Background. A diagnosis is the basis of medical action, the key to various social privileges and national sick leave statistics. The objectives of this study were to investigate which diagnoses general practitioners in Scandinavia give patients with severe subjective health complaints, and what kind of treatments they suggested. Methods. One hundred and twenty-six self-selected general practitioners in Scandinavia diagnosed nine patients, presented as video vignettes, in a cross-sectional study. The main outcome measures were primary, secondary, and tertiary diagnoses. Results. The nine patients got between 13 and 31 different primary diagnoses and a large variety of secondary and tertiary diagnoses. Fifty-eight percent of the general practitioners chose different primary and secondary diagnoses, indicating that they judged the patients to have multimorbid complaints. The most commonly recommended treatment was referral to a psychologist, a mix of psychological and physical treatments, or treatment by the general practitioner. Conclusion. Scandinavian general practitioners give a large variety of symptom diagnoses, mainly psychological and general and unspecified, to patients with severe subjective health complaints. Referral to a psychologist or a mix of psychological or physical treatments was most commonly suggested to treat the patients. 1. Introduction Classification and medical coding of illness and disease capture snapshot views of a patient’s health. A diagnosis is the basis of medical action and it is the key to various social privileges [1]. Simplified diagnostic taxonomies are used to classify illness and disease for epidemiological purposes. In European primary, care the predominant system for classification and coding is the International Classification of Primary Care, Second edition (ICPC-2) [2, 3]. A diagnosis is intended to give a precise name, description, and reason for a complaint, symptom, or disease. It is also expected to guide treatment, predict prognosis, and provide social acceptance of the complaints. In addition, it works as a key to social privileges in many European countries. Patients with severe subjective health complaints (SHCs) [4] frequently seek help from their general practitioner (GP), and severe SHC is the main reason for long-term sick leave [5]. These complaints are also known as medically unexplained symptoms (MUSs), somatoform disorders, functional somatic syndrome, bodily distress syndrome, somatization disorder [6, 7], or multisystem illness [8]. Despite having the same, or similar complaints, the preferred
References
[1]
L. S. King, Medical Thinking. A Historical Prefase, Princeton University Press, Princeton, NJ, USA, 1982.
[2]
S. de Lusignan, C. Minmagh, J. Kennedy, M. Zeimet, H. Bommezijn, and J. Bryant, “A survey to identify the clinical coding and classification systems currently in use across Europe,” Medinfo, vol. 10, no. 1, pp. 86–89, 2001.
[3]
I. M. Okkes, M. Jamoulle, H. Lamberts, and N. Bentzen, “ICPC-2-E: the electronic version of ICPC-2. Differences from the printed version and the consequences,” Family Practice, vol. 17, no. 2, pp. 101–107, 2000.
[4]
H. R. Eriksen and H. Ursin, “Subjective health complaints, sensitization, and sustained cognitive activation (stress),” Journal of Psychosomatic Research, vol. 56, no. 4, pp. 445–448, 2004.
[5]
G. Tellnes. G., “Days lost by sickness certification,” Scandinavian Journal of Primary Health Care, vol. 7, no. 4, pp. 245–251, 1989.
[6]
F. Creed, E. Guthrie, P. Fink et al., “Is there a better term than “Medically unexplained symptoms”?” Journal of Psychosomatic Research, vol. 68, no. 1, pp. 5–8, 2010.
[7]
S. Wessely, C. Nimnuan, and M. Sharpe, “Functional somatic syndromes: one or many?” The Lancet, vol. 354, no. 9182, pp. 936–939, 1999.
[8]
B. D. Naliboff, “Towards a nondualistic approach to multisystem illness,” American Journal of Gastroenterology, vol. 102, no. 12, pp. 2777–2780, 2007.
[9]
E. M. Hagen, E. Svensen, H. R. Eriksen, C. M. Ihleb？k, and H. Ursin, “Comorbid subjective health complaints in low back pain,” Spine, vol. 31, no. 13, pp. 1491–1495, 2006.
[10]
B. Stubhaug, T. H. Tveito, H. R. Eriksen, and H. Ursin, “Neurasthenia, subjective health complaints and sensitization,” Psychoneuroendocrinology, vol. 30, no. 10, pp. 1003–1009, 2005.
[11]
T. Toft, P. Fink, E. Oernboel, K. Christensen, L. Frostholm, and F. Olesen, “Mental disorders in primary care: prevalence and co-morbidity among disorders. Results from the Functional Illness in Primary care (FIP) study,” Psychological Medicine, vol. 35, no. 8, pp. 1175–1184, 2005.
[12]
M. Von Korff, P. Crane, M. Lane et al., “Chronic spinal pain and physical-mental comorbidity in the United States: results from the national comorbidity survey replication,” Pain, vol. 113, no. 3, pp. 331–339, 2005.
[13]
G. Tellnes, K. O. B. Svendsen, D. Bruusgaard, and T. Bjerkedal, “Incidence of sickness certification. Proposal for use as a health status indicator,” Scandinavian Journal of Primary Health Care, vol. 7, no. 2, pp. 111–117, 1989.
[14]
A. Ring, C. F. Dowrick, G. M. Humphris, J. Davies, and P. Salmon, “The somatising effect of clinical consultation: what patients and doctors say and do not say when patients present medically unexplained physical symptoms,” Social Science and Medicine, vol. 61, no. 7, pp. 1505–1515, 2005.
[15]
R. Peveler, L. Kilkenny, and A. L. Kinmonth, “Medically unexplained physical symptoms in primary care: a comparison of self-report screening questionnaires and clinical opinion,” Journal of Psychosomatic Research, vol. 42, no. 3, pp. 245–252, 1997.
[16]
C. Burton, “Beyond somatisation: a review of the understanding and treatment of medically unexplained physical symptoms (MUPS),” British Journal of General Practice, vol. 53, no. 488, pp. 231–239, 2003.
[17]
G. Hanel, P. Henningsen, W. Herzog et al., “Depression, anxiety, and somatoform disorders: vague or distinct categories in primary care? Results from a large cross-sectional study,” Journal of Psychosomatic Research, vol. 67, no. 3, pp. 189–197, 2009.
[18]
N. Steinbrecher, S. Koerber, D. Frieser, and W. Hiller, “The prevalence of medically unexplained symptoms in primary care,” Psychosomatics, vol. 52, pp. 263–271, 2011.
[19]
O. Ekholm, M. Kj？ller, M. Davidsen, U. Hesse, L. Eriksen, and A. I. Christensen, “Health and disease in Denmark since 1987,” in Sundhet og Sygelighet in Danmark & Udviklimgen Siden, Copenhagen, Denmark, 2006.
[20]
J. M. Aiarzaguena, G. Grandes, A. Salazar, I. Gaminde, and A. Sanchez, “The diagnostic challenges presented by patients with medically unexplained symptoms in general practice,” Scandinavian Journal of Primary Health Care, vol. 26, no. 2, pp. 99–105, 2008.
[21]
M. A. van Bokhoven, H. Koch, T. van der Weijden, and G. J. Dinant, “Special methodological challenges when studying the diagnosis of unexplained complaints in primary care,” Journal of Clinical Epidemiology, vol. 61, no. 4, pp. 318–322, 2008.
[22]
H. R. Eriksen and H. Ursin, “Sensitization and subjective health complaints,” Scandinavian Journal of Psychology, vol. 43, no. 2, pp. 189–196, 2002.
[23]
J. B. Overmier, “Sensitization, conditioning, and learning: can they help us understand somatization and disability?” Scandinavian Journal of Psychology, vol. 43, no. 2, pp. 105–112, 2002.
[24]
M. Witth？ft, W. Hiller, N. Loch, and F. Jasper, “The latent structure of medically unexplained symptoms and its relation to functional somatic syndromes,” International Journal of Behavioral Medicine. In press.
[25]
V. Deary, T. Chalder, and M. Sharpe, “The cognitive behavioural model of medically unexplained symptoms: a theoretical and empirical review,” Clinical Psychology Review, vol. 27, no. 7, pp. 781–797, 2007.
[26]
C. Green and J. Holden, “Diagnostic uncertainty in general practice: a unique opportunity for research?” European Journal of General Practice, vol. 9, no. 1, pp. 13–15, 2003.
[27]
Care NCfIiHaS. ICPC-2 pager, http://www.kith.no/templates/kith_WebPage____1633.aspx.
[28]
B. Efron and R. J. Tibshirani, An Introduction to the Bootstrap, Chapman & Hall/CRC, New York, NY ,USA, 1998.
[29]
M. Rosendal, P. Fink, E. Falkoe, H. S. Hansen, and F. Olesen, “Improving the classification of medically unexplained symptoms in primary care,” European Journal of Psychiatry, vol. 21, no. 1, pp. 25–36, 2007.
[30]
S. Nilsen, E. L. Werner, S. Maeland, H. R. Eriksen, and L. H. Magnussen, “Considerations made by the general practitioner when dealing with sick-listing of patients suffering from subjective and composite health complaints,” Scandinavian Journal of Primary Health Care, vol. 29, no. 1, pp. 7–12, 2011.
[31]
R. Schaefert, G. Laux, C. Kaufmann et al., “Diagnosing somatisation disorder (P75) in routine general practice using the International Classification of Primary Care,” Journal of Psychosomatic Research, vol. 69, no. 3, pp. 267–277, 2010.
[32]
A. Ring, C. Dowrick, G. Humphris, and P. Salmon, “Do patients with unexplained physical symptoms pressurise general practitioners for somatic treatment? A qualitative study,” British Medical Journal, vol. 328, no. 7447, pp. 1057–1060, 2004.
[33]
P. Salmon, A. Ring, C. F. Dowrick, and G. M. Humphris, “What do general practice patients want when they present medically unexplained symptoms, and why do their doctors feel pressurized?” Journal of Psychosomatic Research, vol. 59, no. 4, pp. 255–262, 2005.
[34]
J. Van Ravenzwaaij, T. C. Olde Hartman, H. van Ravesteijn, R. Eveleigh, E. van Rijswijk, and P. L. B. J. Lucassen, “Explanatory models of medically unexplained symptoms: a qualitative analysis of the literature,” Mental Health in Family Medicine, vol. 7, no. 4, pp. 223–231, 2011.
[35]
V. B. Wyller, H. R. Eriksen, and K. Malterud, “Can sustained arousal explain the Chronic Fatigue Syndrome?” Behavioral and Brain Functions, vol. 5, article 10, 2009.
