes of excessive or inadequate response to symptoms, including hypochondriasis, somatization, and denial of illness. This review summarizes recent work from sociology, health psychology and psychiatry that contributes to an understanding of the processes that may underlie abnormal illness behaviour.

RECENT FINDINGS

Disturbances in the regulation of physiological systems may account for many 'unexplained' symptoms and sickness behaviour. Increased attention to bodily sensations, sensitivity to pain and catastrophizing play important roles in illness behaviour in medical illness. Developmental adversities and parental modelling of illness behaviour in childhood may increase bodily preoccupation and health care utilization. Apparent cross-national differences in illness behaviour may reflect differences in health care systems, but cultural models of illness and social stigma remain important determinants of illness denial and avoidance of mental health services.

SUMMARY

Research into illness behaviour is relevant to efforts to rethink the psychiatric nosology of somatoform disorders. The discrete somatoform disorders might well be replaced by a dimensional framework that identifies specific pathological processes in cognition, perception and social behaviour that contribute to bodily distress, impaired coping, inappropriate use of health services, chronicity and disability.

The outcomes among patients presenting in primary care with a physical symptom at 5 years

BACKGROUND

Symptoms are common and often remain medically unexplained.

OBJECTIVE

To assess 5-year symptom outcomes, determine how often symptoms remain unexplained and assess their relationship with mental disorders.

DESIGN

Prospective cohort study.

PARTICIPANTS

Five hundred consecutive patients presenting to a medicine clinic with physical symptoms. MEASUREMENTS PREVISIT: Mental disorders, symptom characteristics, stress, expectations, illness worry, and functional status. Postvisit (immediately, 2 weeks, 3 months, 5 years): unmet expectations, satisfaction, symptom outcome, functional status, and stress.

RESULTS

While most subjects (81%) experienced symptom improvement by 5 years, resolution rates were lower (56%), with 35% of symptoms remained medically unexplained. Most patients with medically unexplained symptoms (MUS) did not have a mental disorder. Mood or anxiety disorders were not associated with MUS (relative risks [RR]: 0.94, 95% confidence interval [CI]: 0.79 to 1.13), or with lower rates of symptom improvement (RR: 1.14, 95% CI: 0.60 to 2.2). In contrast, most patients with somatoform disorders had MUS and were unlikely to improve. Worse functioning (RR: 0.95, 95% CI: 0.91 to 0.99), longer duration of symptom at presentation (RR: 0.5, 95% CI: 0.28 to 0.87), illness worry at presentation (RR: 0.56, 95% CI: 0.35 to 0.89), or lack of resolution by 3 months (RR: 0.47, 95% CI: 0.26 to 0.86) reduced the likelihood of symptom improvement at 5 years.

CONCLUSIONS

More than half of patients presenting with a physical symptom resolve by 5 years, while a third remain medically unexplained. Most patients whose symptom remained unexplained had no mental disorder. While mood and anxiety disorders were not associated with MUS or worse outcomes, most patients with somatoform disorders had MUS and were unlikely to improve.

The reporting of specific physical symptoms for mental distress in general practice

OBJECTIVE

Do patients report specific physical symptoms in the presence of mental distress, taking into account the presence of somatic disease?

METHODS

Cross-sectional data were collected from 1458 participants in eight general practices in The Netherlands. Electronic patient records provided information on somatic disease. Questionnaires included the Hospital Anxiety and Depression Scale (HADS) to measure mental distress and the Physical Symptom Checklist (PSC).

RESULTS

Patients reporting mental distress reported all types of physical symptoms more often than did patients without mental distress. Multivariate analyses in women, corrected for the presence of somatic disease, did not substantially change the univariate pattern. Odds ratios were particularly high (>6) for feeling tired or having low energy, fatigue without exertion and forgetfulness.

CONCLUSION

It is the level of mental distress rather than gender or somatic disease that accounts for the reporting of any physical symptom. Fatigue might be an exception, but here, the classification as "physical" rather then "mental" is somewhat ambiguous.