Medically unexplained symptoms: time to and triggers for diagnosis in primary care consultations

Medically Unexplained Symptoms among Adults from Russia: An Assessment using the Patient Health Questionnaire-15

Background

The Patient Health Questionnaire-15 (PHQ-15) is one of the most frequently used instruments to measure medically unexplained symptoms in the general population, as well as in groups of patients with mental and physical health problems.

Objective

This study aimed to examine the psychometric properties of the PHQ-15 in assessing a Russian community sample.

Design

A total of 1153 Russian adults age 18 or older participated in this cross-sectional study. They completed the Russian versions of the PHQ-15 and Symptom Check List-90-Revised, SCL-90-R (SCL-90-R). Exploratory and confirmatory factor analyses were used to examine the factor structure of the Russian PHQ-15, and multi-group confirmatory factor analyses were used to test measurement invariance across sex and age. Cronbach's alpha coefficients and Pearsons Correlation Coefficients were used to evaluate the internal reliability and convergent validity of the Russian PHQ-15.

Results

Exploratory factor analysis revealed a three-factor solution highlighting pain-fatigue, gastrointestinal, and cardiopulmonary symptoms. Confirmatory factor analysis confirmed a bifactor structure for the Russian PHQ-15 merging general and specific somatic symptoms. A multi-group confirmatory factor analysis showed partial invariance across sex and age. The Russian PHQ-15 demonstrated acceptable Cronbach's alpha coefficients ranging from 0.72 to 0.75 for specific factors and a good Cronbach's alpha for the total score (a = 0.85), proving the questionnaire's internal reliability. Finally, positive correlations between the PHQ-15 and SCL-90-R dimensions, and positive intercorrelations between PHQ-15 specific factors, suggested convergent validity.

Conclusion

The Russian PHQ-15 is a reliable and valid instrument for assessing medically unexplained symptoms in the general population. This instrument can be used in diagnostic and counseling settings.

Experiences of general practitioners explaining central sensitisation to patients with persistent physical symptoms: a focus group study

OBJECTIVE

Patients with persistent physical symptoms (PPS) require an explanation that is acceptable and comprehensible to them. Central sensitisation (CS) is an explanatory model for PPS and chronic pain that has been broadly applied in the context of pain medicine, but, until recently, not by general practitioners (GPs). We explored how GPs used the CS model in their consultations with patients with PPS.

DESIGN AND SETTING

A qualitative focus group study among GPs in the Netherlands.

METHODS

We instructed 33 GPs on how to explain CS to patients with PPS. After 0.5-1.5 years of using the CS model, 26 GPs participated in focus groups and interviews to report and discuss their experiences with CS as an explanatory model. Audio recordings were transcribed and two researchers independently analysed the data. The text was coded, codes were organised into themes and discussed until consensus was reached.

RESULTS

We identified eleven themes and grouped these into four categories.The GPs regarded the CS model as evidence-based, credible and giving recognition to the patient. On the other hand, they found explaining the CS model difficult and time-consuming. They tailored the CS model to their patients' needs and used multiple consultations to explain the model. The GPs reported that the use of the CS model seemed to improve the understanding and acceptance of the symptoms by the patients and seemed to reduce their need for more diagnostic tests. Furthermore, patients seemed to become more motivated to accept appropriate therapy.

CONCLUSION

GPs reported that they were able to provide explanations with the CS model to their patients with PPS. They regarded the model as evidence-based, credible and giving recognition to the patient, but explaining it difficult and time-consuming.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

ICD-10-Coding of Medically Unexplained Physical Symptoms and Somatoform Disorders-A Survey With German GPs

Background: General practitioners (GPs) are reluctant to use codes that correspond to somatization syndromes.

Aim: To quantify GPs' views on coding of medically unexplained physical symptoms (MUPS), somatoform disorders, and associated factors.

Design and Setting: Survey with German GPs.

Methods: We developed six survey items [response options “does not apply at all (1)”—“does fully apply (6)”], invited a random sample of 12.004 GPs to participate in the self-administered cross-sectional survey and analysed data using descriptive statistics and logistic regression analyses.

Results: Response rate was 15.2% with N = 1,731 valid responses (54.3% female). Participants considered themselves familiar with ICD-10 criteria for somatoform disorders (M = 4.52; SD =.036) and considered adequate coding as essential prerequisite for treatment (M = 5.02; SD = 1.21). All other item means were close to the scale mean: preference for symptom or functional codes (M = 3.40; SD = 1.21), consideration of the possibility of stigmatisation (M = 3.30; SD = 1.35) and other disadvantages (M = 3.28; SD = 1.30) and coding only if psychotherapy is intended (M = 3.39; SD = 1.46). Exposure, guideline knowledge, and experience were most strongly associated with GPs' self-reported coding behaviour.

Conclusions: Subjective exposure, guideline knowledge, and experience as a GP, but no sociodemographic variable being associated with GPs' subjective coding behaviour could indicate that GPs offer a relatively homogeneous approach to coding and handling of MUPS and somatoform disorders. Strengthening guideline knowledge and implementation, and practise with simulated patients could increase the subjective competence to cope with the challenge that patients with MUPS and somatoform disorders present.

How to learn skilled communication in primary care MUS consultations: a focus group study

BACKGROUND

Many general practitioners (GPs) experience communication problems in medically unexplained symptoms (MUS) consultations as they are insufficiently equipped with adequate communication skills or do not apply these in MUS consultations.

OBJECTIVE

To define the most important learnable communication elements during MUS consultations according to MUS patients, GPs, MUS experts and teachers and to explore how these elements should be taught to GPs and GP trainees.

METHODS

Five focus groups were conducted with homogeneous groups of MUS patients, GPs, MUS experts and teachers. MUS patients and GPs formulated a list of important communication elements. MUS experts identified from this list the most important communication elements. Teachers explored how these elements could be trained to GPs and GP trainees. Two researchers independently analysed the data applying the principles of constant comparative analysis.

RESULTS

MUS patients and GPs identified a list of important communication elements. From this list, MUS experts selected five important communication elements: (1) thorough somatic and psychosocial exploration, (2) communication with empathy, (3) creating a shared understanding of the problem, (4) providing a tangible explanation and (5) taking control. Teachers described three teaching methods for these communication elements: (1) awareness and reflection of GPs about their feelings towards MUS patients, (2) assessment of GPs' individual needs and (3) training and supervision in daily practice.

CONCLUSION

Teachers consider a focus on personal attitudes and needs, which should be guided by opportunities to practice and receive supervision, as the best method to teach GPs about communication in MUS consultations.KEY POINTSMany GPs experience difficulties in communication with patients with MUS.There is a need to equip GPs with communication skills to manage MUS consultations more adequately.Role-playing with simulation patients, reflection on video-consultations and joint consultations with the supervisor may increase the GPs' awareness of their attitude towards MUS patients and may help GPs to identify their individual learning-points.

BMC family practice integrated GP care for patients with persistent physical symptoms: feasibility cluster randomised trial

BACKGROUND

Patients continue to suffer from medically unexplained symptoms otherwise referred to as persistent physical symptoms (PPS). General practitioners (GPs) play a key role in the management of PPS and require further training. Patients are often frustrated with the care they receive. This study aims to assess the acceptability of an 'integrated GP care' approach which consists of offering self-help materials to patients with PPS and offering their GPs training on how to utilise cognitive behavioural skills within their consultations, as well as assessing the feasibility of conducting a future trial in primary care to evaluate its benefit.

METHODS

A feasibility cluster randomised controlled trial was conducted in primary care, South London, UK. GP practices (clusters) were randomly allocated to 'integrated GP care plus treatment as usual' or 'treatment as usual'. Patients with PPS were recruited from participating GP practices before randomisation. Feasibility parameters, process variables and potential outcome measures were collected at pre-randomisation and at 12- and 24-weeks post-randomisation at cluster and individual participant level.

RESULTS

Two thousand nine hundred seventy-eight patients were identified from 18 GP practices. Out of the 424 patients who responded with interest in the study, 164 fully met the eligibility criteria. One hundred sixty-one patients provided baseline data before cluster randomisation and therefore were able to participate in the study. Most feasibility parameters indicated that the intervention was acceptable and a future trial feasible. 50 GPs from 8 GP practices (randomised to intervention) attended the offer of training and provided positive feedback. Scores in GP knowledge and confidence increased post-training. Follow-up rate of patients at 24 weeks was 87%. However estimated effect sizes on potential clinical outcomes were small.

CONCLUSIONS

It was feasible to identify and recruit patients with PPS. Retention rates of participants up to 24 weeks were high. A wide range of health services were used. The intervention was relatively low cost and low risk. This complex intervention should be further developed to improve patients'/GPs' utilisation of audio/visual and training resources before proceeding to a full trial evaluation.

TRIAL REGISTRATION

NCT02444520  (ClinicalTrials.gov).