Review articleMedically unexplained symptoms, somatisation disorder and hypochondriasis: Course and prognosis. A systematic review☆,☆☆
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.
References (67)
- et al.
Common symptoms in ambulatory care: incidence, evaluation, therapy, and outcome
Am J Med
(1989) - et al.
A systematic review of the epidemiology of somatisation disorder and hypochondriasis
J Psychosom Res
(2004) - et al.
Somatoform disorders-new approaches to classification, conceptualization, and treatment
J Psychosom Res
(2004) - et al.
The prognosis of minor depression in the general population: a systematic review
Gen Hosp Psychiatry
(2004) - et al.
Prognostic factors of whiplash-associated disorders: a systematic review of prospective cohort studies
Pain
(2003) - et al.
Systematic review of prognostic cohort studies on shoulder disorders
Pain
(2004) - et al.
Personality and affect as determinants of medically unexplained symptoms in primary care; a follow-up study
J Psychosom Res
(2004) - et al.
Predictors of remission in DSM hypochondriasis
Compr Psychiatry
(2000) - et al.
One-year follow-up of medical outpatients with hypochondriasis
Psychosomatics
(1994) - et al.
Course of hypochondriasis in an international primary care study
Gen Hosp Psychiatry
(2001)
Diagnosis and treatments of hypochondriacal syndromes
Psychosomatics
Psychiatric comorbidity among patients with hypochondriasis
Gen Hosp Psychiatry
Somatization and medicalization in the era of managed care
JAMA
Somatization and hypochondriasis
Persistent presentation of medically unexplained symptoms in general practice
Fam Pract
Diagnostic and statistical manual of mental disorders
The ICD-10 classification of mental and behavioural disorders: diagnostic criteria for research
Psychiatric consultation in somatization disorder. A randomized controlled study
N Engl J Med
Patient satisfaction with medical care for low-back pain
Spine
Explaining the unexplainable: family physicians' management of patients who frequently present medically unexplained symptoms. A focus group study
Ann Fam Med
Somatization reconsidered: incorporating the patient's experience of illness
Arch Intern Med
A randomised controlled trial of brief training in assessment and treatment of somatisation: effects on GPs' attitudes
Fam Pract
ABC of psychological medicine: Functional somatic symptoms and syndromes
BMJ
Inclusion of women in clinical trials–policies for population subgroups
N Engl J Med
Users' guides to the medical literature. V. How to use an article about prognosis. Evidence-Based Medicine Working Group
JAMA
Optimal search strategies for identifying mental health content in MEDLINE: an analytic survey
Ann Gen Psychiatry
A coefficient of agreement for nominal scales
Educational and psychological measurement
The prognosis of different fatigue diagnostic labels: a longitudinal survey
Fam Pract
Perspectives on prognosis of soft tissue musculoskeletal disorders
Int J Rehabil Res
Systematic reviews of evaluations of prognostic variables
BMJ
Evaluation of the quality of prognosis studies in systematic reviews
Ann Intern Med
How to practice and teach EBM. Guidelines
Physical risk factors for neck pain
Scand J Work Environ Health
Cited by (194)
Mental Health, Ill-Defined Conditions, and Health Care Utilization Following Bereavement: A Prospective Case-Control Study
2022, Journal of the Academy of Consultation-Liaison PsychiatryCitation Excerpt :Although we did not observe elevated rates of cardiovascular, endocrine, and immune-related conditions as in prior studies, the 2-year period may have been too short for the development of serious and chronic conditions. A systematic review of 6 studies of the course of medically unexplained symptoms46 indicated that 50%–75% of patients improve, but 10%–30% of patients deteriorate over 6–15 months. Given the possibility that this diagnosis may portend poor long-term outcomes, the necessity of proactive health care monitoring in this population of widows is indicated.
Health anxiety and attentional control interact to predict uncertainty-related attentional biases
2022, Journal of Behavior Therapy and Experimental PsychiatryHealth Anxiety
2022, Comprehensive Clinical Psychology, Second EditionHealthcare professionals' perspectives on a blended care program in primary care; A qualitative study
2021, Internet Interventions
- ☆
This study was supported by grant 920-03-339 from ZonMw (Netherlands Organization for Health Research and Development).
- ☆☆
Competing interest: none.