Psychology of medically unexplained symptoms: A practical review

What psychological interventions are effective for the management of persistent physical symptoms (PPS)? A systematic review and meta-analysis

OBJECTIVES

Presentation of persistent physical symptoms is associated with increased health care utilization, yet clinical outcomes often remain suboptimal. This systematic review aimed to determine whether psychological interventions are effective for the management of PPS and if so, what are the features of the interventions and at what level of care are they delivered. The review also set out to establish which symptoms in those diagnosed with PPS can be effectively managed with psychological intervention.

METHODS

Studies were included if they clearly reported a psychological intervention, specified the study sample as adults with a diagnosis of persistent physical symptoms, included a comparator and as a minimum an outcome measure of somatic symptoms. Risk of bias was assessed using the EPHPP. Meta-analysis was conducted to estimate the overall effect of interventions on somatic symptoms (the primary outcome), anxiety and depression (secondary outcomes).

RESULTS

Seventeen papers of varying quality indicated that psychological interventions can be effective for the management of somatic symptoms reported by individuals with PPS within a primary care setting. Psychological interventions were also found to be effective at reducing depression symptoms in individuals with PPS in twelve of the included studies. However, the meta-analysis results suggest that the psychological interventions utilized within eleven of the included studies did not significantly impact anxiety symptoms.

CONCLUSIONS

Psychological interventions have some success in managing somatic symptoms in PPS patients within primary care settings although their effects on other psychological symptoms is more mixed. The review highlights the importance of establishing a clearer diagnostic classification to inform treatment trajectories and the need for appropriate training and support within a multi-disciplinary team to enable the provision of such therapies.

Understanding Patient-Provider Interaction, Treatment Acceptance, and Outcomes in Medically Unexplained Symptoms

INTRODUCTION

Medically unexplained symptoms (MUS) is an umbrella term used for chronic and often disabling health symptoms and conditions that remain unexplained after standard medical examinations, testing, and/or appropriate workup. Patients with MUS tend to receive little to no treatment but remain distressed, stigmatized, and disabled by symptoms and iatrogenic factors.

METHODS

A qualitative phenomenological study was conducted to explore daily challenges and psychosocial and iatrogenic factors affecting the management of MUS.

RESULTS

The analysis of the interviews revealed that MUS could cause significant distress to patients, impairing their functioning and leading to permanent disability. Conventional healthcare cannot meet the medical needs of these patients and might be a potential source of harm to them. It should be noted that confirmation of conditions associated with clinically significant psychiatric premorbidity was not provided.

CONCLUSION

Inconsistent diagnostic criteria, lack of proper training and research, diagnostic overshadowing, and implicit bias in healthcare professionals can lead to negative patient outcomes and the overuse of alternative or non-evidence-based services. Guidance, practice-based improvement ideas, and suggestions specific to improving patient-provider relationships can be applied to generate positive health effects.

Psychological interventions for medically unexplained physical symptoms: A systematic review and meta-analysis

OBJECTIVE

Individuals seeking treatment for physical symptoms having unknown etiology are common in the primary healthcare setup. Factors such as biomedical, environmental, social, and psychological ones are expected to play an important role in the treatment of Medically Unexplained Physical Symptoms (MUPS). Therefore, this systematic review and meta-analysis aimed to investigate the efficacy of psychological interventions for the treatment of MUPS.

METHOD

Studies were selected using different electronic databases (PubMed, Wiley, Cochrane), to identify RCTs published in the last 11 years on psychological interventions to treat MUPS. A total of 12 studies were finalized for systematic review and 7 for meta-analysis based on the inclusion criteria. The risk of bias was assessed by the two reviewers independently using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. OpenMeta[Analyst] was used to perform meta-analysis.

RESULTS

The findings revealed that psychological interventions can possibly be effective in treating patients with MUPS. Somatic symptom severity and depression improved in the intervention groups as compared to controls, while anxiety, and physical and mental component summary of Short-Form General Health Survey 36 did not significantly improve in the intervention group.

CONCLUSION

A tailored module including psychological interventions to deal with these patients in primary care may be useful in improving the overall functioning of the individuals.

A Qualitative Study of the Views of Patients With Medically Unexplained Symptoms on The BodyMind Approach®: Employing Embodied Methods and Arts Practices for Self-Management

The arts provide openings for symbolic expression by engaging the sensory experience in the body they become a source of insight through embodied cognition and emotion, enabling meaning-making, and acting as a catalyst for change. This synthesis of sensation and enactive, embodied expression through movement and the arts is capitalized on in The BodyMind Approach^® (TBMA). It is integral to this biopsychosocial, innovative, unique intervention for people suffering medically unexplained symptoms (MUS) applied in primary healthcare. The relevance of embodiment and arts practices in TBMA are discussed in relation to the views of participants in the pursuit of self-management. If widely employed TBMA could have an enormous impact, reach, and significance for patients and global health services. This original pre-clinical trial of qualitative research reports on the perceptions of participant patients with generic MUS, a world-wide issue usually treated by either psychological therapy or physiotherapy. TBMA is not a therapy but a health education program founded upon the concept of an integration of psychological elements with physiological, bodily, and sensory experiences. Thematic analysis of qualitative data sets from open-ended questions in semi-structured interviews and a written questionnaire post intervention is presented. Five aspects which appear to be key to learning self-management were derived from analyzing the data: (1) body with mind connections; (2) importance of facilitation; (3) potential benefits; (4) preparedness for change; (5) self-acceptance/compassion. This article advances the discourse on the nature of self-management for MUS through changing the mind-set and the relationship participants have with their bodily symptom/s through employing embodied methods and arts practices, challenging current, and solely verbal, psychological conceptual frameworks. Rigor lies in the method of data analysis using cross verification of credibility between reported findings and scrutiny by stakeholders. We conclude that facilitated TBMA groups employing embodied methods and arts practices can act as a method for developing the self-management of MUS and improving wellbeing.

Functional Stroke Symptoms: A Narrative Review and Conceptual Model

Stroke services have been reconfigured in recent years to facilitate early intervention. Throughout stroke settings, some patients present with functional symptoms that cannot be attributed to a structural cause. Emphasis on fast diagnosis and treatment means that a proportion of patients entering the care pathway present with functional symptoms that mimic stroke or have functional symptoms in addition to vascular stroke. There is limited understanding of mechanisms underlying functional stroke symptoms, how the treatment of such patients should be managed, and no referral pathway or treatment. Predisposing factors vary between individuals, and symptoms are heterogeneous: onset can be acute or insidious, and duration can be short-lived or chronic in the context of new or recurrent illness cognitions and behaviors. This article proposes a conceptual model of functional symptoms identified in stroke services and some hypotheses based on a narrative review of the functional neurological disorder literature. Predisposing factors may include illness experiences, stressors, and chronic autonomic nervous system arousal. Following the onset of distressing symptoms, perpetuating factors may include implicit cognitive processes, classical and operant conditioning, illness beliefs, and behavioral responses, which could form the basis of treatment targets. The proposed model will inform the development of theory-based interventions as well as a functional stroke care pathway.

The psychological nature of seizure conditions

Background/Aims:

Epilepsy is a long-term health condition that is associated with multiple biological, psychological and behavioural factors. Psychogenic or non-epileptic conditions have caused much debate and controversy among clinicians and researchers. This paper outlines comprehensive assessments with the aim of describing the psychological nature of different types of seizure conditions.

Methods:

The retrospective study reports on a range of self-report psychometric data of 26 patients with epileptic, non-epileptic, or both types of seizure conditions. The Hospital and Anxiety and Depression Scale, the Dissociative Experiences Scale and the Emotional Processing Scale were used to assess psychological functioning and emotional distress. The Quality of Life in Epilepsy Inventory and the MOS Short-Form Health Survey 36 were administered to evaluate subjective experiences related to quality of life and disability.

Results:

Epileptic and non-epileptic seizures are formulated in the background of biopsychosocial stress theories. The questionnaire outcomes revealed complex profiles. All patient groups reported reduced quality of life. Differential patterns of psychological distress were discovered for both diagnostic groups.

Conclusion:

The findings from this heterogeneous clinical population suggest that patients with epileptic and non-epileptic conditions demonstrate secondary psychological and functional difficulties. Future systematic research is required to establish valid measures of long-term psychosocial strain and to provide evidence for the link between maladaptive physiological mechanisms and psychological problems (and vice versa).