Unexplained Symptoms In Primary Care Research Articles

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.

Barriers and facilitators to the implementation of interventions for medically unexplained symptoms in primary care: A modified Delphi study

ObjectiveMedically Unexplained Symptoms (MUS) are physical symptoms that last for longer than several weeks and for which no (sufficient) somatic explanation can be found. Interventions for treating MUS in primary care are available, but their implementation in daily practice appears difficult. In the current study we aim to explore key barriers and facilitators to the implementation of MUS-interventions in primary care. MethodsA three-round modified Delphi study was performed, using the input of 58 experts that are (in)directly involved in the care for patients with MUS (e.g. general practitioners (GPs), GP mental health workers, policy advisors). In the first online questionnaire, we generated ideas about relevant barriers and facilitators on different implementation levels. These ideas were independently coded by two researchers, and reformulated into unique barriers and facilitators. In round two, participants selected the ten most relevant barriers and facilitators from round one, which were ranked on importance in round three. ResultsWe identified 42 unique barriers and 57 unique facilitators to the implementation of MUS-interventions. The three highest ranked barriers were all related to time, i.e. too little time for treating complex MUS-patients. The most important facilitator was a positive attitude towards MUS-patients. Results varied somewhat per profession. ConclusionKey barriers and facilitators to the implementation of MUS-interventions seem to exist on the level of the patient, intervention, professional, organization, and external context. All of these levels should be taken into account in order to increase implementation success of MUS-interventions in primary care.

Characteristics and economic burden of frequent attenders with medically unexplained symptoms in primary care in Israel

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.

Personalized, Web-Based, Guided Self-Help for Patients With Medically Unexplained Symptoms in Primary Care: Protocol for a Randomized Controlled Trial.

BackgroundMedically unexplained symptoms (MUS) constitute a major health problem because of their high prevalence, the suffering and disability they cause, and the associated medical costs. Web-based interventions may provide an accessible and convenient tool for managing MUS. We developed a personalized, Web-based, guided self-help intervention for MUS in primary care (Grip self-help) and would compare its effectiveness with that of usual care.ObjectiveThis paper aims to describe the rationale, objectives, and design of a pragmatic randomized controlled trial (RCT) assessing the effectiveness of Grip self-help.MethodsFor a pragmatic multicenter RCT, 165 adult patients with mild to moderate MUS will be recruited through general practices in the Netherlands. Randomization will be performed at general practice level. Over the course of several months, patients in the intervention group will receive a personalized set of Web-based self-help exercises, targeting the unhelpful cognitions, emotions, behaviors, and social factors that are relevant to them. The intervention is guided by a general practice mental health worker. The control group will receive care-as-usual. Primary outcome is physical health-related quality of life (RAND-36 or 36-item general health survey, physical component score). Secondary outcomes include severity of physical and psychological symptoms, mental health–related quality of life, cost-effectiveness, and acceptability. Assessments will take place at baseline, end of treatment, and at 16-, 26-, and 52-week follow-ups.ResultsRecruitment started in December 2018, and enrolment is ongoing. The first results are expected to be submitted for publication in December 2021.ConclusionsTo our knowledge, this is the first study to combine the concepts of electronic health, self-help, and personalized medicine in the treatment of MUS. By improving the quality of life and reducing symptoms of patients with MUS, Grip self-help has the potential to reduce costs and conserve scarce health care resources.Trial RegistrationDutch Trial Register NTR7390; https://www.trialregister.nl/trial/7390.International Registered Report Identifier (IRRID)PRR1-10.2196/13738

Barriers for the diagnosis and management of persistent and medically unexplained symptoms in primary care – Representative survey with general practitioners

The through-the-wall inverse scattering problem is analyzed via the linear sampling method. The reciprocity gap formulation of the linear sampling method is used to reconstruct an object within a closed-off room. In order to apply this method, a numerical method to model a point source is needed, along with knowledge of how the numerical fundamental solution differs from the analytic one. Application of the linear sampling method to the Finite Difference Time Domain solution is described and illustrated, and results to reconstruct objects in the through-the-wall setting are shown.

Symptom management for medically unexplained symptoms in primary care: a qualitative study.

GPs have a central position in the care of patients with medically unexplained symptoms (MUS), but GPs find their care challenging. Currently, little is known about symptom management by GPs in daily practice for patients with MUS. This study aimed to describe management strategies used by GPs when confronted with patients with MUS in daily practice. Qualitative study in which videos and transcripts of 39 general practice consultations involving patients with MUS in the region of Nijmegen in the Netherlands in 2015 were analysed. A thematic analysis of management strategies for MUS used by GPs in real-life consultations was performed. The study revealed 105 management strategies in 39 consultations. Nearly half concerned symptom management; the remainder included medication, referrals, additional tests, follow-up consultations, and watchful waiting. Six themes of symptom management strategies emerged from the data: cognitions and emotions, interaction with health professionals, body focus, symptom knowledge, activity level, and external conditions. Advice on symptom management was often non-specific in terms of content, and ambiguous in terms of communication. Symptom management is a considerable part of the care of MUS in general practice. GPs might benefit from support in how to promote symptom management to patients with MUS in specific and unambiguous terms.

What do guidelines and systematic reviews tell us about the management of medically unexplained symptoms in primary care?

Medically unexplained symptoms (MUS) are symptoms for which the origin remains unclear despite adequate history taking, physical examination, and additional investigations.1 An estimated 3–11% of patients visiting general practice repeatedly consult their GP for MUS.2,3 MUS exist along a continuum ranging from self-limiting symptoms, to recurrent and persistent symptoms, through to symptom disorders.4 Although there are various terms for the condition, for example unexplained physical symptoms, functional symptoms, or somatoform symptoms, we have chosen to use MUS in this article because this is the most frequently used term. This review aims to address current problems with the management of undifferentiated MUS; specific syndromes within the MUS spectrum, such as chronic fatigue syndrome and irritable bowel syndrome, are excluded from discussion. Patients with persistent MUS suffer from their symptoms, are functionally impaired, and are at risk of potentially harmful additional testing and treatment.5 Furthermore, these patients commonly express dissatisfaction with the medical care they receive during their illness.6 They feel stigmatised and not taken seriously.7 GPs often experience patients with persistent MUS as difficult and frustrating to manage.8 In addition, MUS are associated with reduced health-related quality of life, higher healthcare and social costs, and costs associated with lost productivity.9,10 The effects of many treatment strategies have been studied in recent decades. However, not all interventions are acceptable or feasible in routine primary care. In the light of the central role of the GP in managing MUS, we will discuss the importance of consultation skills and the effects of specific treatments in primary care. We will do this by way of a narrative review using available national guidelines and Cochrane Reviews in this field. ### Clinical guidelines on MUS in primary care In recent years several guidelines on MUS have been published: a Dutch multidisciplinary guideline (2010);11 a German multidisciplinary guideline (2012);12 Dutch13 and Danish14 general practice guidelines (2013); and …

Patients with medically unexplained symptoms in primary care: The development of an effective intervention

Patients with medically unexplained symptoms in primary care: The development of an effective intervention

Balancing medical accuracy and diagnostic consequences: diagnosing medically unexplained symptoms in primary care.

Focusing on the case of medically unexplained symptoms (MUS), this article explores diagnostic classification in the absence of biomedical evidence or other strong medical warrants for diagnosis. The data are from three focus group interviews with Norwegian general practitioners (GPs) conducted in 2015, that centred on the issue of what diagnoses to use (or not) for MUS. The qualitative analysis reconstructs the logic underlying GPs' diagnostic accounts, which centred on the meaning of diagnostic categories and on anticipating how 'generalised others' would respond to those meanings (called 'diagnosing by anticipation'). The analysis suggests that GPs confer diagnoses by balancing unwarranted medical accuracy and anticipated harmful diagnostic consequences; the goal of diagnosis was finding categories in the International Classification of Primary Care that would yield acceptable results, without making a liar of the GP in the process. Drawing on the distinction between diagnosis as colligation and classification, the findings and their relevance for medical sociology are discussed. Counter to frequent descriptions as 'illness that cannot be diagnosed', the analysis shows how GPs can diagnose MUS in the bureaucratic sense of diagnosis as classification - a sense that has been missing from sociological view.

Somatoform disorders and medically unexplained symptoms in primary care.

The literature contains variable figures on the prevalence of somatoform disorders and medically unexplained symptoms in primary care. The pertinent literature up to July 2014 was retrieved by a systematic search in the PubMed/MEDLINE, PsychInfo, Scopus, and Cochrane databases. The methodological quality and heterogeneity (I2) of the retrieved trials were analyzed. The prevalence rates of medically unexplained symptoms, somatoform disorders, and their subcategories were estimated, along with corresponding 95% confidence intervals (CI), with the aid of random-effects modeling. From a total of 992 identified publications, 32 studies from 24 countries involving a total of 70 085 patients (age range, 15-95 years) were selected for further analysis. All had been carried out between 1990 and 2012. The primary studies were more heterogeneous overall; point prevalences for the strict diagnosis of a somatization disorder ranged from 0.8% (95% CI 0.3-1.4%, I2 = 86%) to 5.9% (95% CI 2.4-9.4%, I2 = 96%), with higher estimated prevalences in studies that applied less restrictive diagnostic criteria. At least one type of somatoform disorder was diagnosable by DSM-IV and/or ICD-10 criteria in a fraction of primary-care patients that ranged from 26.2% (95% CI 19.1-33.3%, I2 = 98%) to 34.8% (95% CI 26.6-44.6%; I2 = 92%). The percentage of patients complaining of at least one medically unexplained symptom ranged from 40.2% (95% CI 0.9-79.4%; I2 = 98%) to 49% (95% CI 18-79.8%, I2 = 98%). The quality of the studies, in general, was only moderate. No relationship was found between study quality and prevalence estimates. The statistical heterogeneity of the included studies is very high. Somatoform disorders and medically unexplained symptoms are more common than generally assumed. The found prevalences highlight the importance of these conditions in primary care.

Learning to provide patient-centered care with patients with medically unexplained symptoms: a grounded theory study in Australian general practice.

Background Culture shapes the way illness is experienced and disease is understood. Patients with medically unexplained symptoms describe feeling their suffering is not valued because they lack a “legitimate” diagnosis. Doctors also describe feeling frustrated with these patients. This is particularly problematic for young general practitioners (GPs) who lack experience in managing patients with medically unexplained symptoms in primary care settings.Objectives To explore how general practice supervisors help registrars to provide patient-centered care for patients with medically unexplained. Methods A constructivist grounded theory study was undertaken with 24 general practice registrars and supervisors from Australian GP training practices in urban, rural and remote environments. Participants were asked to describe patients with mixed emotional and physical symptoms without an obvious medical diagnosis. Results Registrars came from hospital posts into general practice equipped with skills to diagnose and manage organic disease but lacked a framework for assessing and managing patients with medically unexplained symptoms. They described feelings of helplessness, frustration and sometimes hostility. Because these feelings were inconsistent with their expressed value systems, they were uncomfortable and confronting. The registrars valued interactions that helped them explore this area. Conclusions In hospital practice, biomedical language and explanations predominate, but in general practice patients bring different explanatory illness models to the consultation, using their own language, beliefs and cultural frameworks. Medically unexplained symptoms occupy a contested space in both the social and medical worlds of the doctor and patient. Negative feelings and a lack of diagnostic language and frameworks may prevent registrars from providing patient-centered care.

The body speaks its mind: The BodyMind Approach® for patients with medically unexplained symptoms in primary care in England

This article documents an experience of translating research into the real-world of the National Health Service (NHS) in the England. Transferring new knowledge from research is problematic particularly when negotiating within the context of the changing NHS England. An overview of the pitfalls/challenges and some of the tried and tested methods which were designed to overcome these is provided. The evidence-based intervention, offered by a University of Hertfordshire spin-out company Pathways2Wellbeing, is a service called Symptoms Groups to patients, and termed The Medically Unexplained Symptoms (MUS) Clinic to health professionals. The groups use The BodyMind Approach (TBMA)®11For more information about TBMA please visit www.pathways2wellbeing.com or email: info@pathways2wellbeing.com., based on a bio-psychosocial model derived from dance movement psychotherapy, which has been specifically researched with patients with MUS. These patients have no specific pathway for supporting their wellbeing and are high health utilizers at the interface of primary and community care. They suffer with chronic, physical symptoms or conditions which do not appear to have an organic, medical diagnosis, previously known as psychosomatic conditions.

Managing Medically Unexplained Symptoms in Primary Care: A Narrative Review and Treatment Recommendations.

Medically unexplained symptoms (MUS) are persistent physical symptoms in the absence of identifiable disease. MUS present a major challenge for primary care providers (PCPs) because complex symptom presentations, strained patient-physician relationships, and treatment-resistant symptoms can challenge a PCP's sense of competency. This review is intended to help PCPs understand the burden and theoretical context of MUS and to provide concise recommendations for managing MUS within primary care settings. Based on a narrative review of the literature, these recommendations emphasize in particular the importance of co-creating plausible explanations for MUS, understanding the pitfalls of consultations involving MUS, and developing multimodal treatment plans.

Mindfulness-Based Cognitive Therapy for Patients with Medically Unexplained Symptoms: A Randomized Controlled Trial

Background: Patients with medically unexplained symptoms make heavy demands on the health care system. An offer for psychological treatment is often declined. There is a need for acceptable and effective treatments. We assessed the acceptability and effectiveness of mindfulness-based cognitive therapy (MBCT) for patients with persistent medically unexplained symptoms. Method: A randomized controlled trial comparing MBCT (n = 64) to enhanced usual care (EUC; n = 61). Participants were the 10% most frequently attending patients in primary care. The primary outcome measure was general health status at the end of treatment. Secondary outcome measures were mental and physical functioning. Assessments took place at the end of treatment and at the 9-month follow-up. Results: Health status and physical functioning did not significantly differ between groups. However, participants in the MBCT group reported a significantly greater improvement in mental functioning at the end of treatment (adjusted mean difference, 3.9; 95% CI, 0.24-7.6), in particular with regard to vitality and social functioning. In addition, at 9 months of follow-up, the mindfulness skills ‘observing' and ‘describing' were significantly higher in the MBCT group. Within the MBCT group, almost half of the outcome measures had significantly improved at the end of treatment, whereas in the EUC group none had. Conclusions: MBCT was feasible for frequently attending patients with persistent medically unexplained symptoms in primary care. Although MBCT did not lead to a significant difference in general health status between the two groups, it did result in a significant improvement in mental functioning.

Course and prediction of somatoform disorder and medically unexplained symptoms in primary care, Steinbrecher N, Hiller W : Gen Hosp Psychiatry 33:318-326, 2011

Course and prediction of somatoform disorder and medically unexplained symptoms in primary care, Steinbrecher N, Hiller W : Gen Hosp Psychiatry 33:318-326, 2011

Course and prediction of somatoform disorder and medically unexplained symptoms in primary care

Theory/objective Somatoform disorder (SFD) is associated with considerable psychosocial impairment. However, only a few studies have dealt with the course of this clinical subgroup. Therefore, the objective was to identify predictors for the various courses of SFD and medically unexplained symptoms (MUS). Method We screened 620 consecutive patients in primary care using the Patient Health Questionnaire (PHQ-15). Afterwards, 308 patients were studied in more detail using a diagnostic interview and a set of questionnaires. One year later, we were able to interview 277 participants a second time. Result After 1 year, 48.8% of the respondents had a remitted SFD. The following variables proved to be significant predictors of MUS: current depressive episode, negative life events, number of MUS at baseline, attributional style, autonomic sensations and catastrophizing cognitions. The course of SFD could be predicted through current depressive or anxiety disorder, negative life events, functional disability and attributional style. Conclusion Somatoform disorder has a favorable course. The predictors of the courses of SFD and MUS we found can be integrated into previous explanatory models. The coping with MUS or SFD can be seen as a mediating factor.

The Prevalence of Medically Unexplained Symptoms in Primary Care

There is only a small number of studies dealing with the prevalence of medically unexplained symptoms and somatoform disorder in German primary care practices. Therefore, we aimed to study the prevalence of medically unexplained symptoms and the prevalences and comorbidities of somatoform and other mental disorders. In the initial stage of a two-stage prevalence study, 620 consecutive patients were first screened with a PHQ-15 questionnaire. In the second stage, 308 selected persons were then interviewed in detail. Medically unexplained symptoms made up two-thirds of all reported symptoms with women, younger persons, and non-native speakers having the highest rates. The 12-months prevalences of somatoform disorders was 22.9%, for affective disorders it was 12.4%, and for anxiety disorders it was 11.4%. Somatoform disorder was comorbid with at least one other mental disorder in 43.2% of the cases. Most frequently, somatoform disorder was comorbid with anxiety or depression. 37.1% of the patients had a mental disorder. Somatoform and other mental disorders are highly common in primary care. In order to support an adequate management of mental and somatoform disorders, general practitioners should consider the influences of gender and cultural background on the development of a mental disorder.

Making the economic case for tackling somatoform disorders

Background/Objectives: Studies have suggested that as many as 26% of all primary care consultations may be attributed to medically unexplained symptoms (MUS). These somatoform disorders have previously been estimated to cost the health care system in England alone £ 3 billion per annum. Our objective therefore was to estimate the potential economic case for investing in measures to tackle medically unexplained symptoms in primary care in England.

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 primary care

Adult patients with medically unexplained symptoms (somatisation) in primary care are numerous and make disproportionately high demands on health services. Most of these individuals are open to the suggestion that their illness reflects psychological needs. Empowering explanations from doctors can enable patient and doctor to work collaboratively in managing the problem and can reduce healthcare contacts. Parental medically unexplained symptoms, sexual and physical abuse in childhood and childhood neglect are associated with a greater risk of medically unexplained symptoms in adulthood. The overall prognosis for the majority of primary care patients with medically unexplained symptoms is very good. The two most common approaches to dealing with medically unexplained symptoms in primary care are stepped-care approaches and teaching general practitioners new skills to manage consultations more effectively.