Review article
Medically unexplained symptoms, somatisation disorder and hypochondriasis: Course and prognosis. A systematic review,☆☆

https://doi.org/10.1016/j.jpsychores.2008.09.018Get rights and content

Abstract

Objective

To study the course of medically unexplained symptoms (MUS), somatisation disorder, and hypochondriasis, and related prognostic factors. Knowledge of prognostic factors in patients presenting persistent MUS might improve our understanding of the naturalistic course and the identification of patients with a high risk of a chronic course.

Methods

A comprehensive search of Medline, PsycInfo, CINAHL, and EMBASE was performed to select studies focusing on patients with MUS, somatisation disorder, and hypochondriasis, and assessing prognostic factors. Studies focusing on patients with single-symptom unexplained disorder or distinctive functional somatic syndromes were excluded. A best-evidence synthesis for the interpretation of results was used.

Results

Only six studies on MUS, six studies on hypochondriasis, and one study on abridged somatisation could be included. Approximately 50% to 75% of the patients with MUS improve, whereas 10% to 30% of patients with MUS deteriorate. In patients with hypochondriasis, recovery rates vary between 30% and 50%. In studies on MUS and hypochondriasis, we found some evidence that the number of somatic symptoms at baseline influences the course of these conditions. Furthermore, the seriousness of the condition at baseline seemed to influence the prognosis. Comorbid anxiety and depression do not seem to predict the course of hypochondriasis.

Conclusions

Due to the limited numbers of studies and their high heterogeneity, there is a lack of rigorous empirical evidence to identify relevant prognostic factors in patients presenting persistent MUS. However, it seems that a more serious condition at baseline is associated with a worse outcome.

Introduction

Medically unexplained symptoms (MUS) are common in primary care [1]. In 25–50% of all primary care visits, no somatic cause is found to explain the patient's presenting symptoms [2]. It is generally believed that persistent presentation of MUS is a chronic and disabling disorder [3]. However, in many patients MUS are transient and have a good prognosis. A recent Dutch study found that only 2.5% of the attendees in general practice presenting with such symptoms meet criteria for chronicity [4].

In a recent review, researchers stated that in population-based and primary care samples, MUS is the common characteristic of the DSM-IV and ICD-10 somatoform disorders including somatisation and hypochondriasis [5], [6], [7]. Somatisation is characterized by recurrent and frequent presentation of MUS, whereas hypochondriasis is characterized by excessive worry about illness and the belief of having an undiagnosed physical disease.

Despite the low prevalence of persistent MUS, it represents a serious problem in primary care. Patients are functionally impaired, have high rates of comorbid psychiatric disorders, and are at risk for unnecessary, potentially harmful diagnostic procedures and treatments [2], [3], [8]. Moreover, part of the burden to GPs are the difficulties in explaining the symptoms, finding a shared understanding necessary to reach reassurance and acceptation of the symptoms, and the lack of treatment options [9], [10]. Often, GPs label these patients as ‘heartsink patients’ or ‘helpoholic patients’ [11]. For patients, as well as GPs and the health care system, it is important to prevent persistent MUS. Therefore, GPs should be able to recognize patients with a high risk of persistent MUS. However, GPs experience difficulties in distinguishing self-limiting MUS from persistent MUS [12]. Knowledge of prognostic factors may improve our management of patients with MUS, as patients with a good prognosis can be reassured about the favourable spontaneous recovery rates, whereas a more intensive approach including some form of reattribution or cognitive behavioural therapy might be indicated from the beginning in the high-risk groups.

The aim of our study was to gain an insight into the course of MUS and in factors influencing its course.

Section snippets

Data sources and search strategy

We systematically reviewed prospective cohort studies in primary, secondary, or tertiary care on patients with MUS, somatoform disorders, and hypochondriasis. We studied somatisation disorder, MUS, and hypochondriasis together because they appear to have much in common: medically unexplained symptoms, typical illness and sick role behaviour, disproportionate disability, and preoccupation with health and illness [7].

Although there are many other general terms to describe physical symptoms

Results

We retrieved a total of 4867 publications from searches of the various electronic bibliographies (1673 PubMed, 933 PsycINFO, 1222 CINAHL, and 1039 EMBASE) (see Fig. 1). After screening the titles and abstracts, 68 abstracts seemed to fulfill the inclusion criteria. After assessing the full publication, 13 articles fulfilled all inclusion criteria and were included in our review [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40]. Major reasons for excluding papers were

Main results

Although a lot of research has been done on the epidemiology of and interventions for medically unexplained symptoms, we are not aware of a systematic review of the literature that focuses on the course and the prognosis of medically unexplained symptoms. Creed and Barsky [7] performed a systematic review of the epidemiology of somatisation disorder and hypochondriasis to examine the characteristics and associated features of these disorders. However, they did not systematically search and

Acknowledgments

All authors participated in the research process (study design: ToH, PL, FvdL, CvW; data collection: ToH, MB; data analysis and interpretation: ToH, MB, FvdL, PL, AS. ToH, MB, and PL drafted the manuscript and all authors helped with revisions to the manuscript). ToH and MB had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. All authors approved the final version.

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    This study was supported by grant 920-03-339 from ZonMw (Netherlands Organization for Health Research and Development).

    ☆☆

    Competing interest: none.

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