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36 - Developing links with primary care

from Part V - Different treatment settings

Published online by Cambridge University Press:  10 December 2009

By
Richard Morriss ,
Linda Gask ,
Christopher Dowrick ,
Peter Salmon  and
Sarah Peters
Edited by
Geoffrey Lloyd  and
Elspeth Guthrie
Geoffrey Lloyd
Affiliation:
Priory Hospital, London
Elspeth Guthrie
Affiliation:
University of Manchester
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Summary

Introduction

Most liaison psychiatry is practised in the general-hospital setting, but increasingly services for the physically ill are becoming community based. Family practitioners play a key role in identifying patients with comorbid physical and psychological distress. This chapter describes the developments over the last 10 years in the detection and treatment of patients with medically unexplained symptoms in a primary-care setting.

Medically unexplained symptoms in primary care

Medically unexplained symptoms (MUS) are defined as physical symptoms that doctors cannot explain by physical pathology, which distress or impair the functioning of the patient (Peveler et al. 1997). Patients with MUS seek help from the family doctor and are frequently unwilling to consult mental health professionals or non-medical personnel because many of these patients believe that they have a physical health problem (Kirmayer & Robbins 1996). Around 75% of patients with MUS persisting for more than six months (persistent medically unexplained symptoms or PMUS) are still distressed and/or functionally impaired by them 12 months later (Kroenke & Spitzer 1998; Moore et al. 2000). Persistent MUS is the most common reason for frequent attendance to the family doctor (Jyvasjarvi et al. 1998), and a frequent source of family doctor frustration (Mathers & Gash 1995). Family doctors express lower satisfaction with care for patients with PMUS than patients with psychological problems (Hartz et al. 2000).

Keywords

liaison psychiatrymedically unexplained symptomspersistant medically unexplained symptomsphysical pathologyrandomized controlled trialsprimary-care settingpsychological distress
Type
Chapter
Information
Handbook of Liaison Psychiatry , pp. 847 - 870
Publisher: Cambridge University Press
Print publication year: 2007

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References

Allen, L. A., Gara, M. A., Escobar, J. I., et al. (2001). Somatization: a debilitating syndrome in primary care. Psychosomatics, 42, 63–7.Google Scholar
American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders, 4th edn. Washington DC: American Psychiatric Association.
Barry, C. A., Bradley, C. P., Britten, N., et al. (2000). Patients' unvoiced agendas in general practice consultations: qualitative study. British Medical Journal, 320, 1246–50.Google Scholar
Barsky, A. J., Ettner, S. L., Horsky, J., et al. (2001). Resource utilization of patients with hypochondriacal health anxiety and somatization. Medical Care, 39, 705–15.Google Scholar
Bass, C. and Benjamin, S. (1993). The management of chronic somatization. British Journal of Psychiatry, 162, 472–80.Google Scholar
Blankenstein, A. H., van der Horst, H. E., Schilte, A. F., et al. (2001a). Development and feasibility of a modified reattribution model for somatising patients applied by their own general practitioners. In Somatising Patients in General Practice: Reattribution, a Promising Approach, ed. Blankenstein, A. H.. Ph.D. Thesis. Amsterdam: Vrije University, pp. 33–48.
Blankenstein, A. H., van der Horst, H. E., Schilte, A. F., et al. (2001b). Effectiveness of reattribution for somatisation in general practice, a randomized controlled trial. In Somatising Patients in General Practice: Reattribution, a Promising Approach, ed. Blankenstein, A. H.. Ph.D. Thesis. Amsterdam: Vrije University, pp. 49–65.
Bouman, T. K. and Visser, S. (1998). Cognitive and behavioural treatment of hypochondriasis. Psychotherapy and Psychosomatics, 67, 214–21.Google Scholar
Bruster, S., Jarman, B., Bosanquet, N., et al. (1994). National survey of hospital patients. British Medical Journal, 309, 1542–9.Google Scholar
Cathebras, P., Jacquin, L., Gal, M., et al. (1995). Correlates of somatic causal attributions in primary care patients with fatigue. Psychotherapy and Psychosomatics, 63, 174–80.Google Scholar
Cherkin, D. C., Eisenberg, D., Sherman, K. J., et al. (2001). Randomized trial comparing traditional Chinese medical acupuncture, therapeutic massage, and self-care education for chronic low back pain. Archives of Internal Medicine, 161, 1081–8.Google Scholar
Clark, D. M., Salkovskis, P. M., Hackmann, A., et al. (1998). Two psychological treatments for hypochondriasis. A randomized controlled trial. British Journal of Psychiatry, 173, 218–25.Google Scholar
Clements, A., Sharpe, M., Simkin, S., et al. (1997). Chronic fatigue syndrome: a qualitative investigation of patients' beliefs about the illness. Journal of Psychosmatic Research, 42, 615–24.Google Scholar
Cope, H., David, A., Pelosi, A., et al. (1994). Predictors of chronic ‘post-viral’ fatigue. Lancet, 344, 864–8.Google Scholar
Davis, D. A. and Taylor-Vaisey, A. (1997). Translating guidelines into practice. A systematic review of theoretic concepts, practical experience and research evidence in the adoption of clinical practice guidelines. Canadian Medical Association Journal, 157, 408–16.Google Scholar
Davis, D. A., Thomson, M. A., Oxman, A. D., et al. (1995). Changing physician performance. A systematic review of the effect of continuing medical education strategies. Journal of the American Medical Association, 274, 700–5.Google Scholar
Di Blasi, Z., Harkness, E., Ernst, E., et al. (2001). Influence of context effects on health outcomes: a systematic review. Lancet, 357, 757–62.Google Scholar
Donovan, J. L. and Blake, D. R. (2000). Qualitative study of interpretation of reassurance among patients attending rheumatology clinics: ‘just a touch of arthritis, doctor?’British Medical Journal, 320, 541–4.Google Scholar
Downes-Grainger, E., Morriss, R., Gask, L., et al. (1998). Clinical factors associated with short-term changes in outcome of patients with somatized mental disorder in primary care. Psychological Medicine, 28, 703–11.Google Scholar
Epstein, R. M., Quill, T. E. and McWhinney, I. R. (1999). Somatization reconsidered: incorporating the patient's experience of illness. Archives of Internal Medicine, 159, 215–22.Google Scholar
Faravelli, C., Salvatori, S., Galassi, F., et al. (1997). Epidemiology of somatoform disorder: a community survey in Florence. Social Psychiatry and Psychatric Epidemiology, 32, 24–9.Google Scholar
Fava, G. A., Grandi, S., Rafanelli, C., et al. (2000). Explanatory therapy in hypochondriasis. Journal of Clinical Psychiatry, 61, 317–22.Google Scholar
Fink, P., Sorensen, L., Engberg, M., et al. (1999). Somatization in primary care. Prevalence, health care utilization, and general practitioner recognition. Psychosomatics, 40, 330–8.Google Scholar
Fulcher, K. Y. and White, P. D. (1997). Randomised controlled trial of graded exercise in patients with the chronic fatigue syndrome. British Medical Journal, 314, 1647–52.Google Scholar
Garcia-Campayo, J., Larrubia, J., Lobo, A., et al. (1997). Attribution in somatizers: stability and relationship to outcome at 1-year follow-up. Grupo Morbilidad Psiquica y Psicosomatica de Zaragoza (GMPPZ). Acta Psychiatrica Scandinavica, 95, 433–8.Google Scholar
Garcia-Campayo, J., Sanz-Carrillo, C., Yoldi-Elcid, A., et al. (1998). Management of somatisers in primary care: are family doctors motivated?Australia and New Zealand Journal of Psychiatry, 32, 528–33.Google Scholar
Gask, L. and Morriss, R. (1999). Training general practitioners in mental health skills. Epidemiologia e Psichiatria Sociale, 8, 79–84.Google Scholar
Gask, L., Goldberg, D., Porter, R., et al. (1989). The treatment of somatization: evaluation of a teaching package with general practice trainees. Journal of Psychosomatic Research, 33, 697–703.Google Scholar
Goldberg, D., Gask, L. and O'Dowd, T. (1989). The treatment of somatisation; teaching techniques of reattribution. Journal of Psychosomatic Research, 33, 689–95.Google Scholar
Goldberg, R. J., Novack, D. H. and Gask, L. (1992). The recognition and management of somatisation: what is needed in primary care training. Psychosomatics, 33, 55–61.Google Scholar
Gureje, O. and Obikoya, B. (1992). Somatization in primary care: pattern and correlates in a clinic in Nigeria. Acta Psychiatrica Scandinavica, 86, 223–7.Google Scholar
Gureje, O. and Simon, G. E. (1999). The natural history of somatization in primary care. Psychological Medicine, 29, 669–76.Google Scholar
Han, J. N., Stegen, K., Valck, C., et al. (1996). Influence of breathing therapy on complaints, anxiety and breathing pattern in patients with hyperventilation syndrome and anxiety disorders. Journal of Psychosomatic Research, 41, 481–93.Google Scholar
Hardy, P. (1995). Epidemiology of somatoform disorders in the general French population. Encephale, 21, 191–9.Google Scholar
Hartmann, P. M. (1989). A pilot study of a modified Balint group using cognitive approaches to physician attitudes about somatoform disorder patients. International Journal of Psychosomatics, 36, 86–9.Google Scholar
Hartz, A. J., Noyes, R., Bentler, S. E., et al. (2000). Unexplained symptoms in primary care: perspectives of doctors and patients. General Hospital Psychiatry, 22, 144–52.Google Scholar
Hellman, C. J. C., Budd, M., Borysenko, J., et al. (1990). A study of effectiveness of two group behavioral medicine interventions for patients with psychosomatic complaints. Behavioral Medicine, 16, 165–73.Google Scholar
Hunt, L. M., Jordan, B. and Irwin, S. (1989). Views of what's wrong: diagnosis and patients' concepts of illness. Social Science and Medicine, 28, 945–56.Google Scholar
Jackson, J. L., Chamberlin, J. and Kroenke, K. (2001). Predictors of patient satisfaction. Social Science and Medicine, 52, 609–20.Google Scholar
Jorgensen, C. K., Fink, P. and Olesen, F. (2000). Psychological distress and somatisation as prognostic factors in patients with musculoskeletal illness in general practice. British Journal of General Practice, 50, 537–41.Google Scholar
Jyvasjarvi, S., Keinanen-Kiukaanniemi, S., Vaisanen, E., et al. (1998). Frequent attenders in a Finnish health centre: morbidity and reasons for encounter. Scandinavian Journal of Primary Health Care, 16, 141–8.Google Scholar
Jyvasjarvi, S., Joukamaa, M., Vaisanen, E., et al. (1999). Alexithymia, hypochondriacal beliefs, and psychological distress among frequent attenders in primary health care. Comprehensive Psychiatry, 40, 292–8.Google Scholar
Jyvasjarvi, S., Joukamaa, M., Vaisanen, E., et al. (2001). Somatizing frequent attenders in primary health care. Journal of Psychosomatic Research, 50, 185–92.Google Scholar
Kaaya, S., Goldberg, D. and Gask, L. (1992). Management of somatic presentations of psychiatric illness in general medical settings: evaluation of a new training course for general practitioners. Medical Education, 26, 138–44.Google Scholar
Katon, W., Korff, M., Lin, E., et al. (1992). A randomized trial of psychiatric consultation with distressed high utilisers. General Hospital Psychiatry, 14, 86–98.Google Scholar
Kerwick, S., Jones, R., Mann, A., et al. (1997). Mental health care training priorities in general practice. British Journal of General Practice, 47, 225–7.Google Scholar
Kirmayer, L. J. and Robbins, J. M. (1996). Patients who somatize in primary care: a longitudinal study of cognitive and social characteristics. Psychological Medicine, 26, 937–51.Google Scholar
Kisely, S., Goldberg, D. and Simon, G. (1997). A comparison between somatic symptoms with and without clear organic cause: results of an international study. Psychological Medicine, 27, 1011–19.Google Scholar
Kroenke, K. and Spitzer, R. L. (1998). Gender differences in the reporting of physical and somatoform symptoms. Psychosomatic Medicine, 60, 150–5.Google Scholar
Kroenke, K. and Swindle, R. (2000). Cognitive-behavioral therapy for somatization and symptom syndromes: a critical review of controlled clinical trials. Psychotherapy and Psychosomatics, 69, 205–15.Google Scholar
Kroenke, K., Spitzer, R. L., deGruy, F. V. 3rd, et al. (1997). Multisomatoform disorder; an alternative to undifferentiated somatoform disorder for the somatizing patient in primary care. Archives of General Psychiatry, 54, 352–8.Google Scholar
Levenstein, J. H., McCracken, E. C., McWhinney, I. R., et al. (1986). The patient-centered clinical method. 1. A model for the doctor-patient interaction in family medicine. Family Practice, 3, 24–30.Google Scholar
Lidbeck, J. (1997). Group therapy for somatization disorders in general practice: effectiveness of a short cognitive-behavioural treatment model. Acta Psychiatrica Scandinavica, 96, 14–24.Google Scholar
Lipowski, Z. J. (1988). Somatization: the concept and its clinical application. American Journal of Psychiatry, 145, 1358–68.Google Scholar
Little, P., Everitt, H., Williamson, I., et al. (2001). Preferences of patients for patient-centred approach to consultation in primary care: observational study. British Medical Journal, 322, 468–72.Google Scholar
Lucock, M. P., Morley, C., White, C., et al. (1997). Responses of consecutive patients to reassurance after gastroscopy: results of self-administered questionnaire study. British Medical Journal, 315, 572–5.Google Scholar
Mannion, A. F., Muntener, M., Taimela, S., et al. (2001). Comparison of three active therapies for chronic low back pain: results of a randomised clinical trial with one year follow-up. Rheumatology, 40, 772–8.Google Scholar
Mathers, N. and Gask, L. (1995). Surviving the ‘heartsink’ experience. Family Practice, 12, 176–83.Google Scholar
McDonald, I. G., Daly, J., Jelinek, V. M., et al. (1996). Opening Pandora's box; the unpredictability of reassurance by a normal test result. British Medical Journal, 313, 329–32.Google Scholar
McGrady, A., Lynch, D., Nagel, R., et al. (1999). Application of the high risk model of threat perception to a primary care population. Journal of Nervous and Mental Disease, 187, 369–75.Google Scholar
Moore, J. E., Korff, M., Cherkin, D., et al. (2000). A randomized controlled trial of a cognitive-behavioral program for enhancing back pain self care in a primary care setting. Pain, 88, 145–53.Google Scholar
Morley, S., Eccleston, C. and Williams, A. (1999). Systematic review and meta-analysis of randomized controlled trials of cognitive behavior therapy for chronic pain in adults, excluding headache. Pain, 80, 1–13.Google Scholar
Morriss, R. K. (1992). Interviewing skills and the detection of psychiatric problems. International Review of Psychiatry, 4, 287–92.Google Scholar
Morriss, R. and Gask, L. (2002). The effects of reattribution training for patients with somatized mental disorder on outcomes under the direct control of the family doctor. Psychosomatics, 43, 394–9.Google Scholar
Morriss, R., Gask, L., Ronalds, C., et al. (1998). Cost-effectiveness of a new treatment for somatized mental disorder taught to GPs. Family Practice, 15, 119–25.Google Scholar
Morriss, R. K., Gask, L., Ronalds, C., et al. (1999). Clinical and patient satisfaction outcomes of a new treatment for somatized mental disorder taught to general practitioners. British Journal of General Practice, 49, 263–7.Google Scholar
O'Dowd, T. (1988). Five years of heartsink patients in general practice. British Medical Journal, 297, 528–30.Google Scholar
O'Malley, P. G., Jackson, J. L., Santoro, J., et al. (1999). Antidepressant therapy for unexplained symptoms and symptom syndromes. Journal of Family Practice, 48, 980–90.Google Scholar
Patel, V., Pereira, J. and Mann, A. H. (1998). Somatic and psychological models of common mental disorder in primary care in India. Psychological Medicine, 28, 135–43.Google Scholar
Peters, S., Stanley, I., Rose, M., et al. (1998). Patients with medically unexplained symptoms: sources of patients' authority and implications for demands on medical care. Social Science and Medicine, 46, 559–65.Google Scholar
Petrie, K., Weinman, J., Sharpe, N., et al. (1996). Role of patients' views of their illness in predicting return to work and functioning after myocardial infarction: longitudinal study. British Medical Journal, 30, 747–57.Google Scholar
Peveler, R., Kilkenny, L. and Kinmonth, A. L. (1997). Medically unexplained symptoms in primary care: a comparison of self-report screening questionnaires and clinical opinion. Journal of Psychosomatic Research, 42, 245–52.Google Scholar
Piccinelli, M. and Simon, G. (1997). Gender and cross-cultural differences in somatic symptoms associated with emotional distress. An international study in primary care. Psychological Medicine, 27, 433–44.Google Scholar
Piccinelli, M., Rucci, P., Ustun, B., et al. (1999). Typologies of anxiety, depression and somatization symptoms among primary care attenders with no formal mental disorder. Psychological Medicine, 29, 677–88.Google Scholar
Powell, P., Bentall, R. P., Nye, F. J., et al. (2001). Randomized controlled trial of patient education to encourage graded exercise in chronic fatigue syndrome. British Medical Journal, 322, 387–90.Google Scholar
Ridsdale, L., Evans, A., Jerrett, W., et al. (1994). Patients who consult with tiredness: frequency of consultation, perceived causes of tiredness and its association with psychological distress. British Journal of General Practice, 44, 413–16.Google Scholar
Rossy, L. A., Buckelew, S. P., Dorr, N., et al. (1999). A meta-analysis of fibromyalgia treatment interventions. Annals of Behavioural Medicine, 21, 180–91.Google Scholar
Rost, K., Kashner, T. M. and Smith, G. R. (1994). Effectiveness of psychiatric intervention with somatization disorder patients: improved outcomes at reduced costs. General Hospital Psychiatry, 16, 381–7.Google Scholar
Salmon, P., Wolonyshynowych, M. and Valori, R. (1996). The measurement of beliefs about physical symptoms in English general practice patients. Social Science and Medicine, 42, 1561–7.Google Scholar
Salmon, P., Peters, S. and Stanley, I. (1999). Patients' perceptions of medical explanations for somatisation disorders: qualitative analysis. British Medical Journal, 318, 372–6.Google Scholar
Scharloo, M., Kaptein, A. A., Weinman, J., et al. (2000). Patients' illness perceptions and coping as predictors of functional status in psoriasis: a 1-year follow-up. British Journal of Dermatology, 142, 899–907.Google Scholar
Schilte, A. F., Portegijs, P. J. M., Blankenstein, A. H., et al. (2000). Somatisation in primary care: clinical judgement and standardised measurement compared. Social Psychiatry and Psychiatric Epidemiology, 35, 276–82.Google Scholar
Schilte, A. F., Blankenstein, A. H., Portegijs, P. J. M., et al. (2001a). Predictors of prognosis in long-term somatisation in primary care, the role of stress. In Somatising Patients in General Practice: Reattribution, a Promising, Approach, ed. Blankenstein, A. H.. Ph.D. Thesis. Amsterdam: Vrije University, pp. 67–78.
Schilte, A. F., Portegijs, P. J. M., Blankenstein, A. H., et al. (2001b). Is disclosure of emotionally important events effective in somatisation in primary care? A randomized controlled trial. British Medical Journal, 323, 86–9.Google Scholar
Simon, G., Korff, M., Piccinelli, M., et al. (1999). An international study of the relation between somatic symptoms and depression. New England Journal of Medicine, 341, 1329–35.Google Scholar
Simon, G. E., Gureje, O. and Fullerton, C. (2001). Course of hypochondriasis in an international primary care study. General Hospital Psychiatry, 23, 51–5.Google Scholar
Smith, G. R., Monson, R. A. and Ray, D. C. (1986). Psychiatric consultation in somatization disorder: a randomized controlled study. New England Journal of Medicine, 314, 1407–13.Google Scholar
Smith, G. R., Rost, K. and Kashner, T. M. (1995). A trial of the effect of a standardized psychiatric consultation on health outcomes and costs in somatizing patients. Archives of General Psychiatry, 52, 238–43.Google Scholar
Speckens, A. E. M., Spinhoven, P., Hemert, A. M., et al. (2000). The Reassurance Questionnaire (RQ): psychometric properties of a self-report questionnaire to assess reassurability. Psychological Medicine, 30, 841–7.Google Scholar
Stewart, M., Brown, J. B., Weston, W. W., et al. (1995). Patient-centered Medicine Transforming the Clinical Method. Thousand Oaks: Sage Publications.
Sumithipala, A., Hewege, S., Hanwella, R., et al. (2000). Randomized controlled trial of cognitive behavior therapy for repeated medically unexplained complaints: a feasibility study in Sri Lanka. Psychological Medicine, 20, 747–57.Google Scholar
Thomson O'Brien, M. A., Oxman, A. D., Davis, D. A., et al. (2000). Educational outreach visits: effects on professional practice and health care outcomes. Cochrane Database Systematic Review, 2, CD000409.Google Scholar
Tulder, M. W., Malmivaara, A., Esmail, R., et al. (2001). Exercise therapy for low back pain. Cochrane Database Systematic Review, 4.Google Scholar
Walker, E. A., Unutzer, J. and Katon, W. J. (1998). Understanding and caring for the distressed patient with multiple medically unexplained symptoms. Journal of the American Board of Family Practice, 11, 347–56.Google Scholar
Wearden, A. J., Morriss, R. K., Mullis, R., et al. (1998). Randomised, double-blind, placebo-controlled treatment trial of fluoxetine and graded exercise for chronic fatigue syndrome. British Journal of Psychiatry, 172, 485–90.Google Scholar
Weich, S., Lewis, G., Donmall, R., et al. (1995). Somatic presentation of psychiatric morbidity in general practice. British Journal of General Practice, 45, 143–7.Google Scholar
Weinman, J., Petrie, K. J., Moss-Morris, R., et al. (1996). The Illness Perception Questionnaire: a new method for assessing the cognitive representation of illness. Psychological Health, 11, 457–63.Google Scholar
Wilkinson, P. and Mynors-Wallis, L. (1994). Problem-solving therapy in the treatment of unexplained physical symptoms in primary care; a preliminary study. Journal of Psychosomatic Research, 38, 591–8.Google Scholar
Woloshynowych, M., Valori, R. and Salmon, P. (1998). General practice patients' beliefs about their symptoms. British Journal of General Practice, 48, 885–9.Google Scholar

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