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

Patients in general practice share a common pattern of symptoms that is partly independent of the diagnosis

OBJECTIVE

To describe self-reported symptoms among patients in general practice and to explore the relationships between symptoms experienced by patients and diagnoses given by general practitioners.

DESIGN

Doctor-patient questionnaires focusing on patients' self-reported symptoms during the past 7 days and the doctors' diagnoses.

SETTING

General practices in urban and suburban areas in Southeast Norway.

SUBJECTS

Forty-seven general practitioners who included 866 patients aged ≥18 years on a random day in practice.

RESULTS

The most frequently reported symptoms were tiredness (46%), lower back pain (43%), neck pain (41%), headache (39%), shoulder pain (36%), and sleep problems (35%). Women had a significantly higher prevalence than men for 16 of 38 symptoms (p < 0.05). The mean number of symptoms was 7.5 (range, 0-32; women, 8.1; men, 6.5, p < 0.05). Regression analysis showed that patients who received a social security grant had 59% more symptoms than those who were employed and that people with asthenia and depression/anxiety had 44% and 23% more symptoms, respectively than those with all other diagnoses. The patterns of symptoms reported showed similar patterns across the five most prevalent diagnoses.

CONCLUSIONS

Patients in general practice report a number of symptoms and share a common pattern of symptoms, which appear to be partly independent of the diagnoses given. These findings suggest that symptoms are not necessarily an indication of disease.KEY POINTSPatients consulting general practitioners have a high number of self-reported symptoms.The most frequent symptoms are tiredness, lower back pain, neck pain, headache, shoulder pain, and sleep problems.Patients diagnosed with asthenia and depression/anxiety report the highest number of symptoms.Selected diagnoses show similar patterns in symptom distribution.Symptoms are not necessarily an indication of disease.

Health-related quality of life in porphyria cutanea tarda: a cross-sectional registry based study

BACKGROUND

Porphyria cutanea tarda (PCT) is a rare, photosensitive disease characterized by skin fragility and blistering on sun-exposed areas. There is little previous research on how this condition affects health-related quality of life (HRQoL) and to the best of our knowledge this is the largest sample of PCT patients surveyed about their HRQoL. The aims of this study were to describe HRQoL, symptoms, susceptibility factors, disease activity and treatment in patients with PCT, and investigate the associations between these factors.

METHODS

This is a cross-sectional, retrospective study based on patient-reported outcome and laboratory data. The Norwegian Porphyria Centre diagnoses all patients with PCT in Norway, all of whom are invited to participate in the Norwegian Porphyria Registry. Between December 2013-2015, 111 patients received a postal questionnaire and invitation to participate.

RESULTS

Sixty-eight persons responded, with seven being excluded due to prolonged response time or missing information, resulting in 61 participants in the final analyses (55%). Median age was 60 years and 33 were female. We found a moderate negative relationship between the type and localisation of PCT symptoms and both mental (r = -.354 p < 0.01) and physical (r = -.441, p < 0.01) aspects of HRQoL. Participants who had started treatment when answering the questionnaire reported significantly better physical functioning and less bodily pain than those who had not started treatment. We did not observe an association between biochemical markers of disease activity and symptoms or HRQoL. Itching, a symptom that has received little attention in PCT was reported by 59% of the participants.

CONCLUSIONS

Our results show that reduced HRQoL is associated with more symptoms and not having started treatment. PCT is a rare disease, and there is a need for the development of best-practice guidelines to facilitate good patient care.

Medically explained symptoms: a mixed methods study of diagnostic, symptom and support experiences of patients with lupus and related systemic autoimmune diseases

Objectives

The aim was to explore patient experiences and views of their symptoms, delays in diagnosis, misdiagnoses and medical support, to identify common experiences, preferences and unmet needs.

Methods

Following a review of LUPUS UK's online forum, a questionnaire was posted online during December 2018. This was an exploratory mixed methods study, with qualitative data analysed thematically and combined with descriptive and statistically analysed quantitative data.

Results

There were 233 eligible respondents. The mean time to diagnosis from first experiencing symptoms was 6 years 11 months. Seventy-six per cent reported at least one misdiagnosis for symptoms subsequently attributed to their systemic autoimmune rheumatic disease. Mental health/non-organic misdiagnoses constituted 47% of reported misdiagnoses and were indicated to have reduced trust in physicians and to have changed future health-care-seeking behaviour. Perceptions of physician knowledge and listening skills were highly correlated with patient ratings of trust. The symptom burden was high. Fatigue had the greatest impact on activities of daily living, yet the majority reported receiving no support or poor support in managing it. Assessing and treating patients holistically and with empathy was strongly felt to increase diagnostic accuracy and improve medical relationships.

Conclusion

Patient responses indicated that timely diagnosis could be facilitated if physicians had greater knowledge of lupus/related systemic autoimmune diseases and were more amenable to listening to and believing patient reports of their symptoms. Patient priorities included physicians viewing them holistically, with more emotional support and assistance in improving quality of life, especially in relation to fatigue.

Symptom load and general function among patients with erythema migrans: a prospective study with a 1-year follow-up after antibiotic treatment in Norwegian general practice

OBJECTIVE

Promptly treated erythema migrans (EM) has good prognosis. However, some patients report persistent symptoms. Do patients with EM have more symptoms than the general population? We describe individual symptoms and general function in EM-patients at time of diagnosis and one year after treatment.

DESIGN

Prospective study with 1-year follow up after treatment. Questionnaires included a modified version of the Subjective Health Complaints Inventory, comprising three additional Lyme borreliosis (LB) related symptoms. General function was assessed using a five-point scale modified from the COOP/WONCA charts.

SETTING

Norwegian general practice.

SUBJECTS

A total of 188 patients were included in a randomized controlled trial comparing three antibiotic regimens for EM, of whom 139 had complete data for this study.

MAIN OUTCOME MEASURES

Individual symptoms, symptom load and general function.

RESULTS

Mild symptoms were common, reported by 84.9% at baseline and by 85.6% at follow-up. At baseline, patients reported a mean of 5.4 symptoms, compared with 6.2 after one year. Severely bothersome symptoms and severely impaired general function were rare. Tiredness was the most reported symptom both at baseline and at follow-up. Palsy (other than facial) was the least reported symptom, but the only one with a significant increase. However, this was not associated to the EM.

CONCLUSION

The symptom load was comparable to that reported in the general population. We found an increase in symptom load at follow-up that did not significantly affect general function.

IMPLICATION

Monitoring patients' symptom loads prior to treatment reduce the probability of attributing follow-up symptoms to LB. Key points Erythema migrans has a good prognosis.Patients treated for erythema migrans have a slight increase in symptom load one year after treatment. This increase does not affect general function. The levels of subjective health complaints in patients treated for erythema migrans are comparable to the background population.

Medically unexplained conditions considered by patients in general practice

BACKGROUND

Patients frequently present with multiple and 'unexplained' symptoms, often resulting in complex consultations. To better understand these patients is a challenge to health care professionals, in general, and GPs, in particular.

OBJECTIVES

In our research on symptom reporting, we wanted to explore whether patients consider that they may suffer from conditions commonly regarded as unexplained, and we explored associations between these concerns and symptom load, life stressors and socio-demographic factors.

METHODS

Consecutive, unselected patients in general practice completed questionnaires addressing eight conditions commonly regarded as unexplained (amalgam poisoning, Candida syndrome, fibromyalgia, food intolerance, electromagnetic hypersensitivity, burnout syndrome, chronic fatigue syndrome and irritable bowel syndrome). With logistic regression, we analysed associations with symptom load, burden of life stressors with negative impact on present health and socio-demographic variables.

RESULTS

Out of the 909 respondents (response rate = 88.8%), 863 had complete data. In total, 39.6% of patients had considered that they may suffer from one or more unexplained conditions (UCs). These concerns were strongly and positively associated with recent symptom load and number of life stressors. If we excluded burnout and food intolerance, corresponding associations were found.

CONCLUSION

Patients frequently considered that they may suffer from UCs. The likelihood of such concerns strongly increased with an increasing symptom load and with the number of life stressors with negative impact on present health. Hence, the number of symptoms may be a strong indicator of whether patients consider their symptoms part of such often controversial multisymptom conditions.