Surgery and medical treatment in persistent somatizing patients
Abstract
This study describes the utilization of surgical operations, frequency and outcome of medical and surgical treatment in a group of persistent somatizers compared with a control group of nonsomatizers.
The study was carried out using the Danish national medical register to identify persons in the general population (age range 17–49 yr) with at least 10 general admissions during an 8-yr period. Persistent somatizers were defined as persons with more than six medically unexplained general hospital admissions in their lifetimes before 1985. Conversely, non-somatizers were patients whose admissions could mainly be ascribed to well-defined somatic disorders.
The findings show that persistent somatizers had been exposed to extensive surgery, outnumbering the non-somatizers. Surgical operations were of several categories, with gastrointestinal and gynaecological operations being the most frequent.
The physicians used medical and surgical treatment nearly as often for treating persistent somatizers as in the treatment of the non-somatizers. Surgical or medical treatment was used in nearly half of the medically unexplained admissions. The outcome of the surgical treatment of the persistent somatizers was, however, generally unsuccessful in that the effect was unsatisfactory in three quarters of cases. Similarly, two thirds of the medical treatments were judged to be unsuccessful in persistent somatizers.
The findings suggest that the costs of somatic diagnostic procedures and fruitless surgical and medical treatment attempts on persistent somatizers are enormous, and only exceeded by the risk of iatrogenic harm. This emphasizes the need for an early diagnosis of somatization and of treating it properly.
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Cited by (144)
Potentially traumatic events, social support and burden of persistent somatic symptoms: A longitudinal study
2022, Journal of Psychosomatic ResearchPsychological trauma is a well-known risk factor for the onset of persistent somatic symptoms (PSS). In contrast, little is known on the relation between potentially traumatic events (PTEs) and the severity of PSS, and on the protective effect of social support. We aimed to: (i) determine whether childhood, adulthood and recent PTEs are associated with burden of PSS over four years of follow-up; (ii) examine associations of multiple and cumulative (in childhood and adulthood) exposure to PTEs with burden of PSS; and (iii) determine whether social support modifies these associations.
Longitudinal data of 322 patients with PSS were analyzed. PTEs (Life Events Questionnaire) and social support (Social Support Scale) were assessed at baseline. Burden of PSS was measured in terms of symptom severity (PHQ-15) and physical functioning (RAND-36 PCS) at six repeated measurements over a four-year interval. Associations were analyzed using longitudinal mixed model analysis.
Patients with multiple childhood PTEs reported higher burden of PSS over four-year time. Adulthood PTEs were associated with burden of PSS in patients with, but not in patients without childhood PTEs. Recent PTEs were not associated with burden over time. Social support did not modify any of the associations.
PTEs are associated with higher burden of PSS over time, in addition to the well-known association with the onset of PSS. PTEs in early life and cumulative exposure to PTEs in childhood and adulthood are associated with higher burden over time in patients with PSS. Social support did not attenuate the associations.
Multiple physical symptoms and individual characteristics – A cross-sectional study of the general population
2020, Journal of Psychosomatic ResearchMultiple physical symptoms not attributable to known organic disease are common in all medical fields and associated with major personal and social consequences. This study investigated multiple physical symptoms according to the construct of bodily distress syndrome (BDS) and associated individual characteristics in the general adult population.
A nationwide, population-based study of 100,000 randomly selected individuals aged 20 years and older, conducted in 2012. A web-based questionnaire formed the basis of the study and was combined with Danish national registry data on socioeconomic factors and medication and healthcare use.
49,706 individuals completed the questionnaire. After exclusion of women indicating pregnancy, respondents reporting chronic disease and respondents over 65 years of age, 23,331 remained for analysis. Of these 23,331 individuals, 15.5% fulfilled the criteria for BDS. BDS positives were more often younger (20–40 years) and female. Self-rated health and self-reported functional capacity were impaired among these individuals. Fulfilling the BDS criteria was significantly associated with current or former smoking, overweight and obesity, low educational level and income, and unemployment. Moreover, individuals with BDS were more often from ethnic minorities and had higher use of healthcare and medication.
Multiple physical symptoms, as captured by the concept of BDS, are common in the general adult population, especially among younger women. Fulfilling the BDS criteria is associated with substantial negative impact on self-perceived health and socioeconomic parameters. Fulfilling BDS criteria is positively associated with health risk behaviors (smoking, overweight and obesity) and higher use of healthcare and medication.
Educational intervention to improve diagnostic accuracy regarding psychological morbidity in general practice
2019, Zeitschrift fur Evidenz, Fortbildung und Qualitat im GesundheitswesenIm Rahmen einer Pilotstudie wurde untersucht, inwiefern eine intensive, eintägige Schulungsmaßnahme zur Verbesserung der diagnostischen Kompetenzen von Hausärzt*innen zur Erkennung von Depression, Angst und Somatisierungsstörung beiträgt.
Cluster-randomisierte kontrollierte Pilotstudie mit jeweils 6 Praxen in der Interventions- und Kontrollgruppe. Zur Erfassung der psychischen Erkrankungen bearbeiteten die Patient*innen den Patient-Health-Questionnaire (PHQ-D). Nach Abschluss der Konsultation schätzten Hausärzte*innen auf einer numerischen Ratingskala von 0 (keine Ausprägung) bis 10 (höchste Ausprägung) ein, inwiefern bei Patienten/-innen eine psychische Erkrankung besteht – unabhängig vom Beratungsanlass.
364 Patient*innen nahmen teil. Arztrating und PHQ-Ergebnisse korrelierten in beiden Gruppen signifikant (p< 0,001) mit mäßiger Effektstärke (Spearman Korrelationskoeffizienten zwischen 0,27 und 0,42). Weder in der Korrelationsanalyse noch bei der diagnostischen Genauigkeit, ermittelt mit der area under the curve (AUC), gab es signifikante Unterschiede zwischen der Interventions- und Kontrollgruppe. Die diagnostische Genauigkeit der einzelnen Ärzte*innen war minimal 0,52 (95%KI 0,30-0,73) und maximal 0,84 (95%KI 0,67-1,00). Die diagnostische Genauigkeit zeigte hierbei eine signifikante Heterogenität (Cochran Q = 25,0; p< 0,01). In der Regressionsanalyse mit dem „Vorhandensein einer psychischen Erkrankung“ (gemäß PHQ) als abhängiger Variable war eine lange Arzt-Patient-Beziehung war negativ mit dem Vorhandensein einer psychischen Erkrankung assoziiert (OR 0,96; 95%KI 0,92-0,99; p = 0,01). Es zeigte sich eine signifikante Interaktion zwischen den Faktoren „Zeitliche Dauer der Arzt-Patient-Beziehung“ und „Ärztliches Rating“ (ß = 0,02; OR 1,02, 95%KI 1,01-1,03; p< 0,001), wobei mit längerdauernder Beziehung die diagnostische Treffsicherheit zunimmt.
Es konnte kein signifikanter Interventionseffekt detektiert werden. Die hausärztliche Einschätzung zeigt eine signifikante Korrelation mit der Selbsteinschätzung von Patient*innen bezüglich einer erhöhten psychischen Krankheitslast, wobei ärztlicherseits eine erhebliche inter-individuelle Variation besteht. Die diagnostische Einschätzung wird mit zunehmender Dauer der Arzt-Patient-Beziehung besser.
Eine einmalige Schulungsintervention scheint nicht ausreichend zu sein, die diagnostische Kompetenz bei psychischen Erkrankungen zu verbessern. Die erhebliche Variation der diagnostischen Treffsicherheit a priori könnte erklären, warum eine „one-size-fits-all“-Schulungsmaßnahme alleine keine Verbesserung der diagnostischen Kompetenzen ermöglicht.
The aim of this pilot study was to evaluate the effectiveness of a complex educational intervention to improve the diagnostic competencies of general practitioners (GPs) regarding the detection of depression, anxiety and somatization.
Cluster-randomized controlled pilot study with six practices each in the intervention group and in the control group. Psychological morbidity was determined by patient self-report using the Patient Health Questionnaire (PHQ-D). GPs rated the extent of psychological morbidity on a numerical rating scale from 0 (no co-morbidity) to 10 (maximum) of the individual patient after the consultation, independent of the reason for encounter.
364 patients participated. There were moderate correlations between GP rating and the PHQ scales (Spearman correlation between 0.27 and 0.42). There was no significant difference between intervention and control group. Diagnostic accuracy of the GPs, as determined with areas under the curves (AUCs), ranged between 0.52 (95%KI 0.30-0.73) and 0.84 (95%KI 0.67-1.00). The AUCs showed significant heterogeneity (Cochran Q = 25.0; p< 0.01). The regression analysis with 'presence of psychological disorder' (in PHQ) as the dependent variable showed that longer duration of doctor-patient-relationship was negatively associated with psychological morbidity (OR 0.96; 95%KI 0.92-0.99; p = 0.01). There was a significant interaction between the factors 'time of doctor-patient relationship' and 'GP rating' (ß = 0.02; OR 1.02, 95%KI 1.01-1.03; p< 0.001), pointing towards increasing diagnostic accuracy when patients are known for a longer time.
We found no significant effect regarding the educational intervention. The GPs’ estimation regarding psychological morbidity correlated significantly with the self-rating of the patients on PHQ scales. However, there was a considerable inter-individual variation between the GPs’ diagnostic accuracy. The diagnostic estimation improved with increasing duration of doctor-physician relationship.
A one-time educational intervention seems not to be sufficient to improve diagnostic competencies in the detection of psychological morbidity. The considerable variation of the diagnostic accuracy might explain why 'one-size-fits-all' educational interventions will not help improve diagnostic competencies.
Screening for functional neurological disorders by questionnaire
2019, Journal of Psychosomatic ResearchDiagnostic screening for functional neurological disorders (FNDs) continues to pose a challenge. Simple symptom counts fail clearly to discriminate patients with FND but there is increasing recognition of ‘positive’ features which are useful diagnostically during face-to-face assessments. A self-completed questionnaire evaluating specific features of FNDs would be useful for screening purposes in clinical and research settings.
The Edinburgh Neurosymptoms Questionnaire (ENS) is a 30-item survey of presence and nature of: blackouts, weakness, hemisensory syndrome, memory problems, tremor, pain, fatigue, globus, multiple medical problems, and operations constructed via literature review and expert consensus. We conducted a pilot of the ENS on new general neurology clinic attendees at a large regional neuroscience centre. Patients were grouped according to consultant neurologist impression as having symptoms that were ‘Not at all’, ’Somewhat’, ’Largely’ or ’Completely’ due to a functional disorder.
Blackouts, weakness and memory questions provided reasonable diagnostic utility (AUROC = 0.94, 0.71, 0.74 respectively) in single symptom analysis. All other symptoms lacked discriminating features. A multivariate linear model with all symptoms predicted functional classification with moderate diagnostic utility (AUROC = 0.83), specificity of 0.97, sensitivity of 0.47. Pain and blackout scores provided the most accurate predictor of functional classification.
The ENS questionnaire provides some utility in differentiating patients presenting with functional blackouts but failed to provide diagnostic value in other types of FND, highlighting the limitations of this self-report tool.
High healthcare utilization near the onset of medically unexplained symptoms
2017, Journal of Psychosomatic ResearchPatients with medically unexplained syndromes (MUS) often do not receive appropriate healthcare. A critical time for effective healthcare is the inception of MUS. The current study examined data from a prospective longitudinal study of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) soldiers to understand the relationship of increasing physical symptom burden to healthcare utilization.
Data was examined from a prospective study of OEF/OIF soldiers assessed before and one year after deployment (n = 336). Physical symptom burden was measured with the Patient Health Questionnaire (PHQ-15). Analyses were conducted with polynomial regression and response surface analysis (RSA).
Increases in physical symptom burden predicted greater healthcare utilization one year after deployment: primary care practitioner (slope = − 0.26, F = 4.07, p = 0.04), specialist (slope = − 0.43, F = 8.67, p = 0.003), allied health therapy (e.g., physical therapy) (slope = − 0.41, F = 5.71, p = 0.02) and mental health (slope = − 0.32, F = 4.04, p = 0.05). There were no significant difference in utilization between those with consistently high levels and those with increases in physical symptom burden.
This is the first prospective study to examine, and show, a relationship between onset of clinically significant physical symptoms and greater healthcare utilization. Our data suggest that patients with increasing physical symptom burden have the same level of healthcare as patients with chronic physical symptom burden. Needed next steps are to better understand the quality of care at inception and determine how to intervene so that recommended approaches to care are provided from the onset.
Syndromes of bodily distress or functional somatic syndromes - Where are we heading. Lecture on the occasion of receiving the Alison Creed award 2017
2017, Journal of Psychosomatic Research