How to diagnose and treat medically unexplained physical symptoms and somatoform disorders

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A multidisciplinary group of Dutch scientists have produced a guideline to help diagnose and treat medically unexplained physical symptoms (MUPS) and somatoform disorders (SD) in primary care, hospitals and occupational health settings.

The guideline summarises the best available evidence and attempts to answer 4 key questions, for which the following findings are presented:

1. Preventive interventions, including patient-doctor communication

  • The guideline found no RCTs concerned with the prevention of MUPS
  • The guideline only retrieved one RCT that looked at open doctor-patient communication between GPs and patients using a systemic approach in the primary care psychiatric consultation. The trial found that this approach was effective in terms of severity of MUPS

2. Diagnosis

  • The guideline found no validated instruments that could be recommended for identifying MUPS and SD in non-psychiatric settings
  • Instead, the guideline presents a consensus-based stepwise diagnostic procedure and patient–doctor communication strategy

3. Treating MUPS

  • A systematic review identified Cognitive Behavioural Therapy (CBT), treatment of comorbid depressive and anxiety disorder, psychiatric consultation with a consultation letter to GPs and stepped care as evidence based interventions for MUPS and SD
  • In view of the prognosis and the risk associated with high health care utilisation patterns in patients with MUPS and SD, a disease management approach was deemed appropriate

4. Treating different types of patients

  • In order to apply the best fitting treatment to patients, patient risk profiles were formulated to guide stepped-care treatment that should start at an appropriate level and treatment setting. Three levels are discerned:
    • Low risk patients need reassuring by the GP
    • Moderate risk patients suffer from comorbidity. They need case-management and generally can be treated by the GP as well, who can be supported by psychiatric consultation
    • High risk patients often have long term SD and a perturbed patient-doctor relationship with their GP. For this group, specialist mental health treatment is needed

The guideline concludes with the following implications for practice and research:

A disease management approach is recommended in which risk profiles are defined and a stepped care algorithm for treatment is described.

Thorough diagnostic procedures, for somatic as well as mental disorder, explanation of the symptoms and psychoeducation provided in a parallel track diagnostic procedure by the GP, followed by case management by the GP aimed at limiting iatrogenic harm is of high priority in these patients. Case management can be provided by the GP, and in case of serious somatic problems or comorbidity by a medical specialist or general hospital psychiatrist.

High risk patients should receive treatment by a multidisciplinary team in a psychiatric setting.

In case of (sick-listed) employees with MUPS and SD the occupational health physician should also follow the guideline.

Further research is needed for validation of screening instruments for MUPS and SD, for preventive interventions, and for interventions aimed at improvement of the patient–doctor relationship in MUPS.

van der Feltz-Cornelis CM, Hoedeman R, Keuter EJ, Swinkels JA. Presentation of the Multidisciplinary Guideline Medically Unexplained Physical Symptoms (MUPS) and Somatoform Disorder in the Netherlands: Disease management according to risk profiles (PDF). J Psychosom Res. 2012 Feb;72(2):168-9. Epub 2011 Dec 9.

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