Frequent attenders in general practice: a retrospective 20-year follow-up study.

We describe a 20-year retrospective study of 58 patients with a cross-matched control group in one practice, who initially attended more than 12 times in 1975. The study establishes that frequent attendance is not consistent; the majority of high-attending patients in general practice revert over a short period of time to a normal consulting pattern. Diseases, rather than patients, appear to dictate high consulting rates. Consistent high attendance is largely owing to multiple pathology.     

Coping with patients with medically unexplained symptoms: work-related strategies of physicians in primary health care

General practitioners (GPs) often meet patients with medically unexplained symptoms (MUS). From a patient perspective, MUS is a well-acknowledged problem within the primary health care services today, but less is known about the GPs' perceptions. This study aims to elucidate GPs' perceptions of patients with MUS, focusing on stressing situations, emotional reactions and coping strategies. Twenty-seven physicians participated in focus-group discussions. In the analysis, where a phenomenographic approach was used, six situations were identified as being especially stressful in the encounter with these patients. The GPs described how they used both problem-focused and emotion-focused strategies, but with emotion-focused strategies slightly dominating, indicating that the GPs had difficulties in managing their own stress when working with patients with MUS.     

Explaining medically unexplained symptoms: Somatizing patients’ responses in primary care

Objective

To examine (1) how physicians present an explanation of symptoms in terms of a hormonal imbalance as a means to initiate a psychosocial discussion with somatizing patients; and (2) how they respond to this explanation of symptoms.

Methods

Qualitative study of 11 sequences in which physicians explain patients’ symptoms in terms of a hormonal imbalance are micro-analyzed using Conversation Analysis.

Results

Symptom explanations (SEs) were vague, tentative, and uncertain. Two patterns of SEs (general vs. specific) and five different patterns of patient response were found. Patient responses are classified according to whether they occur during or after the SE, and according to the degree of work patients carry out to verbalize a response.

Conclusion

Symptom explanations elicited varying degrees of patient agreement, and allowed physicians to obtain patients’ permission to conduct a psychosocial exploration.

Practice implications

Physicians may start SEs by associating symptoms to a hormonal imbalance, and by relating them to universally recognizable emotions and familiar situations. Excessive emphasis on long and complex SEs and on seeking extended verbalizations of patient agreement may be counterproductive and antagonize the patient.     

A one-session treatment for patients suffering from medically unexplained symptoms in primary care: a randomized clinical trial

The aim of the study was to evaluate a one-session cognitive-behavior treatment (CBT) versus standard medical care for 140 primary-care patients with multiple somatoform symptoms. DSM-IV diagnoses were assessed with structured interviews. Primary outcome variables were healthcare utilization, number, and severity of somatoform symptoms, and secondary outcome measures were psychopathology dimensions. Assessments were done at study enrollment, at 4-weeks, and at 6-month follow-up. General acceptance of CBT was high (positive session evaluations, low dropout rate: 15%). Using an intent-to-treat analytic strategy, both groups improved. Yet results showed a stronger reduction in doctor visits and somatization severity in CBT versus standard care.     

Association of attachment style to lifetime medically unexplained symptoms in patients with hepatitis C

In this study, we sought to establish whether there was an association between adult attachment style and number of medically unexplained physical symptoms in patients with hepatitis C. Thirty-two patients with hepatitis C were assessed with regard to attachment style classification, number of lifetime medically unexplained symptoms, lifetime psychiatric diagnoses, medical comorbidity, disease severity, use of interferon, and demographic characteristics. Analysis of covariance was used to compare the four attachment groups on number of lifetime medically unexplained symptoms, and Pearson correlations were used to assess the association of continuous ratings of attachment style with lifetime medically unexplained symptoms. Number of lifetime medically unexplained symptoms varied significantly as a function of attachment style group, with patients with fearful attachment reporting significantly more medically unexplained symptoms than patients with secure attachment (P < 0.01). Number of lifetime medically unexplained symptoms was positively correlated with continuous ratings of fearful attachment (r = 0.53, P < 0.01) and preoccupied attachment (r = 0.46, P < 0.01). Implications for treatment are discussed.     

Economics of medically unexplained symptoms: a systematic review of the literature

Objective: To review cost-of-illness studies (COI) and economic evaluations (EE) conducted for medically unexplained symptoms and to analyze their methods and results. Methods: We searched the databases PubMed, PsycINFO and National Health Service Economic Evaluations Database of the University of York. Cost data were inflated to 2006 using country-specific gross domestic product inflators and converted to 2006 USD purchasing power parities. Results: We identified 5 COI and 8 EE, of which 6 were cost-minimization analyses and 2 were cost-effectiveness analyses. All studies used patient level data collected between 1980 and 2004 and were predominantly conducted in the USA (n = 10). COI found annual excess health care costs of somatizing patients between 432 and 5,353 USD in 2006 values. Indirect costs were estimated by only one EE and added up to about 18,000 USD per year. In EE, educational interventions for physicians as well as cognitive-behavioral therapy approaches for patients were evaluated. For both types of interventions, effectiveness was either shown within EE or by previous studies. Most EE found (often insignificant) cost reductions resulting from the interventions, but only two studies explicitly combined changes in costs with data on effectiveness to cost-effectiveness ratios (ratio of additional costs to additional effects). Conclusions: Medically unexplained symptoms cause relevant annual excess costs in health care that are comparable to mental health problems like depression or anxiety disorders and which may be reduced by interventions targeting physicians as well as patients. More extensive research on indirect costs and cost-effectiveness is needed.     

Disagreement in doctor's and patient's rating about medically unexplained symptoms and health care use

Background

Medically unexplained (somatoform) symptoms (MUS) are highly prevalent in primary care. It remains unclear to what extent patients and their general practitioners (GPs) agree upon the etiology of physical symptoms as well as on the number of visits to the GP.

Purpose

The purpose of this study is to determine patient–physician agreement on reported symptoms.

Method

A sample of 103 persons provided information on MUS and health care utilization (HCU) during the previous 12 months. The persons' GPs (n?=?103) were asked for the same information. By determining patient–physician agreement on reported symptoms, the sample was subdivided into a concordance group (high agreement: Pt?=?GP) and two discordance groups (substantial disagreement: Pt?>?GP, Pt?<?GP).

Results

Patients and their GPs showed substantial disagreement concerning physical symptom reports for the prior 12 months. On means, patients named 3.26 (SD?=?3.23; range 0–21) physical complaints of which 71.6% were considered to be medically unexplained (MUS), whereas GPs only determined 1.77 (SD?=?1.94; range 0–11) symptoms of which 57.5% were MUS. Substantial patient–physician agreement regarding the number of reported MUS was detected in 29.1% of the cases (Pt?=?GP). Patients of all groups underestimated their HCU.

Conclusion

Since patients' and GPs' reports differ substantially concerning the etiology of symptoms and concerning HCU, both sources of data gathering should be treated carefully in primary care research.     

A method for rating charts to identify and classify patients with medically unexplained symptoms

BACKGROUND: As part of conducting a randomized control trial (RCT) to treat chronically high utilizing patients with medically unexplained symptoms (MUS), we developed the chart rating method reported here to identify and classify MUS subjects. METHOD: Intended at this point only as a research tool, the method is comprehensive, uses explicit guidelines, and requires clinician raters. It distinguishes primary organic disease patients from those with primary MUS, quantifies medical comorbidities in primary MUS patients, and also distinguishes subgroups among MUS patients that we call somatization (resembles DSM-IV somatoform disorders) and minor acute illness (MAI) which differs from DSM-IV somatoform definitions. Scoring rules are used to generate the diagnoses above. The rules may be set according to the investigator's needs, from highly sensitive to highly specific. RESULTS: We found high levels of agreement with the gold standard for MUS vs. organic disease (97.6%) and among raters for the key individual chart elements rated (92-96%). The method identified 206 MUS subjects and the extent of their medical comorbidities for entry into a RCT. It also identified somatization and MAI; the latter supports the validity of this newly reported MAI syndrome. CONCLUSION: We concluded that this method offered research potential for identifying MUS patients, for quantifying their medical comorbidities, and for classifying MUS subgroups.     

Tardive dyskinesia: a 3-year follow-up study

A prospective study of tardive dyskinesia was carried out to gain information regarding the natural history of the condition and to identify risk factors. Out of an original cohort of 182 psychiatric patients receiving maintenance antipsychotic drugs 99 were available for reassessment after 3 years. In this follow-up group the point prevalence of oro-facial dyskinesia increased from 39% to 47% over the 3-year period. Twenty-two patients developed the disorder, while remission occurred in 14 others. Risk factors predicting the presence of oro-facial dyskinesia at follow-up included being over 50 years of age and the presence of akathisia. There was no convincing association between the duration of antipsychotic drug treatment and the presence or severity of oro-facial dyskinesia. Patients receiving over 1000 mg chlorpromazine equivalents of antipsychotic drug per day were unlikely to have the condition. The amount of purposeless trunk and limb movement present proved to be a relatively stable phenomenon, showing only a slight increase with age and no change over the follow-up period. The implications of these findings are discussed, with particular consideration being given to the effects of loss of patients to follow-up.     

Efficacy of short-term psychotherapy for multiple medically unexplained physical symptoms: a meta-analysis

Multiple medically unexplained physical symptoms (MUPS) are considered to be difficult and costly to treat. The current meta-analysis therefore investigates the efficacy of short-term psychotherapy for MUPS. Based on a multiple-phase literature search, studies were selected according to a-priori defined inclusion criteria. The standardized mean gain was used as the effect size index. Separate data aggregation of between- and within-group contrasts was performed on the basis of a mixed effects model. Outcome variables were physical symptoms, disorder specific emotions, cognitions and behaviors, depressive symptoms, general psychopathology, functional impairment, and health care utilization. Based on 27 included studies, small between-group effect sizes (range: d₊ = 0.06-d₊ = 0.40) and small to large within-group effect sizes (range: d₊ = 0.36-d₊ = 0.80) were found for post-treatment and follow-up assessments for the different outcome variables. Significant moderator variables were identified as the type, mode, and setting of therapy, number of therapy sessions, profession of therapist, age and sex of patients, quality of diagnostic procedure, and the control of concomitant treatments. Implications of the results for clinical practice and future research are discussed.