Explaining medically unexplained symptoms: somatizing patients' responses in primary care

Patients' acceptance of explanatory models for persistent somatic symptoms: A qualitative analysis within the HERMES study

OBJECTIVE

The aim of this qualitative study was to provide an in-depth analysis of participants' experiences with video-animated explanatory models developed within the three-arm randomized controlled HERMES study ('Helpful explanatory models for somatic symptoms') and suggestions for further intervention improvement.

METHODS

Semi-structured qualitative interviews were conducted with psychosomatic outpatients with persistent somatic symptoms (PSS) after they were randomized to view one of three psychoeducational videos on a tablet computer: a) an explanatory model without personalization or b) an explanatory model with personalization in the two experimental groups or c) PSS guidelines without an explanatory model in the control group. Qualitative interviews were audiotaped, transcribed and analyzed applying thematic analysis.

RESULTS

Seventy-five patients with PSS were allocated to the study arms, mean duration of interviews was 8.19 min (SD = 3.19, range 4.02-19.49 min). Although all participants gave positive feedback regardless of their allocated study arm, those in the explanatory model without and with personalization groups were especially likely to rate the psychoeducational interventions as helpful. Results highlighted previous illness course, symptom perceptions and patient characteristics as key factors related to patients' response to the video interventions and optimal personalization of the explanatory model.

CONCLUSION

The present study not only demonstrated the acceptance of all three psychoeducational interventions developed within the HERMES study, but also provided valuable insights into potential key factors that may increase their impact and potential starting points for tailored psychoeducation in patients with PSS.

How General Practitioners Raise Psychosocial Concerns as a Potential Cause of Medically Unexplained Symptoms: A Conversation Analysis

A common explanation for medically unexplained symptoms (MUS) relates patients' psychosocial concerns to their physical ailments. The present study used conversation analysis to examine how general practitioners (GPs) ascribe psychosocial causes to patients' unexplained symptoms during medical consultations. Our data consisted of 36 recorded consultations from Dutch general practice. We found that GPs raise psychosocial concerns as a potential cause of MUS in 14 consultations, either captured in 1) history-taking questions, or 2) diagnostic explanations. Whereas questions invited patient ideas, explanations did not make relevant patient responses in adjacent turns and subordinated patients' knowledge in symptom experiences to the GP's medical expertise. By questioning patients whether their symptoms may have psychosocial causes GPs enabled symptom explanations to be constructed collaboratively. Furthermore, additional data exploration showed that GPs lay ground for psychosocial ascriptions by first introducing psychosocial concerns as a consequence rather than a cause of complaints. Such preliminary activities allowed GPs to initiate rather delicate psychosocial ascriptions later in the consultation.

Unexplained versus explained symptoms: The difference is not in patients' language use. A quantitative analysis of linguistic markers

OBJECTIVE

Patients with medically unexplained symptoms (MUS) are believed to have a deviant way of talking about complaints. This study systematically compared linguistic markers in symptom presentations of patients with MUS and medically explained symptoms (MES).

METHODS

This content analysis (cross-sectional study) conceptualized relevant linguistic markers based on previous research about MUS communication. Linguistic markers included negations ("not"), intensifiers ("very"), diminishers ("a little"), first or third person subject ("I" vs. "my body"), subjectivity markers ("I think") and abstraction ("I'm gasping for breath" vs. "I'm short of breath"). We also coded valence, reference to physical or mental states, and consultation phase. We compared 41 MUS and 41 MES transcribed video-recorded general practice consultations. Data were analyzed with binary random intercepts models.

RESULTS

We selected and coded 2752 relevant utterances. Patients with MUS used less diminishers compared to patients with MES, but this main effect disappeared when consultation phase was included as predictor. For all other linguistic variables, the analyses did not reveal any variation in language use based on whether patients had MUS or MES. Importantly, utterances' valence and reference to physical or mental state did predict the use of linguistic markers.

CONCLUSION

We observed no systematic variations in linguistic markers for patients who suffered from MUS compared to MES. Patients varied their language use based on utterances' valence and reference to physical or mental states. Current ideas about deviant patient communication may be based on stigmatized perceptions of how patients with MUS communicate, rather than actual differences in their talk.

Helpful explanatory models for somatoform symptoms (HERMES): study protocol of a randomised mixed-methods pilot trial

INTRODUCTION

Persistent somatic symptoms (PSS) are common both in the general population and primary care. They are bothersome in terms of psychological and somatic symptom burden. Health professionals often struggle with communication, as there is a lack of scientifically supported explanatory models for PSS or a focus merely on somatic aspects of the complaints, which both frustrate patients' needs. The objective of the present study is therefore to develop a psychoeducational intervention based on a current evidence-based explanatory model, to examine its feasibility and form the basis for a large-scale randomised controlled trial.

METHODS AND ANALYSIS

In a randomised controlled mixed-methods pilot trial, 75 adult psychosomatic outpatients with PSS (duration of symptoms ≥6 months) and accompanying psychological (Somatic Symptom B-Criteria Scale total score ≥18) and somatic symptom burden (Patient Health Questionnaire-15 score >10) and no prior psychosomatic treatment will be eligible. Participants will be presented with either the explanatory model without (intervention group 1, n=25) or with elements of personalisation (intervention group 2, n=25). Participants in the control group (n=25) will receive information on current PSS guidelines. Participants will be blinded to group assignment and interventions will be shown on tablet computers at the outpatient clinic. After 1 month, qualitative follow-up telephone interviews will be conducted. As primary outcomes, mean changes in psychological and somatic symptom burden will quantitatively be compared between groups, respectively. Behavioural change mechanisms and feasibility of the three interventions will be evaluated using quantitative and qualitative measures.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the medical ethics board of the Hamburg Medical Chamber (PV5653). Results from this study will be published in peer-reviewed journals and presented at national and international conferences.

TRIAL REGISTRATION NUMBER

DRKS00018803.

Psychotherapists' perspective on the treatment of patients with somatic symptom disorders

OBJECTIVE

Guidelines recommend psychotherapy in addition to primary care for patients with moderate to severe somatic symptom disorders. While general practitioners' experiences have been well studied, psychotherapists' experiences with this patient group and the explanatory models psychotherapists use in psychotherapy are unknown.

METHODS

Semi-structured qualitative interviews were conducted between April and July 2018 with 20 German licensed outpatient psychotherapists with either a medical or a psychological background, using the label "somatoform disorders". Interviews were analyzed applying thematic analysis.

RESULTS

Psychotherapists experienced management of affected patients as challenging and partly frustrating, mainly due to the difficult diagnostic process and the "somatic fixation" of some patients. Diagnostic labelling was considered a delicate issue, with some psychotherapists using the term "somatoform", while others preferred either "functional" or vague descriptions like "psychosomatic". The explanatory process was deemed essential for treatment, as was the adaptation of explanations to both a patient's biography and language. As main explanatory factors, psychotherapists referred to generic vulnerability factors, previous somatic illness and health care system influences.

CONCLUSIONS

Explanatory models used in psychotherapy are patient-centred, processual and constitute a major component of the psychotherapeutic process. However, this process might be impeded if patients are confronted with different diagnostic labels and explanatory models during their pathways through care.

Standardizing Pediatric Somatic Symptom and Related Disorders Care: Clinical Pathway Reduces Health Care Cost and Use

BACKGROUND

Pediatric somatic symptom and related disorders (SSRDs) are common with high health care costs and use because of lack of standardized, evidence-based practice. Our hospital implemented a clinical pathway (CP) for SSRD evaluation and management. Our study objective was to evaluate health care cost and use associated with the organization's SSRD CP in the emergency department (ED) and inpatient settings hypothesizing lower cost and use in the CP group relative to controls.

METHODS

We conducted a retrospective analysis of costs and use before and after implementation of the SSRD CP. Data were collected from the hospital's electronic health record and the Pediatric Health Information System database. Participants included pediatric patients on the CP ("P" group) and control groups with an SSRD diagnosis and mental health consultation either the year before the CP ("C" group) or during the CP study period ("T" group). Primary outcomes included costs, length of stay, diagnostic testing, imaging, subspecialty consultation, and readmission rates.

RESULTS

The ED P group had more lower-cost imaging, whereas the inpatient T group greater higher-cost imaging than other groups. The inpatient P group had significantly shorter length of stay, fewer subspecialty consults, and lower costs. There were no significant group differences in readmission rates. The CP reduced median total costs per patient encounter by $51 433 for the inpatient group and $6075 for the ED group.

CONCLUSIONS

The CP group showed significant reductions in health care cost and use after implementation of a CP for SSRD care. In future work, researchers should explore patient and practitioner experience with the SSRD CP and long-term outcomes.

Linguistic and interactional aspects that characterize consultations about medically unexplained symptoms: A systematic review

OBJECTIVE

The apparent absence of any specific underlying diseases challenges patient-provider communication about medically unexplained symptoms (MUS). Previous research focused on general communication patterns in these interactions; however, an overview of more detailed interactional and linguistic aspects is lacking. This review aims to gain a detailed understanding of communicative challenges in MUS consultations by synthesizing evidence from conversation and discourse analytic research.

METHODS

A systematic review of publications using eight databases (PubMed, Embase, CINAHL, PsychINFO, Web of Science, MLA International Bibliography, LLBA and Communication Abstracts). Search terms included 'MUS', 'linguistics' and 'communication'. Additional studies were identified by contacting experts and searching bibliographies. We included linguistic and/or interactional analyses of natural patient-provider interactions about MUS. Two authors independently extracted the data, and quality appraisal was based on internal and external validity.

RESULTS

We identified 18 publications that met the inclusion criteria. The linguistic and interactional features of MUS consultations pertained to three dimensions: 1) symptom recognition, 2) double trouble potential (i.e. patients and providers may have differing views on symptoms and differing knowledge domains), and 3) negotiation and persuasion (in terms of acceptable explanations and subsequent psychological treatment). We describe the recurrent linguistic and interactional features of these interactions.

CONCLUSIONS

Despite the presence of a double trouble potential in MUS consultations, validation of symptoms and subtle persuasive conduct may facilitate agreement on illness models and subsequent (psychological) treatment.

Patients' descriptions of the relation between physical symptoms and negative emotions: a qualitative analysis of primary care consultations

BACKGROUND

Primary care guidelines for the management of persistent, often 'medically unexplained', physical symptoms encourage GPs to discuss with patients how these symptoms relate to negative emotions. However, many GPs experience difficulties in reaching a shared understanding with patients.

AIM

To explore how patients with persistent symptoms describe their negative emotions in relation to their physical symptoms in primary care consultations, in order to help GPs recognise the patient's starting points in such discussions.

DESIGN AND SETTING

A qualitative analysis of 47 audiorecorded extended primary care consultations with 15 patients with persistent physical symptoms.

METHOD

The types of relationships patients described between their physical symptoms and their negative emotions were categorised using content analysis. In a secondary analysis, the study explored whether patients made transitions between the types of relations they described through the course of the consultations.

RESULTS

All patients talked spontaneously about their negative emotions. Three main categories of relations between these emotions and physical symptoms were identified: separated (negation of a link between the two); connected (symptom and emotion are distinct entities that are connected); and inseparable (symptom and emotion are combined within a single entity). Some patients showed a transition between categories of relations during the intervention.

CONCLUSION

Patients describe different types of relations between physical symptoms and negative emotions in consultations. Physical symptoms can be attributed to emotions when patients introduce this link themselves, but this link tends to be denied when introduced by the GP. Awareness of the ways patients discuss these relations could help GPs to better understand the patient's view and, in this way, collaboratively move towards constructive explanations and symptom management strategies.

"Understand your illness and your needs": Assessment-informed patient education for people with multiple functional somatic syndromes

OBJECTIVES

Patients suffering from multiple functional somatic syndromes (FSS) such as fibromyalgia, chronic fatigue syndrome, or irritable bowel syndrome, often lack both a clear diagnosis and tangible illness explanations, which is a barrier for treatment engagement. We tested a short-term intervention taking the unifying concept of Bodily Distress Syndrome (BDS) as a point of departure. The intervention consisted of a clinical assessment, group-based patient education, and one follow-up consultation.

METHODS

174 patients were included and received questionnaires at baseline, after clinical assessment, after patient education, and median 19 weeks after baseline. Data were analyzed using random effects models and simple t-tests. Qualitative data were thematically analyzed.

RESULTS

We found small reductions in symptom levels, considerable reductions in illness worry, and improvement of illness perceptions and illness-related behaviors. Overall, patients evaluated the intervention positively and expressed high expectations for further treatment. Qualitative results mainly supported these findings.

CONCLUSION

Targeting illness perceptions through patient education is crucial to obtain patient engagement in self-help management or further treatment. This may lead to improved outcomes.

PRACTICAL IMPLICATIONS

Physicians in primary and secondary care should strive to give patients with multiple FSS a clear understanding that their various FSS diagnoses are related and provide tangible illness explanations.

[Functional somatic syndromes: A comprehensive cognitive model]

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

Quantifying positive communication: Doctor's language and patient anxiety in primary care consultations

OBJECTIVE

Positive communication is advocated for physicians during consultations with patients presenting medically unexplained symptoms (MUS), but studies generally focus on what is said rather than how it is said. This study quantified language use differences of general practitioners (GPs), and assessed their relation to patient anxiety.

METHODS

Language use of 18 Dutch GPs during 82 consultations was compared for patients with MUS versus medically explained symptoms (MES). Message content (positive or negative) was differentiated from its directness (direct or indirect), and related to changes in patient's state anxiety (abbreviated State Trait Anxiety Inventory; STAI).

RESULTS

In total, 2590 clauses were identified. GPs approached patients with MES with relatively more direct (vs. indirect) positive and indirect (vs. direct) negative messages (OR 1.91, 95% CI 1.42-2.59). Anxiety of both patient groups increased when GPs used more direct (vs. indirect) negative messages (b = 0.67, 95% CI 0.07-1.27) CONCLUSIONS: GPs use different language depending on the content of messages for patients with MES, but not MUS. Direct negative messages relate to an increase in patient anxiety.

PRACTICE IMPLICATIONS

GPs could manage patient's state anxiety by expressing negative messages in an indirect rather than direct manner.

Pediatric Somatic Symptom and Related Disorders: Primary Care Provider Perspectives

Somatization, or physical symptoms that are inconsistent with a physiological cause that may or may not involve an identified stressor, is common in outpatient pediatrics. When these symptoms persist, they can impair function and progress to a somatic symptom and related disorder (SSRD), resulting in increased health care use and increased demands on primary care providers (PCPs). We performed a needs assessment among PCPs to better understand how best to support providers caring for children with SSRDs. Pediatric PCPs (n = 77) were surveyed to better understand their training, experience, perceptions, and practices of SSRD care. Findings indicate that PCPs have limited training in SSRD care but express interest in learning more. Many barriers to effective care were reported. We hope to use these findings to develop training materials and support services for pediatric PCPs managing SSRDs.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

PRACTICE IMPLICATIONS

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

Pediatric Somatic Symptom Disorders

Somatic symptom disorder (SSD) is a common disorder encountered in pediatric medicine. It involves the presentation of physical symptoms that are either disproportionate or inconsistent with history, physical examination, laboratory, and other investigative findings. SSDs result in significant impairment with considerable increase in healthcare utilization, school absenteeism, and the potential for unnecessary diagnostic evaluation and treatment intervention. Patients and families often feel dismissed and may worry that a serious condition has been missed. Primary care providers are frequently frustrated due to a lack of a successful approach to patients and families impacted by SSD. The result is often a cycle of disability, frustration and missed opportunities for collaboration towards enhanced patient functionality. This review summarizes the current evidence-based understanding, as well as insights from clinician experience, on the evaluation and management of pediatric SSD.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Clinical practitioners' views on the management of patients with medically unexplained physical symptoms (MUPS): a qualitative study

OBJECTIVES

By identifying strategies that practicing physicians use in managing patients with medically unexplained physical symptoms (MUPS), we present an interim practical management guide (IPMG) that clinical practitioners may find useful in their clinical practices and that may help guide future research.

DESIGN

A qualitative research study based on interview data from practicing physicians with experience in dealing with MUPS and known to the physician members of the research team. A parallel exploration of patient experiences was carried out simultaneously and is reported elsewhere.

SETTING

2 urban centres in 2 different Canadian provinces in a healthcare system where family physicians provide the majority of primary care and self-referral to specialists rarely occurs.

PARTICIPANTS

The physician members of the research team invited practicing family and specialty physicians to participate in the study.

RESULTS

We characterise the care of patients with MUPS in terms of a 4-part framework: (1) the challenge of diagnosis; (2) the challenge of management/treatment; (3) the importance of communication and (4) the importance of the therapeutic relationship.

CONCLUSIONS

On the basis of the details in the different parts of the framework, we propose an IPMG that practitioners may find useful to facilitate the clinical care of patients with MUPS. The guide can be readily implemented into the practice of any physician who cares for patients with MUPS.

What's 'difficult'? A multi-stage qualitative analysis of secondary care specialists' experiences with medically unexplained symptoms

BACKGROUND

The term 'difficult' is pervasively used in relation to medically unexplained symptoms (MUS) and patients with MUS. This article scrutinises the use of the term by analysing interview data from a study of secondary care specialists' experiences with and attitudes towards patients suffering from MUS.

DESIGN

Qualitative design employing semi-structured open-ended interviews systematically analysed in three stages: first, data were analysed according to the principles of content analysis. The analysis subsequently focused on the use of the term 'difficult'. Iterations of the term were extracted by summative analysis and thematic coding revealed its different meanings. Finally, alternative expressions were explored.

SETTING

Three NHS trust secondary care hospitals in North-East England.

PARTICIPANTS

17 senior clinicians from seven medical and two surgical specialities.

RESULTS

Unsolicited use of the term 'difficult' was common. 'Difficult' was rarely used as a patient characteristic or to describe the therapeutic relationship. Participants used 'difficult' to describe their experience of diagnosing, explaining, communicating and managing these conditions and their own emotional reactions. Health care system deficits and the conceptual basis for MUS were other facets of 'difficult'. Participants also reported experiences that were rewarding and positive.

CONCLUSIONS

This study shows that blanket statements such as 'difficult patients' mask the complexity of doctors' experiences in the context of MUS. Our nuanced analysis of the use of 'difficult' challenges preconceived attitudes. This can help counter the unreflexive perpetuation of negative evaluations that stigmatize patients with MUS, encourage greater acknowledgement of doctors' emotions, and lead to more appropriate conceptualizations and management of MUS.

Developmental study of treatment fidelity, safety and acceptability of a Symptoms Clinic intervention delivered by General Practitioners to patients with multiple medically unexplained symptoms

BACKGROUND

There is a need for primary care interventions for patients with multiple medically unexplained symptoms (MUS). We examined whether GPs could be taught to deliver one such intervention, the Symptoms Clinic Intervention (SCI), to patients. The intervention includes recognition and validation of patients' symptoms, explanation of symptoms and actions to manage symptoms.

METHODS

We conducted an uncontrolled observational study in Northeast Scotland. GPs were recruited and received two days of structured training. Patients were identified via a two stage process (database searching followed by postal questionnaire) and received the SCI intervention from a GP in their practice. Treatment fidelity was assessed by applying a coding framework to consultation transcripts. Safety was assessed by examining changes in patient symptoms (PHQ-15) and checking for unexpected events. Acceptability was primarily assessed by patient interview.

RESULTS

Four GPs delivered the SCI to 23 patients. GPs delivered all core components of the SCI, and used the components flexibly across the consultations and between patients. They spent more time on recognition than either explanation or actions components. 10 out of 17 patients interviewed described feeling validated, receiving useful explanation and learning actions. 9 out of 20 patients (45%) reported an improvement in PHQ-15 of between 3 and 8 points. Patients who reported the most improvement also described receiving all three components of the intervention.

CONCLUSIONS

GPs can be taught to deliver the SCI with reasonable fidelity, safety and acceptability, although some items were inconsistently delivered: further training would be needed before use.

The Meaning of Patient Experiences of Medically Unexplained Physical Symptoms

Current diagnostic models in medical practice do not adequately account for patient symptoms that cannot be classified. At the moment, when all known diagnostic possibilities have been excluded, physicians-and patients-confront uncertainty in diagnosis, which gives rise to the label of Medically Unexplained Physical Symptoms (MUPS). This phenomenological study, conducted by two research teams in two geographic locations, sought to explore patients' experiences of prolonged uncertainty in diagnosis. Participants in this study described their experiences with and consequences of MUPS primarily in relation to levels of acuity and acceptance of uncertainty, the latter loosely correlated to length of time since onset of symptoms (the longer the time, the more forbearance participants expressed). We identified three experiential periods including the active search for a diagnosis, living with MUPS, and, finally, acceptance/resignation of their condition. Findings point to the heightened importance of the therapeutic relationship when dealing with uncertainty.