Medically unexplained physical symptoms in emergency medicine

Halifax somatic symptom disorder trial: A pilot randomized controlled trial of intensive short-term dynamic psychotherapy in the emergency department

BACKGROUND

Patients commonly present at hospital Emergency Departments (ED) with distress that meet criteria for a Somatic Symptom and Related Disorder (SSRD). Without access to effective treatment, risk of ongoing patient disability and further ED visits is high.

METHOD

This pilot trial used a randomized parallel group design to test the efficacy of Intensive Short-Term Dynamic Psychotherapy (ISTDP). ED patients who met criteria for SSRD were recruited. The effects of ISTDP plus medical care as usual (MCAU) were judged through comparison against 8 weeks of MCAU plus wait-list symptom monitoring (WL-SM). The primary outcome was somatic symptom at 8 weeks. Patients allocated to WL-SM could cross-over to receive ISTDP and 6-month follow-up data was collected. Baseline measures of patient attachment style and alexithymia were collected to examine vulnerabilities to somatic symptoms.

CLINICALTRIALS

gov: NCT02076867.

RESULTS

Thirty-seven patients were randomized to 2 groups (ISTDP = 19 and WL-SM = 18). Multi-level modelling showed that change over time on somatic symptoms was significantly greater in the ISTDP group. Between-group differences were large at 8 weeks (Cohen's d = 0.94) and increased by end of treatment (Cohen's d = 1.54). Observed differences in symptoms of depression and illness anxiety were also large, favoring ISTDP, and effects were maintained at follow-up. Patients receiving ISTDP had reduced ED service utilization at 2-year follow-up.

CONCLUSIONS

ISTDP appears an efficacious treatment for SSRD and a larger randomized trial is justified.

Functional somatic symptoms in Emergency Department frequent presenters

BACKGROUND

Patients with Functional Somatic Symptoms (FSS) are frequently encountered within healthcare settings such as Emergency Departments (ED). There is limited research regarding characterisation and frequency of FSS within frequent presenters to ED and no previous Australian evidence. This study aims to fill this gap.

METHODS

A retrospective, single-centre study of frequent ED presenters over a 6-month period was undertaken. Patients with > 3 re-presentations/month were reviewed for the presence of FSS using Stephenson and Price's (Stephenson DT, Price JR. Medically unexplained physical symptoms in emergency medicine. Emerg Med J. 2006;23(8):595.) categorisation of FSS. Patients were divided into three groups - FSS, possible FSS (pos-FSS) and non-FSS. The characteristics of these groups were compared using descriptive statistics (chi-square tests, Welch's ANOVA). Person-time at risk during the 6-month study period was estimated for patients in each group and incidence of ED presentation for each group was then calculated. Psychological distress indicators for ED presenters with FSS, as noted by the treating clinician, were also analysed.

RESULTS

11% (71/638) of frequent ED presenters were categorised as having FSS and 72% (458/638) as having possible FSS (Pos-FSS). Mean ED presentations in the FSS group during the study period were significantly higher than in the non-FSS and Pos-FSS groups (p < 0.01). Anxiety was found to be the primary psychological distress indicator associated with ED presentations with FSS.

CONCLUSION

We found that, amongst frequent ED presenters, patients with FSS presented significantly more frequently to ED than those without FSS. We propose revising the model of care for FSS in ED to promote appropriate referral to therapy services as a possible demand reduction strategy to improve patient care and efficiency in ED.

Symptom attribution and stress level in patients with medically unexplained symptoms in a Mexican emergency department

Background

Patients who come to the emergency department are different from those seen in outpatient clinics. The former suffer greater stress.

Aim

Establish an association between the attribution of the symptoms (psychosocial or organic) by the patient and the level of perceived stress in patients with Medically Unexplained Physical Symptoms (MUS) in an emergency department.

Methods

A correlational cross-sectional study was conducted in 138 patients with MUS in the emergency department of a 3rd level public hospital where the psychosocial or organic attribution of nonspecific symptom(s) by patients and the perceived stress were measured with validated scales. Bivariate analysis was performed with Chi square for categorical variables, and a Spearman correlation, p <0.05.

Results

75% of patients with psychosocial attribution have higher stress compared to patients with organic symptom attribution (25%). In Spearman's correlation, a medium but statistically significant correlation was obtained.

Conclusions

The psychosocial attribution of the patient's complaint might coexist in MUS patients with higher level of perceived stress by the patients. Health professionals might need to address both psychosocial attributions and stress in MUS patients.

Comprehensive Treatment Module for Medically Unexplained Physical Symptoms - A Guide for General Practitioners

Purpose: This study was aimed to develop a comprehensive treatment module that the general physician can use to manage patients with Medically Unexplained Physical Symptoms (MUPS) at a primary care level. 

Methods: This comprehensive module was developed after a literature review followed by its validation by a two-step Delphi technique with experts from internal medicine, psychiatry, and clinical psychology.

Results: The developed module for the patients with MUPS includes case diagnosis, initial evaluation, strategy for referral, and a comprehensive treatment module. The comprehensive treatment module includes symptom discussion, rapport establishment, physical health counselling, stress management, cognitive strategies for symptom control, comorbidities treatment, and medical management. 

Conclusion: The developed module has unique features, such as intensive sessions with these patients, a patient-specific treatment strategy, and a holistic approach incorporating pharmacological and non-pharmacological interventions. General Practitioners across the world can use this comprehensive treatment module for the management of patients with MUPS.

Pediatric somatization in the emergency department: assessing missed opportunities for early management

OBJECTIVE

Somatization is a common phenomenon that can severely complicate youths' functioning and health. The burden of somatization on pediatric acute care settings is currently unclear; better understanding it may address challenges clinicians experience in effectively caring for somatizing patients. In this study, we estimate the prevalence of somatization in a pediatric emergency department (ED).

METHODS

We conducted a retrospective cross-sectional study of visits for non-critical, non-mental health-related concerns (n = 150) to a quaternary-level pediatric ED between July 2016 and August 2017. Demographic and clinical visit details were collected through chart review and used by two reviewing clinicians to classify whether each visit had a "probable," "unclear" (possible), or "unlikely" somatizing component.

RESULTS

Approximately 3.33% (n = 5) of youth displayed probable somatization, and an additional 13.33% (n = 20) possibly experienced a somatizing component but require additional psychosocial and visit documentation to be certain. Longer symptom duration and multiple negative diagnostic tests were associated with a higher likelihood of either probable or possible somatization.

CONCLUSIONS

A considerable proportion of non-mental health-related visits may involve a somatizing component, indicating the burden of mental health concerns on the ED may be underestimated. A higher index of suspicion for the possibility of somatization may support clinicians in managing somatizing patients.

The relationship of cortical activity induced by pain stimulation with clinical and cognitive features of somatic symptom disorder: A controlled functional near infrared spectroscopy study

OBJECTIVE

The neurobiological correlates of Somatic Symptom Disorder (SSD) introduced in the DSM-5 has been the focus of a limited investigation. We aimed to examine the cortical response to painful stimuli and its relationship to symptom severity as well as cognitive and psychological characteristics in proposed models of somatoform disorders.

METHODS

We measured hemodynamic responses by 52-channel functional near-infrared spectroscopy. We compared the cortical response to painful stimuli in index patients with SSD (N = 21) versus age, and gender matched healthy control subjects (N = 21). We used brush stimulation as the control condition. We analyzed the relationship of cortical activity with SSD symptom severity as well as somatosensory amplification (SSA), alexithymia, dysfunctional illness behaviour, worry, and neuroticism.

RESULTS

Patients with SSD had higher somatic symptom severity, SSA, alexithymia, neuroticism, illness-related worry, and behaviour. Somatic symptom severity was predicted by a model including SSA and subjective feeling of pain in the index patients. Activity in the left-angular and right-middle temporal gyri was higher in the SSD subjects than the controls during pain stimulation. Positive correlations were detected between mean pain threshold levels and left middle occipital gyrus activity, as well as between SSA-scores and right-angular gyrus activity during pain condition in the index patients with SSD.

CONCLUSION

We present the first evidence that representation of pain in terms of cortical activity is different in subjects with SSD than healthy controls. SSA has functional neuroanatomic correlates and predicts symptom severity in SSD and therefore is involved as a valid intermediate phenotype in SSD pathophysiology.

Interventions for medically unexplained symptoms in the emergency department: a critical literature review

Medically unexplained symptoms, defined as physical symptoms for which no organic pathology can be found, represent 4% of all emergency department attendances annually. The standard management of these patients involves extensive investigation to rule out organic pathology, followed by simple reassurance. We conducted a literature review to determine if there was any intervention that could improve these patient's symptoms and reduce emergency department attendances. A search of MEDLINE, EMBASE and PsycINFO yielded 1612 unique citations, of which six studies met inclusion criteria. The studies were heterogeneous in terms of the participants involved, interventions tested and conclusions drawn. Three studies tested cognitive behavioural therapy, with two finding a reduction in emergency department attendance. Overall, evidence regarding interventions for patients with medically unexplained symptoms in the emergency department is limited and of a variable quality, despite comprising 4% of emergency department attendances. Further research is required to determine the best intervention for this challenging patient group.

A comparison of Emergency Department presentations for Medically Unexplained Symptoms in Frequent Attenders during COVID-19.. [DOI: 10.1101/2020.08.25.20181511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Background

Medically Unexplained Symptoms (MUS) refer to symptoms with no identified organic aetiology, and are amongst the most challenging for patients and Emergency Department (ED) staff. Providers working in our ED perceived an increase in severity and frequency of these types of presentations during the COVID-19 pandemic.

Methods

A retrospective list of frequent attenders (FA) presenting five or more times to the ED between two 122-day periods were examined: 01 Mar to 30 Jun 2019 (Control) and 2020 (COVID-19). The FA group were then examined to identify patients presenting with MUS (FA-MUS). Data were analysed in Prism; presented as n(%), % (95% confidence interval (95%CI) – Wilson/Brown method). Proportions were compared with a two-tailed Fisher’s exact test. A Baptista-Pike odds ratio was used to estimate magnitude and precision.

Results

The total number of ED attendances during the control period was n=42,785 which reduced to n=28,806 in the COVID-19 period, a decrease of 32.7%. The control FA cohort had n=44 FA-MUS patients with 149 ED visits. This increased to n=65 FA-MUS patients with 267 visits during COVID-19, p=0.44. There was a significant increase in the proportion of all ED visits that were FA-MUS: 0.3% (control) compared to 0.9% (COVID-19); OR 2.7, p<0.001. There was a significant increase in shortness of breath amongst MUS during the COVID-19 pandemic relative to the control period (p<0.01), with no significant difference in any other MUS category.

Conclusion

Whilst the total number of ED attendances reduced by almost one third during COVID-19, the actual number of all visits by frequent attenders with MUS increased and the proportion of attendances by these tripled during the same period. This presents an increasing challenge to ED clinicians who may feel underprepared to manage these patients effectively.

What is already known

Medically Unexplained Symptoms (MUS) are those that have no identified organic aetiology - they are amongst the most challenging presentations for patients and Emergency Department (ED) staff.

During times of stress and uncertainty, frequent attenders (FA) appear to be disproportionately affected by MUS. However, there are few data examining the impact of COVID-19 on the FA population.

What this paper adds

There was a significant increase in the proportion of all ED visits by FAs during the first four months of the COVID-19 pandemic.

There was a significant increase in the proportion of all ED visits by FAs with MUS during the first four months of the COVID-19 pandemic.

The proportion of MUS presentations that were ‘shortness of breath’ was significantly higher in the COVID-19 period compared to the control period. There were no other proportional differences observed in MUS categories.

Medically unexplained physical symptoms in patients visiting the emergency department: an international multicentre retrospective study

OBJECTIVE

The objective of this study was to assess the incidence and characteristics of patients presenting with physical symptoms that remain medically unexplained at the emergency department (ED).

PATIENTS AND METHODS

A retrospective chart study was carried out in three hospitals in The Netherlands and Belgium. All patients (age > 18 years) visiting the ED in 4 selected weeks in 2013 at the Erasmus University Medical Center (Erasmus MC) in Rotterdam, The Netherlands, and 1 selected week in 2013 at the Haaglanden Medical Center, Westeinde HMC in The Hague, The Netherlands, and the University Hospital Ghent (UZG), Belgium, were included. Descriptive statistics were used for data analysis.

RESULTS

A total of 2869 patients (Erasmus MC 1674, HMC 691, UZG 504) were included. Medically unexplained physical symptoms in the emergency department (EDMUPS) were present in 13.4% of all ED visits (Erasmus MC 12.5%, HMC 18.7%, UZG 9.1%). No EDMUPS were identified in trauma patients. When excluding trauma patients, EDMUPS were present in 18.5% (Erasmus MC 16.8%, HMC 26.5%, UZG 13.3%) of the visits. The characteristics of patients with and without EDMUPS differed significantly; patients with EDMUPS were more often younger, female, self-referred, frequent visitors, were prescribed less medication and more often had a psychiatric disease. Dutch and Belgian Hospital differed in the distribution of patients in triage categories and in the incidence of psychiatric illnesses.

CONCLUSION

Physical symptoms remain unexplained in a significant number of patients at the time of ED assessment.

From Conversion Disorders to Functional Neurological Disorders. Overcoming the Rule-out Diagnosis?

Functional neurological disorders, formerly referred to as conversion disorders, are a frequent clinical problem in neurology, psychiatry and primary care departments. In the new diagnostic categories, emphasis is placed on the positive characteristics necessary to diagnose this disorder. A narrative review of the scientific medical literature related to the subject was performed in order to determine the differences and advantages that the new classification of functional neurological disorders gives to doctors and patients. Historical, diagnostic, clinical and treatment concepts related to functional neurological disorders are reviewed. The conceptual differences between conversion disorders and functional neurological disorders and the implications of these changes in the clinical approach are identified. The new proposed diagnosis for functional neurological disorders provides the opportunity to transform a diagnosis made by ruling out other pathologies to a diagnosis where the presence of neurological signs suggestive of the disorder are verified and can be taught to the patient, and based on them, treatment strategies posed.

Biopsychosocial approach to understanding resilience: Stress habituation and where to intervene

BACKGROUND

Resilience in the face of adversity is a human experience that leads to better health, both mentally and physically. We briefly review its historical origins rooted in ecological biology and its adoption into health care. Resilience is the common response to adversity or potential traumatic events. Individual differences in emotion regulation and coping skills as well as social capital and one's physical environment influence a person's ability to achieve resilience.

PROPOSED MECHANISM

One potential biopsychosocial measure of resilience includes stress habituation to repeated stress as demonstrated in the laboratory, possibly providing a tool to observe mastery of resilience training in the clinic. Evidence-based interventions at the individual and small group level (eg, family, classroom) have successfully shown development of resilient behaviours and improved mental and physical health outcomes. However, the role of social context and public policy clearly influence an individual's ability to be resilient.

CONCLUSIONS

Despite the current limited evidence of the effectiveness of resilience building interventions, clinicians, researchers, and other health care professions have an obligation to become advocates for laws and policies that support the most vulnerable, and least resilient, in our society to attain resilience for their health. This salutary effect will enable them to become socially as well as economically productive members of the community at large. It is not possible to remove stress or adversity from life, but we can influence the development of regulatory flexibility and decrease the sociocultural factors linked to the nonresilient experience, thus mitigating adversity's long-term effects on health.

Attachment and medically unexplained somatic symptoms: The role of mentalization

Previous research has found an association between insecure attachment and increased somatization in adults. However, the mechanisms underlying this association are unknown. In the present study, we examined whether the association between attachment insecurity and somatization in psychiatric patients diagnosed with medically unexplained somatic symptoms (MUSS) is mediated by mentalization deficits. Attachment security of 58 outpatients diagnosed with MUSS was measured with the Experiences in Social Relationships Questionnaire (ECR). Difficulty with understanding own emotions was measured with the Toronto Alexithymia Scale-20. In addition, others' mental state comprehension was measured with the Reading the Mind in the Eyes Test (RMET). Somatic symptom severity experienced by MUSS patients was related to attachment anxiety and alexithymia. These associations remained significant after controlling for sex, age, medication use, and depressive symptoms. Moreover, alexithymia mediated the association between anxious attachment and severity of somatic symptoms. Somatic symptom severity was also related to better RMET performance, although this association was not significant after controlling for sex, age, medication use, and depressive symptoms. Our findings may indicate that individuals with an anxious attachment style have difficulties in clarifying own emotions. This may in turn result in somatic experience of emotional distress and risk for development of MUSS.

Acute cardiac dyspnea in the emergency department: diagnostic value of N-terminal prohormone of brain natriuretic peptide and galectin-3

OBJECTIVE

This study was performed to determine whether a dual-biomarker approach using N-terminal prohormone of brain natriuretic peptide (NT-proBNP) and galectin-3 optimizes the diagnosis and risk stratification of acute cardiac dyspnea. Atypical clinical manifestations and overlapping pathologies require objective and effective diagnostic methods to avoid treatment delays.

METHODS

This prospective observational study included 208 patients who presented to the emergency department for acute dyspnea. NT-proBNP and galectin-3 were measured upon admission. The patients were divided into two groups according to the etiology of their clinical manifestations: cardiac and non-cardiac dyspnea. The patients' New York Heart Association functional class, left ventricular ejection fraction, and discharge status were assessed.

RESULTS

Diagnostic criteria for acute heart failure were fulfilled in 61.1% of the patients. NT-proBNP and galectin-3 were strongly and significantly correlated. Receiver operating characteristic analysis revealed similar areas under the curve for both markers in the entire group of patients as well as in the high-risk subsets of patients.

CONCLUSIONS

The diagnostic performance of NT-proBNP and galectin-3 is comparable for both the total population and high-risk subsets. Galectin-3 adds diagnostic value to the conventional NT-proBNP in patients with acute cardiac dyspnea, and its utility is of major interest in uncertain clinical situations.

Functional Stroke Mimics: Incidence and Characteristics at a Primary Stroke Center in the Middle East

OBJECTIVE

Approximately 30% of individuals who initially present with stroke are found to be stroke mimics (SM), with functional/psychological SM (FSM) accounting for up to 6.4% of all stroke presentations. Middle Eastern countries may have higher rates of somatization of emotional distress. The aim of this study was to evaluate the incidence and characteristics of FSM at a large general hospital in the Middle East.

METHODS

All patients presenting with an initial diagnosis of stroke from June 2015 to September 2016 were eligible for this study. Clinical and sociodemographic data were obtained from the hospital's stroke database. All SM and strokes were diagnosed by Joint Commission International-certified stroke program neurologists. SM was defined as any discharge diagnosis (other than acute stroke) for symptoms that prompted initial admission for suspected stroke. FSM were compared with medical stroke mimics (MSM) and strokes (ischemic, hemorrhagic, and transient ischemic attacks).

RESULTS

A total of 1961 patients were identified; 161 FSM (8.2%), 390 MSM (19.9%), and 1410 strokes (71.9%) (985 ischemic strokes, 196 transient ischemic attacks, 229 intracerebral hemorrhages). Admission with FSM was related to patients' nationality, with the highest frequency in Arabic (15.6%) and African (16.8%) patients. FSM patients were younger, more often female, and had fewer cardiovascular risk factors except for smoking compared with the strokes. FSM patients presented with more left-sided weakness and had more magnetic resonance imagings than the stroke and MSM groups. A total of 9.9% of FSM patients received thrombolysis versus only 0.5% of the MSM and 16.4% of ischemic strokes.

CONCLUSIONS

FSM frequencies varied by nationality, with Arab and African nationals being twice as prevalent. Stress, vulnerable status as expats, sociopolitical instability, and exposure to trauma are proposed as potential factors contributing to FSM.

" Blaming, shaming, humiliation": Stigmatising medical interactions among people with non-epileptic seizures

Background: People with non-epileptic seizures (NES) describe challenging relationships with health professionals, and explain negative interactions as common and expected. Despite these difficulties, little is known about how people with NES experience difficult healthcare encounters. Methods: Using a thematic discourse analysis approach, we analysed the free-text survey responses of 135 people with NES and asked: what kind of challenges do people living with this condition encounter when interacting with health professionals, and how do they experience the consequences of difficult interactions? We explore their experiences by interpreting the latent meaning of participants' texts from a social-constructionist perspective on health and illness. Results: The overarching narrative depicts a fundamental breakdown in patient-provider relationships. According to our data, the negative experiences of study participants emerge from more than practitioners' lack of awareness of NES and access to information about the condition - to the extent that it is available. In examining the challenges people with NES encounter when interacting with health professionals, their main experiences centre on blame and humiliation. When exploring their experiences, theories of stigma serve as a useful theoretical framework. Conclusions: Normative judgements arising from psychogenic understandings of NES are stigmatising and restrict professional displays of respectful (patient-centred) care. Those with the condition depict being negatively stereotyped, illegitimated and held morally culpable by health professionals. Perceived to lack medical, moral and credible status, participants describe practitioners who treat them with disrespect, and some recount conduct that defies all ethical and professional obligations and standards. These encounters can have wide-ranging adverse consequences for patients: emotionally, physically, and for their future healthcare. The quality of healthcare interactions for people with NES requires urgent improvements. In addition to increased awareness of the condition, practitioners need to be conscious of making and acting on adverse moral appraisals when interacting with this patient group.

" Blaming, shaming, humiliation": Stigmatising medical interactions among people with non-epileptic seizures

Background: People with non-epileptic seizures (NES) describe challenging relationships with health professionals, and explain negative interactions as common and expected. Despite these difficulties, little is known about how people with NES experience difficult healthcare encounters. Methods: Using a thematic discourse analysis approach, we analysed the free-text survey responses of 135 people with NES and asked: what kind of challenges do people living with this condition encounter when interacting with health professionals, and how do they experience the consequences of difficult interactions? We explore their experiences by interpreting the latent meaning of participants' texts from a social-constructionist perspective on health and illness. Results: The overarching narrative depicts a fundamental breakdown in patient-provider relationships. According to our data, the negative experiences of study participants emerge from more than practitioners' lack of awareness of NES and access to information about the condition - to the extent that it is available. In examining the challenges people with NES encounter when interacting with health professionals, their main experiences centre on blame and humiliation. When exploring their experiences, theories of stigma serve as a useful theoretical framework. Conclusions: Normative judgements arising from psychogenic understandings of NES are stigmatising and restrict professional displays of respectful (patient-centred) care. Those with the condition depict being negatively stereotyped, illegitimated and held morally culpable by health professionals. Perceived to lack medical, moral and credible status, participants describe practitioners who treat them with disrespect, and some recount conduct that defies all ethical and professional obligations and standards. These encounters can have wide-ranging adverse consequences for patients: emotionally, physically, and for their future healthcare. The quality of healthcare interactions for people with NES requires urgent improvements. In addition to increased awareness of the condition, practitioners need to be conscious of making and acting on adverse moral appraisals when interacting with this patient group.

High healthcare utilization near the onset of medically unexplained symptoms

OBJECTIVE

Patients with medically unexplained syndromes (MUS) often do not receive appropriate healthcare. A critical time for effective healthcare is the inception of MUS. The current study examined data from a prospective longitudinal study of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) soldiers to understand the relationship of increasing physical symptom burden to healthcare utilization.

METHODS

Data was examined from a prospective study of OEF/OIF soldiers assessed before and one year after deployment (n=336). Physical symptom burden was measured with the Patient Health Questionnaire (PHQ-15). Analyses were conducted with polynomial regression and response surface analysis (RSA).

RESULTS

Increases in physical symptom burden predicted greater healthcare utilization one year after deployment: primary care practitioner (slope=-0.26, F=4.07, p=0.04), specialist (slope=-0.43, F=8.67, p=0.003), allied health therapy (e.g., physical therapy) (slope=-0.41, F=5.71, p=0.02) and mental health (slope=-0.32, F=4.04, p=0.05). There were no significant difference in utilization between those with consistently high levels and those with increases in physical symptom burden.

CONCLUSION

This is the first prospective study to examine, and show, a relationship between onset of clinically significant physical symptoms and greater healthcare utilization. Our data suggest that patients with increasing physical symptom burden have the same level of healthcare as patients with chronic physical symptom burden. Needed next steps are to better understand the quality of care at inception and determine how to intervene so that recommended approaches to care are provided from the onset.

Junior doctors' experiences of managing patients with medically unexplained symptoms: a qualitative study

OBJECTIVES

To explore junior doctors' knowledge about and experiences of managing patients with medically unexplained symptoms (MUS) and to seek their recommendations for improved future training on this important topic about which they currently receive little education.

DESIGN

Qualitative study using in-depth interviews analysed using the framework method.

SETTING

Participants were recruited from three North Thames London hospitals within the UK.

PARTICIPANTS

Twenty-two junior doctors undertaking the UK foundation two-year training programme (FY1/FY2).

RESULTS

The junior doctors interviewed identified a significant gap in their training on the topic of MUS, particularly in relation to their awareness of the topic, the appropriate level of investigations, possible psychological comorbidities, the formulation of suitable explanations for patients' symptoms and longer term management strategies. Many junior doctors expressed feelings of anxiety, frustration and a self-perceived lack of competency in this area, and spoke of over-investigating patients or avoiding patient contact altogether due to the challenging nature of MUS and a difficulty in managing the accompanying uncertainty. They also identified the negative attitudes of some senior clinicians and potential role models towards patients with MUS as a factor contributing to their own attitudes and management choices. Most reported a need for more training during the foundation years, and recommended interactive case-based group discussions with a focus on providing meaningful explanations to patients for their symptoms.

CONCLUSIONS

There is an urgent need to improve postgraduate training about the topics of MUS and avoiding over-investigation, as current training does not equip junior doctors with the necessary knowledge and skills to effectively and confidently manage patients in these areas. Training needs to focus on practical skill development to increase clinical knowledge in areas such as delivering suitable explanations, and to incorporate individual management strategies to help junior doctors tolerate the uncertainty associated with MUS.

[Factitious diseases in oncology]

Factitious diseases and pathomimias and particularly Munchausen's syndrome, due to their rarity, are poorly diagnosed by medical teams working in oncology. Consequences can be serious and result in unadapted surgery or non justified implementation of chemotherapy and radiotherapy regimens. These patients simulate diseases in order to attract medical attention. They might become belligerent and are likely to promptly discharge themselves from hospital if they do not get the desired attention or are unmasked. With two following case reports and literature review, we would like to alert clinicians about difficulties encountered in diagnosis and management of factitious disorders. When faced with this diagnosis, the patient will tend to deny reality and break contact with the medical team who exposed him. Medical peregrinating behavior surrounded by conflicts with medical team, past psychiatric illness, history of working in the medical and paramedical field and social isolation can guide the diagnosis. Somaticians and especially surgeons working in the oncologic field must remain vigilant about this diagnosis and collaborate with either the psycho-oncologic team or the consultation-liaison psychiatric team. Some recommendations for medical professionals how to cope with these patients will be suggested.

A prospective cohort study to refine and validate the Panic Screening Score for identifying panic attacks associated with unexplained chest pain in the emergency department

INTRODUCTION

Panic-like anxiety (panic attacks with or without panic disorder), a highly treatable condition, is the most prevalent condition associated with unexplained chest pain in the emergency department. Panic-like anxiety may be responsible for a significant portion of the negative consequences of unexplained chest pain, such as functional limitations and chronicity. However, more than 92% of panic-like anxiety cases remain undiagnosed at the time of discharge from the emergency department. The 4-item Panic Screening Score (PSS) questionnaire was derived in order to increase the identification of panic-like anxiety in emergency department patients with unexplained chest pain.

METHODS AND ANALYSIS

The goals of this prospective cohort study were to (1) refine the PSS; (2) validate the revised version of the PSS; (3) measure the reliability of the revised version of the PSS and (4) assess the acceptability of the instrument among emergency physicians. Eligible and consenting patients will be administered the PSS in a large emergency department. Patients will be contacted by phone for administration of the criterion standard for panic attacks as well as by a standardised interview to collect information for other predictors of panic attacks. Multivariate analysis will be used to refine the PSS. The new version will be prospectively validated in an independent sample and inter-rater agreement will be assessed in 10% of cases. The screening instrument acceptability will be assessed with the Ottawa Acceptability of Decision Rules Instrument.

ETHICS AND DISSEMINATION

This study protocol has been reviewed and approved by the Alphonse-Desjardins research ethics committee. The results of the study will be presented in scientific conferences and published in peer-reviewed scientific journals. Further dissemination via workshops and a dedicated website is planned.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

PRACTICE IMPLICATIONS

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

Encounters between medical specialists and patients with medically unexplained physical symptoms; influences of communication on patient outcomes and use of health care: a literature overview

Medically unexplained physical symptoms (MUPS) burden patients and health services due to large quantities of consultations and medical interventions. The aim of this study is to determine which elements of communication in non-psychiatric specialist MUPS care influence health outcomes. Systematic search in PubMed, PsycINFO and Embase. Data extraction comprising study design, patient characteristics, number of patients, communication strategies, outcome measures and results. Elements of doctor-patient communication were framed according to symptoms, health anxiety, satisfaction, daily functioning and use of health care. Eight included studies. Two studies described the effect of communication on patient outcome in physical symptoms, three studies on health anxiety and patient satisfaction and one study on daily functioning. Two studies contained research on use of health care. Qualitative synthesis of findings was conducted. Communication matters in non-psychiatric MUPS specialist care. Perceiving patients' expectations correctly enables specialists to influence patients' cognitions, to reduce patients' anxiety and improve patients' satisfaction. Patients report less symptoms and health anxiety when symptoms are properly explained. Positive interaction and feedback reduces use of health care and improves coping. Development of communication skills focused on MUPS patients should be part of postgraduate education for medical specialists.

Biopsychosocial health care needs at the emergency room: challenge of complexity

BACKGROUND

In an emergency room of internal medicine, triage and treatment of patients deserve first priority. However, biopsychosocial case complexity may also affect patient health outcome but has not yet been explored in this setting. Therefore, the aims of the study are (1) to estimate prevalence rates of complex patients in the emergency room (ER), (2) to describe biopsychosocial complexity in this population and (3) to evaluate possible correlations between patient profiles regarding case complexity and further clinical treatment.

METHODS

During a study period of one week, all patients of an emergency room of internal medicine who were triaged to Manchester levels three to five were invited to participate in the study. Biopsychosocial case complexity was assessed by the INTERMED method. Psychosocial interventions were evaluated based on all documented interventions and recommendations given at the emergency room and during inpatient treatment.

RESULTS

Study participants consisted of 167 patients with a subgroup of 19% (n = 32) receiving subsequent inpatient-treatment at the department. High biopsychosocial case complexity was found in 12% (n = 20) of the total sample (INTERMED score >20). This finding was paralleled by a cluster analysis suggesting three clusters with one highly complex patient group of 14%. These highly complex patients differed significantly from the other clusters as they had visited the emergency room more often within the last year and lived alone more frequently. In addition, admission rates were highest in this group. During ER treatment and subsequent inpatient treatment, 21% of highly complex patients received interventions addressing psychosocial factors as compared to 6% and 7%, respectively, in the other clusters.

CONCLUSIONS

A standardized screening of biopsychosocial case complexity among 'frequent utilizers' of the ER would be helpful to detect specific multidisciplinary health care needs among this particularly burdened patient group.

When non-epileptic seizures fool the experts

Even when non-epileptic seizures are correctly diagnosed, appropriate treatment recommendations may not be fully or correctly implemented. We present a case of a 17-year-old girl with frequent non-epileptic seizures who presented for frequent trips to the emergency room (ER) and was admitted to an inpatient Child and Adolescent Psychiatric Facility. Despite being informed that episodes were non-epileptic seizures, various staff and healthcare providers at the psychiatric hospital continued to send the patient to the ER to treat suspected epileptic seizures. We discuss possible reasons why this may have occurred, including psychosocial and emotional reactions of staff members to the episodes. This discussion may also help to explain the persistence of the patient's episodes. We also present options for minimizing the potential for future mismanagement of non-epileptic seizures.

Experts' opinions on the management of medically unexplained symptoms in primary care. A qualitative analysis of narrative reviews and scientific editorials

BACKGROUND

The feasibility as well as the suitability of several therapies for medically unexplained symptoms (MUS) in primary care applied by the family physician (FP) appeared to be low. FPs need effective and acceptable strategies to manage these functionally impaired patients.

OBJECTIVE

To review important and effective elements in the treatment of patients with MUS in primary care according to experts in MUS research.

METHODS

We performed a systematic search of narrative reviews and scientific editorials in Medline and PsycINFO and triangulated our findings by conducting a focus group with MUS experts.

RESULTS

We included 7 scientific editorials and 23 narrative reviews. According to MUS experts, the most important elements in the treatment of MUS are creating a safe therapeutic environment, generic interventions (such as motivational interviewing, giving tangible explanations, reassurance and regularly scheduled appointments) and specific interventions (such as cognitive approaches and pharmacotherapy). Furthermore, MUS experts indicate that a multi-component approach in which these three important elements are combined are most helpful for patients with MUS. In contrast to most specific interventions, opinions of MUS experts regarding generic interventions and creating a safe therapeutic relationship seem to be more based on theory and experience than on quantitative research.

CONCLUSIONS

MUS experts highlight the importance of generic interventions and doctor-patient communication and relationship. However, studies showing the effectiveness of these elements in the management of MUS in primary care is still scarce. Research as well as medical practice should focus more on these non-specific aspects of the medical consultation.

Intensive short-term dynamic psychotherapy to reduce rates of emergency department return visits for patients with medically unexplained symptoms: preliminary evidence from a pre-post intervention study

OBJECTIVE

Somatization of emotions accounts for excess emergency department (ED) visits in the form of medically unexplained symptoms (MUS). Intensive short-term dynamic psychotherapy (ISTDP) has been used to diagnose and manage somatization. We examined the effectiveness of this procedure for ED patients with MUS.

METHODS

We implemented a service that included staff education, timely access to consultation and gathering of outcome data.

RESULTS

Patients were assessed and treated shortly after referral. There was a mean reduction of 3.2 (69.0%) ED visits per patient (standard deviation [SD] 6.4) the year afterward (95% confidence interval [CI] 1.3-5.0, p< 0.001). In comparison revisit rates during the same time interval for 3 available ED populations (i.e., those matched by visit rates, those with matching complaints and all patients referred to the service but never seen) showed either smaller reductions or higher ED use (ranging from a 15% reduction to a 43% increase). Treatments averaged 3.8 sessions per patient (SD 5.3). Self reported symptoms improved significantly with the Brief Symptom Inventory global rating, which changed from a mean of 1.21 (SD 0.58) before assessment to 0.86 (SD 0.63) ( p< 0.01) at the end of contact with the service. The service appeared acceptable to both emergency physicians and patients.

CONCLUSION

This emotion-focused assessment and treatment method appeared to be feasible and may be effective in reducing both symptoms and repeat ED use.

Challenges in the treatment of factitious disorder: a case study

Factitious disorder is difficult to diagnose and effectively treat. It is often met with intense emotion by both the care provider(s) and the client when suspected. However, if missed or untreated, it can become a chronic syndrome that is expensive and potentially dangerous. This article examines barriers to successful treatment of factitious disorder as manifested by a woman who received services from an urban community mental health center over a 7-year period for the management of multiple mental health issues. The unique role of the advanced practice psychiatric nurse is discussed through application of the nursing theory modeling and role modeling.