m102 nhg guideline on medically unexplained symptoms (mus)

NH G-S ta nda a r d

M102 NHG GUIDELINE ON MEDICALLY UNEXPLAINED SYMPTOMS (MUS)

This guideline should be quoted as:

Olde Hartman TC, Blankenstein AH, Molenaar AO, Bentz van den Berg D, Van der Horst HE, Arnold IA, Burgers JS, Wiersma Tj, Woutersen-Koch H. NHG Guideline on Medically Unexplained Symptoms (MUS). Huisarts Wet 2013;56(5):222-30.

NHG GUIDELINE ON MEDICALLY UNEXPLAINED SYMPTOMS (MUS) Tim Olde Hartman, Nettie Blankenstein, Bart Molenaar, David Bentz van den Berg, Henriëtte van der Horst, Ingrid Arnold, Jako Burgers, Tjerk Wiersma, Hèlen Woutersen-Koch

NH G g u id el ine

Key messages •• Medically

unexplained

symptoms

(MUS) are defined as physical symptoms persisting for more than several weeks and for which adequate medical examination has not revealed a condition that adequately explains the symptoms.

•• Estimating the severity of MUS is

M102

based on exploration of five symptom dimensions, namely the somatic, cognitive, emotional, behavioural and social dimensions.

•• A good doctor-patient relationship and communication are essential for the treatment of MUS. •• Management is focused on providing

information and advice with a view to increasing activities in a time-contingent manner.

Experiencing physical symptoms is a

dations for cases in which no specific

of the general population report in

does provide treatment recommensomatic condition is found, the symptoms do not disappear or are associated

with functional limitations, and the

patient continues to contact the gen-

eral practitioner for these symptoms.

The guideline does not discuss the management of specific somatoform disorders. For diagnostic and therapeutic recommendations for patients with hypochondriasis, we refer to the NHG Guideline on anxiety.

Patient contribution The NHG Guidelines provide guidance for treatment by the GP; therefore, the GP

Introduction

factors always influence treatment. For

The NHG Guideline on MUS provides

phasized repeatedly in this guideline, but

and treatment of adult patients with medically

unexplained

symptoms

Background

cover a specific symptom or illness, but

holds a central position. However, patient

recommendations for the diagnosis

practical reasons, this aspect is not emis mentioned explicitly at this point. Wherever possible, the GP creates a treatment plan in consultation with the

part of normal life; approximately 90%

surveys that they have experienced at least 1 physical symptom in the past 2 weeks. Whether or not people visit their

doctor for physical symptoms appears to be more strongly correlated to the significance of the symptom to them personally and their ideas concerning

these symptoms, rather than the severity of their symptoms. In several nonWestern cultures, expressing physical

symptoms is the most common method of indicating distress.2

Almost all types of symptoms that

patients present to their GPs could – either quickly, or over time and after further analysis – turn out to be symptoms that cannot be (adequately) explained

by a specific medical condition. Even

if symptoms or combinations of symp-

toms initially appear to be strongly indicative of a specific condition (for

example, the combination of diarrhoea,

(MUS). MUS is defined as physical symp-

patient, taking the patient’s specific situ-

several weeks and for which adequate

the patient’s own responsibilities, with

any condition that sufficiently explains

prerequisite for success.

that the patient does not have this

GP’s considerations

such as fatigue, stomach pain, back

toms that have existed for more than

ation into account and acknowledging

medical examination has not revealed

adequate information provision being a

the symptoms.

MUS is a working hypothesis based

on the (justified) assumption that somatic/psychological

pathology

has

been adequately ruled out. Any change

in symptoms could be a reason to revise the working hypothesis.

After formulating the working hy-

pothesis, the general practitioner will estimate the severity of the MUS. This

The GP’s personal insight is a key aspect in all guidelines. Weighing relevant factors in specific situations can justify reasoned deviations from the treatment policy described below. Nonetheless, this guideline is meant to serve as a standard and aid. Delegating tasks

guideline distinguishes between mild,

NHG Guidelines are written for GPs. This

of the MUS guides the treatment.

tasks personally. Certain tasks may be

moderate and severe MUS. The severity This guideline is based on the mul-

tidisciplinary guideline on medically

unexplained symptoms and somatoform disorders1 and follows as closely as possible other NHG Guidelines on symptoms and conditions that could

include MUS (see ‘Diagnostic RecomOlde Hartman TC, Blankenstein AH, Molenaar AO, Bentz van den Berg D, Van der Horst HE, Arnold IA, Burgers JS, Wiersma Tj, WoutersenKoch H. NHG Guideline on Medically Unexplained Symptoms (MUS). Huisarts Wet 2013;56(5):222-30

2

mendations’). The guideline does not

huisarts & wetenschap

does not mean the GP must perform all delegated to the doctor's assistant, practice support staff or practice nurse, as long as they are provided with support in the form of clear working agreements, defining the conditions under which the GP must be consulted, and as long as the GP retains quality control. As the decision on whether or not to delegate is strongly dependent on the local situations, the guidelines do not contain any concrete recommendations in this area.

trembling, weight loss and hot flushes

is suggestive of hyperthyroidism), ad-

equate examination will often reveal

disease. In case of common symptoms, pain, dizziness and nausea, the general practitioner will often not find a disease that can explain those symptoms.3 Terminology

Many terms are used to describe this large group of physical symptoms for which doctors cannot find a satisfactory explanation. Historically, symptoms that regularly cluster together were

frequently grouped into syndromes,

such as irritable bowel syndrome (IBS), fibromyalgia and chronic fatigue syndrome. However, many of the existing

syndromes show significant overlap in their symptoms, and virtually every

specialism has its own syndrome. 4 This

raises the question whether the clustering of MUS into distinct syndromes

are an artefact of medical specialisation and whether these symptoms are

in fact different syndromes or just one.5 Furthermore, one could also group

5 6 (5) m ay 2 0 1 3

NH G g u id el ine

these symptoms into clusters based on

mon and have a prevalence of 2.5%.8

mild forms of MUS. In patients with se-

pulmonary, musculoskeletal and gen-

grant patients visit their general prac-

sion or anxiety disorder is over three

If the MUS are not grouped into

non-immigrant patients. However, this

localization: gastro-intestinal, cardioeral non-specific.6

syndromes or clusters, there are also

various terms to describe the separate physical symptoms, such as physically unexplained

symptoms,

functional

symptoms, psychosomatic symptoms or somatoform symptoms.

For this guideline, we decided to

adhere to the terminology in the multidisciplinary guideline and to use the

term medically unexplained symptoms

Doctors often indicate that immi-

titioner more often due to MUS than

has only been confirmed for refugees. Various causes are listed for this, such as a history of violence experiences, a

tients suffer from both depression and anxiety disorder.10 Pathophysiology

body and mind, and the attention, ad-

origin of MUS. Over the years, various

There is no clear explanation for the

vantages and (legal, social and/or soci-

explanatory models have been drawn

etal) recognition that can be obtained with physical symptoms.9

which adequate medical examination

There is no firm association with anxi-

sist for more than several weeks and for

depression

has not revealed a medical condition

ety disorders and/or depression for the

This description is not very specific

MUS. More than a quarter of these pa-

often no distinction is made between

Combination with anxiety disorders and/or

toms.

times higher than in patients without

different perception of disease in which

(MUS) for physical symptoms that per-

that adequately explains the symp-

vere forms of MUS, the risk of a depres-

up to explain the origin and persistence of MUS. These models are usually theoretical in nature and only based on

empirical research to a limited extent.11 Every society has its own explana-

tory models. Non-Western cultures of-

ten do not distinguish between body

Abstract

as far as the duration of the symptoms

Olde Hartman TC, Blankenstein AH, Molenaar AO, Bentz van den Berg D, Van der Horst HE, Arnold IA, Bur-

ration varies per type of symptoms, and

2013;56(5):222-30.

tion to the general practitioner can

ment of adult patients with medically unexplained symptoms (MUS). It is based on the Dutch multidis-

For some patients with physical

produced by the College on MUS-related symptoms and disorders. The guideline is not about a specific

be identified, but if the symptoms

lead to functional impairment, even though investigations have not identified a specific underlying

limit functioning to a greater extent

MUS is a working diagnosis based on the assumption that somatic/psychiatric pathology has been ad-

in question, they too are referred to as

ing the diagnosis, the general practitioner (GP) must estimate the severity of MUS, as further manage-

MUS can be divided into mild MUS,

MUS. Treatment is tailored to the individual patient. The main objectives of treatment are to define the

pending on the duration of the symp-

and discomfort, despite the presence of symptoms; and to improve the patient’s functioning in somatic,

impact of the symptoms on daily life.

Treatment proceeds in a stepwise fashion (stepped care), starting with the lightest possible effective

out clearly defined cut-off points.7

to other primary care professionals (e.g., physiotherapist, psychologist), and in step 3 treatment is pro-

Epidemiological data

intensified. If a patient presents with moderate or severe MUS, the GP can consider starting more inten-

Occurrence of MUS

sive treatment (step 2 or even 3 if necessary) simultaneously with step 1.

is concerned, as the average episode du-

gers JS, Wiersma Tj, Woutersen-Koch H. The NHG guideline medically unexplained symptoms (MUS). Huisarts Wet

also because the moment of presenta-

This guideline of the Dutch College of General Practitioners (NHG) concerns the diagnosis and manage-

vary significantly.

ciplinary guideline on MUS and somatoform disorders, and where possible refers to other guidelines

symptoms a somatic condition can

symptom or disease, but provides tools on how to manage patients whose symptoms are persistent and

are more severe or more persistent or

medical condition. These patients continue to seek medical care.

than expected based on the condition

equately excluded. If symptoms change, the working diagnosis may need to be revised. After establish-

MUS.

ment depends on symptom severity. This guideline distinguishes between mild, moderate, and severe

moderate MUS and severe MUS de-

problem in a way that is acceptable to both the patient and the doctor; to reduce unnecessary anxiety

toms, the number of symptoms and the

cognitive, emotional, behavioural, and social dimensions.

This is a sliding scale of severity with-

treatment. In step 1, the GP treats the patient, in step 2 the GP works together with or refers the patient

There is no ICPC code for MUS. Therefore, derived codes – for example

vided by multidisciplinary teams or treatment centres. If results are unsatisfactory, then treatment is

Main messages

symptom coding – must be used when

•• MUS is defined as physical symptoms that last for longer than a few weeks and which cannot be

Up to 40% of the consultations

•• Assessment of MUS severity is based on five dimensions of symptoms, i.e. the somatic, cognitive,

studying the occurrence of MUS.

in general practice concern physical symptoms for which no (adequate)

somatic condition can be found. Persistent, severe MUS are much less com5 6 (5) m ay 2 0 1 3

satisfactorily explained after adequate medical examination. emotional, behavioural, and social dimensions.

•• Good doctor–patient relationship and communication are essential for the management of MUS.

•• Management is focused on providing information and advice with a view to increasing activities in a time-contingent manner.

huisarts & wetenschap

3

NH G g u id el ine

and mind. People often look for exter-

anxious, whilst the doctor begins to feel

be wary of this if alarming symptoms

problems. Cultural differences and oth-

come to a shared understanding of the

occur.18 Focus on the somatic dimen-

nal causes of – and solutions to – their er differences affect the applicability of some explanatory models.12

In 50 to 75% of people diagnosed with

MUS by the general practitioner, the will

decrease

over

the

course of 12 to 15 months. However, in 10 to 30%, the symptoms will increase

over time. The number of symptoms,

duration and severity at presentation to the general practitioner are factors associated with a less favourable course

of MUS in patients in primary care.13

A positive perception of the doctorpatient relationship (by patient and/or

doctor) has a favourable effect on the

tient. Doctors also experience (diagnosthey should not show their uncertainty to patients with MUS. The doctor-pa-

tient relationship is strengthened by taking the patient and his or her symptoms seriously and by showing empa-

living

conditions,

work-related problems, stress, trauma,

be categorised into predisposing, exacerbating and maintaining factors.

Predisposing factors are mainly susceptibility/nature and possibly also poor

health literacy.16 Exacerbating factors vary

quently and in increased consultation rates.14

to the MUS patient’s ‘culture’ in the

of whether this culture concerns the patient’s ethnicity, age, gender or socioeconomic status.

A number of specific points of at-

patients. Firstly, the immigrant life in

language problems and cultural differences – particularly for non-Western

immigrants – can place significant demands on the communication skills of the general practitioner.

toms in some people with IBS, but the

tioner becomes able to formulate the

nificant life event. Maintaining factors are often behavioural factors that can

inhibit recovery, for example, reduced exercise can result in maintenance of

low back pain, and continuously seeking help can maintain symptoms of anxiety. This causes vicious circles. Doctor-patient relationship

situation in which the general practiworking hypothesis ‘MUS’. In other

words, the guideline assumes that somatic/psychological

pathology

has been reasonably ruled out in preceding consultations. The general practitioner can use the NHG Guidelines

that provide diagnostic recommendations for symptoms that often do not

have a somatic cause [table 1].17 MUS

always remains a working hypothesis,

patients with MUS. The patient often

become clear over time that the symp-

feels that he/she is not being taken se-

riously, not understood and remains huisarts & wetenschap

or her MUS, identifying prognostically inhibit recovery) and estimating the

severity of the MUS. Allowing the patient to speak for a few minutes without interruption can help to broaden

the exploration of symptoms. This method can reveal relevant starting

points (clues) for the treatment. They

could consist of words used by the pa-

tient, but also of non-verbal behaviour

(body language) that is noted during the consultation.19 Explicitly asking

the patient whether he or she has any specific questions also forms part of the complete exploration of symptoms.

The acronym SCEBS can assist the

general practitioner in determining been explored. SCEBS stands for the

somatic, cognitive, emotional, behavioural and social dimensions.

These dimensions originate from

the biopsychosocial model.11

that

could be responsible for the symptoms

The doctor-patient relationship is often

pressurised during consultations with

understanding of the patient and his

whether all symptom dimensions have

Diagnostic guidelines Starting point of the guideline is the

symptoms can also be induced by a sig-

the symptoms aimed at getting a fuller favourable or unfavourable factors (that

Diversity

in nature: a severe gastro-intestinal

infection appears to precede the symp-

in the exploration of symptoms.

should start additional exploration of

in symptoms being reported more fre-

itself can be a stress factor. In addition,

Factors that play a role in MUS can

somatic dimension has been included

esis of MUS, the general practitioner

symptoms; on their own these factors are not a good predictor of MUS.

the symptoms change. Therefore, the

poor doctor-patient relationship results

tention can be listed for immigrant

15

for patients with MUS. Particularly if

After forming the working hypoth-

sexual abuse) appear to play a causal

role in both explained and unexplained

al investigations remains important

proved health outcomes. By contrast, a

broadest sense of the word, regardless

difficult

physical re-examination and addition-

Exploration of symptoms

Factors that affect occurrence and persis-

events,

sion of the symptoms and considering

results in patient satisfaction and im-

The care provider should also be open

Psychosocial stressors (negative life

or changes in the pattern of symptoms

thy. A good doctor-patient relationship

prognosis of MUS.14 tence

4

symptoms and problems with the patic) uncertainty, and (unjustly) feel that

Natural course and prognosis

symptoms

powerless and irritated and is unable to

as in a limited number of cases it could

toms were in fact caused by somatic pathology. It is particularly important to

Table 1 Guidelines about symptoms that often cannot be adequately explained in a somatic context NHG Guideline on irritable bowel syndrome (M71) NHG Guideline on dyspepsia (M36) NHG Guideline on non-specific low back pain (M54) NHG Guideline on headache (M19) NHG Guideline on sleep problems (M23) NHG Guideline on dizziness (M75)

5 6 (5) m ay 2 0 1 3

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Somatic dimension Check the following aspects of the symptom(s):

•• symptom cluster (gastro-intestinal,

symptoms? Some patients become de-

The general practitioner can adjust the

ate, despondent or rebellious.

ences between a collectivistic culture

symptoms, whilst others feel desper-

cardio-pulmonary, musculoskeletal,

•• Is the patient very anxious about the

headache, dizziness, concentration/

worried about? What is the reason for

general

non-specific

(i.e.

fatigue,

memory problems));

•• nature, location, duration, severity and pattern of the symptoms;

•• accompanying symptoms;

•• use of medication (including non-pre-

scription treatment and potentially addictive drugs such as benzodiazepines and analgesics.

Focussing on the somatic aspects of the

symptom demonstrates to the patient

that his or her symptoms and their bur-

at work?

pressed or anxious as a result of the

symptoms? What exactly is he/she these concerns?

Symptoms and the thoughts and concerns about the symptoms can be associated with anxiety, fear or a depressive

mood. The general practitioner can use a questionnaire as a tool to create room to discuss distress (‘being unable to

cope’), anxiety and feelings of depression.20

Behavioural dimension

order of questions to account for differand the Western individualistic culture for patients with a different cultural background: first ask about social reactions and consequences, then ask

about the patient’s own ideas, concerns

and emotions.21 The use of a professional interpreter – via the telephone if

necessary – is recommended. Wherever

possible, avoid asking a child or another family member to act as an interpreter,

in order to increase the chances of uncovering psychosocial problems. Visit

www.huisarts-migrant.nl for more information about caring for immigrant patients with MUS.

den are recognised and taken seriously.

Ask about the behavioural consequences

Cognitive dimension

•• avoiding weight bearing or move-

Based on the exploration of symptoms,

•• sick leave;

whether any additional psychological

Ask about:

•• the patient’s ideas about the origin and persistence of his/her symptoms (frame of reference);

•• what the patient thinks he/she can do to influence these aspects;

•• why the patient thinks that he/she

of the symptom(s):

ment, or other avoidance behaviour;

•• ignoring the symptom and carrying on, which causes overburdening;

•• other behaviour that could inhibit the recovery.

cannot or can no longer perform cer-

Also focus on the help-seeking behav-

•• the patient’s expectations concern-

•• Does the patient seek medical as-

tain activities or jobs;

ing the contribution by the general

practitioner or other care providers in managing the symptoms.

Exploration of these aspects often allows the general practitioner to identify certain patient perspectives that

could prevent recovery: catastrophising

thoughts (“I’ll never get back to work

iour:

sistance quickly or does he/she try to solve the problems by him/herself for a long period?

•• Does he/she visit different doctors/ care providers for the same problem?

•• What did the patient do in order to re-

solve the symptoms, which measures has he/she taken?

with these back issues” or “my brother/

Also look at non-verbal behaviour dur-

disease attributions (“such severe pain

patient with back pain who does not sit

neighbour never got over this either”),

ing the consultation (for example, a

Additional psychological disorders the general practitioner will determine disorders are suspected. This particularly includes psychological disorders

that affect the physical symptoms, such as depression and anxiety disorders (see the relevant NHG Guidelines).10

If there is concern about the pres-

ence of a psychiatric condition (such as a somatisation disorder), the pa-

tient can be referred to a psychiatrist for diagnosis. The general practitioner can also ask a psychiatrist for advice at

this stage, potentially in the form of a joint consultation with the patient, the

general practitioner and the psychiatrist. Preferably, the general practitio-

ner should refer to a psychiatrist who works together with other therapists

with experience in treating patients with MUS.

upright in the chair).

Physical examination, additional inves-

dealing with the symptoms (“I must

Social dimension

Physical examination is indicated if the

completely healed”).

the symptom(s):

must mean that my neck has been damaged in some way”), or ideas about

not bear weight on my leg until it is Emotional dimension

Ask about the social consequences of •• What are the consequences of the symptoms on those around him/her?

Ask about the emotional consequences

•• How do they respond: (overly) con-

•• What feelings and emotions does the

•• What effect do the symptoms have on

of the symptom(s):

patient experience as a result of the

5 6 (5) m ay 2 0 1 3

cerned, negative or supportive?

the patient’s functioning at home and

tigations and diagnostic referral exploration of symptoms reveals that

the symptoms have changed in nature and when alarming symptoms occur.

Additional investigations or diagnostic referral to a specialist can also be considered for the same reasons. For the most common symptoms, indications

for referral can be found in the previhuisarts & wetenschap

5

NH G g u id el ine

ously mentioned NHG Guidelines.

unfavourable factors.13 Furthermore,

present before the depression or anxi-

doubt the working hypothesis of MUS

tations (for example: not being able to

•• both are of a severity that requires

If the general practitioner starts to

due to an altered pattern of symptoms,

and in order to rule out somatic pathology again, it is important that he/

she explains thoroughly to the patient

why additional investigations are be-

work, loss of social activities, inability

to perform family duties) is also prog-

separate treatment.

Therapeutic recommendations

MUS.

24

Treatment of patients with MUS re-

Evaluation of the severity

usually serves to further reduce the

tion of the prognostic factors, the gen-

diagnostic referral to a specialist. This

Based on the outcome of the explora-

small chance of pathology. Laboratory

eral practitioner can determine the

of disease have a relatively high risk of

ety disorder started;

nostically unfavourable for a number of

ing performed. The same applies to a

tests performed with a low prior chance

approximate location of this patient on

the severity scale from mild via moder-

quires an individual approach. The

most important goals of the therapeutic recommendations are:

•• finding a definition of the problem

that is acceptable for both the patient and the general practitioner;

ate to severe MUS, as explained in the

•• reducing unnecessary concern and

while there is no indication for this,

Mild MUS:

•• improving the functioning of the pa-

that he/she does not think additional

•• one or several MUS within one or two

false positive test results.22

If the patient specifically asks for

additional investigations or referral the general practitioner will explain

investigations are necessary and does not expect them to provide any new

findings. However, he can follow the

patient’s request in order to try to reassure the patient. It is important in that

case to explain to the patient in ad-

introduction.

•• slight functional limitations; and

symptom clusters (gastro-intestinal, cardio-pulmonary, musculoskeletal, general

non-specific

(i.e.

fatigue,

headache, dizziness, concentration/ memory problems)). Moderate MUS:

in that case.23 When referring a patient

•• several MUS in at least three symp-

to a medical specialist at the request of the patient, it is important to formulate

a clear question in the referral letter – ideally drafted by the patient and the

general practitioner together – with

•• moderate functional limitations; and tom clusters; and/or

•• duration of symptoms longer than expected, depending on the normal course of the relevant symptom.

the request that the patient be referred

Severe MUS:

abnormalities are found. This in order

•• MUS in all symptom clusters; and/or

back to the general practitioner if no to prevent the patient being passed from one specialist to the next.

•• severe functional limitations; and

•• duration of symptoms longer than three months.

Evaluation

Comorbid depression and/or anxiety disorder

Based on the exploration of the symp-

Although physical symptoms accom-

al psychological problems, the general

order can often be explained as part

toms and the presence of any additionpractitioner will evaluate the severity

of the MUS, taking into consideration the prognostic factors. Prognostic factors A short duration of the symptoms, few different symptoms and few functional limitations are seen as prognostically

favourable. Long persistence of symptoms and presentation of many different symptoms are prognostically huisarts & wetenschap

panying depression or an anxiety disof the psychiatric diagnosis, they are

sometimes caused by two co-existing conditions.

Making a dual diagnosis of MUS in

combination with a depression or anxiety disorder can be useful if:

•• the physical symptoms are more pronounced than would be consistent

with depression or an anxiety disorder;

functional limitations, despite the presence of symptoms;

vance what a negative test result would mean and what the next steps would be

6

experiencing several functional limi-

•• the physical symptom was already

tient in the somatic, cognitive, emotional, behavioural and social dimensions.

The treatment is a so-called ‘stepped care’ process, in which the general practitioner starts with the mildest

possible effective treatment [table 2].

If this step does not provide adequate results, the treatment is intensified

in step 2.26 In the event of moderate or

severe MUS at first presentation, the general practitioner can consider combining step 1 with immediate initiation of more intensive treatment (step 2 or possibly step 3). Consider the patient’s ethnical-cultural background in all steps.21 STEP 1 Step 1 includes a number of activities that the general practitioner can

spread over several consultations: (1)

using the exploration of symptoms to identify and discuss the factors that could inhibit recovery, (2) education

and advice (also with regard to drug

treatment), (3) Formulation of a shared

time-contingent plan and (4) followup appointments during which the general practitioner will monitor the

plan and patient’s functioning. A new exploration of symptoms is performed

if the recovery stagnates. As MUS always remains a working hypothesis,

the general practitioner will perform a

new exploration of symptoms, targeted 5 6 (5) m ay 2 0 1 3

NH G g u id el ine

Table 2 Overview of the step-by-step plan Step

Recommendation

Step 1 Patient with mild MUS By general practitioner

Conclude exploration of symptoms and potentially perform a physical examination and/or additional investigations. Shared definition of problem, based on exploration of symptoms. Education and advice: ▪ education and explanation; ▪ discussion of factors that inhibit recovery; ▪ advice. Formulation of a shared time-contingent plan. Follow-up: ▪ monitor progress of plan and repeat exploration of symptoms if recovery stagnates; ▪ if the symptoms change, repeat exploration of symptoms and perform a targeted physical examination and additional investigations if necessary.

Step 2 Patient with moderate MUS In collaboration with other primary care providers

Collaboration with/referral to: ▪ (psychosomatic) physiotherapist or exercise therapist; ▪ mental health nurse practitioner or social psychiatric nurse in primary care; ▪ primary care psychologist trained in cognitive behavioural therapy.

Step 3 Patient with severe MUS In collaboration with secondary care providers

Collaboration with/referral to: ▪ multidisciplinary teams/treatment centres.

physical examination and additional investigations if changes in the symptoms make this necessary.

Step 1 usually involves patients with

symptoms and the fact that the patient is troubled by them.

nothing” or “we cannot find anything”, but

Education and explanation

eral symptoms in 1 or 2 symptom clusters

and tangible information that links

(gastro-intestinal,

cardio-pulmonary,

musculoskeletal, general non-specific

(i.e.: fatigue, headache, dizziness, concentration/memory problems)).

•• Conclude the exploration of symptoms and

Next, provide the patient with targeted

up with the information that the general practitioner obtained during the

diagnostic exploration of the somatic, cognitive, emotional, behavioural and social dimensions of the symptoms. Avoid

repeatedly

reassurance

of

any physical examination and/or additional

anxious patients with general state-

As part of the education process, the

tient’s anxiety is treated seriously and

investigations

general practitioner will summarise the findings of the symptom explora-

tion (SCEBS), the physical examination

and any additional diagnostic tests. It is important to discuss clearly what was found and mention explicitly what

ments. It is very important that the pain a sensitive manner. Patients who notice that the doctor listens to and rec-

problem together with the patient, for

example “your back pain started after

your move, your spine has recovered, but the pain has stayed, and prevent

you from performing a number of activities that you would now like to start again”. It is important to recognise the 5 6 (5) m ay 2 0 1 3

ic fear of a certain condition (for example, cancer) it is important to explain

what they do not have (“you do not have

lung cancer, which is what you were so afraid of”). People with limited health skills16 (among immigrants and people with low literacy skills, for instance)

have little knowledge about the normal

functioning of the human body. An explanation can help in this case.29

When providing specific and tan-

models that provide recommendations

It is preferable to list the symptom(s)

patient could interpret as a disease.

Try to come to a shared definition of the

contrast, for patients who have a specif-

more readily reassured.27

are being taken more seriously and are

tions or anxieties that have previously •• Shared definition of the problem

can make all normal movements”.28 In

gible information, the general practi-

as far as possible in descriptive terms

been expressed by the patient.

rather say “your back is straight and

ognises their problems feel that they

was not found. If possible, the general

practitioner should include expecta-

positive terms wherever possible. Do not say “we did not find anything”, “it’s

Education and advice

MUS who experience mild functional

limitations and who suffer from 1 or sev-

the general practitioner should use

and to avoid explanations that the General practitioners tend to reassure

patients by telling them which severe

conditions have not been found. If a patient is not specifically worried about

tioner can use the various explanatory for the treatment of MUS.11 Link this in with the words, images and key points that were noted during the exploratory

phase. Ensure that you select a model that fits both the general practitioner and this patient, and find and use your own words when using the model.

In addition to the oral informa-

a certain condition, such an explana-

tion provided, the general practitioner

cause additional anxiety. As negative

about MUS on the NHG public website

tion (“you do not have lung cancer”) can

explanations or normalisation have the disadvantage of making the patient feel

that he/she is not being taken seriously or making the patient more anxious,

can refer the patient to information www.thuisarts.nl or give the patient

the relevant text (previously called the

NHG patient letter) to take home (via

the HIS or the NHG ConsultWijzer [consulhuisarts & wetenschap

7

NH G g u id el ine

tation tool]). This patient information is based on the NHG Guideline.

Discussing factors that inhibit recovery

Discuss the factors that can inhibit re-

covery that were observed during the exploration of symptoms in the various SCEBS dimensions, and provide concrete advice based on these factors.

Treatment with medication

always present with long-term MUS.31

ers advising pain management with

tivities or being too active, are virtually

If the general practitioner consid-

The

over-the-counter

general

practitioner

explains

what the effect of this behaviour is on

the MUS, explores which behavioural changes the patient is motivated to

make, and provides targeted and tangible advice.

Somatic factors, such as a comorbid so-

Social factors, such as the situation in

result in persistence of MUS. If present,

a large portion of the burden of the

matic condition or a sleep disorder, can the general practitioner will optimise the treatment of these factors.

Cognitive factors, such as patients’ negative thoughts and ideas about the symptoms,

can

influence

recovery

negatively. The general practitioner discusses the negative effects of catastrophising beliefs such as “it will never get any better” and asks the patient

to consider alternatives such as replacing the negative thoughts with realistic neutral or positive thoughts like “I

do have pain, but I am still able to do my job”. Challenging and adjusting such

negative thoughts has a positive effect on recovery.30

Emotional factors, such as worry, fear of

disease, fear of movement and hope-

the family or at work, often determine symptoms. Discuss the effects of the patient’s context: support from his/her

context can have a positive effect on

the course, and incorrect thoughts/as-

gible information and advice. If the patient is worried or afraid of disease,

the general practitioner will explore what the patient is worried about and

in what way he/she can be reassured.

With fear of movement, the conviction that pain is a signal of a (serious) condi-

tion often plays a role. In that case, the

general practitioner will explain that pain usually does not indicate danger or a severe condition and that this is true for the patient in this case too.

For patients suffering from feelings of

depression or hopelessness, the general

practitioner can use the NHG Guideline on depression.

huisarts & wetenschap

contra-indications), an NSAID (see the Farmacotherapeutische richtlijn Pijnbestrijding [Pharmacotherapeutic

guideline

on

pain management] and the symptomspecific NHG Guidelines). It is preferable

to reduce the pain medication gradually after the acute stage, in order to

prevent chronic use of pain medication and medication dependency.

questions about the work situation, for

Instruct the patient to return in the

health risks in the work place (work

•• if there is a strong increase in the

contingent plan

example, about sick leave and possible

following cases:

pressure as a factor causing MUS to

persist, or attribution of symptoms to work-related factors, for example toxic

substances or electromagnetic radia-

tion), the general practitioner can refer the patient to an occupational health

dysfunction or persistence of severe symptoms: after one week;

•• if the dysfunction has not improved or is no longer improving: after two to four weeks.

physician. The general practitioner

At a follow-up consultation, always

can return to work and resume his/her

evant parts of the exploration of symp-

discusses ways in which the patient daily activities.

sage is that the prognosis is good, that

formation to provide targeted and tan-

a second option (and in the absence of

Follow-up and formulation of a shared time-

has made an inventory of these emoThe general practitioner uses this in-

medication,

analgesia with acetaminophen or, as

form an inhibiting factor. If there are

Advice

tional factors in the diagnostic phase.

pain

the working group advises short-term

sumptions by his/her surroundings can

lessness, can make the original symp-

toms worse. The general practitioner

8

Behavioural factors, such as avoiding ac-

When providing advice, the key mesthe symptoms can vary over the course

of time13 and that it is not harmful to exercise or perform activities. Experi-

encing pain or fatigue does not mean

evaluate the previously confirmed rel-

toms and any physical examination and/or additional investigations. Check why the patient’s functioning has not

improved and the symptoms have not disappeared. Always use an inventory of

the functioning according to the various dimensions (SCEBS) when doing so.

During this follow-up consultation,

that there is a disease or that damage

formulate a shared plan with goals and

ally goes away without intervention.

consists of a gradual (time-based) in-

has occurred: it is common and usuThe recovery will be faster if the patient gradually expands his/her activities.

Advise the patient to remain active and

continue with his/her daily activities

– including (paid) work – as far as pos-

a time schedule. This approach, which crease of, is preferable over a symptom-

based approach (movement ‘if the pain

allows’ or becoming active ‘if the fatigue has disappeared’) [table 3].32

Preferably the road to recovery is

sible. Give practical advice about this. If

made tangible and illustrated with

performs too many activities and does

match the limitations experienced by

the patient avoids certain activities or not relax enough, this can inhibit normal recovery.32

tips; the advice or exercise given should the patient in his/her daily life. The

general practitioner and the patient

should agree on the time schedule for all steps in the treatment plan.

5 6 (5) m ay 2 0 1 3

NH G g u id el ine

Table 3 Concrete examples of time-based (desirable) and symptom-based (undesirable) advice

Activity

Desirable: time-based

Undesirable: symptom-based

Keep moving and expand activities back to normal in x days.

Try to move if the pain/fatigue permits.

Work/daily activities Go back to work (half days if necessary) after 1 week. Follow-up

Go back to work as soon as the pain/fatigue allows or has disappeared.

Return after x weeks, unless you are functioning normally again.

STEP 2 The intensification of the treatment in step 2 consists of continuation of the treatment in accordance with step 1,

and of collaboration with and referral to other primary care providers. The

Come back if you are not coping.

if the decision is made to refer. Being

referral to secondary care providers and

(SCEBS) and being able to build a safe,

centres. This involves patients with

able to explore all symptom dimensions supportive and open relationship with the patient are required competencies.

In the primary care setting, the gen-

general practitioner implements step 2

eral practitioner can also collaborate

usually involves patients with MUS

or exercise therapist, mental health

if step 1 yields inadequate results. This who experience moderate functional limitations (including, for example,

sick leave for more than 4 to 6 weeks) and who have several MUS in multiple

symptom clusters or a symptom duration longer than expected (depending on the nature and the normal course of the symptom). Follow-up Make regular follow-up appointments if the functional limitations persist,

for example once every 4 to 6 weeks. Evaluate the progress of the treatment

(see ‘Collaboration/referral’ below) and the course of the symptoms together

with a (psychosomatic) physiotherapist nurse practitioner, primary care social

psychiatric nurse or primary care psy-

multidisciplinary teams or treatment

inadequate results from step 1 and 2,

probably patients with severe MUS (severe functional limitations (including,

for example, sick leave for more than 3 months) and a large number of differ-

ent MUS and/or a duration of symptoms > 3 months).

In this stage, it is important that

chologist (trained in cognitive behav-

one care provider keeps control of the

other primary care disciplines can also

In many cases, the general practitioner

ioural therapy). Care providers from be involved, depending on the local situation.

If musculoskeletal symptoms are

predominant, the general practitioner

will preferably refer to a physiotherapist or exercise therapist with additional specialist training (for example,

in psychosomatic physiotherapy or exercise therapy)34 or who has had training in counselling patients with MUS. If

the

general

practitioner

col-

care provided to the patient with MUS.26 is the best person for this job, but a social psychiatric nurse, psychologist or occupational health physician can also fill this role.

In this step, the role of the general

practitioner consists of:

1. continuing to stimulate the expansion of the patient’s functioning and detecting any deterioration in his/ her functioning (see step 1);

2. limiting long-term treatments and

with the patient. Advise the patient to

laborates with a mental health nurse

ments in which the patient partici-

chiatric nurse, this person can support

3. if several or long-term specific and

ample – PST (problem-solving treatment).

sulted in any further improvement:

work actively on his/her recovery. Treatpates actively (such as psychotherapy,

psychosomatic physiotherapy and ex-

practitioner or primary care social psypatients in this step and offer – for ex-

ercise therapy) are more effective than

The mental health nurse practitioner or

operations and passive forms of phys-

takes over the monitoring role from

passive treatments such as injections, iotherapy.33

Collaboration/referral If the patient is unable to expand his/

primary care social psychiatric nurse

apy that matches his/her capabilities, wishes and needs.

A care provider with affinity and

experience with – as well as specific

knowledge about – MUS is preferable 5 6 (5) m ay 2 0 1 3

the status quo.

term control.

during the treatment, for example once

Make regular follow-up appointments

The general practitioner can re-

every four to six weeks. In the event of

short-term supportive counselling or

cuss with the patient the type of ther-

encouraging the patient to accept Follow-up

factors, the general practitioner can

the general practitioner should dis-

intensive treatments have not re-

but the general practitioner keeps longfer the patient to a primary care psy-

decide to refer the patient. In that case,

and may even be harmful;

the general practitioner in those cases,

her activities to an acceptable level

because there are many inhibiting

investigations that are not useful

chologist for patient education and

cognitive behavioural therapy.30 The primary care psychologist should have

experience in treating patients with

persistent dysfunctioning without active treatment, the advice is to evaluate

the situation at least once a year and to

potentially offer any new treatment options.

MUS.

Collaboration/referral

STEP 3

mono-disciplinary pain specialist is

The intensification of the treatment in

step 3 consists of collaboration with and

Referral for therapeutic reasons to a not recommended if he/she only applies local invasive analgesic methods,

huisarts & wetenschap

9

NH G g u id el ine

such as denervation and injections with

tidisciplinary approach that integrates

© 2013 Nederlands Huisartsen Genoot-

agents, since these treatments are not

pects in the treatment offers the oppor-

tioners]

analgesics, corticosteroids or sclerosing

effective when applied as monotherapy.33 If the approach in the previous steps

has failed or if the evaluation immediately revealed that this is a case of severe MUS, the general practitioner can refer for a multidisciplinary approach,

in which the previously mentioned disciplines are represented and collaborate in an integrated manner. A mulGuideline development method Following the decision to start the development of an NHG Guideline on medically unexplained symptoms, a MUS working group started in 2009. This working group created a draft version. The working group consisted of the following members: I.A. Arnold, MD, PhD, general practitioner in Leiderdorp; D. Bentz van den Berg, MD, general practitioner in Maartensdijk; A.H. Blankenstein, MD, PhD, general practitioner and head of the Department of Vocational Training for general practice of the VU University Medical Center; Prof. H.E. van der Horst, MD, PhD, general practitioner in Amsterdam and professor of general practice medicine at the VUmc; T.C. Olde Hartman, MD, PhD, general practitioner in Nijmegen; A.O. Molenaar, MD, locum general practitioner based in De Rijp. H. Woutersen-Koch, MD, PhD, guided the working group and performed the editing. She is a doctor and staff member of the Department Guideline development and Research; Tj. Wiersma, MD, PhD, was involved as a senior staff member of this department, M.M. Verduijn as a senior staff member Pharmacotherapy. E. Oostenberg, MD, was involved as staff member of the Implementation Department. In the period 2009 through 2013, none of the members of the working group received payment for an advisory role or research grants from pharmaceutical companies involved in the field of MUS. Vested interests were reported by: A.H. Blankenstein, H.E. van der Horst, and H. Woutersen-Koch. These three individuals were or are involved in research into MUS and have published on this subject. The members I.A. Arnold, D. Bentz van den

10

huisarts & wetenschap

somatic, psychological and social astunity of improving the functioning in

schap [Dutch College of General Practi-

various areas. An intense physical and cognitive-behavioural

rehabilitation

programme promotes a return to an acceptable level of activity.35 A multidisciplinary approach allows for long-term

and more specific treatments to be offered, either as out-patient treatment or in combination with admission.

Berg, T.C. Olde Hartman, A.O. Molenaar and E. Oostenberg reported no conflicts of interest. More details about this can be found on the web version of the guideline, at www.nhg.org. In June 2012, the draft guideline was sent to a number of experts for comments. A total of 14 comments were returned. The following experts returned comments: J.A.H. Eekhof, MD, PhD, general practitioner-epidemiologist and editor-in-chief of Huisarts & Wetenschap [General Practice & Science]; on behalf of the Dutch Association of Psychologists: C.E. Flik, clinical psychologist/psychotherapist and employed by the department of Psychiatry and Psychology of the St. Antonius hospital; Prof. A.L.M. Lagro-Janssen, MD, PhD, professor of Women’s Studies and Medical Sciences and employed by the department of Primary Care Medicine, Women’s Studies and Medical Sciences Unit at the UMC St. Radboud Nijmegen; P. Lucassen, MD, PhD, general practitioner, senior scientist and employed by the department of Primary Care Medicine at the UMC St. Radboud Nijmegen; N.C. Makkes, MD, general practitioner and project leader of the ZonMw-project SOLK – Gezond georganiseerd vanuit de 1e lijn [MUS – Healthily organised in primary care] (2011 to 2012), employed by general practice clinic Overvecht, Stichting Overvecht Gezond [Foundation Overvecht Healthy]; on behalf of the Netherlands Association of Internal Medicine (NIV): Prof. A.C. Nieuwenhuijzen Kruseman, MD, PhD, department of Internal Medicine at the Maastricht University Medical Centre; M.J.T. Oud, MD, PhD, general practitioner in Groningen; C.F.H. Rosmalen, MD, PhD, general practitioner and head of the department B&O at the LHV [Dutch associ-

ation of General Practitioners]; on behalf of VAGZ: G.W. Salemink, MD, Community Medicine physician employed by Zorgverzekeraars Nederland; on behalf of Nefarma, Health Economy: J.J. Oltvoort, PhD; J. Stoffels, MD, PhD, general practitioner and retired lecturer in general practice training, UMCG; on behalf of Domus Medica, the Flemish GP association: Prof. A. Dirk, General Practice Medicine and Primary Health Care and employed by the Faculty of Medicine and Health Sciences Ghent University, Belgium; on behalf of Pharos: M. van den Muijsenbergh, MD, PhD, general practitioner and senior researcher and employed by Pharos, National Knowledge and Advisory Centre on Migrants, Refugees and Health Care Issues, and department of Primary Care Medicine of the UMC St. Radboud Nijmegen and University Health Centre Heyendael Nijmegen, and M. Vintges, MD, PhD, physician and researcher; Y.R. Van Rood, PhD, clinical psychologist and psychotherapist, employed by the department of Psychiatry of the LUMC. Being recorded as an expert does not mean that the expert supports every detail of the content in the guideline. R. Starmans and J. van Dongen – on behalf of NAS – evaluated during the commentary round whether the draft guideline answers the questions defined in the basic plan. In September 2012, the guideline was commented on and authorised by the NHG Authorisation Committee. The search strategy used to locate the supporting literature is presented in the web version of this guideline. The procedures for the development of the NHG Guidelines can also be viewed in the procedures book (see www.nhg.org).

5 6 (5) m ay 2 0 1 3

NH G g u id el ine

Notes and literature

1 Multidisciplinary guideline on medically unexplained symptoms and somatoform disorders The NHG Guideline on MUS is an expansion of aspects from the multidisciplinary guideline on MUS and somatoform disorders [Fisher 2010] that are relevant to general practice medicine, and describes how they can be applied in the general practice setting. 2 Expression of physical symptoms in nonWestern cultures In many cultures, social harmony and non-confrontational interaction with other people take precedence over the expression of emotions. The use of metaphors and physical symptoms as a language of distress prevents the patient and those around him from feelings of shame [Kirmayer 1998]. Turkish and Moroccan individuals in particular tend to focus mainly on the somatic side of their problems, in contrast to individuals from Surinam [Knipscheer 2005]. 3 Absence of a medical explanation for physical symptoms Quite regularly when a person visits a doctor due to physical symptoms, the doctor is unable to find a physical cause. In about 30 to 50% of cases, the general practitioner cannot find a medical explanation for the symptoms [Khan 2003]. These percentages are also high – between 40 and 60% – for the neurologist, rheumatologist, pulmonologist, gastroenterologist, cardiologist, dentist, gynaecologist [Nimnuan 2001a] and internist [van Hemert 1996]. 4 Common MUS per specialism with accompanying ICPC code See [table 4]. 5 Functional syndromes: one or many? There is much discussion about the question whether functional symptoms cluster into clearly defined syndromes such as fibromyalgia, chronic fatigue syndrome or tension headache, or whether these specific somatic syndromes are primarily an artefact of medical specialisation [Wessely 1999, Nimnuan 2001b, Olde Hartman 2004]. 6 Clusters of medically unexplained symptoms In an exploratory study of a group of 978 MUS patients – with 701 patients originating from general practice – the symptoms experienced by these patients could be grouped in 4 clusters:

• gastro-intestinal: stomach pain, varying pattern of defecation, feeling bloated/swollen abdomen, gastro-oesophageal reflux, nausea, vomiting, borborygmi; • cardio-pulmonary: palpitations, unpleasant sensation across the chest, shortness of breath without exertion, hyperventilation, warm or cold sweats, trembling/shaking, dry mouth, butterflies in the stomach, blushing; • musculoskeletal: pain in arms/legs, muscle pain, joint pain, local sensation of loss of strength or weakness, back pain, pain with movement, unpleasantly numb sensation/tingling; • general non-specific: excessive fatigue, headache, dizziness, concentration problems, memory problems. The authors only counted symptoms that a person experienced as a burden. The average MUS patient had five symptoms. The more symptoms patients had, the more frequently they had a high score for distress, anxiety or depression domains on a questionnaire. It made little difference whether the symptoms were located in many different clusters. The authors concluded that MUS (though they felt that bodily distress syndrome was a better name) can be viewed as one syndrome, which can be expressed in various areas [Fink 2007, Fink 2010]. 7 Site of somatoform disorders and epidemiology in general practice Apart from the continuum based on severity (mild, moderate and severe MUS), there are also the somatoform disorders according to the DSM. The DSM-IV-TR [American Psychiatric Association 2000] – the world’s most widely used psychiatric classification system, which describes all psychiatric disorders – includes seven somatoform disorders. The undifferentiated somatoform disorder and the somatoform disorder not otherwise specified are less severe – in terms of prognosis and limitations – than the somatisation disorder, the pain disorder and conversion disorder; they are more common than the other somatoform disorders and do not often require a specialist approach. Hypochondriasis and body dysmorphic disorder often result in significant suffering, but less often in severe limitations in functioning and require specialist treatment. Also see [Table 5]. 8 Epidemiology of MUS The large variation in observed prevalence of MUS is partly due to the definition used, the point in the symptom episode at which the diagnosis is made, and inter-doctor variation. Melville et al. found that 3% of the patients with a new symptom episode received the diagnosis of MUS after 3

Table 4 Common MUS per specialism with accompanying ICPC code Internal medicine

Fatigue

A02

Dermatology

Hyperhidrosis (excessive sweating) Itching

A09.02 S02

ENT

Ringing of the ears/tinnitus Difficulty swallowing/globus sensation

H03 D21/R21

Neurology

Headache Dizziness/vertigo/lightheadedness Muscle weakness

N01 N17/01-02 N18

Cardiology

Cold extremities Chest pain Palpitations

K29.02 K01/K02 K04/K05

Pulmonology

Feeling of tightness

R02

Gastroenterology

Stomach pain

D01-02-06-08

Rheumatology

Pain in muscles/joints

L01-L02-L04

Psychiatry

Sleep problems

P06

Endocrinology

Decreased appetite

T03

Ophthalmology

Burning eyes

F05

5 6 (5) m ay 2 0 1 3

months [Melville 1987]. In an English study, general practitioners classified MUS as the reason for consultation for 19% of the consultation visitors. Based on screening instruments, 35% were found to have MUS, with 5% of these possibly suffering from a somatoform disorder [Peveler 1997]. A Dutch study found that an average of 13% of all consultations concerned at least one symptom that the general practitioners labelled as MUS [Van der Weijden 2003]. One of the highest rates of prevalence observed was in an Australian study, which showed that patients presented with MUS in 39% of the scheduled consultations in primary care [Pilowsky 1987]. Of course, the prevalence of MUS after first consultations about a symptom also differs from the prevalence for consultations due to symptoms that have existed for a longer period. For example, Verhaak et al. found a prevalence of 2.5% for patients visiting their general practitioner frequently with MUS in Dutch general practice [Verhaak 2006]. Another cause of the variation in prevalence is a large inter-doctor variation in labelling the presented health problems as ‘inadequately explained’. What one doctor deems ‘unexplained’ may have a perfectly logical explanation according to another doctor. Some doctors require a pathological or anatomical foundation before they can define a symptom as ‘explained’, whilst others are satisfied with functional symptoms or syndromes as an explanation. 9 Somatisation in immigrant versus non-immigrant patients Statement based on the book Een arts van de wereld: etnische diversiteit in de medische praktijk [A global doctor: ethnic diversity in medical practice] [Seeleman 2005]. 10 Association of MUS with anxiety disorder or depression Both an anxiety disorder and depression can be associated with physical symptoms. Depression and anxiety disorder can also present initially in the form of physical symptoms. In the case of depression, this is often in the form of fatigue and pain; anxiety disorders are often expressed in the form of shortness of breath, dizziness, palpitations, tingling (more generally: symptoms that present as cardio-pulmonary symptoms). However, the predictive value of having physical symptoms for making the diagnosis of depression or anxiety disorder is low (See the NHG Guidelines on anxiety and depression). In a survey amongst 2447 patients registered at 5 general practices, 451 people reported pain at various sites in the musculoskeletal system (chronic widespread pain (CWP)), and 60% of them also reported persistent fatigue symptoms. A total of 809 people reported persistent fatigue, with 33% of them also reporting CWP. These combinations of fatigue and CWP were much more common than would be expected based on chance, particularly in people with chronic illness and/or obesity. People with one of these two symptoms did not report depression or anxiety symptoms more often, whilst the combination of fatigue and CWP was associated with an increased prevalence of symptoms of anxiety and depression [Creavin 2010]. Using data from the Transition Project (16,000 patients from 10 general practitioners), Van Boven et al. examined the correlation between MUS and psychological disorders. They compared patients with new MUS (including palpitations, low back pain and headache) with patients with symptoms that are usually explained by a somatic condition (for example, enlarged lymph nodes and swollen ankles). The researchers found a statistical relationship between having MUS and an anxiety disorder or depression (OR varying from 1.7 to 5.1 for anxiety disorders, and from 1.7 to 4.2 for depression). In addition, the researchers found that the predictive value of MUS for developing an anxiety disorder or depression disorder was just as low as the predictive value of explained symptoms for the development of such a disorder [Van Boven 2011].

huisarts & wetenschap

11

NH G g u id el ine

Table 5 Description of somatoform disorders and estimated prevalence in general practice [de Waal 2004] Description Somatisation disorder

Condition of multi-symptoms that often starts before the age of thirty, persists for a long time and is characterised by a combination of pain, gastro-intestinal, sexual and pseudo-neurological symptoms.

Pain disorder

Unexplained pain that is severe enough to limit functioning and to seek medical help. Occurrence, severity, exacerbation and persistence are linked to psychological factors. Inadequately explained pain in the presence of a somatic condition is also included in the pain disorder.

2%

Conversion disorder

Unexplained symptoms or loss of function that affects random motor or sensory functions, or seizures/ convulsions that suggest a neurological or other somatic condition. A link to psychological factors is deemed likely.

0.2%

Undifferentiated somatoform disorder

At least one medically unexplained physical symptom that has caused a limitation in daily life for at least six months. The functional syndromes (IBS, CFS, FM, etc.) fall into this group of undifferentiated somatoform disorders.

13%

Somatoform disorder not otherwise specified

Somatoform symptoms and syndromes that do not meet the criteria of one of the specific somatoform disorders.

Unknown

Hypochondriasis

Strong preoccupation with and fear of having a serious illness, as a result of an incorrect interpretation of physical symptoms for at least six months.

1 – 5%

Body dysmorphic disorder

Preoccupation with a supposed flaw in the appearance.

< 0.1%

11 Explanatory models The various explanatory models differ in the extent to which they explain physical symptoms and processes and the extent to which they take account of certain physiological, psychological and social aspects. However, pathophysiological mechanisms of various symptoms are becoming increasingly clear. Research is focussing predominantly on the physiology of psychological processes. This somato-psychological research focuses on the physical symptoms of psychological disorders (cardiovascular or inflammatory symptoms occurring with depression) and psychological consequences of somatic conditions (effect of rheumatoid arthritis on ideas and personality), among other things. In this way, we are gaining increasing insight into the way in which somatic phenomena, ideas, emotions, behaviour and environment are linked. Biopsychosocial model The biopsychosocial model [Engel 1977] clearly emphasises the importance of the context of the patient. The model assumes that (perceived) health is associated with all dimensions of human existence and that humans are constantly interacting with their environment. Medical schools have now incorporated this model in their curricula. Capacity/burden model A model that expounds on the capacity/burden principle is the so-called SSSV model [De Jonghe 1997]. SSSV stands for: support, stress, strength and vulnerability. The balance between these factors is important. If vulnerability and strength are unbalanced in a person, this can lead to symptoms as a result of a specific type of stress and lack of support, for instance. Stress model De Gucht and Fischler [De Gucht 2002] demonstrate in their ‘analysis of the relationship between professional stress, psychosocial parameters and various dimensions of physical health’ that a high level of professional stress is correlat-

12

Estimated prevalence in general practice

huisarts & wetenschap

≤ 0.5%

ed with fatigue, pain and somatoform disorders. Psychological distress plays an important role in this relationship. Their hypothesis is that certain psychosocial factors combined with a chronically high level of professional stress can result in experiencing unexplained physical symptoms. Perceptual-cognitive perspective In their somato-sensory amplification theory, Robbins and Kirmayer [Robbins 1991] describe that patients focus their attention on physical sensations. These physical sensations result in ideas and emotions in patients, resulting in physical attributes [Rief 2007]. This amplifies and magnifies the initial symptoms. This results in a vicious circle of maintaining and amplifying the physical symptoms. The concept of somatic fixation also fits into this model. Somatic fixation is defined as a process of persistent inadequate coping with and response to disease, symptoms or problems by patients themselves, by their social environment or by healthcare representatives. Although the concept of somatic fixation has never been successfully operationalised for study purposes, it does have practical value in healthcare, because it indicates so clearly how symptoms are maintained by an interaction between patient, healthcare and social environment [Van Eijk 1983]. Neurobiological models The neurosciences [Brown 2002] emphasise the complex interaction between neurobiological processes (HPA axis (hypothalamus-pituitaryadrenal axis), cytokines), environmental factors, attention and behaviour [Dantzer 2005, Kirmayer 2006]. Presumed abnormalities – for example in the limbic system – are the starting point of theory formation. Neural endocrinological and neurovegetative processes also form part of the neurobiological approach. Psycho-immunology also emphasises the consequences of somatic illnesses on endocrine processes, immunological processes, mood and behaviour. This could explain why certain physically explained conditions do not recover despite adequate medical treatment.

Vicious circles play an important role in maintaining symptoms, irrespective of the origin of the symptoms. The focus lies particularly on the interpretation of symptoms and the resulting disease behaviour and/or help-seeking behaviour [Sharpe 1992, Speckens 2004, Van Rood 2001]. In addition, it has been shown that previous and repeated stimuli of pain and other symptoms in the past make the central nervous system more susceptible to these stimuli (sensitisation) [Rief 2007]. Emotions also play an important role in physical sensations. Severe emotions are often associated with obvious, tangible physical symptoms such as becoming pale with fright or red with anger. Not being able to regulate emotions often results in physical disruption that can result in persistent physical symptoms. According to the psychoanalytical tradition, unexplained physical symptoms are associated with repressed emotions. Other theories emphasise the selective perception of emotions. There are indications in the literature that patients with unexplained physical symptoms have difficulty recognising feelings and emotions and have difficulty distinguishing these from physical sensations (alexithymia) [De Gucht 2004, Bankier 2001]. Looking at the individual development, the unexplained physical symptoms are associated with pre-natal and post-natal experiences and experiences in early childhood and other early experiences. Since recently, there has been attention for the link between an early unsafe attachment style and later susceptibility to unexplained symptoms. The effect of early trauma, early affectionate neglect and early acquired methods of coping with physical symptoms make a person more susceptible to developing and maintaining unexplained physical symptoms. 12 Explanatory models and non-Western cultures Every society has its own explanatory models for disease and health. The biomedical model dominates in Western cultures: a disease can be traced to a disorder in the body or the mind. In contrast, non-Western cultures often do not distinguish between body and mind and the causes of and solutions to problems are sought elsewhere (gods/ spirits). For example, in Morocco, a distinction is made between disease due to natural causes (disruption in the balance between warm and cold), supernatural causes (contact with djinns, demons that inhabit a world parallel to humans) or human causes (the evil eye, witchcraft or magic) [Borra 2003]. Some Islamic patients see their symptoms as the fate that Allah has bestowed upon them and do not feel that they can actively intervene. You cannot create or earn health, it is a favour bestowed by Allah [Noordenbos 2007]. 13 Course of MUS In a meta-analysis – following an extensive search – the authors identified 6 prospective cohort studies (with 81 to 337 patients per study) on the prognosis of MUS in a population corresponding to patients in primary care. The studies included in the meta-analysis revealed that the symptoms improved during the follow-up period (6 to 15 months) for 50 to 75% of the patients. Ten to 30% deteriorated during the follow-up. For most of the studies, the extent of treatment was not clear. The meta-analysis also revealed that a greater number of symptoms in the beginning resulted in a poorer prognosis. The same applies to the severity of the symptoms; the more severe the symptoms were at the start, the greater the chance that the symptoms will persist [Olde Hartman 2009a]. In general, the majority of MUS develop in a favourable manner: only 20 to 30% of the patients still experience symptoms one year after their first visit to the general practitioner [De Waal 2006].

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However, the course can also be more complex. A 1-year cohort study followed 642 patients who visited their general practitioner with new-onset fatigue symptoms. Recovery was fast for 17%, slow for 25%, high fatigue scores persisted for the entire year for 26%, and 32% recovered quickly but suffered a relapse within a year [Nijrolder 2008]. 14 Effect of doctor-patient relationship and communication on health outcomes It is known from the literature that a good doctorpatient relationship – as well as good doctor-patient communication – in general results in improved health outcomes, a higher level of patient satisfaction and improved compliance [Cabana 2004, Kim 2008, Nutting 2003]. In psychotherapy, this relationship is even responsible for 30% of the effect of the treatment [Lambert 2012]. In a literature study on the therapeutic effect of the general practitioner-patient relationship, the investigators concluded that – despite the large heterogeneity of the studies found – general practitioners that had a warm and personal relationship with their patients were ‘more effective’ than general practitioners who kept their relationship more neutral and formal [Di Blasi 2001]. A Dutch study on the treatment of depression in primary care revealed that treatment according to the guideline alone is insufficiently effective, but that it is effective in combination with empathy and support [Van Os 2005]. Also for the treatment of IBS, a warm, empathic and trusted doctor-patient relationship is more effective than the same treatment without such a relationship (alleviation of symptoms 61% versus 53%) [Kaptchuk 2008]. The relationship between doctor-patient communication and health outcomes for the patient was examined in a systematic review of 10 RCTs and 11 controlled trials and cohort studies [Stewart 1995]. In 16 of the 21 studies, the quality of the communication had a positive effect on the health outcomes. The following communication aspects had an effect on the health outcomes: • a broad exploration of symptoms covering somatic, emotional and cognitive aspects and expectations and the effect of the symptoms on functioning as experienced by the patient; • a shared vision of the problem and a mutually developed treatment plan, in which the patient is given the opportunity to ask for more information and to give his/her reactions. Aiarzaguena et al. [Aiarzaguena 2007] demonstrated in a cluster RCT that if general practitioners (n = 19) applied special communication techniques, their somatising patients (n = 76) improved significantly more in the aspects of physical health, physical pain and mental health than the patients (n = 20) of the general practitioners (n = 20) who applied a standard reattribution technique. The effect was present for up to 12 months. The communication techniques included that the doctor provided a physiological explanation (hormonal factors) and approached sensitive subjects indirectly. Dobkin et al. [Dobkin 2006] examined which factors predicted compliance – in particular regarding drug treatment – in 142 patients with fibromyalgia. Less discordance between doctor and patient equated to improved compliance by the patients to the proposed treatment and to the patient feeling better. Owens et al. [Owens 1995] used pre-defined criteria derived from the medical records of 112 IBS patients to demonstrate that a positive doctorpatient relationship was associated with fewer consultations during the follow-up period. Conclusion: the working group is of the opinion that there are enough indications that a good doctor-patient relationship and communication have a favourable effect on the perceived health and behaviour of patients. 15 Predictive value of psychosocial stressors Walker [Walker 1993] compared children with abdominal complaints to children with organic stomach conditions, children with emotional

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problems and healthy children. Children with recurrent abdominal complaints reported fewer negative life events than children with emotional problems. They suffered the same amount of emotional distress as children with a stomach condition. In the 1980s, Bleijenberg [Bleijenberg 1989] examined whether patients with functional stomach symptoms could be distinguished from people with organically explained abdominal complaints based on history and psychological factors. This turned out not to be the case. A study in a tertiary care population of patients with abdominal complaints demonstrated that a history of sexual abuse is more common in people with IBS than in people with colitis [Drossman 1990]. 16 Health literacy It is known that low literacy is associated with a lower state of health in many areas and that this is particularly common among the elderly, ethnic minorities, people with a lower level of education and the chronically ill. The National Institutes of Health defines health literacy (health skills) as the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions. Therefore, according to this definition, health skills are related to the cognitive and functional skills for making health-related decisions [Paasche-Orlow 2007]. 17 Other NHG Guidelines Other NHG Guidelines may also apply, depending on the initial symptoms, for example the NHG Guidelines on: food intolerance (M47), non-traumatic knee problems in adults (M67), anxiety (M62), depression (M44), problematic alcohol use (M10), thyroid conditions (M31), menopause (M73), urination problems in men (M42), epicondylitis (M60), hand and wrist complaints (M91) and erectile dysfunction (M87). 18 The chance of a somatic condition being the cause of symptoms initially explained as MUS IBS Two prospective studies examined how reliable the diagnosis of irritable bowel syndrome (IBS) was. Harvey et al. [Harvey 1987] monitored 104 patients with IBS for 5 years. The diagnosis was found to be correct in all cases. Owens et al. [Owens 1995] monitored 112 patients with IBS for an average of 29 years. Over the course of time, 3 people were diagnosed with a gastro-intestinal disease, and for 2 of the 3 cases it was very unlikely that the IBS symptoms were the result of that condition. In 1 case the symptoms of IBS were possibly related to the condition that was diagnosed at a later stage. Fatigue A prospective cohort study in Dutch general practices examined the diagnoses resulting from newly presented, initially unexplained symptoms. A total of 63 general practitioners included 444 patients (73% female, average age 43 years), primarily with symptoms of fatigue (70%). After a follow-up duration of one year, 82 patients (18%) were found to have at least one somatic component that (partially) explained the symptoms. These were mainly somatic (partial) explanations in the categories infectious/inflammatory (22% of 82), osteoarthritis/degenerative abnormalities (13%), diabetes mellitus (9%), anemia (6%), hypothyroidism (4%), infectious mononucleosis (4%) [Koch 2009a]. Dizziness A Dutch cross-sectional diagnostic study of elderly patients who consulted their general practitioner due to dizziness, examined causes that could contribute to this dizziness, among other things. A total of 417 patients between the ages of 65 and 95 years were included. Cardiovascular disease was the most common contributing cause of dizziness (57%), followed by peripheral vestibular dizziness (14%) and psychiatric disease (10%). Side effects of medication played a contrib-

uting role in 23% of the cases [Maarsingh 2010]. Conclusion: the chance of an organic disease underlying symptoms previously categorised as MUS varies according to the initial symptom. This chance is very low for abdominal complaints categorised as MUS and slightly higher for fatigue categorised as MUS. The greatest chance of a somatic cause is present for dizziness previously categorised as MUS in elderly patients. 19 Clues/cues There is a long-standing tradition in primary care of paying attention to clues/cues and their significance. Recognising cues is important for the mutual understanding between doctor and patient. The importance of paying attention to cues came back into fashion with the patient-centered movement at the end of the 1980s. Responding to cues presented by the patient is one of the most important tools for a successful consultation [Olde Hartman 2008]. Cues are described in various ways by various authors: Gask en Usherwood [Gask 2002] refer to the verbal and non-verbal expressions of the patient as cues that the patient gives about psychosocial or social problems. Levinson et al. [Levinson 1997] describe cues as direct or indirect expressions that contain information about the lives and emotions of the patient. Balint uses the word ‘offer’ for remarks by the patient about the importance of the symptoms and the reason for visiting the general practitioner [Balint 2000]. Branch en Malik [Branch 1993] see cues as a chance for the doctor to display empathy. It is important to detect cues and to respond at the moment that the patient ‘offers’ these cues. Not responding to cues can result in the patient withholding further revelations. Bertakis et al. [Bertakis 1991] performed a study in which they analysed recordings of consultations in combination with a patient satisfaction questionnaire, and they reported a significant relationship between the reaction by the doctor to emotional cues and the extent to which the patient made further revelations. Furthermore, cues also allow for a better understanding of the patient’s life and his/her thoughts and emotions. There is another benefit to recognising and exploring cues. It shows that the general practitioner is listening carefully, wants to understand the significance of the symptoms for the patient and is interested in the patient. This has a favourable effect on the therapeutic relationship and thereby on disease outcomes and patient satisfaction. Doctors have difficulty recognising cues. Levinson et al. [Levinson 1997] examined how patients presented cues and how doctors responded to them. Cues were present in more than half of the consultations (average of 2.6 cues per consultation). Patients initiated 71% of the cues themselves and 29% of the cues were initiated by the doctors as a result of asking open questions. Doctors missed out on the opportunity to respond to a cue in the majority of the consultations (79%). These consultations lasted significantly longer. Butow et al. [Butow 2002] found the same result in their study of verbal cues of cancer patients: oncologists failed to recognise cues consistently and did not always respond to them. The consultations in which oncologists did respond to cues to a greater extent did not take any longer than other consultations. Cegala [Cegala 1997] analysed video recordings of consultations in primary care of 16 doctors with 32 patients, and found that doctors rarely provide information in the absence of a direct question from the patient. Conclusion: there is sufficient evidence to indicate that it is important to pay attention to clues/ cues. 20 Questionnaires/symptom lists/detection instruments There are various symptom questionnaires, such as the 4-DKL, Van Hemert’s list, the PHQ, Beck Anxiety (BAI-PC) and Beck Depression (BDI-PC).

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The ZonMw/NIVEL Kennissynthese ggz [Mental health care knowledge synthesis] [Zwaanswijk 2009] asked a panel of 54 primary care providers (general practitioners, social workers, primary care psychologists, social psychiatric nurses, mental health nurse practitioners) and patient representatives how these questionnaires can best be used in general practice. A total of 82% of the respondents sees support of the diagnosis as a role, if the presence of a certain condition is already suspected. Questionnaires can also be used to provide an opportunity for discussion (listed by 74%) and to detect problems in high-risk groups (44%). Only 14% thinks that such an instrument can be used to detect problems in a general group of patients. In addition, it was also mentioned that questionnaires can be used to monitor the severity of patients’ symptoms during treatment or during watchful waiting. According to most respondents (76%), the number of questions that a questionnaire contains and the time that it takes to complete such an instrument are deciding factors for the level of applicability of the instrument in daily general practice. A total of 47% of the general practitioners in the panel used 1 or more questionnaires, in particular for depression, anxiety and dementia. The instruments included in [table 6] are the questionnaires relevant to MUS that were evaluated as adequately to highly reliable and valid in the knowledge synthesis. They can all be completed by the patient himself/herself. There are regional differences in which instrument is used. The working group has not indicated a preference in this matter. 21 Ethnic-cultural points important for communication In the absence of any strong evidence, the comments and advice provided below were obtained from the Handleiding voor anamnestisch gesprek met migranten bij verholen psychosociale problemen [Manual for discussing the medical history with immigrants with disguised psychosocial problems] [Limburg-Okken 1989]. Method of questioning and order of questions An amended method of questioning is important when questioning immigrants from non-Western cultures. In contrast to Dutch culture, which is individualistic and in which it is somewhat more common to talk about emotions, non-Western cultures are often collectivistic. In collectivistic cultures, individuals are often expected to maintain group harmony above all else and it is not acceptable to place too much emphasis on one’s own opinion and emotions. A common question in the Netherlands, such as: “Do you have any problems?” will be answered negatively, as one does not discuss problems with people outside the family. It is also important to word the questions as directly as possible: • When exactly did the symptoms start? What happened on that day? • How are things at work? • What does your family think about this? (can also express patient’s unspoken opinion) • Are you able to sleep with this illness? Do you

dream a lot? (dreams are important in indigenous disease interpretations) Turkish and Moroccan patients can have difficulty with the direct communication style of Dutch care providers and with discussing taboo subjects. They can remain passive out of respect for the care provider or because they feel that they do not have any control over the symptoms [Rabbae 2008]. The order of questions (‘from the outside to the inside’) can help to make it easier to discuss emotions. If unknown, first discuss the general family conditions (including country of origin) and the daily activities (work, household). Then focus on the symptoms expressed, followed by the social context in which the symptoms are experienced (relationship to work, housing, etc.), then the relationship of the symptoms to the family and finally the patient’s own perception of the symptoms (psychological consequences, causes). Cultural barriers If the emphasis is placed squarely on physical symptoms, bear in mind that it may be more difficult for the patient to express thoughts and emotions – compared to physical symptoms – in a language that is not his/her mother tongue. It is often helpful to ask about facts first, then opinions and finally emotions. The patient does expect questions about the various aspects of the symptoms, but more as a matter of social interest than as part of the medical diagnostic process. Particularly in the case of MUS, the general practitioner will have to explain clearly that he needs a lot of information in order to be able to help the patient. It is possible to discuss the psychological and social consequences of symptoms, but an explanation in the form of a vicious circle is often not compatible. It is often not acceptable to discuss with your doctor the fact that your family is a source of stress or part of the problem, but the patient can talk about the impact of the symptoms on the whole family. The general practitioner can link into this by asking which family members can become involved in the treatment as confidants. Misunderstandings in communication are even more common in contact with second-generation immigrants from non-Western cultures. The general practitioner often forgets that cultural barriers still exist if patients speak Dutch fluently [Boevink 2001]. Research also shows that the chance of mutual misunderstanding between doctor and patient becomes greater if the patient belongs to a later generation of immigrants or to a partially acculturated group of immigrants from non-Western cultures. It is more important to aim for understanding than to reach an agreement [Harmsen 2005]. Explanation Patients of non-Western extraction have a language of distress in which the body is used to express emotions and metaphors are used. This protects patients and their surroundings from feelings of shame [Kirmayer 1998]. Therefore, in many cultures, information about symptoms and disease is provided with the use of metaphors: • Your head is full of unpleasant and painful

memories, so there is no room in your head to remember things. The sadness is taking up all the space in your head and takes up a lot of energy. • The roots of a tree go deep underground. When they encounter resistance – such as a large bolder or a rock – they grow around that obstacle. The important thing is that the tree can continue to grow. The same applies to humans. Learn to deal with the symptoms by working around them, as the roots of a tree do. Be flexible [Vloeberghs 2005]. Attention for perception regarding magic and religion Many patients use alternative medicine. In the case of immigrant patients this can include winti, magic, voodoo and the like, as well as the use of traditional healers (such as fqih, hoca, imam, bonoeman, lukuman). It is best that the therapist takes note of this and discusses with the client any other help or treatment that he/she is receiving. It is also relevant to determine whether this alternative treatment will support and amplify the treatment that is offered or whether it will contradict the treatment [Noordenbos 2007]. Effectiveness of immigrant treatment programmes An intervention amongst female immigrants with chronic pain symptoms (n = 249) resulted in a decrease in severe pain symptoms, an increase in perceived health and a decrease in visits to the general practitioner (by 8%). The intervention consisted of supervised movement in a group setting for two months and a meeting with a health educator speaking the same language and having the same cultural background (‘voorlichter eigen taal en cultuur’; VETC) about the relationship between stress and pain [Van Ravensberg 2008]. Recent indications from research show that the use of cultural workers in the treatment of psychosomatic symptoms result in improved perceived health compared to the standard approach by general practitioners. The culturally sensitive approach includes psycho-education with special attention for the patient’s cultural background, and immigrant care consultants providing support in the communication between patient and general practitioner [Joosten-Van Zwanenburg 2004]. 22 False positive test results with low prior risk of a somatic condition The VAMPIRE trial examined the diagnostic yield of blood tests in 173 patients who visited the general practitioner with new-onset unexplained symptoms of fatigue. With the limited blood tests recommended in the NHG Guideline on blood test ordering (Hb, sed. rate, glucose and TSH), a true positive test result was obtained for 6.4%, whilst 22.0% of the patients had a false positive test result. A more extensive fatigue-specific panel of blood tests designed by experts (Hb, sed. rate, glucose, TSH as well as liver functions, creatinine, leuko-diff., ferritin, transferrin and monosticon) resulted in a true positive test result for 7.5% of the patients, but the percentage of patients with a false positive test result increased to 55.5%. The diagnoses discovered by the blood tests in the 173 patients were diabetes mellitus (4x), anemia (3x), infectious mononucleosis and hypothyroidism,

Table 6 Characteristics of questionnaires evaluated as adequately to highly reliable and valid Detection of

Questionnaire

Number of questions

Completion time Test characteristics in minutes

Comments

Depression

PHQ-9

9

5

Measures the 9 depression criteria of the DSM IV.

BDI-PC*

7

1-2

Sensitivity: 82 – 97%, specificity: 82 – 99%.

Anxiety

BAI-PC*

7

1

Sensitivity 85% and specificity 80% at cut-off point 5.

Distress, depression, anxiety and somatisation

4-DKL†

50

5 – 10

Distinguishes uncomplicated stress-related problems from psychiatric conditions.

* can be ordered via www.pearson-nl.com using personal BIG number. † can be downloaded from www.emgo.nl/researchtools/4DSQ.asp or via www.spreekuurassistent.nl

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thalassemia and vitamin B12 deficiency (all 1x). Two patients with mononucleosis and 1 with a dust mite allergy had a false negative test result. Patient history and physical examination were unable to predict which patients would have abnormal blood test results [Koch 2009b]. 23 Effect of additional investigations on the level of reassurance A narrative review provided a descriptive summary of RCTs that examined the effectiveness of the use of diagnostic tests as a method of reassuring patients. A total of 5 RCTs with 1544 patients were found. The RCTs examined various tests (ECG, X-ray examination of the lumbar spine, MRI of the brain, laboratory tests, MRI of the lumbar spine) for various symptoms (including chest pains, low back pain and headache). Of the 5 RCTs, 4 found no significant effect of the tests on the patient’s level of reassurance. One study reported a reassuring effect after 3 months, which had disappeared after one year. The authors of the review concluded that despite the small number of studies and the heterogeneity, performing diagnostic tests hardly appears to contribute to the extent of reassurance. A clear explanation and a policy of watchful waiting can make additional diagnostic tests unnecessary. If diagnostic tests are used, it is important to provide adequate pre-test information about normal test results [Van Ravesteijn 2012]. 24 Presence of functional limitations as a prognostically unfavourable factor For the broad group of MUS patients in general, the presence of functional limitations has not been demonstrated to be a prognostically unfavourable factor. 25 Categorisation of MUS patients in severity classes The categorisation of MUS patients in severity classes is based on consensus within the working group. The need for categorisation according to severity is motivated by the treatment principle of stepped care. We can distinguish between three dimensions of severity: the extent of functional limitations, the duration of the symptoms and the number of symptoms/symptom clusters involved. 26 Stepped care Based on a review of systematic reviews and meta-analyses, Henningsen et al. [Henningsen 2007] made the recommendation to implement a stepped-care approach in primary and secondary care. Stepped care is a more flexible treatment method than traditional forms of treatment. It means that various interventions of varying intensity are offered subsequently, depending on the effect of a previous step. Stepped-care treatment is based on three assumptions. The first is that the minimal interventions that are used in stepped care (for example, patient education) can have a significantly positive effect on the symptoms that is equal to that of traditional psychological treatment, at least for a number of the patients. The second assumption is that the use of minimal interventions will ensure that mental health care services are used more effectively. The third assumption is that minimal interventions and the entire stepped-care approach are acceptable for both the patient and the care provider [Bower 2005]. In the case of MUS and somatoform disorders, stepped care entails opting for the mildest possible effective treatment based on the evaluation. The choice depends – among other factors – on the experiences with and effects of previous treatments and the nature and severity of the symptoms and limitations. For all these approaches, it is important that an explicit goal is formulated and that monitoring of the course and the outcome of the intervention is performed. If the effect is inadequate, a subsequent (more intense) step in the care path is selected. As various

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disciplines play a role in this stepped-care approach, their communication with each other is vitally important, as is the central role of the general practitioner as case manager. The steppedcare principle demands regular evaluation of the treatment effect if active treatment is used. However, as yet, there is no empirical evidence to support a stepped-care approach for MUS and somatoform disorders [Fisher 2010]. 27 Effect of blood tests and doctor-patient relationship on the level of satisfaction and concern A cluster RCT (63 general practitioners; 498 patients) revealed that patients with MUS for whom the general practitioner immediately requests blood tests are no more or less satisfied or concerned than patients for whom the general practitioner employs watchful waiting for a month. Patient satisfaction was greater and the level of concern was lower if the patient generally trusted his/her general practitioner, felt that he/she was being taken seriously, had obtained clarity about the severity of the symptom, if the option of testing was discussed, if the general practitioner had not created the impression that he/she did not think that the symptoms were that bad and if the general practitioner was older [Van Bokhoven 2009]. 28 Ways of explaining and consequences A focus group study amongst Dutch general practitioners revealed that general practitioners are aware of the importance of the way in which they explain the working hypothesis of MUS to their patients. However, they find it difficult to explain the nature and origin of the symptoms during a consultation. The general practitioners indicated that they use three methods when providing the explanation: the ‘normalisation’ of symptoms (explaining that experiencing symptoms is part of normal life), explaining that there is no disease and the use of metaphors [Olde Hartman 2009b]. However, the normalisation of symptoms and telling patients that they do not have a disease without providing a tangible explanation about how the symptoms could develop is not effective and could even lead to more help-seeking behaviour [Salmon 1999, Dowrick 2004]. 29 Anatomical knowledge In 2009, a cross-sectional, multiple-choice questionnaire study tested the anatomical knowledge of 722 participants (598 patients from 6 different diagnostic groups and 133 people from the general population). In general, the knowledge of the anatomy was poor (average 52.5% correct, standard deviation 20.1) and had not improved significantly since a previous, similar study 30 years ago. Only patients from the groups with liver diseases and diabetes scored higher. There was a negative correlation with age (the older the individual, the poorer the anatomical knowledge) and a positive correlation with the level of education (the higher the level of education, the better the anatomical knowledge). The authors concluded that these outcomes should have consequences for doctor-patient communication [Weinman 2009]. In the case of refugees, a lack of sufficient knowledge and insight into the functioning of the body and mind and the emotional charge associated with certain subjects makes it extra difficult for the care provider to explain matters in the usual manner to this group of individuals [Vloeberghs 2005]. 30 Effectiveness of CBT and reattribution for MUS Various treatments have been described for patients with MUS, with quite a lot of recent research focussing on treatment in primary care. Some studies demonstrate that antidepressants and cognitive behavioural therapy are effective in the treatment of persistent MUS, with symptoms

and functioning apparently improving and psychological stress apparently decreasing [Kroenke 2007, Sumathipala 2007]. Reattribution is a structured intervention in which an explanation for the mechanism of the patient’s symptoms is provided by means of negotiation and patient-centred communication [Little 2001]. This therapy is probably not effective, as three of the four studies show no benefits [Morriss 2010]. Furthermore, one RCT demonstrated that reattribution therapy by general practitioners was associated with a decreased quality of life [Morriss 2007]. 31 Avoidance behaviour and other behavioural factors In the experience of the working group, behavioural factors such as avoidance or over-activity are almost always present with long-term MUS. This has been scientifically studied and proven for fibromyalgia [Van Koulil 2008]. 32 Time-contingent approach The literature describes the step-by-step expansion of activities according to a set schedule as graded activity [Lindstrom 1992]. The care provider reaches an agreement with the patient – in advance – about the exercises and activities that the patient will perform over the coming period. The starting level is determined based on the maximum ability level of the patient. The exercises are not performed based on the pain (pain-based approach) but are performed according to a timebased approach: the exercises are gradually increased in nature, duration, frequency and intensity. The therapist’s task is to schedule activities in such a way that patients who overestimate themselves are slowed down and patients who underestimate themselves are stimulated. For a long time it was assumed that patients with chronic non-specific lower back pain (which can also be regarded as MUS) were less physically active. Objective measurements demonstrate that there is no significant difference between the activity levels of patients with chronic non-specific low back pain and healthy individuals [Verbunt 2001]. However, a particular feature in the behaviour of many patients with back pain is that they will systematically avoid a small number of specific activities [Waddell 1993, Vlaeyen 2002]. From a behavioural therapy point of view, it is important to work towards such activities gradually in these situations. In this way, the patient is gradually exposed to the situation that forms the basis of his/her dysfunction. (Also refer to the NHG Guideline on non-specific low back pain). 33 Active participation A literature review of systematic reviews and meta-analyses provides an overview of the results of therapeutic trials for various functional syndromes and diagnostic analogies of these syndromes [Henningsen 2007]. The authors conclude that non-drug treatments that require active participation from the patient – such as exercises and psychotherapy – appear to be more effective than passive physical treatments, including injections and operations, for functional somatic syndromes in general. The literature review does not quantify the effects. The authors indicate that this was not feasible for the integration of so many different systematic reviews, which used such different criteria and represented different interpretations in heterogeneous clinical settings. Their overview provides empirical trends in the treatment of functional somatic syndromes in general. Conclusion: non-drug treatments that require active participation from the patient – such as exercises and psychotherapy – appear to be more effective than passive physical treatments, including injections and operations, for functional somatic syndromes in general.

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34 Effectiveness of psychosomatic exercise therapy (PSET) An observational study performed in 2010 [Van Ravensberg 2010] into the effects of the treatment by psychosomatic exercise therapists included 14 psychosomatic exercise therapists and 119 patients with stress-related and/or unexplained physical symptoms. At the intake, 49% were found to have stress-related symptoms, 26% suffered from emotional exhaustion and burnout, and 24% suffered from anxiety and panic symptoms and hyperventilation. Approximately half the patients (44%) had experienced symptoms for more than 6 months. Ten percent of the patients had even experienced symptoms for more than 5 years. Almost 30% of the patients had dysfunctional thoughts (incorrect ideas and views that inhibited recovery), and approximately half of the patients displayed dysfunctional behaviour (forcing themselves or over-taxing themselves). The number of patients with a distress score of more than 20 on the 4-DKL questionnaire was significantly reduced after the PSET treatment (1% ver-

sus 49%; p < 0.001). The other dimensions of the 4-DKL also improved significantly. The separate SF-36 (quality of life questionnaire) dimensions and the VAS scores improved significantly during the treatment (p < 0.001). After the treatment, more than 90% of the patients indicated that their health problems had improved significantly. Conclusion: although the level of evidence of the observational study is low – because it was unable to demonstrate that the observed difference was not the result of natural course – the working group is of the opinion that the observed effect of PSET in this group of patients (who have a poorer prognosis due to the duration of their symptoms (> 6 months)) is related to the PSET. Therefore, the working group is also of the opinion that there are strong indications for the effectiveness of PSET in patients with MUS. 35 Effectiveness of intensive rehabilitation programmes Relatively little research has been performed on

Literature Aiarzaguena JM, Grandes G, Gaminde I, Salazar A, Sanchez A, Arino J. A randomized controlled clinical trial of a psychosocial and communication intervention carried out by GPs for patients with medically unexplained symptoms. Psychol Med 2007;37:283-94. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-IV-TR. Washington: American Psychiatric Association, 2000. Balint M. The doctor, his patient and the illness. Edinburgh: Churchill Livingstone, 2000. Bankier B, Aigner M, Bach M. Alexithymia in DSM-IV disorder: comparative evaluation of somatoform disorder, panic disorder, obsessive-compulsive disorder, and depression. Psychosomatics 2001;42:235-40. Bertakis KD, Roter D, Putnam SM. The relationship of physician medical interview style to patient satisfaction. J Fam Pract 1991;32:175-81. Bleijenberg G, Fennis JF. Anamnestic and psychological features in diagnosis and prognosis of functional abdominal complaints: a prospective study. Gut 1989;30:1076-81. Boevink G, Duchenne-Van den Berge W, Stegerhoek R. Gesprekken zonder grenzen : communiceren met patiënten van Turkse, Marokkaanse, Surinaamse en Antilliaanse afkomst [Conversations without boarders: communicating with patients of Turkish, Moroccan, Surinamese and Antillian origin]. Woerden: NIGZ, 2001. Borra R. Cultuur en psychiatrische diagnostiek: stemmingsstoornissen bij allochtonen [Culture and psychiatric diagnoses: mood disorders in immigrants]. Bijblijven 2003;19:42-58. Bower P, Gilbody S. Managing common mental health disorders in primary care: conceptual models and evidence base. BMJ 2005;330:839-42. Branch WT, Malik TK. Using 'windows of opportunities' in brief interviews to understand patients' concerns. JAMA 1993;269:1667-8. Brown CS, Ling FW, Wan JY, Pilla AA. Efficacy of static magnetic field therapy in chronic pelvic pain: a double-blind pilot study. Am J Obstet Gynecol 2002;187:1581-7. Butow PN, Brown RF, Cogar S, Tattersall MH, Dunn SM. Oncologists' reactions to cancer patients' verbal cues. Psychooncology 2002;11:47-58. Cabana MD, Jee SH. Does continuity of care improve patient outcomes? J Fam Pract 2004;53:974-80. Cegala DJ. A study of doctors' and patients' communication during a primary care consultation: implications for communication training. J Health Commun 1997;2:169-94. Creavin ST, Dunn KM, Mallen CD, Nijrolder I, Van der Windt DA. Co-occurrence and associations of pain and fatigue in a community sample of Dutch adults. Eur J Pain 2010;14:327-34. Dantzer R. Somatization: a psychoneuroimmune perspective. Psychoneuroendocrinology 2005;30:947-52. De Gucht V, Fischler B. Somatization: a critical review of conceptual and methodological issues. Psychosomatics 2002;43:1-9. De Gucht V, Fischler B, Heiser W. Neuroticism, alexithymia, negative affect, and positive affect as determinants of medically unexplained symptoms. Pers Individ Dif 2004;36:1655-67. De Jonghe F, Dekker J. Steun, stress, kracht en kwetsbaarheid in de psychiatrie [Support, stress, strength and vulnerability in psychiatry]. Assen: Koninklijke Van Gorcum BV, 1997. De Waal M, Arnold I. Somatoform disorders in general practice. Epidemiology, treatment and comorbidity with depression and anxiety [thesis]. Leiden: Universiteit Leiden, 2006.

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the effectiveness of non-somatic clinical treatment, and the treated disorders and treatment modalities studied also vary too much to make general conclusions with a high level of evidence. An effect study (not an RCT) was performed in the Netherlands into the multidisciplinary treatment of severe MUS and somatoform disorders in a specialised centre for the treatment of psychosomatic conditions [Veselka 2005]. This study formed part of the so-called STEP study (Standard Evaluation Project), a national initiative of some fifteen clinical mental health departments aimed at obtaining national figures about the effectiveness and efficiency of treatment. This study evaluated intensive clinical (in-patient), multi-day or one-day multidisciplinary treatment. It was concluded that – in the case of severe to very severe MUS and somatoform disorders – there are strong indications that an intensive, integrative, multidisciplinary approach can be effective in achieving a reduction in symptoms, an increase in quality of life and a decrease in medical consumption.

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