Download m102 nhg guideline on medically unexplained symptoms

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
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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)
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NH G g u id el ine
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
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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].
5 6 (5) m ay 2 0 1 3
NH G g u id el ine
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
5 6 (5) m ay 2 0 1 3
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).
huisarts & wetenschap
13
NH G g u id el ine
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
14
huisarts & wetenschap
5 6 (5) m ay 2 0 1 3
NH G g u id el ine
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
5 6 (5) m ay 2 0 1 3
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.
huisarts & wetenschap
15
NH G g u id el ine
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
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