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BMC Primary Care
Published in: BMC Primary Care 1/2021

01-12-2021 | Somatoform Disorder | Research Article

Diagnostic and treatment barriers to persistent somatic symptoms in primary care – representative survey with physicians

Authors: Marco Lehmann, Nadine Janis Pohontsch, Thomas Zimmermann, Martin Scherer, Bernd Löwe

Published in: BMC Primary Care | Issue 1/2021

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Abstract

Background

Many patients consult their primary care physician with persistent somatic symptoms such as pain or sickness. Quite often these consultations and further diagnostic measures yield no medical explanation for the symptoms – patients and physicians are left in uncertainty. In fact, diagnostic and treatment barriers in primary care hinder timely health-care provision for patients suffering from persistent somatic symptoms (PSS). The significance of individual barriers is still unknown. We compare and quantify these barriers from the perspective of primary care physicians and identify subpopulations of primary care physicians who experience particular barriers as most severe.

Methods

We mailed a questionnaire to primary care physicians (PCP) in Germany and asked them which barriers they consider most important. We invited a random sample of 12,004 primary care physicians in eight federal states in Germany. Physicians provided anonymous mailed or online responses. We also mailed a postcard to announce the survey and a mail reminder. Main measures were Likert rating scales of items relating to barriers in the diagnosis and treatment of PSS in primary care. Information on demography and medical practice were also collected.

Results

We analyzed 1719 data sets from 1829 respondents. PCPs showed strongest agreement with statements regarding (1.) their lack of knowledge about treatment guidelines, (2.) their perceptions that patients with PSS would expect symptom relief, (3.) their concern to overlook physical disease in these patients, and (4.) their usage of psychotropic drugs with these patients. More experienced PCPs were better able to cope with the possibility of overlooking physical disease than those less experienced.

Conclusions

The PCPs in our survey answered that the obligation to rule out severe physical disease and the demand to relieve patients from symptoms belong to the most severe barriers for adequate treatment and diagnosis. Moreover, many physicians admitted to not knowing the appropriate treatment guidelines for these patients. Based on our results, raising awareness of guidelines and improving knowledge about the management of persistent somatic symptoms appear to be promising approaches for overcoming the barriers to diagnosis and treatment of persistent somatic symptoms in primary care.

Trial registration

German Clinical Trials Register (Deutschen Register Klinischer Studien, DRKS)
The date the study was registered: October 2nd 2017
The date the first participant was enrolled: February 9th 2018
DRKS-ID: DRKS00012942
Appendix
Available only for authorised users
Literature
1.
Hiller W, Rief W, Brähler E. Somatization in the population: from mild bodily misperceptions to disabling symptoms. Soc Psychiatry PsychiatrEpidemiol. 2006;41(9):704–12.CrossRef
2.
Steinbrecher N, Koerber S, Frieser D, Hiller W. The prevalence of medically unexplained symptoms in primary care. Psychosomatics. 2011;52(3):263–71.PubMedCrossRef
3.
Herzog A, Shedden-Mora MC, Jordan P, Löwe B. Duration of untreated illness in patients with somatoform disorders. J Psychosom Res. 2018;107:1–6.PubMedCrossRef
4.
Konnopka A, Kaufmann C, König H-H, Heider D, Wild B, Szecsenyi J, et al. Association of costs with somatic symptom severity in patients with medically unexplained symptoms. J Psychosom Res. 2013;75(4):370–5.PubMedCrossRef
5.
Barsky AJ, Orav EJ, Bates DW. Somatization increases medical utilization and costs independent of psychiatric and medical comorbidity. Arch Gen Psychiatry. 2005;62(8):903–10.PubMedCrossRef
6.
Hoedeman R, Blankenstein AH, Krol B, Koopmans PC, Groothoff JW. The contribution of high levels of somatic symptom severity to sickness absence duration, disability and discharge. J OccupRehabil. 2010;20(2):264–73.
7.
Rask MT, Carlsen AH, Budtz-Lilly A, Rosendal M. Multiple somatic symptoms in primary care patients: a cross-sectional study of consultation content, clinical management strategy and burden of encounter. BMC FamPract. 2016;17:100.
8.
Smith RC, Gardiner JC, Lyles JS, Sirbu C, Dwamena FC, Hodges A, et al. Exploration of DSM-IV criteria in primary care patients with medically unexplained symptoms. Psychosom Med. 2005;67(1):123–9.PubMedPubMedCentralCrossRef
9.
10.
Smith GR, Monson RA, Ray DC. Patients with multiple unexplained symptoms. Their characteristics, functional health, and health care utilization. Arch Internal Med. 1986;146:69–72.CrossRef
11.
van Ravenzwaaij J, Olde Hartman T, van Ravesteijn H, Eveleigh R, van Rijswijk E, Lucassen P. Explanatory models of medically unexplained symptoms: a qualitative analysis of the literature. Mental health in family medicine. 2010;7(4):223–31.PubMedPubMedCentral
12.
Nimnuan C, Hotopf M, Wessely S. Medically unexplained symptoms: an epidemiological study in seven specialities. J Psychosom Res. 2001;51(1):361–7.PubMedCrossRef
13.
Dowrick CF, Ring A, Humphris GM, Salmon P. Normalisation of unexplained symptoms by general practitioners: a functional typology. Br J Gen Pract. 2004;54(500):165–70.PubMedPubMedCentral
14.
Smith GR, Miller LM, Monson RA. Consultation-liaison intervention in somatization disorder. Hosp Community Psychiatry. 1986;37(12):1207–10.PubMed
15.
Klaus K, Rief W, Brähler E, Martin A, Glaesmer H, Mewes R. The distinction between “medically unexplained” and “medically explained” in the context of somatoform disorders. Int J Behav Med. 2013;20:161–71.PubMedCrossRef
16.
Murray AM, Toussaint A, Althaus A, Löwe B. The challenge of diagnosing non-specific, functional, and somatoform disorders: A systematic review of barriers to diagnosis in primary care. J Psychosom Res. 2016;80:1–10.PubMedCrossRef
17.
Pohontsch NJ, Zimmermann T, Jonas C, Lehmann M, Löwe B, Scherer M. Coding of medically unexplained symptoms and somatoform disorders by general practitioners - an exploratory focus group study. BMC FamPract. 2018;19(1):129.
18.
Heinbokel C, Lehmann M, Pohontsch NJ, Zimmermann T, Althaus A, Scherer M, et al. Diagnostic barriers for somatic symptom disorders in primary care: study protocol for a mixed methods study in Germany. BMJ Open. 2017;7(8):e014157-e.PubMedPubMedCentralCrossRef
19.
Roenneberg C, Sattel H, Schaefert R, Henningsen P, Hausteiner-Wiehle C. Functional Somatic Symptoms. DtschArzteblInt. 2019;116(33–34):553–60.
20.
Howman M, Walters K, Rosenthal J, Ajjawi R, Buszewicz M. “You kind of want to fix it don’t you?” Exploring general practice trainees’ experiences of managing patients with medically unexplained symptoms. BMC Med Educ. 2016;16:27.PubMedPubMedCentralCrossRef
21.
Kassenärztliche Bundesvereinigung. Statistische Informationen aus dem Bundesarztregister. 2017.
22.
Ärztestatistik zum 31. Dezember 2017. In: Bundesärztekammer, editor. 2018.
23.
INFAS Tabellenband Ärztemonitor 2018 Ergebnisse für Haus- und Fachärzte. In: Kassenärztliche Bundesvereinigung der niedergelassenen Ärzte Deutschlands e. V., editor. 2018.
24.
Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed: Hillsdale, NJ: Erlbaum; 1988.
25.
Sirri L, Grandi S, Tossani E. Medically unexplained symptoms and general practitioners: a comprehensive survey about their attitudes, experiences and management strategies. FamPract. 2017;34(2):201–5.
26.
Olde Hartman TC, Hassink-Franke LJ, Lucassen PL, van Spaendonck KP, van Weel C. Explanation and relations. How do general practitioners deal with patients with persistent medically unexplained symptoms: a focus group study. BMC FamPract. 2009;10:68.
27.
Salmon P, Humphris GM, Ring A, Davies JC, Dowrick CF. Why do primary care physicians propose medical care to patients with medically unexplained symptoms? A new method of sequence analysis to test theories of patient pressure. Psychosom Med. 2006;68:570–7.PubMedCrossRef
28.
Kleinstäuber M, Witthöft M, Steffanowski A, van Marwijk H, Hiller W, Lambert MJ. Pharmacological interventions for somatoform disorders in adults. The Cochrane database of systematic reviews. 2014:CD010628-CD.
29.
Lehmann M, Jonas C, Pohontsch NJ, Zimmermann T, Scherer M, Löwe B. General practitioners’ views on the diagnostic innovations in DSM-5 somatic symptom disorder - A focus group study. J Psychosom Res. 2019;123:109734.PubMedCrossRef
30.
Ring A, Dowrick CF, Humphris GM, Davies J, Salmon P. Thesomatising effect of clinical consultation: what patients and doctors say and do not say when patients present medically unexplained physical symptoms. SocSci Med. 2005;61(7):1505–15.CrossRef
31.
Salmon P, Dowrick CF, Ring A, Humphris GM. Voiced but unheard agendas: qualitative analysis of the psychosocial cues that patients with unexplained symptoms present to general practitioners. Br J Gen Pract. 2004;54:171–6.PubMedPubMedCentral
32.
Rasmussen EB, Rø KI. How general practitioners understand and handle medically unexplained symptoms: a focus group study. BMC FamPract. 2018;19(1):50.
33.
Olde Hartman TC, Woutersen-Koch H, Van der Horst HE. Medically unexplained symptoms: evidence, guidelines, and beyond. Br J Gen Pract. 2013;63(617):625–6.PubMedPubMedCentralCrossRef
34.
Houwen J, Lucassen PL, Stappers HW, Assendelft WJ, van Dulmen S, Olde Hartman TC. Improving GP communication in consultations on medically unexplained symptoms: a qualitative interview study with patients in primary care. Br J Gen Pract. 2017;67(663):e716–23.PubMedPubMedCentralCrossRef
35.
Bushnell J, McLeod D, Dowell A, Salmond C, Ramage S, Collings S, et al. Do patients want to disclose psychological problems to GPs? FamPract. 2005;22(6):631–7.CrossRef
36.
Lieberman JA 3rd, Stuart MR. The BATHE Method: Incorporating Counseling and Psychotherapy Into the Everyday Management of Patients. Prim Care Companion J Clin Psychiatry. 1999;1(2):35–8.PubMedPubMedCentralCrossRef
37.
Terluin B, van Marwijk HW, Ader HJ, de Vet HC, Penninx BW, Hermens ML, et al. The Four-Dimensional Symptom Questionnaire (4DSQ): a validation study of a multidimensional self-report questionnaire to assess distress, depression, anxiety and somatization. BMC Psychiatry. 2006;6:34.PubMedPubMedCentralCrossRef
38.
Hüsing P, Bassler M, Löwe B, Koch S, Toussaint A. Validity and sensitivity to change of the Somatic Symptom Disorder-B Criteria Scale (SSD-12) in a clinical population. Gen Hosp Psychiatry. 2018;55:20–6.PubMedCrossRef
39.
Toussaint A, Riedl B, Kehrer S, Schneider A, Löwe B, Linde K. Validity of the Somatic Symptom Disorder-B Criteria Scale (SSD-12) in primary care. FamPract. 2018;35:342–7.CrossRef
40.
Toussaint A, Murray AM, Voigt K, Herzog A, Gierk B, Kroenke K, et al. Development and Validation of the Somatic Symptom Disorder-B Criteria Scale (SSD-12). Psychosom Med. 2016;78(1):5–12.PubMedCrossRef
41.
Olde Hartman T, Hassink-Franke L, Dowrick C, Fortes S, Lam C, van der Horst H, et al. Medically unexplained symptoms in family medicine: defining a research agenda. Proceedings from WONCA 2007. FamPract. 2008;25(4):266–71.CrossRef
42.
Engel GL. The need for a new medical model: a challenge for biomedicine. Science. 1977;196(4286):129–36.PubMedCrossRef
43.
Kowall B, Breckenkamp J, Berg-Beckhoff G. General practitioners using complementary and alternative medicine differ from general practitioners using conventional medicine in their view of the risks of electromagnetic fields: a postal survey from Germany. J Prim Care Community Health. 2015;6:21–8.PubMedCrossRef
44.
Schnakenberg R, Goeldlin A, Boehm-Stiel C, Bleckwenn M, Weckbecker K, Radbruch L. Written survey on recently deceased patients in germany and switzerland: how do general practitioners see their role? BMC Health Serv Res. 2016;16:22.PubMedPubMedCentralCrossRef
45.
Schneider S, Diehl K, Bock C, Herr RM, Mayer M, Gorig T. Modifying health behavior to prevent cardiovascular diseases: a nationwide survey among German primary care physicians. Int J Environ Res Public Health. 2014;11(4):4218–32.PubMedPubMedCentralCrossRef
46.
Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA, et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999;282(15):1458–65.PubMedCrossRef
Metadata
Title
Diagnostic and treatment barriers to persistent somatic symptoms in primary care – representative survey with physicians
Authors
Marco Lehmann
Nadine Janis Pohontsch
Thomas Zimmermann
Martin Scherer
Bernd Löwe
Publication date
01-12-2021
Publisher
BioMed Central
Published in
BMC Primary Care / Issue 1/2021
Electronic ISSN: 2731-4553
DOI
https://doi.org/10.1186/s12875-021-01397-w

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