Developmental Influences on Medically Unexplained Symptoms

Background: Patients with medically unexplained symptoms (MUS) are frequent in primary care and substantially impaired in their quality of life (QoL). Specific training of general practitioners (GPs) alone did not demonstrate sustained improvement at later follow-up in current reviews. We evaluated a collaborative group intervention. Methods: We conducted a cluster randomized controlled trial. Thirty-five GPs recruited 304 MUS patients (intervention group: 170; control group: 134). All GPs were trained in diagnosis and management of MUS (control condition). Eighteen randomly selected intervention GPs participated in training for a specific collaborative group intervention. They conducted 10 weekly group sessions and 2 booster meetings in their practices, together with a psychosomatic specialist. Six and 12 months after baseline, QoL was assessed with the Short-Form 36. The primary outcome was the physical composite score (PCS), and the secondary outcome was the mental composite score (MCS). Results: At 12 months, intention-to-treat analyses showed a significant between-group effect for the MCS (p = 0.023) but not for the PCS (p = 0.674). This effect was preceded by a significant reduction of somatic symptom severity (15-item somatic symptom severity scale of the Patient Health Questionnaire, PHQ-15) at 6 months (p = 0.008) that lacked significance at 12 months (p = 0.078). As additional between-group effects at 12 months, per-protocol analyses showed less health anxiety (Whiteley-7; p = 0.038) and less psychosocial distress (PHQ; p = 0.024); GP visits were significantly (p = 0.042) reduced in the intervention group. Conclusions: Compared to pure GP training, collaborative group intervention achieved a progressive, clinically meaningful improvement in mental but not physical QoL. It could bridge gaps between general practice and mental health care.

Section: Methodsmentioning

confidence: 99%

Specific Collaborative Group Intervention for Patients with Medically Unexplained Symptoms in General Practice: A Cluster Randomized Controlled Trial

Schaefert¹,

Kaufmann²,

Wild³

et al. 2012

“…medically unexplained or functional somatic symptoms (FSS) [1,2,3,4,5,6,7]. The severity of FSS ranges from mild transient cases to severe and chronic somatoform disorders (SDs) [8].…”

Section: Introductionmentioning

confidence: 99%

Training General Practitioners in the Treatment of Functional Somatic Symptoms: Effects on Patient Health in a Cluster-Randomised Controlled Trial (the Functional Illness in Primary Care Study)

Toft

Rosendal

Ørnbøl

et al. 2010

Background: Patients with medically unexplained or functional somatic symptoms (FSS) are prevalent in primary care. In this pragmatic cluster-randomised controlled trial we aimed to test the effect of a training programme (The Extended Reattribution and Management model) for general practitioners (GPs) in the treatment of FSS. Methods: 38 participating GPs were randomised to the control group or the training group. The GPs included consecutive 18- to 65-year-old patients presenting during a 3-week period for new health complaints. We assessed a stratified subsample with the psychiatric interview Schedules of Clinical Assessment in Neuropsychiatry. Of 701 patients interviewed, 350 fulfilled the diagnostic criteria for any ICD-10 somatoform disorder (SD) and 111 presented FSS without fulfilling these criteria (sub-threshold SD). Patients completed questionnaires at baseline and after 3, 12 and 24 months. The questionnaires included assessment of health status (36-item Medical Outcomes Study Short Form; SF-36), health anxiety (Whiteley-7) and physical symptoms (Symptom Check List-90, somatization subscale). Results: Patients with SD consulting trained GPs improved more on our primary outcome of physical functioning than patients consulting control GPs at the 3-month follow-up (p = 0.004), but the improvement was not statistically significant at later follow-up. We found no significant differences in improvement between patients with SD and those with sub-threshold SD. Results for other SF-36 subscales, physical symptoms and health anxiety only showed statistically significant differences between the intervention and control groups for patients with SD; patients consulting trained GPs had less improvement in vitality, health anxiety and physical symptoms at 24 months compared with the control group. Conclusions: GP training may accelerate improvement in physical functioning for patients with SD. However, the effect is small and may not be clinically significant.

“…It has been widely accepted that functional somatic symptoms (FSS), that is, physical complaints not explained by underlying organic pathology, have a multifactorial etiology with numerous contributing factors of biological, psychological, and social origin [1,2,3,4]. Although psychosocial stress is widely regarded as an important etiological factor [1], it is largely unknown how increased levels of psychosocial stress contribute to the experience of FSS.…”

Section: Introductionmentioning

confidence: 99%

Age-Specific Associations between Cardiac Vagal Activity and Functional Somatic Symptoms: A Population-Based Study

Tak¹,

Janssens²,

Dietrich

et al. 2010

Background: Functional somatic symptoms (FSS) are symptoms not explained by underlying organic pathology. It has frequently been suggested that dysfunction of the autonomic nervous system (ANS) contributes to the development of FSS. We hypothesized that decreased cardiac vagal activity is cross-sectionally and prospectively associated with the number of FSS in the general population. Methods: This study was performed in a population-based cohort of 774 adults (45.1% male, mean age ± SD 53.5 ± 10.7 years). Participants completed the somatization section of the Composite International Diagnostic Interview surveying the presence of 43 FSS. ANS function was assessed by spectral analysis of heart rate variability in the high-frequency band (HRV-HF), reflecting cardiac vagal activity. Follow-up measurements of HRV-HF and FSS were performed approximately 2 years later. Results: Linear regression analyses, with adjustments for gender, age, body mass index, anxiety, depression, smoking, alcohol use, and frequency of exercise, revealed an interaction of cardiac vagal activity with age: HRV-HF was negatively associated with FSS in adults ≤52 years of age (β = –0.12, t = –2.37, p = 0.018), but positively with FSS in adults aged >52 years (β = 0.13, t = 2.51, p = 0.012). Longitudinal analysis demonstrated a similar pattern. Conclusions: Decreased cardiac vagal activity is associated with a higher number of FSS in adults aged ≤52 years in the general population. The unexpected association between increased cardiac vagal activity and FSS in adults aged >52 years needs further exploration. The role of age should be acknowledged in future studies on ANS function in the etiology of FSS.