Self-help interventions for persistent physical symptoms: a systematic review of behaviour change components and their potential effects.

Persistent physical symptoms (PPS) remain a challenge in the healthcare system due to time-constrained consultations, uncertainty and limited specialised care capacity. Self-help interventions may be a cost-effective way to widen the access to treatment. As a foundation for future interventions, we aimed to describe intervention components and their potential effects in self-help interventions for PPS. A systematic literature search was made in PubMed, EMBASE, PsycINFO and CENTRAL. Fifty-one randomised controlled trials were included. Interventions were coded for effect on outcomes (standardised mean difference ≥0.2) related to symptom burden, anxiety, depression, quality of life, healthcare utilisation and sickness absence. The Behaviour Change Technique (BCT) Taxonomy v1 was used to code intervention components. An index of potential was calculated for each BCT within an outcome category. Each BCT was assessed as 'potentially effective' or 'not effective' based on a two-sided test for binomial random variables. Sixteen BCTs showed potential effect as treatment components. These BCTs represented the themes: goals and planning, feedback and monitoring, shaping knowledge, natural consequences, comparison of behaviour, associations, repetition and substitution, regulation, antecedents and identity. The results suggest that specific BCTs should be included in new PPS self-help interventions aiming to improve the patients' physical and mental health.

Managing persistent physical symptoms when being social and active is the norm: a qualitative study among young people in Denmark.

BACKGROUND: An increasing number of young people in Western countries report persistent physical symptoms (PPS). PPS may disturb everyday activities and they may have negative consequences for later adult mental and physical health. Still little is known about how young people handle PPS in their everyday lives. This study examines how young people with PPS attempt to manage their symptoms while staying engaged in their daily activities and what is at stake in these attempts. METHODS: This qualitative study involved semi-structured interviews with 11 young people with PPS. Photo-elicitation was used to capture the participants' experiences as they occurred in their everyday lives. The data material was analysed using a thematic analysis approach, as well as theory on subjectivity and social acceleration. RESULTS: The participants employed alleviating measures and tried to find patterns between their activities and the severity of their symptoms in order to adjust their activity level. Decisions not to participate in social activities were accompanied by feelings of missing out. The participants' attempts at adjusting their activity level was challenged by norms of being social and active, and they experienced difficulty prioritizing their activities and explaining their symptoms to others. CONCLUSION: PPS shaped the participants' sense of how to act towards their bodies and social relationships in interaction with societal norms. The participants' subject formation and symptom experiences should thus be seen as a biosocial process.

Designing and Developing an eHealth Program for Patients With Persistent Physical Symptoms: Usability Study.

BACKGROUND: Patients with persistent physical symptoms presenting in primary care are often affected by multiple symptoms and reduced functioning. The medical and societal costs of these patients are high, and there is a need for new interventions tailored to both the patients and health care system. OBJECTIVE: This study aimed to examine the usability of an unguided, self-help treatment program, "My Symptoms," developed to assist patients and general practitioners in symptom management. METHODS: In all, 11 users (4 patients with persistent physical symptoms and 7 laypeople) participated in web-based thinking-aloud interviews involving the performance of predefined tasks in the program. Thematic analysis was used to categorize the severity of usability issues. General usability heuristics were cross-referenced with the usability issues. RESULTS: The analysis identified important usability issues related to functionality, navigation, and content. The study shows how therapeutic knowledge in some cases was lost in the translation of face-to-face therapy to a digital format. The user testing helped uncover how the functionality of the digital elements and general navigation of the program played a huge part in locating and accessing the needed treatment. Examples of redesign to mediate the therapeutic value in the digital format involving health care professionals, web developers, and users are provided. The study also highlights the differences of involving patients and laypeople in the interviews. CONCLUSIONS: Taking the experience of common symptoms as a point of departure, patients and laypeople contributed to finding usability issues on program functionality, navigation, and content to improve the program and make the treatment more accessible to users.

Coping strategies among individuals with multiple physical symptoms: A general population-based cross-sectional study.

OBJECTIVE: Coping has been suggested as a perpetuating factor for physical symptoms. The aim of this study was to examine the use of the coping strategies approach, resignation, and diversion in individuals with multiple physical symptoms according to the construct of Bodily Distress Syndrome (BDS). METHODS: This cross-sectional study was part of the nationwide web-based survey Danish Symptom Cohort (DaSC). In total, 100,000 individuals were invited to participate, and individuals eligible for the present study were respondents aged 20-64 years without a current or recent pregnancy. Multiple physical symptoms were identified using the BDS checklist, and coping was assessed by the Brief Approach/Avoidance Coping Questionnaire. Statistical analyses included descriptive statistics and multinomial and logistic regression. RESULTS: A total of 35,810 respondents were included in the study, of which 8512 (23.8%) fulfilled the criteria for having multiple physical symptoms. This group of respondents had lower coping scores on approach and higher coping scores on resignation and diversion compared with the non-BDS group. The regression analyses showed that high scores on approach were associated with a lower probability of having multiple symptoms (adjusted OR 0.92, 95% CI: 0.91-0.92), whereas high scores on diversion and resignation were associated with a higher probability of having multiple symptoms (adjusted OR 1.10; 95% CI: 1.09-1.11 and adjusted OR 1.19; 95% CI: 1.18-1.20, respectively). CONCLUSION: The study supports the hypothesis that experiencing multiple physical symptoms is associated with certain coping strategies. This is relevant knowledge for health care professionals who will be treating this patient group.

[Facts and myths about chronic fatigue syndrome].

Contrary to its precursor, the new NICE guidelines for myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) caution against graded exercise therapy for the severely ill, and cognitive behavioural therapy is only recommended for treating consequence of ME/CFS and not the condition itself. Instead, energy management is recommended. The recommendations are based on dismissing most current evidence from studies not using new diagnostic criteria introduced by NICE or not including patient viewpoints. As argued in this review, instead of a scientific approach, the committee attaches importance to a consensus-driven approach among a biased group of specialists and patients; many associated to the ME action community.

Development of an eHealth programme for self-management of persistent physical symptoms: a qualitative study on user needs in general practice.

BACKGROUND: Persistent physical symptoms (PPS) are estimated to be present in 17% of patients in general practice. Hence, general practitioners (GPs) play a key role in both the diagnostic assessment and the management of PPS. However, research indicates a need to improve their strategies to support self-help in patients, and eHealth tools may serve as an opportunity. This study aimed to explore patients' and GPs' needs related to self-management of PPS. The study was designed to inform the future development of eHealth interventions in this field. METHODS: This qualitative study was based on 20 semi-structured interviews (6 GPs and 14 patients with PPS). Interviews were audiotaped, transcribed verbatim and analysed through a five-step thematic analysis approach. First, we conducted an inductive analysis to identify and explore emerging subthemes. Second, using a deductive mapping strategy, we categorised the derived subthemes according to the COM-B behaviour change model and its three domains: capability, opportunity and motivation. RESULTS: We identified eleven subthemes in the patient interviews and seven subthemes in the GP interviews. Several unmet needs emerged. First, we identified a need to consider PPS early in the illness trajectory by taking a bio-psycho-social approach. Second, both patients and GPs need better skills to manage uncertainty. Third, hope is important for the patients. Fourth, patients need guidance from their GP in how to self-manage their PPS. CONCLUSIONS: This study provides important insight into key issues and needs related to capability, opportunity and motivation that should be addressed in the design of future eHealth self-management interventions targeting patients with PPS in general practice in order to support and improve care.

The BDS checklist as measure of illness severity: a cross-sectional cohort study in the Danish general population, primary care and specialised setting.

OBJECTIVE: The bodily distress syndrome (BDS) checklist has proven to be useful in the diagnostic categorisation and as screening tool for functional somatic disorders (FSD). This study aims to investigate whether the BDS checklist total sum score (0-100) can be used as a measure of physical symptom burden and FSD illness severity. DESIGN: Cross-sectional. SETTING: Danish general population, primary care and specialised clinical setting. PARTICIPANTS: A general population cohort (n=9656), a primary care cohort (n=2480) and a cohort of patients with multiorgan BDS from specialised clinical setting (n=492). OUTCOME MEASURES: All data were self-reported. Physical symptoms were measured with the 25-item BDS checklist. Overall self-perceived health was measured with one item from the 36-item Short-Form Health Survey (SF-36). Physical functioning was measured with an aggregate score of four items from the SF-36/SF-12 scales 'physical functioning', 'bodily pain' and 'vitality'. Emotional distress was measured with the mental distress subscale (SCL-8) from the Danish version of the Hopkins Symptom Checklist-90. Illness worry was measured with the six-item Whiteley Index. RESULTS: For all cohorts, bifactor models established that despite some multidimensionality the total sum score of the BDS checklist adequately reflected physical symptom burden and illness severity. The BDS checklist had acceptable convergent validity with measures of overall health (r=0.25-0.58), physical functioning (r=0.22-0.58), emotional distress (r=0.47-0.62) and illness worry (r=0.36-0.55). Acceptability was good with a low number of missing responses to items (<3%). Internal consistency was high (α ≥0.879). BDS score means varied and reflected symptom burden across cohorts (13.03-46.15). We provide normative data for the Danish general population. CONCLUSIONS: The BDS checklist total sum score can be used as a measure of symptom burden and FSD illness severity across settings. These findings establish the usefulness of the BDS checklist in clinics and in research, both as a diagnostic screening tool and as an instrument to assess illness severity.

General practitioners' management of patients with psychological stress: audit results from Denmark.

BACKGROUND: In western countries, psychological stress is among the most common causes of long-lasting sick leave and a frequent reason to consult the general practitioner (GP). This study aimed to investigate how GPs manage patients with psychological stress and how the management is associated with the patient's sex, the GP's assessment of causality, and coexisting mental disorders. METHODS: We conducted an audit of consecutive cases in Danish general practice. The GPs used electronic medical records to fill in a registration form for each 18-65-year-old patient with whom they had had at least one consultation regarding stress during the past 6 months. Only patients initially in the workforce were included. Age- and sex-adjusted binary regression was applied. RESULTS: Fifty-six GPs (61% women) identified 785 cases. The patients' mean age was 44 years and 70% were women. The cause of stress was considered at least partially work-related in 69% of the cases and multifactorial in a third of cases. The management included sick leave (54%), counselling (47%), pharmaceutical treatment (37%), and referral to psychologist (38%). Compared to women, stress in men was less often considered work-related (RR: 0.84, CI95%: 0.77-0.92) and men were less often sick-listed (RR: 0.83 CI95%: 0.73-0.96) but were more often prescribed tranquilizers (RR: 1.72 CI95%: 1.08-2.74). CONCLUSIONS: GPs' management of patients with stress usually involve elements of counselling, sick leave, referral to psychologist, and medication. Women and men with stress are perceived of and managed differently.

Multiple physical symptoms and individual characteristics - A cross-sectional study of the general population.

OBJECTIVE: Multiple physical symptoms not attributable to known organic disease are common in all medical fields and associated with major personal and social consequences. This study investigated multiple physical symptoms according to the construct of bodily distress syndrome (BDS) and associated individual characteristics in the general adult population. METHODS: A nationwide, population-based study of 100,000 randomly selected individuals aged 20 years and older, conducted in 2012. A web-based questionnaire formed the basis of the study and was combined with Danish national registry data on socioeconomic factors and medication and healthcare use. RESULTS: 49,706 individuals completed the questionnaire. After exclusion of women indicating pregnancy, respondents reporting chronic disease and respondents over 65 years of age, 23,331 remained for analysis. Of these 23,331 individuals, 15.5% fulfilled the criteria for BDS. BDS positives were more often younger (20-40 years) and female. Self-rated health and self-reported functional capacity were impaired among these individuals. Fulfilling the BDS criteria was significantly associated with current or former smoking, overweight and obesity, low educational level and income, and unemployment. Moreover, individuals with BDS were more often from ethnic minorities and had higher use of healthcare and medication. CONCLUSION: Multiple physical symptoms, as captured by the concept of BDS, are common in the general adult population, especially among younger women. Fulfilling the BDS criteria is associated with substantial negative impact on self-perceived health and socioeconomic parameters. Fulfilling BDS criteria is positively associated with health risk behaviors (smoking, overweight and obesity) and higher use of healthcare and medication.

Urinary incontinence among women-which personal and professional relations are involved? A population-based study.

INTRODUCTION AND HYPOTHESIS: Urinary incontinence (UI) is frequent among women worldwide, but embarrassment and shame can prevent them from discussing symptoms with others. This study aimed to identify personal and professional relations involved by Danish women with UI. It further aimed to investigate whether age, persistence of symptoms, number of symptoms, influence on daily activities and concern about the symptoms are associated with involving personal and professional relations. METHODS: A sample of 51,090 Danish women, aged ≥ 20 years, were invited to participate in a web-based cross-sectional survey in 2012. We identified individuals with self-reported symptoms of stress incontinence, urge incontinence and UI without stress/urge and explored the involvement of personal and professional relations. Descriptive statistics and multivariate logistic regression were used for analyses. RESULTS: In total, 26,466 women completed the questionnaire. Of the 5861 (22.1%) women who had experienced a minimum of one UI symptom within the preceding 4 weeks, 71.4% did not involve any professional relations and 45.0% did not involve any personal relations. Further, 38.8% involved neither personal nor professional relations. Personal relations were most often involved, mainly those with the spouse/partner, friends and children. Involving a personal relation was associated with three to five times increased odds of involving health care professionals for all UI types. CONCLUSIONS: UI is highly prevalent, but the condition is infrequently discussed in personal and professional relations. Future research should address the quality of the contacts made and barriers to involving other people.

Prevalence of persons contacting general practice for psychological stress in Denmark.

OBJECTIVE: The prevalence of psychological stress has previously been estimated based on self-reported questionnaires. This study aimed to investigate the prevalence of persons who contact the general practitioner (GP) for psychological stress and to explore associations between psychological stress and characteristics relating to the patient, the GP, and area-specific socioeconomic factors. DESIGN: Cross-sectional computer assisted journal audit. SETTING: General practice in the Region of Southern Denmark. SUBJECTS: Patients aged 18-65 years with a consultation during a six-month period that was classified with a stress-related diagnosis code. MAIN OUTCOME MEASURES: Six months prevalence of GP-assessed psychological stress and characteristics relating to the patient, the GP, and area-specific socioeconomic factors. RESULTS: Fifty-six GPs (7% of the invited) identified 1066 patients considered to have psychological stress among 51,422 listed patients. Accordingly, a 2.1% six months prevalence of psychological stress was estimated; 69% of cases were women. High prevalence of psychological stress was associated with female sex, age 35-54 years, high education level and low population density in the municipality, but not with unemployment in the municipality or household income in the postal district. GP female sex and age <50 years, few GPs in the practice and few patients per GP were also associated with a higher prevalence of psychological stress. CONCLUSIONS: A total of 2% of the working-age population contacted the GP during a six-month period for psychological stress. The prevalence of psychological stress varies with age, sex and characteristics of both the regional area and the GP. Key points Psychological stress is a leading cause of days on sick leave, but its prevalence has been based on population surveys rather than on assessment by health care professionals. • This study found that during six months 2.1% of all working-age persons have at least one contact with the GP regarding psychological stress. • The six months prevalence of psychological stress was associated with patient age and sex, GP age and sex, practices' number of GPs and patients per GP, and area education and urbanization level.

Primary care physicians' use of the proposed classification of common mental disorders for ICD-11.

Background: The World Health Organization is revising the classification of common mental disorders in primary care for ICD-11. Major changes from the ICD-10 primary care version have been proposed for: (i) mood and anxiety disorders; and (ii) presentations of multiple somatic symptoms (bodily stress syndrome). This three-part field study explored the implementation of the revised classification by primary care physicians (PCPs) in five countries. Methods: Participating PCPs in Brazil, China, Mexico, Pakistan and Spain were asked to use the revised classification, first in patients that they suspected might be psychologically distressed (Part 1), and second in patients with multiple somatic symptoms causing distress or disability not wholly attributable to a known physical pathology, or with high levels of health anxiety (Part 2). Patients referred to Part 1 or Part 2 underwent a structured diagnostic interview. Part 3 consisted of feedback from PCPs regarding the classification. Results: In Part 1, anxious depression was the most common disorder among referred patients. PCPs assigned the highest severity ratings to anxious depression, and the next highest to current depression; current anxiety was rated as least severe. Considerable overlap was found between bodily stress syndrome (BSS) and health anxiety (HA). The psychiatric interview recorded higher rates of mood and anxiety disorders diagnoses among patients with BSS than did PCPs. PCPs' satisfaction with the revised classification was high. Conclusions: Results generally supported the inclusion of the new categories of anxious depression, BSS and HA for ICD-11 PHC and suggested that PCPs could implement these categories satisfactorily.

Screening for anxiety, depression, and anxious depression in primary care: A field study for ICD-11 PHC.

BACKGROUND: In this field study of WHO's revised classification of mental disorders for primary care settings, the ICD-11 PHC, we tested the usefulness of two five-item screening scales for anxiety and depression to be administered in primary care settings. METHODS: The study was conducted in primary care settings in four large middle-income countries. Primary care physicians (PCPs) referred individuals who they suspected might be psychologically distressed to the study. Screening scales as well as a structured diagnostic interview, the revised Clinical Interview Schedule (CIS-R), adapted for proposed decision rules in ICD-11 PHC, were administered to 1488 participants. RESULTS: A score of 3 or more on one or both screening scale predicted 89.6% of above-threshold mood or anxiety disorder diagnoses on the CIS-R. Anxious depression was the most common CIS-R diagnosis among referred patients. However, there was an exact diagnostic match between the screening scales and the CIS-R in only 62.9% of those with high scores. LIMITATIONS: This study was confined to those in whom the PCP suspected psychological distress, so does not provide information about the prevalence of mental disorders in primary care settings. CONCLUSIONS: The two five-item screening scales for anxiety and depression provide a practical way for PCPs to evaluate the likelihood of mood and anxiety disorders without paper and pencil measures that are not feasible in many settings. These scales may provide substantially improved case detection as compared to current primary care practice and a realistic alternative to complex diagnostic algorithms used by specialist mental health professionals.

"Medically unexplained" symptoms and symptom disorders in primary care: prognosis-based recognition and classification.

BACKGROUND: Many patients consult their GP because they experience bodily symptoms. In a substantial proportion of cases, the clinical picture does not meet the existing diagnostic criteria for diseases or disorders. This may be because symptoms are recent and evolving or because symptoms are persistent but, either by their character or the negative results of clinical investigation cannot be attributed to disease: so-called "medically unexplained symptoms" (MUS). MUS are inconsistently recognised, diagnosed and managed in primary care. The specialist classification systems for MUS pose several problems in a primary care setting. The systems generally require great certainty about presence or absence of physical disease, they tend to be mind-body dualistic, and they view symptoms from a narrow specialty determined perspective. We need a new classification of MUS in primary care; a classification that better supports clinical decision-making, creates clearer communication and provides scientific underpinning of research to ensure effective interventions. DISCUSSION: We propose a classification of symptoms that places greater emphasis on prognostic factors. Prognosis-based classification aims to categorise the patient's risk of ongoing symptoms, complications, increased healthcare use or disability because of the symptoms. Current evidence suggests several factors which may be used: symptom characteristics such as: number, multi-system pattern, frequency, severity. Other factors are: concurrent mental disorders, psychological features and demographic data. We discuss how these characteristics may be used to classify symptoms into three groups: self-limiting symptoms, recurrent and persistent symptoms, and symptom disorders. The middle group is especially relevant in primary care; as these patients generally have reduced quality of life but often go unrecognised and are at risk of iatrogenic harm. The presented characteristics do not contain immediately obvious cut-points, and the assessment of prognosis depends on a combination of several factors. CONCLUSION: Three criteria (multiple symptoms, multiple systems, multiple times) may support the classification into good, intermediate and poor prognosis when dealing with symptoms in primary care. The proposed new classification specifically targets the patient population in primary care and may provide a rational framework for decision-making in clinical practice and for epidemiologic and clinical research of symptoms.

Long-Term Outcome of Bodily Distress Syndrome in Primary Care: A Follow-Up Study on Health Care Costs, Work Disability, and Self-Rated Health.

OBJECTIVE: The upcoming International Classification of Diseases, 11th Revision for primary care use suggests inclusion of a new diagnostic construct, bodily (di)stress syndrome (BDS), for individuals with medically unexplained symptoms. We aimed to explore the long-term outcome of BDS in health care costs, work disability, and self-rated health. METHODS: Consecutive patients consulting their family physician for a new health problem were screened for physical and mental symptoms by questionnaires (n = 1785). A stratified subsample was examined with a standardized diagnostic interview (n = 701). Patients with single-organ BDS (n = 124) and multiorgan BDS (n = 35), and a reference group with a family physician-verified medical condition (n = 880) were included. All included patients completed a questionnaire at 3, 12, and 24 months of follow-up. Register data on health care costs and work disability were obtained after 2 and 10 years of follow-up, respectively. RESULTS: Patients with BDS displayed poorer self-rated health and higher illness worry at index consultation and throughout follow-up than the reference group (p ≤ .001). The annual health care costs were higher in the BDS groups (2270 USD and 4066 USD) than in the reference group (1392 USD) (achieved significance level (ASL) ≤ 0.001). Both BDS groups had higher risk of sick leave during the first 2 years of follow-up (RRsingle-organ BDS = 3.0; 95% confidence interval [CI] = 1.8-5.0; RRmultiorgan BDS = 3.4; 95% CI = 1.5-7.5) and substantially higher risk of newly awarded disability pension than the reference group (HRsingle-organ BDS = 4.9; 95% CI = 2.8-8.4; HRmultiorgan BDS = 8.7; 95% CI = 3.7-20.7). CONCLUSIONS: Patients with BDS have poor long-term outcome of health care costs, work disability, and subjective suffering. These findings stress the need for adequate recognition and management of BDS.

Multiple somatic symptoms in primary care: A field study for ICD-11 PHC, WHO's revised classification of mental disorders in primary care settings.

OBJECTIVE: A World Health Organization (WHO) field study conducted in five countries assessed proposals for Bodily Stress Syndrome (BSS) and Health Anxiety (HA) for the Primary Health Care Version of ICD-11. BSS requires multiple somatic symptoms not caused by known physical pathology and associated with distress or dysfunction. HA involves persistent, intrusive fears of having an illness or intense preoccupation with and misinterpretation of bodily sensations. This study examined how the proposed descriptions for BSS and HA corresponded to what was observed by working primary care physicians (PCPs) in participating countries, and the relationship of BSS and HA to depressive and anxiety disorders and to disability. METHOD: PCPs referred patients judged to have BSS or HA, who were then interviewed using a standardized psychiatric interview and a standardized measure of disability. RESULTS: Of 587 patients with BSS or HA, 70.4% were identified as having both conditions. Participants had an average of 10.9 somatic symptoms. Patients who presented somatic symptoms across multiple body systems were more disabled than patients with symptoms in a single system. Most referred patients (78.9%) had co-occurring diagnoses of depression, anxiety, or both. Anxious depression was the most common co-occurring psychological disorder, associated with the greatest disability. CONCLUSION: Study results indicate the importance of assessing for mood and anxiety disorders among patients who present multiple somatic symptoms without identifiable physical pathology. Although highly co-occurring with each other and with mood and anxiety disorders, BSS and HA represent distinct constructs that correspond to important presentations in primary care.

Multiple somatic symptoms in primary care patients: a cross-sectional study of consultation content, clinical management strategy and burden of encounter.

BACKGROUND: Consultations involving patients with multiple somatic symptoms may be considered as challenging and time-consuming by general practitioners (GPs). Yet, little is known about the possible links between consultation characteristics and GP-experienced burden of encounter. We aimed to explore consultation content, clinical management strategies, time consumption and GP-experienced burden of encounters with patients suffering from multiple somatic symptoms as defined by the concept of bodily distress syndrome (BDS). METHODS: Cross-sectional study of patient encounters in primary care from December 2008 to December 2009; 387 GPs participated (response rate: 44.4 %). Data were based on a one-page registration form completed by the GP and a patient questionnaire including the 25-item BDS checklist for somatic symptoms. Using logistic regression analyses, we compared patients who met the BDS criteria with patients who did not. RESULTS: A total of 1505 patients were included (response rate: 55.6 %). Health problems were less frequently reported as 'new' in patients with BDS (odds ratio (OR) = 0.73, 95 % confidence interval (CI): 0.54; 0.97). Medical prescriptions and referral rates were comparable in the two patient groups. Consultations focusing on mainly biomedical aspects were less frequent among patients with BDS (OR = 0.31, 95 % CI: 0.22; 0.43), whereas additional biomedical and psychosocial problems were more often discussed. GPs were more likely to ensure continuity of care in BDS patients by watchful waiting strategies (OR = 2.32, 95 % CI: 1.53; 3.52) or scheduled follow-up visits (OR = 1.61, 95 % CI: 1.09; 2.37). Patients with BDS were found to be more time-consuming (OR = 1.77, 95 % CI: 1.26; 2.48) and burdensome (OR = 2.54, 95 % CI: 1.81; 3.55) than patients without BDS. However, after adjustments for biomedical and psychosocial content of the consultation, the identified differences for time consumption and burden were no longer statistically significant. CONCLUSIONS: Patients with BDS represent higher care complexity in terms of biomedical and psychosocial needs. GPs seem to allow space and time for discussing these issues and to aim at ensuring continuity in care through watchful waiting or scheduled follow-up consultations. However, the reported GP-experienced burden call for professional development.

Symptoms as the main problem: a cross- sectional study of patient experience in primary care.

BACKGROUND: Symptoms are common in primary care. Besides providing thorough assessment of possible severe disease, the general practitioner (GP) must ensure good health care to all patients, irrespective of diagnoses. We aimed to explore patient satisfaction with the provided care and how well expectations in patients were met when no diagnosis was made during the consultation. METHOD: Cross-sectional study based on a questionnaire survey conducted in 2008-2009 among 377 GPs and their patients in the Central Denmark Region. A total of 2286 patients completed a questionnaire after the consultation (response rate: 54 %). The questionnaire included four satisfaction items from the EUROPEP instrument and a question about unmet expectations. For each patient, the GP answered a one-page registration form including information about the main problem in the consultation, chronic disorders and assessment of prognosis. Statistical analyses were adjusted for patient characteristics and GP clustering. RESULTS: A higher proportion of patients reported illness worry (20 vs. 17 %, p-value: 0.005), unmet expectations (17 vs. 13 %, p-value: 0.019) and dissatisfaction with their GP after the consultation when no diagnosis was made. Dissatisfaction was primarily related to the medical examination (adjusted OR 1.30; 95 % CI: 1.06-1.60) and GP explanations (adjusted OR 1.40; 95 % CI: 1.14-1.71). Exploratory analyses revealed an association between dissatisfaction with examination and the GP assessment that symptoms were unrelated to biomedical disease. This association was found both in patients with 'symptoms only' and patients given a specific diagnosis. CONCLUSION: GPs are challenged by patients presenting symptoms that do not fit the patterns of biomedical diagnoses. The current study demonstrates more illness worry, unmet expectations and dissatisfaction with the consultation in these patients compared to patients receiving a diagnosis. This trend is true for all patients assessed as having 'symptoms only' at the end of a consultation and not only for the minority group with 'medically unexplained symptoms'. As primary care is the frontline of the health-care system, symptoms are managed as the main problem in almost one in three consultations. It is about time that we take the same professional approach to symptoms as we have done for years to biomedical disease.