Functional disorders - new proposals for definition, psychosomatics, somatization. / Zaburzenia funkcjonalne ­ nowe propozycje definicji, klasyfikacji, psychosomatyka, somatyzacja.

Functional Disorders are common medical problems both in primary and in secondary health care. The mechanisms that cause symptoms such as primary pain, fatigue, dizziness are still unknown. Various classifications, including ICD-10 or DSM-5, describe these conditions differently, and new proposals are being developed e.g. in ICD-11, RDoC. Many controversies are evoked by lack of unequivocal explanatory theory. The early psychoanalytical concept has been modified by other explanations, such as immunological abnormalities, dysfunction of vegetative system and HPA axis, central sensitization, diverted processes of perception or predictive processes within cognitive homeostasis dysregulation. Insufficient scientific evidence makes therapies unsuccessful and justifies further study. Psychotherapy, pharmacology and complementary medicine are supplemented by new experimental methods of treatment connected with progress in neuroscience. The recently developed non-invasive Transcranial Direct Current Stimulation (tDCS), Transcranial Magnetic Stimulation (TMS) and - neurofeedback (EEG-NF), based on EEG registration, are undergoing tests. Applying complex mathematical algorithms to localized bioelectrical signal sources makes it possible to modulate and reshape connections of neuronal networks within specific cortex areas. This article presents the current state of knowledge concerning functional disorders, highlighting the ways in which different definitions of FD have an impact on approaches to treatment.

Nine Forward-Backward Translations of the Hopkins Symptom Checklist-25 With Cultural Checks.

Introduction: The Hopkins Symptom Checklist-25 (HSCL-25) is an effective, reliable, and ergonomic tool that can be used for depression diagnosis and monitoring in daily practice. To allow its broad use by family practice physicians (FPs), it was translated from English into nine European languages (Greek, Polish, Bulgarian, Croatian, Catalan, Galician, Spanish, Italian, and French) and the translation homogeneity was confirmed. This study describes this process. Methods: First, two translators (an academic translator and an FP researcher) were recruited for the forward translation (FT). A panel of English-speaking FPs that included at least 15 experts (researchers, teachers, and practitioners) was organized in each country to finalize the FT using a Delphi procedure. Results: One or two Delphi procedure rounds were sufficient for each translation. Then, a different translator, who did not know the original version of the HSCL-25, performed a backward translation in English. An expert panel of linguists compared the two English versions. Differences were listed and a multicultural consensus group determined whether they were due to linguistic problems or to cultural differences. All versions underwent cultural check. Conclusion: All nine translations were finalized without altering the original meaning.

PSYCHLOPS in Polish primary care: how do clients conceptualise their problems on a patient-generated outcome measure?

BACKGROUND: PSYCHLOPS, a patient-generated mental health outcome questionnaire, invites clients to describe the problem that troubles them most. PSYCHLOPS was utilised in Polish primary care in the context of a brief CBT-based intervention for mild to moderate mental health problems. AIM: To explore how patients conceptualise their problems and the consequences of these problems with the aid of PSYCHLOPS. METHOD: 243 patients were recruited from a primary care setting; 241 completed PSYCHLOPS. Free-text data were obtained from the Problem and Function domains of PSYCHLOPS, blind translated into English and independently analysed using a pre-existing thematic framework. A total of 780 free-text responses were analysed. RESULTS: The most commonly reported responses to the pre-therapy Problem domain category were "somatic" (denoting responses relating to physical health); the most common responses to the Function domain category were "competence/performance" (denoting responses relating to the respondents' perceived ability to achieve, cope, function). Compared with pre-therapy Problem 1 domain categories, during-therapy responses revealed a higher proportion of the "interpersonal" category (denoting responses relating to social relationships) and a lower proportion of the "somatic" category. CONCLUSIONS: Despite the brevity of clients' responses, PSYCHLOPS allowed an insight into patients' most troubling problems and their consequences. Possible reasons underlying the transition from a somatic to an interpersonal problem reporting during the course of talking therapy are discussed.

Patients' experiences of living with medically unexplained symptoms (MUS): a qualitative study.

BACKGROUND: Patients with medically unexplained symptoms (MUS) are common in primary care, and pose a communicative and therapeutic challenge to GPs. Although much has been written about GPs' frustration and difficulties while dealing with these patients, research presenting the patients' perspectives on MUS still seems to be scarce. Existing studies have demonstrated the patients' desire to make sense of symptoms, addressed the necessity for appropriate and acceptable explanation of MUS, and revealed stigmatization of patients with symptoms of mental origin. Treatment in primary care should focus on the patient's most essential needs and concerns. The objective of this paper is to explore Polish patients' perspectives on living with MUS. METHODS: A qualitative content analysis of 20 filmed, semi-structured interviews with patients presenting MUS (8 men and 12 women, aged 18 to 57) was conducted. All patients were diagnosed with distinctive somatoform disorders (F45), and presented the symptoms for at least 2 years. The interviews were transcribed verbatim and analysed independently by two researchers. RESULTS: Four major themes emerged: (1) experiences of symptoms; (2) explanations for symptoms; (3) coping; (4) expectations about healthcare. Within the first theme, the patients identified the following sub-themes: persistence of symptoms or variability, and negative emotions. Patients who observed that their symptoms had changed over time were better disposed to accept the existence of a relationship between the symptoms and the mind. The second theme embraced the following sub-themes: (1) personal explanations; (2) social explanations; (3) somatic explanations. The most effective coping strategies the patients mentioned included: the rationalization of the symptoms, self-development and ignoring the symptoms. The majority of our respondents had no expectations from the healthcare system, and stated they did not use medical services; instead, they admitted to visiting psychologists or psychiatrists privately. CONCLUSION: Patients with MUS have their own experiences of illness. They undertake attempts to interpret their symptoms and learn to live with them. The role of the GP in this process is significant, especially when access to psychological help is restricted. Management of patients with MUS in the Polish healthcare system can be improved, if access to psychologists and psychotherapists is facilitated and increased financial resources are allocated for primary care. Patients with MUS can benefit from a video/filmed consultation with a follow-up analysis with their GP.

The linguistic validation of the gut feelings questionnaire in three European languages.

BACKGROUND: Physicians' clinical decision-making may be influenced by non-analytical thinking, especially when perceiving uncertainty. Incidental gut feelings in general practice have been described, namely, as "a sense of alarm" and "a sense of reassurance". A Dutch Gut Feelings Questionnaire (GFQ) was developed, validated and afterwards translated into English following a linguistic validation procedure. The aims were to translate the GFQ from English into French, German and Polish; to describe uniform elements as well as differences and difficulties in the linguistic validation processes; to propose a procedural scheme for future GFQ translations into other languages. METHODS: We followed a structured, similar and equivalent procedure. Forward and backward-translations, repeated consensus procedures and cultural validations performed in six steps. Exchanges between the several research teams, the authors of the Dutch GFQ, and the translators involved continued throughout the procedure. RESULTS: 12 translators, 52 GPs and 8 researchers in the field participated to the study in France, Germany, Switzerland and Poland. The collaborating research teams created three versions of the 10-item GFQ. Each research team found and agreed on compromises between comparability and similarity on one hand, and linguistic and cultural specificities on the other. CONCLUSIONS: The gut feeling questionnaire is now available in five European languages: Dutch, English, French, German and Polish. The uniform procedural validation scheme presented, and agreed upon by the teams, can be used for the translation of the GFQ into other languages. Comparing results of research into the predictive value of gut feelings and into the significance of the main determinants in five European countries is now possible.

Self-Care for Common Colds by Primary Care Patients: A European Multicenter Survey on the Prevalence and Patterns of Practices-The COCO Study.

Background. Patients use self-care to relieve symptoms of common colds, yet little is known about the prevalence and patterns across Europe. Methods/Design. In a cross-sectional study 27 primary care practices from 14 countries distributed 120 questionnaires to consecutive patients (≥18 years, any reason for consultation). A 27-item questionnaire asked for patients' self-care for their last common cold. Results. 3,074 patients from 27 European sites participated. Their mean age was 46.7 years, and 62.5% were females. 99% of the participants used ≥1 self-care practice. In total, 527 different practices were reported; the age-standardized mean was 11.5 (±SD 6.0) per participant. The most frequent self-care categories were foodstuffs (95%), extras at home (81%), preparations for intestinal absorption (81%), and intranasal applications (53%). Patterns were similar across all sites, while the number of practices varied between and within countries. The most frequent single practices were water (43%), honey (42%), paracetamol (38%), oranges/orange juice (38%), and staying in bed (38%). Participants used 9 times more nonpharmaceutical items than pharmaceutical items. The majority (69%) combined self-care with and without proof of evidence, while ≤1% used only evidence-based items. Discussion. This first cross-national study on self-care for common colds showed a similar pattern across sites but quantitative differences.

How do general practitioners recognize the definition of multimorbidity? A European qualitative study.

BACKGROUND: Multimorbidity is a challenging concept for general practice. An EGPRN working group has published a comprehensive definition of the concept of multimorbidity. As multimorbidity could be a way to explore complexity in general practice, it was of importance to explore whether European general practitioners (GPs) recognize this concept and whether they would change it. OBJECTIVES: To investigate whether European GPs recognize the EGPRN concept of multimorbidity and whether they would change it. METHODS: Focus group meetings and semi-structured interviews as data collection techniques with a purposive sample of practicing GPs from every country. Data collection continued until saturation was reached in every country. The analysis was undertaken using a grounded theory based method. In each national team, four independent researchers, working blind and pooling data, carried out the analysis. To ensure the internationalization of the data, an international team of 10 researchers pooled the axial and selective coding of all national teams to check the concept and highlight emerging themes. RESULTS: The maximal variation and saturation of the sample were reached in all countries with 211 selected GPs. The EGPRN definition was recognized in all countries. Two additional ideas emerged, the use of Wonca's core competencies of general practice, and the dynamics of the doctor-patient relationship for detecting and managing multimorbidity and patient's complexity. CONCLUSION: European GPs recognized and enhanced the EGPRN concept of multimorbidity. These results open new perspectives regarding the management of complexity using the concept of multimorbidity in general practice. [Box: see text].

Self-Care Practices for Common Colds by Primary Care Patients: Study Protocol of a European Multicenter Survey-The COCO Study.

Background. Self-care for common colds is frequent, yet little is known about the spectrum, regional differences, and potential risks of self-care practices in patients from various European regions. Methods/Design. We describe the study protocol for a cross-sectional survey in 27 primary care centers from 14 European countries. At all sites, 120 consecutive adult patients, who visit their general practitioner for any reason, filled in a self-administered 27-item questionnaire. This addresses patients' self-care practices for common colds. Separately, the subjective level of discomfort when having a common cold, knowing about the diseases' self-limited nature, and medical and sociodemographic data are requested. Additionally, physicians are surveyed on their use of and recommendations for self-care practices. We are interested in investigating which self-care practices for common colds are used, whether the number of self-care practices used is influenced by knowledge about the self-limited nature of the disease, and the subjective level of discomfort when having a cold and to identify potential adverse interactions with chronic physician-prescribed medications. Further factors that will be considered are, for example, demographic characteristics, chronic conditions, and sources of information for self-care practices. All descriptive and analytical statistics will be performed on the pooled dataset and stratified by country and site. Discussion. To our knowledge, COCO is the first European survey on the use of self-care practices for common colds. The study will provide new insight into patients' and general practitioners' self-care measures for common colds across Europe.

Association between genetic variants on chromosome 15q25 locus and several nicotine dependence traits in Polish population: a case-control study.

Tobacco smoking continues to be a leading cause of disease and mortality. Recent research has confirmed the important role of nicotinic acetylcholine receptor (nAChR) gene cluster on chromosome 15q 24-25 in nicotine dependence and smoking. In this study we tested the association of smoking initiation, age at onset of daily smoking, and heaviness of smoking with five single nucleotide polymorphisms (SNPs) within the CHRNA5-CHRNA3-CHRNB4 cluster. The group of 389 adult subjects of European ancestry from the north of Poland, including 212 ever (140 current and 72 former) and 177 never smokers with mean age 49.26, was genotyped for rs16969868, rs1051730, rs588765, rs6495308, and rs578776 polymorphisms. Distributions of genotypes for rs16969868 and rs1051730 were identical so they were analyzed together. Further analysis revealed the association between rs16969868-1051730 (OR = 2.66; 95% CI: 1.30-5.42) and number of cigarettes smoked per day (CPD) with heaviness of nicotine addiction measured by the Fagerström Test for Nicotine Dependence (FTND) (OR = 2.60; 95% CI: 1.24-5.43). No association between these polymorphisms and other phenotypes was found. Similarly, the association between rs588765, rs6495308, rs578776, and analyzed phenotypes was not confirmed. This study provides strong evidence for the role of the CHRNA5-CHRNA3-CHRNB4 cluster in heaviness of nicotine addiction.

The European general practice research network presents the translations of its comprehensive definition of multimorbidity in family medicine in ten European languages.

BACKGROUND: Multimorbidity, according to the World Health Organization, exists when there are two or more chronic conditions in one patient. This definition seems inaccurate for the holistic approach to Family Medicine (FM) and long-term care. To avoid this pitfall the European General Practitioners Research Network (EGPRN) designed a comprehensive definition of multimorbidity using a systematic literature review. OBJECTIVE: To translate that English definition into European languages and to validate the semantic, conceptual and cultural homogeneity of the translations for further research. METHOD: Forward translation of the EGPRN's definition of multimorbidity followed by a Delphi consensus procedure assessment, a backward translation and a cultural check with all teams to ensure the homogeneity of the translations in their national context. Consensus was defined as 70% of the scores being higher than 6. Delphi rounds were repeated in each country until a consensus was reached. RESULTS: 229 European medical expert FPs participated in the study. Ten consensual translations of the EGPRN comprehensive definition of multimorbidity were achieved. CONCLUSION: A comprehensive definition of multimorbidity is now available in English and ten European languages for further collaborative research in FM and long-term care.

Cross-Cultural Validation of the Definition of Multimorbidity in the Bulgarian Language.

INTRODUCTION: Multimorbidity is a health issue with growing importance. During the last few decades the populations of most countries in the world have been ageing rapidly. Bulgaria is affected by the issue because of the high prevalence of ageing population in the country with multiple chronic conditions. The AIM of the present study was to validate the translated definition of multimorbidity from English into the Bulgarian language. MATERIALS AND METHODS: The present study is part of an international project involving 8 national groups. We performed a forward and backward translation of the original English definition of multimorbidity using a Delphi consensus procedure. RESULTS: The physicians involved accepted the definition with a high percentage of agreement in the first round. The backward translation was accepted by the scientific committee using the Nominal group technique. DISCUSSION: Some of the GPs provided comments on the linguistic expressions which arose in order to improve understanding in Bulgarian. The remarks were not relevant to the content. The conclusion of the discussion, using a meta-ethnographic approach, was that the differences were acceptable and no further changes were required. CONCLUSIONS: A native version of the published English multimorbidity definition has been finalized. This definition is a prerequisite for better management of multimorbidity by clinicians, researchers and policy makers.

Say it in Croatian--Croatian translation of the EGPRN definition of multimorbidity using a Delphi consensus technique.

Patients coming to their family physician (FP) usually have more than one condition or problem. Multimorbidity as well as dealing with it, is challenging for FPs even as a mere concept. The World Health Organization (WHO) has simply defined multimorbidity as two or more chronic conditions existing in one patient. However, this definition seems inadequate for a holistic approach to patient care within Family Medicine. Using systematic literature review the European General Practitioners Research Network (EGPRN) developed a comprehensive definition of multimorbidity. For practical and wider use, this definition had to be translated into other languages, including Croatian. Here presented is the Croatian translation of this comprehensive definition using a Delphi consensus procedure for forward/backward translation. 23 expert FPs fluent in English were asked to rank the translation from 1 (absolutely disagreeable) to 9 (fully agreeable) and to explain each score under 7. It was previously defined that consensus would be reached when 70% of the scores are above 6. Finally, a backward translation from Croatian into English was undertaken and approved by the authors of the English definition. Consensus was reached after the first Delphi round with 100% of the scores above 6; therefore the Croatian translation was immediately accepted. The authors of the English definition accepted the backward translation. A comprehensive definition of multimorbidity is now available in English and Croatian, as well as other European languages which will surely make further implications for clinicians, researchers or policy makers.

Motivations toward smoking cessation, reasons for relapse, and modes of quitting: results from a qualitative study among former and current smokers.

BACKGROUND: Smoking cessation plays a crucial role in reducing preventable morbidity and mortality and is a recognized public-health-policy issue in many countries. Two of the most important factors that affect the efficacy of quitting smoking are motivation and the ability to cope with situations causing relapse. AIM: The objective of the study reported here was to investigate former and current smokers' motivations for smoking cessation, reasons for relapse, and modes of quitting. METHODS: We arranged four focus groups with 24 participants (twelve current and twelve former smokers) and eleven semi-structured interviews (five current and six former smokers) with a view to understanding and categorizing their opinions on motivations and the course and process of smoking cessation. The data were next analyzed using descriptive qualitative methods. RESULTS: THREE MAIN THEMES WERE IDENTIFIED: (1) motivations to quit smoking, (2) reasons why smokers sometimes relapse, and (3) modes of quitting smoking. Within the first theme, the following six subthemes surfaced: (1) a smoking ban at home and at work due to other people's wishes and rules, (2) the high cost of cigarettes, (3) the unpleasant smell, (4) health concern, (5) pregnancy and breastfeeding, and (6) a variety of other factors. The second theme encompassed the following subthemes: (1) stress and the need to lessen it by smoking a cigarette, (2) the need to experience the pleasure connected with smoking, and (3) the smoking environment both at home and at work. Participants presented different smoking-cessation modes, but mainly they were unplanned attempts. CONCLUSION: Two very important motivations for smoking cessation were a smoking ban at home and at work due to other people's wishes and rules, and the high cost of cigarettes. The most common smoking-cessation mode was a spontaneous decision to quit, caused by a particular trigger factor. Relapse causes encompassed, most notably: stress, lack of the pleasure previously obtained from smoking, and the smoking environment.

"What kind of general practitioner do I need for smoking cessation?" Results from a qualitative study in Poland.

BACKGROUND: Cigarette smoking remains the leading preventable cause of death and disease. Thus, all activities aiming to reduce smoking play an important role in improving population health. The positive role of the general practitioner (GP) in smoking cessation could increase the success rate for quitting smoking, if compared with unassisted cessation. The aim of this study was to determine what kind of general practitioner smokers need in order to stop smoking. METHODS: Four focus groups with 12 current and 12 former smokers (aged 20-59, 11 women and 13 men), were arranged in the city of Torun, Poland, with a view to describe their opinions on the GP's role in smoking cessation. The data were subjected to descriptive qualitative content analysis. RESULTS: Two major themes emerged in the analysis: the smokers' positive and negative experiences of the GP in smoking cessation and their expectations regarding the role of the GP in smoking cessation. The first theme embraced the following subthemes: (1) GP's passivity, (2) routine questions about the patient's smoking during the visit, (3) lack of time during the visit, and (4) the role model of the GP in smoking cessation. Within the second theme, the respondents identified the following subthemes: (1) bringing up the topic of smoking cessation, even in situations when the patient is unprepared for this; (2) the necessity of a tailored approach to the patient; (3) access to information and evidence confirming the harms of smoking tobacco; (4) prescription of pharmacological and other treatment; and (5) referral to specialists in smoking cessation. CONCLUSIONS: Patients expect their GP to actively participate in smoking cessation through a more tailored approach to the patient's needs. The patients' experiences did not match their expectations: the smokers rarely got advice on smoking cessation from their GPs. Finally, they emphasized the importance of the GP as a role model in smoking cessation.

The European General Practice Research Network presents a comprehensive definition of multimorbidity in family medicine and long term care, following a systematic review of relevant literature.

BACKGROUND: Multimorbidity is a new concept encompassing all the medical conditions of an individual patient. The concept links into the European definition of family medicine and its core competencies. However, the definition of multimorbidity and its subsequent operationalization are still unclear. The European General Practice Research Network wanted to produce a comprehensive definition of multimorbidity. METHOD: Systematic review of literature involving eight European General Practice Research Network national teams. The databases searched were PubMed, Embase, and Cochrane (1990-2010). Only articles containing descriptions of multimorbidity criteria were selected for inclusion. The multinational team undertook a methodic data extraction, according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. RESULTS: The team identified 416 documents, selected 68 abstracts, included 54 articles, and found 132 definitions with 1631 different criteria. These criteria were aggregated into 11 themes that led to the following definition: Multimorbidity is defined as any combination of chronic disease with at least one other disease (acute or chronic) or biopsychosocial factor (associated or not) or somatic risk factor. Any biopsychosocial factor, any risk factor, the social network, the burden of diseases, the health care consumption, and the patient's coping strategies may function as modifiers (of the effects of multimorbidity). Multimorbidity may modify the health outcomes and lead to an increased disability or a decreased quality of life or frailty. CONCLUSION: This study has produced a comprehensive definition of multimorbidity. The resulting improvements in the management of multimorbidity, and its usefulness in long term care and in family medicine, will have to be assessed in future studies.

Evaluating the cross-cultural validity of the Polish version of the Four-Dimensional Symptom Questionnaire (4DSQ) using differential item functioning (DIF) analysis.

BACKGROUND: The original Dutch Four-Dimensional Symptom Questionnaire (4DSQ), which measures distress, depression, anxiety and somatization, has been translated into Polish with the aim of providing primary health care with a good screening instrument for the detection of the most prevalent mental health problems (anxiety, somatization, depression and distress). AIM: To check if the Polish version is cross-culturally valid so that the scores of Polish subjects can be compared with the scores of Dutch subjects and the Dutch cut-off points can be used in Polish subjects. METHOD: 4DSQ data were collected from a mixed sample of students and primary care attendees. The Polish data were compared with the 4DSQ data of a matched sample of Dutch students and primary care attendees. Two methods of differential item functioning (DIF) analysis, ordinal logistic regression and generalized Mantel-Haenszel, were used to detect items with DIF, and linear regression analysis was used to estimate the scale-level impact of DIF. RESULTS: Four items showing DIF were detected in the distress scale, one in the somatization scale and one in the anxiety scale. The DIF in distress caused Polish subjects with moderate scores to score circa 1 point less than their Dutch counterparts. CONCLUSIONS: The results of the DIF analyses suggest that the Polish 4DSQ measures the same constructs as the Dutch 4DSQ and that the Dutch norms can be used for the Polish subjects, except for distress: the first cut-off point should be one point lower.

Challenges in the management of patients with medically unexplained symptoms in Poland: a qualitative study.

BACKGROUND: Patients with medically unexplained symptoms (MUS) are highly prevalent in primary care. There are no guidelines for treatment and management of this group of patients in the Polish health care system and the establishment of a long-term doctor-patient relationship, which is the crux of the therapy, is impeded. OBJECTIVE: To establish what challenges Polish GPs encounter while dealing with patients with MUS. METHOD: A thematic analysis of 4 focus groups (14 GPs altogether), using a three-level coding of data. RESULTS: Three main themes surfaced in the analysis: negative emotions among the investigated GPs, their insufficient training in the management of patients with MUS and the lack of guidelines and the influence of the changed health care environment on the management of patients with MUS. Four major influences of the changed health care environment emerged: GPs' negative image as professionals, barriers to building a continuous doctor-patient relationship, limited resources and limited access to specialists and lack of a multidisciplinary primary care team. CONCLUSIONS: Treatment and management of patients with MUS should make provision for a personalized approach to the patient within the Polish primary health care system. This can be enhanced by providing additional training in the biopsychosocial model during medical education and establishing a GP multidisciplinary team. Allocating increased financial resources for primary health care and facilitating access to psychologists and psychotherapists could also prove beneficial.

Measuring psychological change during cognitive behaviour therapy in primary care: a Polish study using 'PSYCHLOPS' (Psychological Outcome Profiles).

BACKGROUND: Psychological outcome measures are evolving into measures that depict progress over time. Interval measurement during therapy has not previously been reported for a patient-generated measure in primary care. We aimed to determine the sensitivity to change throughout therapy, using 'PSYCHLOPS' (Psychological Outcome Profiles), and to determine if new problems appearing during therapy diminish overall improvement. METHODS: Responses to PSYCHLOPS, pre-, during- and post-therapy were compared. SETTING: patients offered brief cognitive behaviour therapy in primary care in Poland. RESULTS: 238 patients completed the pre-therapy questionnaire, 194 (81.5%) the during-therapy questionnaire and 142 the post-therapy questionnaire (59.7%). For those completing all three questionnaires (n = 135), improvement in total scores produced an overall Effect Size of 3.1 (2.7 to 3.4). We estimated change using three methods for dealing with missing values. Single and multiple imputation did not significantly change the Effect Size; 'Last Value Carried Forward', the most conservative method, produced an overall Effect Size of 2.3 (1.9 to 2.6). New problems during therapy were reported by 81 patients (60.0%): new problem and original problem scores were of similar magnitude and change scores were not significantly different when compared to patients who did not report new problems. CONCLUSION: A large proportion of outcome data is lost when outcome measures depend upon completed end of therapy questionnaires. The use of a during-therapy measure increases data capture. Missing data still produce difficulties in interpreting overall effect sizes for change. We found no evidence that new problems appearing during therapy hampered overall recovery.