Medically Unexplained Symptoms In Primary Care Research Articles

TIBBİ OLARAK AÇIKLANAMAYAN SEMPTOMLAR(MUS); KISA BİR BAKIŞ

Medikal değerlendirmeyle, organik bir sebebe dayandırılamayan ve en az üç aydır devam eden bu şikayetler, DSM-V’de somatik şikayetlerin MUS ve tıbbi olarak açıklanan semptomlar (MES) olarak gerekli ikiliğe ayrılması önerilmiştir. MUS tanılı hastaların, artmış anksiyete, depresyon ve bozulmuş sosyal fonksiyonları ile belirgin morbiditelerinin olduğu, ayrıca yüksek seviyede sağlık harcamalarına sebep oldukları bilinmektedir. Birinci basamakta MUS prevelansı %3-11 olarak tespit edilmiştir. Semptomlar genelde sırt ağrısı, halsizlik, güçsüzlük hissi, ekstremite ağrıları, uyku bozukluğu ve dispeptik şikayetler şeklindedir ve prognozlarının 5 yıllık periyotta kötüleştiği bilinmektedir. Herhangi bir patolojiyi atlamamak adına bu hastalar, ciddi araştırmalara tabi tutulup gereksiz tetkik ve tedaviye maruz kalabilmektedir. Mezuniyet öncesi ve/veya sonrasında MUS ile ilgili eğitim almış olan doktorların, hastaya yaklaşımı, iletişimi ve hastayı anlamadaki becerisinin daha olumlu olduğu belirtilmiştir. Hastaların yönetimi ile ilgili ortak bir tutum geliştirilmediği gibi, ülkemizde de bu konuda yapılmış herhangi bir çalışmaya rastlanmamıştır. Bu nedenle bu alanda çalışma yapılmasına ve hekimlerin farkındalığının arttırılmasına ihtiyaç vardır.

Development of a blended communication training program for managing medically unexplained symptoms in primary care using the intervention mapping approach

BackgroundGeneral practice (GP) training in how to communicate with patients with medically unexplained symptoms (MUS) is limited. ObjectiveDevelopment, implementation and evaluation of an evidence-based communication training program for GP residents focused on patients with MUS in primary care. MethodsWe used the intervention mapping (IM) framework to systematically develop the MUS training program. We conducted a needs assessment to formulate change objectives and identified teaching methods for a MUS communication training program. Next, we developed, implemented and evaluated the training program with 46 residents by assessing their self-efficacy and by exploring their experiences with the training. ResultsThe resulting program is a blended training with an online course and two training days. After attending the training program, GP residents reported significantly higher self-efficacy for communication with patients with MUS at four weeks follow up compared to baseline. Furthermore, GP residents experienced the training program as useful and valued the combination of the online course and training days. Conclusion and practice implicationsWe developed an evidence-based communication training program for the management of patients with MUS in primary care. Future research should examine the effect of the training on GP residents’ communication skills in MUS consultations in daily practice.

Different Strokes for Different Folks: The BodyMind Approach as a Learning Tool for Patients With Medically Unexplained Symptoms to Self-Manage.

Medically unexplained symptoms (MUS) are common in both primary and secondary health care. It is gradually being acknowledged that there needs to be a variety of interventions for patients with MUS to meet the needs of different groups of patients with such chronic long-term symptoms. The proposed intervention described herewith is called The BodyMind Approach (TBMA) and promotes learning for self-management through establishing a dynamic and continuous process of emotional self-regulation. The problem is the mismatch between the patient’s mind-set and profile and current interventions. This theoretical article, based on practice-based evidence, takes forward the idea that different approaches (other than cognitive behavioral therapy) are required for people with MUS. The mind-set and characteristics of patients with MUS are reflected upon to shape the rationale and design of this novel approach. Improving services for this population in primary care is crucial to prevent the iterative spiraling downward of frequent general practitioner (GP) visits, hospital appointments, and accident and emergency attendance (A&E), all of which are common for these patients. The approach derives from embodied psychotherapy (authentic movement in dance movement psychotherapy) and adult models of learning for self-management. It has been developed from research and practice-based evidence. In this article the problem of MUS in primary care is introduced and the importance of the reluctance of patients to accept a psychological/mental health referral in the first instance is drawn out. A description of the theoretical underpinnings and philosophy of the proposed alternative to current interventions is then presented related to the design, delivery, facilitation, and educational content of the program. The unique intervention is also described to give the reader a flavor.

Brief multimodal psychosomatic therapy in patients with medically unexplained symptoms: feasibility and treatment effects.

Patients repeatedly presenting with medically unexplained symptoms (MUS) to their GPs, suffer from their symptoms. Experts in the field suggest a multicomponent approach for these patients. Brief multimodal psychosomatic therapy (BMPT) is such an intervention. To test the systematic identification of eligible patients, acceptability of BMPT and potential treatment effects of BMPT. The participants in this randomized pilot trial, patients consulting their GPs more than once with MUS, were randomized to intervention [usual care (UC) and additional BMPT] or control condition (UC alone).We monitored the number of patients identified and recruited, trial recruitment and retention. Potential treatment effects were measured with perceived symptom severity [Visual Analogue Scale (VAS)]; patients' self-rated symptoms of distress, depression, anxiety and somatization [Four-Dimensional Symptom Questionnaire (4DSQ)]; symptoms of hyperventilation [Nijmegen Hyperventilation List (NHL)]; physical and mental health status and quality of life [Short-Form Health Survey-36 items (SF-36)]; and level of functioning (measure of general functioning). Follow-up was 1 year. A total of 42 patients could be included in the trial. Four patients withdrew after randomization and two patients were lost to follow-up, resulting in 36 patients (86%). During the 12-month follow-up after BMPT, there was an improvement in perceived symptom severity [adjusted mean difference -2.0, 95% confidence interval (CI) -3.6 to -0.3], in somatization (adjusted mean difference -4.4, 95% CI -7.5 to -1.4) and in symptoms of hyperventilation (adjusted mean difference -5.7, 95% CI -10.5 to -0.8). This randomized pilot study shows that a larger trial studying the effectiveness of BMPT in patients with MUS in primary care is feasible and useful.

Opinions of Slovenian family physicians on medically unexplained symptoms: A qualitative study

To determine the views of Slovenian family physicians on medically unexplained symptoms (MUS) and learn more about potential types of treatment for such patients. Five focus groups, comprising 24 family medicine physicians (FMPs) from two Slovenian University centres, were convened. Conversations were led towards the research objectives by professionally trained researchers and followed a preliminarily established protocol. Qualitative content analysis of audio and transcripts of the discussions was performed using ATLAS.ti software to establish categories ('codes') relevant to issues regarding MUS. Slovenian FMPs emphasized the importance of good communication and trust between physicians and patients with MUS. Systemic barriers to effective management of MUS arising from the Slovenian health system were highlighted. FMPs stressed the need for more education in the recognition and treatment of MUS in primary care. From the discussions, 64 codes comprising broader research fields of MUS were developed, then grouped into a further eight categories: communication; doctor-patient relationship; causes of MUS; patient characteristics; physician characteristics; courses of action so far; positive relationship with patients; proposals for treatment. The results are valuable in terms of investigating the treatment of patients with MUS in Slovenia, thereby opening new avenues of research on the subject of MUS.

The General Practitioner's Consultation Approaches to Medically Unexplained Symptoms: A Qualitative Study.

Background. The prevalence of medically unexplained symptoms (MUSs) in primary care is about 10–15%. The definition of MUS is descriptive and there are no specific diagnostic criteria for MUS in primary care. Furthermore, a general practitioner's (GP's) categorisation of patients with MUS shows large variation. The aim of the present study is to investigate how GPs employ the definition of MUS and how they manage patients with MUS in daily practice. Methods. With a grounded theory approach five focus group interviews with GPs were performed. The interviews addressed how GPs managed MUS and their reflections on the course and prognosis for MUS patients. Results. Consultations about MUS develop around the individual patient and usually include several appointments. We identified three different types of consultations: (1) “searching for a disease,” (2) “going by the routine,” and (3) “following various paths.” These types of consultations spanned from a biomedical approach to an approach where multiple explanations were offered to explain the patient's problem. The choice of consultation types was influenced by the GP, the patient and contextual factors which, in turn, affected the diagnostic process. Conclusions. A diagnosis of MUS is contextually embedded and the diagnostic process is shaped by the consultation.

Are medically unexplained symptoms and functional disorders predictive for the illness course?: A two-year follow-up on patients' health and health care utilisation

Objective To investigate whether the general practitioners' (GP) diagnosis of medically unexplained symptoms (MUS) and/or the diagnosis functional disorders (FD) can predict the patients' 2-year outcome in relation to physical and mental health and health care utilisation. Furthermore, to identify relevant clinical factors which may help the GP predict the patient's outcome. Method The study included 38 GPs and 1785 consecutive patients who presented a new health problem. The GPs completed a questionnaire on diagnosis for each patient. Patients completed the Common Mental Disorder Questionnaire (CMDQ) and the SF-36 questionnaire at baseline and after 24 months. A stratified sample of 701 patients was diagnosed with a psychiatric research interview. Data on health cost was obtained from national registers. Results A FD diagnosis following the research interview was associated with a decline in physical health (OR 3.27(95%CI 1.84–5.81)), but this was not the case with MUS diagnosed by the GP. MUS was associated with a poor outcome on mental health (OR 2.16 (95%CI 1.07–4.31)). More than 4 symptoms were associated with a poor outcome on physical health (OR 5.35 (95%CI 2.28–12.56)) and on mental health (OR 2.17(95%CI 1.02–4.59)). Neither FD nor MUS were associated with higher total health care use. However, FD (OR 2.31(95%CI 1.24–4.31)) and MUS (OR 1.98(95%CI 1.04–3.75)) was associated with increased cost in primary care. Conclusion Our current diagnoses of MUS show limitations in their prediction of the patients' illness course. Although, the ICD-10 diagnoses of functional disorders was not developed for the primary care setting, our results indicate that some of its elements would be useful to bring in when rethinking the diagnosis for MUS in primary care, elements that are easily obtainable for the GP in a normal consultation. Our results may contribute to the construction of a more useful diagnostic for these patients in primary care.

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

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

Medically unexplained symptoms in family medicine: defining a research agenda. Proceedings from WONCA 2007

Medically unexplained symptoms (MUSs) are frequently presented in primary care. Unfortunately, knowledge of these patients and/or symptoms in primary care is still limited. Available research comes mainly from Europe and North America, while the perspectives of cultures such as Africa, Asia and South America are relatively unknown. To bring cultural perspectives together, a symposium and workshop on MUS in primary care was held at the WONCA World Conference 2007 in Singapore. Main goals of this symposium and workshop-apart from presenting ongoing research and bringing together experts in MUS-were to detect knowledge gaps in MUS and to establish priorities in MUS research. This publication focuses on the proposed research agenda. Using a nominal group technique, we generated research topics and set priorities. Research topics were grouped into research themes. Participants' (66 researchers and GPs from 29 nationalities) most important research topics were 'formulating a broadly accepted definition of MUS', 'finding a strategy to recognize MUS better and at an earlier stage', 'studying the value of self-management and empowerment in patients with MUS' and 'finding predictors to decide which strategy will best help the individual patient with MUS'. Priorities in research themes of MUS are as follows: (i) therapeutic options for patients with MUS and (ii) problems in consultations with these patients. More research on MUS in primary care is needed to improve the consultations with and management of these patients. Internationally primary care conferences are excellent for exchanging ideas and formulating central issues of research.

Improving the Classification of Medically Unexplained Symptoms in Primary Care

Many patients in primary care complain of physical symptoms not attributable to any known conventionally defined disease, i.e. medically unexplained symptoms (MUS). Objectives: This paper aims to present the problems with our current classification of MUS in general practice and propose new criteria for the classification of Medically Unexplained Symptoms in a future edition of the International Classification of Primary Care (ICPC). Methods: Discussion of European classification systems in relation to current evidence about MUS in primary care. Results: At present, clinical care and research are hampered by the lack of a valid and reliable diagnostic classification of MUS. A particular problem in primary care is that the diagnostic category of somatoform disorders only includes persistent cases and therefore offers no opportunity for the classification of many patients with MUS in general practice. We propose new diagnostic criteria for MUS that can easily be integrated in a future edition of the ICPC. The criteria introduce mild to moderate MUS into the chapter of general and unspecified health problems if the patient has at least three MUS during an episode of care, whereas severe conditions are kept in the psychological chapter under the diagnoses applied until now. Conclusion: A diagnosis and classification of MUS is essential for the prediction of prognosis and the choice of appropriate care for these patients in general practice. It remains to be evaluated in epidemiologic research whether the proposed classification criteria fulfil this purpose

Assessment and management of patients with medically unexplained symptoms in primary care

Medically unexplained symptoms (MUS) are common in primary care and associated with high healthcare usage, impaired function or distress. They are not explainable by lasting organic pathology. Usually they have a reversible physiological explanation, they are precipitated by life stress or modern lifestyle, and sometimes they are associated with depressive and anxiety disorders. The definition is more acceptable to GPs than somatoform disorder because it does not suggest a psychiatric process and does not require lifetime symptom counts in a busy surgery. Most patients seek an alliance with their general practitioner (GP) to legitimize their distress and help understand their cause, but GPs commonly manage MUS using a biomedical model rather than manage the underlying distress. The article outlines a number of useful assessment and management approaches to MUS in primary care. Reattribution is a structured consultation used by GPs to provide patients with an explanation for their MUS in terms of life stress, lifestyle or psychiatric disorder. The use of regular appointments to manage chronic MUS associated with high consultation rates is also established. Graded exercise and antidepressants can be helpful in patients with particular types of MUS. Cognitive behavioural therapy is a helpful second line treatment but few GPs are currently willing to utilize it. Despite the high distress and cost of these patients, there are few incentives to GPs to manage MUS in health systems around the world.