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Chaabouni A, Houwen J, Grewer G, Liebau M, Akkermans R, van Boven K, Walraven I, Schers H, Olde Hartman T. The burden of persistent symptom diagnoses in primary care patients: a cross-sectional study. Scand J Prim Health Care 2024; 42:112-122. [PMID: 38189313 PMCID: PMC10851811 DOI: 10.1080/02813432.2023.2293930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 12/06/2023] [Indexed: 01/09/2024] Open
Abstract
INTRODUCTION The burden of symptoms is a subjective experience of distress. Little is known on the burden of feeling unwell in patients with persistent symptom diagnoses. The aim of this study was to assess the burden in primary care patients with persistent symptom diagnoses compared to other primary care patients. METHODS A cross-sectional study was performed in which an online survey was sent to random samples of 889 patients with persistent symptom diagnoses (>1 year) and 443 other primary care patients after a transactional identification in a Dutch primary care data registry. Validated questionnaires were used to assess the severity of symptoms (PHQ-15), Symptom Intensity and Symptom Interference questionnaires, depression (PHQ-9), anxiety (GAD-7), quality of life (SF-12 and EQ-5D-5L)) and social functioning (SPF-ILs). RESULTS Overall, 243 patients completed the survey: 178 (73.3%) patients in the persistent symptom diagnoses group and 65 (26.7%) patients in the control group. In the persistent group, 65 (36.5%) patients did not have persistent symptom(s) anymore according to the survey response. Patients who still had persistent symptom diagnoses (n = 113, 63.5%) reported significantly more severe somatic symptoms (mean difference = 3.6, [95% CI: 0.24, 4.41]), depression (mean difference = 3.0 [95% CI: 1.24, 3.61]) and anxiety (mean difference = 2.3 [95% CI: 0.28, 3.10]) and significantly lower physical functioning (mean difference = - 6.8 [95% CI: -8.96, -3.92]). CONCLUSION Patients with persistent symptom diagnoses suffer from high levels of symptoms burden. The burden in patient with persistent symptoms should not be underestimated as awareness of this burden may enhance person-centered care.
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Affiliation(s)
- Asma Chaabouni
- Department of Primary and Community care, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Juul Houwen
- Department of Primary and Community care, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Georg Grewer
- USUMA Markt- und Sozialforschung GmbH, Berlin, Germany
| | - Martin Liebau
- USUMA Markt- und Sozialforschung GmbH, Berlin, Germany
| | - Reinier Akkermans
- Department of Primary and Community care, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
- Scientific Institute for Quality of Healthcare, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Kees van Boven
- Department of Primary and Community care, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Iris Walraven
- Department for Health Evidence, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Henk Schers
- Department of Primary and Community care, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Tim Olde Hartman
- Department of Primary and Community care, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
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Abstract
OBJECTIVE Up to 10% of the general population experiences persistent somatic symptoms (PSS). Numerous studies in a variety of health domains are dedicated to identifying factors that are associated with PSS onset. The present study aimed to provide an overview of predictors for PSS onset in the general population and the related health domains. METHODS A systematic search was performed identifying longitudinal cohort studies that examined factors associated with PSS onset in the general population. Included studies measured potential predictors before PSS onset and were categorized according to the dynamic biopsychosocial model. Four levels of evidence were discerned for predictors, based on the number of studies and percentage of consistent findings. RESULTS In the 154 articles eligible for analysis, 27 PSS subtypes were studied, with primary focus on fibromyalgia (25.0%) and irritable bowel syndrome (23.3%). Of the >250 predictors of PSS onset, 46 were investigated more than once and showed consistent results. Strong evidence identifies biological (e.g., infections, body weight-related metrics), psychological (e.g., sleep problems, psychopathology), interpersonal (life events, childhood/interpersonal stress), contextual (employment), and health behavioral (health care utilization) predictors. CONCLUSIONS The results provide strong evidence for factors from all dynamic biopsychosocial domains, although interpersonal and health behavioral factors are relatively under investigated. Thus, evidence suggests that reduction of predictors of PSS onset to a specific factor/domain may be too restrictive. There is no evidence that this differs per PSS subtype. Exploring all domains and measuring common factors across subtypes are essential to improve the clinical course of PSS.
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The careful assessment tool for managing patients with medically unexplained symptoms – The experience of Slovenian family medicine trainees: A qualitative study. Zdr Varst 2021; 61:48-54. [PMID: 35111266 PMCID: PMC8776293 DOI: 10.2478/sjph-2022-0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 11/19/2021] [Indexed: 11/20/2022] Open
Abstract
Introduction Primary care physicians use various tools and methods to identify medically unexplained symptoms (MUS). The main purpose of our study is to determine the views of Slovenian family medicine trainees (FMT) about using the “Careful Assessment” tool for managing patients with MUS. Methods A qualitative study using open survey questions focused on the experience of family medicine trainees in managing patients with MUS. The sample consisted of surveys from 184 family medicine trainees. These trainees analysed a total of 702 patients with MUS. Manual coding was used for quantitative content analysis. Results In the coding process, 49 codes were developed that included broader research fields about using the “Careful Assessment” tool for managing patients with MUS. The codes were grouped into four theoretically grounded, logical categories in accordance with the elaborated theoretical concept: multi-purpose utility; improved patient management; in-depth knowledge and new skills; and patient response. Conclusion The study demonstrated that, in the view of Slovenian FMT, the “Careful Assessment” tool has multi-purpose utility. The study showed that FMT felt that this tool helps them in systematic patient management. Their opinion is that it helps them establish a trusting relationship with patients, which is a precondition for providing further treatment.
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Hammerman O, Halperin D, Tsalihin D, Greenberg D, Kushnir T, Ezra Y. Characteristics and economic burden of frequent attenders with medically unexplained symptoms in primary care in Israel. Eur J Gen Pract 2021; 27:294-302. [PMID: 34633891 PMCID: PMC8510588 DOI: 10.1080/13814788.2021.1985997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background Frequent Attenders with Medically Unexplained Symptoms (FA/MUS) are common in primary care, though challenging to identify and treat. Objectives This study sought to compare FA/MUS to FA with organic illnesses (FA/OI) and the general clinic population (Non-FA) to understand their demographic characteristics and healthcare utilisation patterns. Methods For this retrospective, observational study, Electronic Medical Records (EMR) were obtained from Clalit Health Services, regarding the population of a sizeable primary care clinic in Be’er-Sheva, Israel. Electronic medical records were screened to identify the top 5% of FA. FA were stratified based on whether they had OI. FA without OI were then corroborated as having MUS by their physicians. Demographics, healthcare utilisation and costs were analysed for FA/OI, FA/MUS and Non-FA. Results Out of 594 FA, 305 (53.6%) were FA/OI and 264 (46.4%) were FA/MUS. FA/OI were older (69.1 vs. 56.4 years, p<.001) and costlier (ILS27693 vs. ILS9075, p<.001) than FA/MUS. Average costs for FA/MUS were over four times higher than Non-FA (ILS9075 vs. ILS2035, p<.001). The largest disparities between FA/OI and FA/MUS were in hospitalisations (ILS6998 vs. ILS2033) and surgical procedures (ILS8143 vs. ILS3175). Regarding laboratory tests, differences were smaller between groups of FA but significantly different between FA and Non-FA. Conclusion FA/MUS are more costly than Non-FA and exhibit unique healthcare utilisation and costs patterns. FA/OI had more severe illnesses necessitating hospitalisations and surgical interventions, while FA/MUS had more investigations and tests, attempting to find an explanation for their symptoms.
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Affiliation(s)
- Oded Hammerman
- Department of Neurology, Soroka Medical Center, Be'er-Sheva, Israel.,Department of Health Policy and Management, Faculty of Health Sciences, School of Public Health, Ben-Gurion University of the Negev, Be'er-Sheva, Israel
| | - Daniel Halperin
- Soroka Clinical Research Center, Soroka Medical Center, Be'er-Sheva, Israel
| | - Daniel Tsalihin
- Yud Alef Clinic, Clalit Health Services, Be'er-Sheva, Israel
| | - Dan Greenberg
- Department of Health Policy and Management, Faculty of Health Sciences, School of Public Health, Ben-Gurion University of the Negev, Be'er-Sheva, Israel
| | - Talma Kushnir
- Department of Psychology and Adelson School of Medicine, Ariel University, Ariel, Israel.,Faculty of Health Sciences, School of Public Health, Ben-Gurion University of the Negev, Be'er-Sheva, Israel
| | - Yacov Ezra
- Department of Neurology, Soroka Medical Center, Be'er-Sheva, Israel
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Kitselaar WM, Numans ME, Sutch SP, Faiq A, Evers AW, van der Vaart R. Identifying persistent somatic symptoms in electronic health records: exploring multiple theory-driven methods of identification. BMJ Open 2021; 11:e049907. [PMID: 34535479 PMCID: PMC8451292 DOI: 10.1136/bmjopen-2021-049907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Persistent somatic symptoms (PSSs) are defined as symptoms not fully explained by well-established pathophysiological mechanisms and are prevalent in up to 10% of patients in primary care. The present study aimed to explore methods to identify patients with a recognisable risk of having PSS in routine primary care data. DESIGN A cross-sectional study to explore four identification methods that each cover part of the broad spectrum of PSS was performed. Cases were selected based on (1) PSS-related syndrome codes, (2) PSS-related symptom codes, (3) PSS-related terminology and (4) Four-Dimensional Symptom Questionnaire scores and all methods combined. SETTING Coded electronic health record data were extracted from 76 general practices in the Netherlands. PARTICIPANTS Patients who were registered for at least 1 year during 2014-2018, were included (n=169 138). OUTCOME MEASURES Identification methods were explored based on (1) PSS sample sizes and demographics, (2) presence of chronic conditions and (3) healthcare utilisation (HCU) variables. Overlap between methods and practice specific differences were examined. RESULTS The percentage of cases identified varied between 0.3% and 7.0% across the methods. Over 58.1% of cases had chronic physical condition(s) and over 33.8% had chronic mental condition(s). HCU was generally higher for cases selected by any method compared with the total cohort. HCU was higher for method B compared with the other methods. In 26.7% of cases, cases were selected by multiple methods. Overlap between methods was low. CONCLUSIONS Different methods yielded different patient samples which were general practice specific. Therefore, for the most comprehensive data-based selection of PSS cases, a combination of methods A, C and D would be recommended. Advanced (data-driven) methods are needed to create a more sensitive algorithm for identifying the full spectrum of PSS. For clinical purposes, method B could possibly support screening of patients who are currently missed in daily practice.
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Affiliation(s)
- Willeke M Kitselaar
- Health, Medical and Neuropsychology, Leiden University Faculty of Social and Behavioural Sciences, Leiden, The Netherlands
- Public Health and Primary Care / LUMC-Campus The Hague, Leiden University Medical Center, Den Haag, The Netherlands
| | - Mattijs E Numans
- Public Health and Primary Care / LUMC-Campus The Hague, Leiden University Medical Center, Den Haag, The Netherlands
| | - Stephen P Sutch
- Public Health and Primary Care / LUMC-Campus The Hague, Leiden University Medical Center, Den Haag, The Netherlands
- Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ammar Faiq
- Public Health and Primary Care / LUMC-Campus The Hague, Leiden University Medical Center, Den Haag, The Netherlands
| | - Andrea Wm Evers
- Health, Medical and Neuropsychology, Leiden University Faculty of Social and Behavioural Sciences, Leiden, The Netherlands
- Medical Delta, Leiden University, Delft University of Technology & Erasmus University, Leiden / Delft/ Rotterdam, The Netherlands
| | - Rosalie van der Vaart
- Health, Medical and Neuropsychology, Leiden University Faculty of Social and Behavioural Sciences, Leiden, The Netherlands
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Kitselaar WM, van der Vaart R, van Tilborg-den Boeft M, Vos HMM, Numans ME, Evers AWM. The general practitioners perspective regarding registration of persistent somatic symptoms in primary care: a survey. BMC FAMILY PRACTICE 2021; 22:182. [PMID: 34511065 PMCID: PMC8436507 DOI: 10.1186/s12875-021-01525-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 08/18/2021] [Indexed: 12/28/2022]
Abstract
Background Persistent somatic symptoms (PSS) are common in primary care and often accompanied by an increasing disease burden for both the patient and healthcare. In medical practice, PSS is historically considered a diagnosis by exclusion or primarily seen as psychological. Besides, registration of PSS in electronic health records (EHR) is unambiguous and possibly does not reflect classification adequately. The present study explores how general practitioners (GPs) currently register PSS, and their view regarding the need for improvements in classification, registration, and consultations. Method Dutch GPs were invited by email to participate in a national cross-sectional online survey. The survey addressed ICPC-codes used by GPs to register PSS, PSS-related terminology added to free text areas, usage of PSS-related syndrome codes, and GPs’ need for improvement of PSS classification, registration and care. Results GPs (n = 259) were most likely to use codes specific to the symptom presented (89.3%). PSS-related terminology in free-text areas was used sparsely. PSS-related syndrome codes were reportedly used by 91.5% of GPs, but this was primarily the case for the code for irritable bowel syndrome. The ambiguous registration of PSS is reported as problematic by 47.9% of GPs. Over 56.7% of GPs reported needing additional training, tools or other support for PSS classification and consultation. GPs also reported needing other referral options and better guidelines. Conclusions Registration of PSS in primary care is currently ambiguous. Approximately half of GPs felt a need for more options for registration of PSS and reported a need for further support. In order to improve classification, registration and care for patients with PSS, there is a need for a more appropriate coding scheme and additional training. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-021-01525-6.
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Affiliation(s)
- Willeke M Kitselaar
- Health, Medical and Neuropsychology Department, Leiden University, Faculty of Social and Behavioral Sciences, Leiden, the Netherlands. .,Public Health and Primary Care Department / LUMC-Campus Den Haag, Leiden University Medical Center, The Hague, the Netherlands.
| | - Rosalie van der Vaart
- Health, Medical and Neuropsychology Department, Leiden University, Faculty of Social and Behavioral Sciences, Leiden, the Netherlands
| | - Madelon van Tilborg-den Boeft
- Public Health and Primary Care Department / LUMC-Campus Den Haag, Leiden University Medical Center, The Hague, the Netherlands
| | - Hedwig M M Vos
- Public Health and Primary Care Department / LUMC-Campus Den Haag, Leiden University Medical Center, The Hague, the Netherlands
| | - Mattijs E Numans
- Public Health and Primary Care Department / LUMC-Campus Den Haag, Leiden University Medical Center, The Hague, the Netherlands
| | - Andrea W M Evers
- Health, Medical and Neuropsychology Department, Leiden University, Faculty of Social and Behavioral Sciences, Leiden, the Netherlands
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Holtman GA, Burger H, Verheij RA, Wouters H, Berger MY, Rosmalen JG, Verhaak PF. Developing a clinical prediction rule for repeated consultations with functional somatic symptoms in primary care: a cohort study. BMJ Open 2021; 11:e040730. [PMID: 33419906 PMCID: PMC7799137 DOI: 10.1136/bmjopen-2020-040730] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Patients who present in primary care with chronic functional somatic symptoms (FSS) have reduced quality of life and increased health care costs. Recognising these early is a challenge. The aim is to develop and internally validate a clinical prediction rule for repeated consultations with FSS. DESIGN AND SETTING Records from the longitudinal population-based ('Lifelines') cohort study were linked to electronic health records from general practitioners (GPs). PARTICIPANTS We included patients consulting a GP with FSS within 1 year after baseline assessment in the Lifelines cohort. OUTCOME MEASURES The outcome is repeated consultations with FSS, defined as ≥3 extra consultations for FSS within 1 year after the first consultation. Multivariable logistic regression, with bootstrapping for internal validation, was used to develop a risk prediction model from 14 literature-based predictors. Model discrimination, calibration and diagnostic accuracy were assessed. RESULTS 18 810 participants were identified by database linkage, of whom 2650 consulted a GP with FSS and 297 (11%) had ≥3 extra consultations. In the final multivariable model, older age, female sex, lack of healthy activity, presence of generalised anxiety disorder and higher number of GP consultations in the last year predicted repeated consultations. Discrimination after internal validation was 0.64 with a calibration slope of 0.95. The positive predictive value of patients with high scores on the model was 0.37 (0.29-0.47). CONCLUSIONS Several theoretically suggested predisposing and precipitating predictors, including neuroticism and stressful life events, surprisingly failed to contribute to our final model. Moreover, this model mostly included general predictors of increased risk of repeated consultations among patients with FSS. The model discrimination and positive predictive values were insufficient and preclude clinical implementation.
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Affiliation(s)
- Gea A Holtman
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Huibert Burger
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Robert A Verheij
- NIVEL, Netherlands Institute of Health Services Research, Utrecht, The Netherlands
- Tranzo Scientific Center for Care and Welfare, Tilburg School of Social and Behavioral Sciences, Tilburg University, Tilburg, The Netherlands
| | - Hans Wouters
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- General Practitioners Research Institute, Groningen, The Netherlands
| | - Marjolein Y Berger
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Judith Gm Rosmalen
- Interdisciplinary Center Psychopathology and Emotion Regulation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Peter Fm Verhaak
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- NIVEL, Netherlands Institute of Health Services Research, Utrecht, The Netherlands
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North CS, Hong BA, Lai HH, Alpers DH. Assessing somatization in urologic chronic pelvic pain syndrome. BMC Urol 2019; 19:130. [PMID: 31823813 PMCID: PMC6902613 DOI: 10.1186/s12894-019-0556-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 11/11/2019] [Indexed: 12/29/2022] Open
Abstract
Background This study examined the prevalence of somatization disorder in Urological Chronic Pelvic Pain Syndrome (UCPPS) and the utility of two self-report symptom screening tools for assessment of somatization in patients with UCPPS. Methods The study sample included 65 patients with UCPPS who enrolled in the Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) Study at Washington University. Patients completed the PolySymptomatic PolySyndromic Questionnaire (PSPS-Q) (n = 64) and the Patient Health Questionnaire-15 Somatic Symptom Severity Scale (PHQ-15) (n = 50). Review of patient medical records found that only 47% (n = 30) contained sufficient documentation to assess Perley-Guze criteria for somatization disorder. Results Few (only 6.5%) of the UCPPS sample met Perley-Guze criteria for definite somatization disorder. Perley-Guze somatization disorder was predicted by definite PSPS-Q somatization with at least 75% sensitivity and specificity. Perley-Guze somatization disorder was predicted by severe (> 15) PHQ-15 threshold that had > 90% sensitivity and specificity but was met by only 16% of patients. The moderate (> 10) PHQ-15 threshold had higher sensitivity (100%) but lower specificity (52%) and was met by 52% of the sample. Conclusions The PHQ-15 is brief, but it measures symptoms constituting only one dimension of somatization. The PSPS-Q uniquely captures two conceptual dimensions inherent in the definition of somatization disorder, both number of symptoms and symptom distribution across multiple organ systems, with relevance for UCPPS as a syndrome that is not just a collection of urological symptoms but a broader syndrome with symptoms extending beyond the urological system.
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Affiliation(s)
- C S North
- The Altshuler Center for Education & Research at Metrocare Services, The University of Texas Southwestern Medical Center, 1250 Mockingbird Lane, Suite 330, Dallas, TX, 75247-4914, USA. .,Department of Psychiatry, The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Suite NE5.102, Dallas, TX, 75390-9070, USA.
| | - B A Hong
- Department of Psychiatry, School of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - H H Lai
- Departments of Surgery and Anesthesiology, Division of Urologic Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - D H Alpers
- Department of Internal Medicine, Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, 63110, USA
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Payne H, Brooks SD. Medically Unexplained Symptoms and Attachment Theory: The BodyMind Approach®. Front Psychol 2019; 10:1818. [PMID: 31780974 PMCID: PMC6851196 DOI: 10.3389/fpsyg.2019.01818] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 07/22/2019] [Indexed: 12/20/2022] Open
Abstract
This article discusses how The BodyMind Approach® (TBMA) addresses insecure attachment styles in medically unexplained symptoms (MUS). Insecure attachment styles are associated with adverse childhood experiences (ACEs) and MUS (Adshead and Guthrie, 2015) and affect sufferers’ capacity to self-manage. The article goes on to make a new hypothesis to account for TBMA’s effectiveness (Payne and Brooks, 2017), that is, it addresses insecure attachment styles, which may be present in some MUS sufferers, leading to their capacity to self-manage. Three insecure attachment styles (dismissive, pre-occupied and fearful) associated with MUS are discussed. TBMA is described and explanations provided of how TBMA has been specifically designed to support people’s insecure attachment styles. Three key concepts to support insecure attachment styles involved in the content of TBMA are identified and debated: (a) emotional regulation; (b) safety; and (c) bodymindfulness. There is a rationale for the design of TBMA as opposed to psychological interventions for this population. The programme’s structure, facilitation and content, takes account of the three insecure attachment styles above. Examples of how TBMA works with their specific characteristics are presented. TBMA has been tested and found to be effective during delivery in the United Kingdom National Health Service (NHS). Improved self-management has potential to reduce costs for the NHS and in General Practitioner time and resources.
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Affiliation(s)
- Helen Payne
- School of Education, University of Hertfordshire, Hertfordshire, United Kingdom
| | - Susan D Brooks
- School of Education, University of Hertfordshire, Hertfordshire, United Kingdom
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Beems MEC, Toonders SAJ, van Westrienen PE, Veenhof C, Pisters MF. Identifying subgroups based on self-management skills in primary care patients with moderate medically unexplained physical symptoms. J Psychosom Res 2019; 125:109785. [PMID: 31421323 DOI: 10.1016/j.jpsychores.2019.109785] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 07/15/2019] [Accepted: 07/20/2019] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Medically Unexplained Physical Symptoms (MUPS) are a major burden on both patients and society and frequently develop into chronic MUPS. Self-management interventions may prevent moderate MUPS from becoming chronic. Tailoring interventions to the patient population is strongly recommended. This can be facilitated by identifying subgroups based on self-management skills. This study aimed to identify these subgroups and their clinical profiles in primary care patients with moderate MUPS. METHODS A cross-sectional study was performed on baseline measurements from a randomized clinical trial (PARASOL-study). To identify subgroups based on self-management skills, a hierarchical cluster analysis was conducted for adults with moderate MUPS from primary health care centers. Self-management skills were measured with the Health education impact Questionnaire. Cluster variables were seven constructs of this questionnaire. Additionally, specific patient profiles were determined by comparing the identified clusters on the clinical variables pain, fatigue and physical functioning. RESULTS Four subgroups were identified: High-Self-Management Skills (SMS) (n = 29), Medium-SMS (n = 55), Low-SMS (n = 49) and Active & Low Distress-SMS (n = 20). The latter showed a distinctly different pattern on cluster variables, while the other subgroups differed significantly on means of the cluster variables (p < .001). On clinical variables, significant differences between subgroups were mainly found on fatigue and physical functioning. CONCLUSION This study found four specific subgroups based on self-management skills in moderate MUPS-patients. One subgroup demonstrated a distinctly different pattern on self-management skills. In other subgroups, more similar patterns on self-management skills were found that negatively correlated with pain and fatigue and positively correlated with physical functioning.
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Affiliation(s)
- M E C Beems
- Physical Therapy Sciences, Program in Clinical Health Sciences, University Medical Center Utrecht, Utrecht, the Netherlands; Center for Physical Therapy Research and Innovation in Primary Care, Leidsche Rijn Julius Health Care Centers, Utrecht, the Netherlands; Fysio Center Den Haag, The Hague, the Netherlands.
| | - S A J Toonders
- Center for Physical Therapy Research and Innovation in Primary Care, Leidsche Rijn Julius Health Care Centers, Utrecht, the Netherlands; Physical Therapy Research, Department of Rehabilitation, Physical Therapy Science and Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Health Innovation and Technology, Fontys University of Applied Sciences, Eindhoven, the Netherlands.
| | - P E van Westrienen
- Center for Physical Therapy Research and Innovation in Primary Care, Leidsche Rijn Julius Health Care Centers, Utrecht, the Netherlands; Physical Therapy Research, Department of Rehabilitation, Physical Therapy Science and Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Health Innovation and Technology, Fontys University of Applied Sciences, Eindhoven, the Netherlands.
| | - C Veenhof
- Center for Physical Therapy Research and Innovation in Primary Care, Leidsche Rijn Julius Health Care Centers, Utrecht, the Netherlands; Physical Therapy Research, Department of Rehabilitation, Physical Therapy Science and Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands; Expertise Center Innovation of Care, Research Group Innovation of Mobility Care, Utrecht University of Applied Sciences, Utrecht, the Netherlands.
| | - M F Pisters
- Physical Therapy Sciences, Program in Clinical Health Sciences, University Medical Center Utrecht, Utrecht, the Netherlands; Center for Physical Therapy Research and Innovation in Primary Care, Leidsche Rijn Julius Health Care Centers, Utrecht, the Netherlands; Physical Therapy Research, Department of Rehabilitation, Physical Therapy Science and Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Health Innovation and Technology, Fontys University of Applied Sciences, Eindhoven, the Netherlands.
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11
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van Westrienen PE, Pisters MF, Veenhof C, de Wit NJ. Identification of patients with moderate medically unexplained physical symptoms in primary care with a five years follow-up. BMC FAMILY PRACTICE 2019; 20:66. [PMID: 31113381 PMCID: PMC6530058 DOI: 10.1186/s12875-019-0950-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 04/26/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Patients with medically unexplained physical symptoms (MUPS) are common in primary care, with a spectrum from mild to moderate and chronic MUPS. The burden of chronic MUPS is high, and early identification of moderate MUPS patients is important to prevent chronicity. The PRESUME screening method to identify moderate MUPS patients in primary care was developed, but insight in prognostic accuracy is needed. Therefore, our objective is to determine the prognostic accuracy for identification of moderate MUPS patients using the screening method with 5 year follow-up. METHODS The PRESUME screening method consists of three subsequent steps based on consultation frequency, exclusion of medical/psychiatric diagnosis and identification of MUPS. In a random 10% sample of patients from the Julius General Practitioners Network (n = 114.185), patients were identified with mild, moderate or chronic MUPS in 2008 (index year), using routine care data. In 5 years follow-up we calculated predictive values and odds ratio's for sustained MUPS related symptoms. RESULTS In 2008, 789 patients (6.9% of the patient population) were identified as having mild, moderate or chronic MUPS. On average 55.5% of the moderate MUPS patients in 2008, still had MUPS related symptoms or developed chronic MUPS in 5 year follow-up. Positive predictive values for maintaining MUPS related symptoms or worsening was 67% after 1 year, and 48.7% after 5 years for moderate MUPS patients. CONCLUSION The prognostic accuracy of the PRESUME screening method using electronic medical record data for identification of moderate MUPS patients is moderate. However, it might be a useful method to identify patients at increased risk of moderate MUPS, if combined with a validity check by the GP.
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Affiliation(s)
- Paula Elisabeth van Westrienen
- Center for Physical Therapy Research and Innovation in Primary Care, Leidsche Rijn Julius Health Care Centers, Utrecht, The Netherlands
- Physical Therapy Research, department of Rehabilitation, Physical Therapy Science and Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Health Innovation and Technology, Fontys University of Applied Sciences, Eindhoven, The Netherlands
| | - Martijn Frits Pisters
- Center for Physical Therapy Research and Innovation in Primary Care, Leidsche Rijn Julius Health Care Centers, Utrecht, The Netherlands
- Physical Therapy Research, department of Rehabilitation, Physical Therapy Science and Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Health Innovation and Technology, Fontys University of Applied Sciences, Eindhoven, The Netherlands
| | - Cindy Veenhof
- Center for Physical Therapy Research and Innovation in Primary Care, Leidsche Rijn Julius Health Care Centers, Utrecht, The Netherlands
- Physical Therapy Research, department of Rehabilitation, Physical Therapy Science and Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
- Expertise Center Innovation of Care, Research Group Innovation of Mobility Care, University of Applied Sciences Utrecht, Utrecht, the Netherlands
| | - Nicolaas Johannes de Wit
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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Pohontsch NJ, Zimmermann T, Jonas C, Lehmann M, Löwe B, Scherer M. Coding of medically unexplained symptoms and somatoform disorders by general practitioners - an exploratory focus group study. BMC FAMILY PRACTICE 2018; 19:129. [PMID: 30053834 PMCID: PMC6064152 DOI: 10.1186/s12875-018-0812-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 06/28/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Medically unexplained symptoms (MUS) and somatoform disorders are common in general practices, but there is evidence that general practitioners (GPs) rarely use these codes. Assuming that correct classification and coding of symptoms and diseases are important for adequate management and treatment, insights into these processes could reveal problematic areas and possible solutions. Our study aims at exploring general practitioners' views on coding and reasons for not coding MUS/somatoform disorders. METHODS We invited GPs to participate in six focus groups (N = 42). Patient vignettes and a semi-structured guideline were used by two moderators to facilitate the discussions. Recordings were transcribed verbatim. Two researchers analyzed the data using structuring content analysis with deductive and inductive category building. RESULTS Three main categories turned out to be most relevant. For category a) "benefits of coding" GPs described that coding is seen as being done for reimbursement purposes and is not necessarily linked to the content of their reference files for a specific patient. Others reported to code specific diagnoses only if longer consultations to explore psychosomatic symptoms or psychotherapy are intended to be billed. Reasons for b) "restrained coding" were attempting to protect the patient from stigma through certain diagnoses and the preference for tentative diagnoses and functional coding. Some GPs admitted to c) "code inaccurately" attributing this to insufficient knowledge of ICD-10-criteria, time constraints or using "rules of thumb" for coding. CONCLUSIONS There seem to be challenges in the process of coding of MUS and somatoform disorders, but GPs appear not to contest the patients' suffering and accept uncertainty (about diagnoses) as an elementary part of their work. From GPs' points of view ICD-10-coding does not appear to be a necessary requirement for treating patients and coding might be avoided to protect the patients from stigma and other negative consequences. Our findings supply a possible explanation for the commonly seen difference between routine and epidemiological data. The recent developments in the DSM-5 and the upcoming ICD-11 will supposedly change acceptance and handling of these diagnoses for GPs and patients. Either way, consequences for GPs' diagnosing and coding behavior are not yet foreseeable.
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Affiliation(s)
- N. J. Pohontsch
- Department of General Practice / Primary Care, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - T. Zimmermann
- Department of General Practice / Primary Care, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - C. Jonas
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf and Schön Clinic Hamburg Eilbek, Martinistr. 52, 20246 Hamburg, Germany
| | - M. Lehmann
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf and Schön Clinic Hamburg Eilbek, Martinistr. 52, 20246 Hamburg, Germany
| | - B. Löwe
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf and Schön Clinic Hamburg Eilbek, Martinistr. 52, 20246 Hamburg, Germany
| | - M. Scherer
- Department of General Practice / Primary Care, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
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13
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Abstract
SummaryPatients with severe and enduring somatoform disorders (SESD) characteristically present with multiple, recurrent and frequently changing physical symptoms that have usually been present for several years before referral to a psychiatrist/psychologist. Many patients report long histories of contact with both primary and tertiary care services, have undergone repeated fruitless investigations and have high levels of disability. SESD are responsible for disproportionately high healthcare costs and are the third most common cause of workplace absence. Identification of patients with SESD by psychiatrists requires particular skills: collaboration with colleagues is vital and there are risks of iatrogenic harm. We describe the obstacles encountered in identifying these patients as well as methods of assessment and management. Treatment pathways best suited to managing this large and as yet untended group of patients are described.
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van Eck van der Sluijs JF, Ten Have M, de Graaf R, Rijnders CAT, van Marwijk HWJ, van der Feltz-Cornelis CM. Predictors of Persistent Medically Unexplained Physical Symptoms: Findings From a General Population Study. Front Psychiatry 2018; 9:613. [PMID: 30524322 PMCID: PMC6262298 DOI: 10.3389/fpsyt.2018.00613] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 10/31/2018] [Indexed: 12/11/2022] Open
Abstract
Objective: To explore the persistency of Medically Unexplained Symptoms (MUS) and its prognostic factors in the general adult population. Knowledge of prognostic factors of MUS may indicate possible avenues for intervention development. Methods: Data were derived from the Netherlands Mental Health Survey and Incidence Study-2 (NEMESIS-2), a nationally representative face-to-face cohort study among the Dutch general population aged 18-64 years. We selected subjects with MUS at baseline and who participated at follow-up (N = 324) and reassessed those subjects for having MUS at 3 year follow-up. Logistic regression analyses were used to determine risk factors for persistency of MUS. Results: 36.4% of the subjects had persistent MUS at follow-up. In logistic regression analyses adjusted for sex and age, persistency of MUS was predicted by the number of comorbid chronic medical disorder(s), lower education, female sex, not having a paid job, parental psychopathology as well as lower functioning. In the logistic regression analysis in which all significant variables adjusted for sex and age were entered simultaneously, three variables predicted persistent MUS: parental psychopathology, the number of comorbid chronic medical disorder(s) and physical functioning, with odds ratios of 2.01 (1.20-3.38), 1.19 (1.01-1.40), and 0.99 (0.97-1.00), respectively. Conclusion: In the adult general population, MUS were persistent in over one third of the subjects with MUS at baseline. Persistency was significantly predicted by parental psychopathology, number of comorbid chronic medical disorders, and physical functioning. These findings warrant further research into early intervention and treatment options for persons with an increased risk of persistent MUS.
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Affiliation(s)
- Jonna F van Eck van der Sluijs
- Top clinical Center for Body, Mind and Health, GGz Breburg, Tilburg, Netherlands.,Department of Tranzo, Tilburg University, Tilburg, Netherlands
| | - Margreet Ten Have
- Netherlands Institute of Mental Health and Addiction, Utrecht, Netherlands
| | - Ron de Graaf
- Netherlands Institute of Mental Health and Addiction, Utrecht, Netherlands
| | | | - Harm W J van Marwijk
- Division of Primary Care and Public Health, Brighton and Sussex Medical School, University of Brighton, Brighton, United Kingdom
| | - Christina M van der Feltz-Cornelis
- Top clinical Center for Body, Mind and Health, GGz Breburg, Tilburg, Netherlands.,Department of Tranzo, Tilburg University, Tilburg, Netherlands.,Department of Health Sciences, Hull York Medical School, University of York, York, United Kingdom
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Affiliation(s)
- Christopher Burton
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK.
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