Presentation of the Multidisciplinary Guideline Medically Unexplained Physical Symptoms (MUPS) and Somatoform Disorder in the Netherlands: disease management according to risk profiles.

OBJECTIVE: January 2011, the Dutch Multidisciplinary Guideline for Medically Unexplained Symptoms (MUPS) and Somatoform Disorder (SD) was published. The aim was to set a standard for multidisciplinary prevention, diagnosis and treatment of MUPS and SD. METHODS: First, the Multidisciplinary Guideline group defined a conceptual approach for the guideline. After this, a systematic literature review, followed by consensus meetings in the Multidisciplinary working group, aimed to answer the following questions: 1) What evidence exists for preventive interventions, including the patient-doctor communication in MUPS and SD? 2) How can the diagnosis of MUPS be established? 3) What effective treatments of MUPS are available? 4) Which types of treatment are most effective for which patients? RESULTS: As conceptual approach for the guideline, based on existing literature, in this guideline MUPS are considered a category of symptoms that have many common aspects and are best approached by one, generic approach. 1) Research for preventive interventions and the patient-doctor relationship in MUPS and SD is scanty. 2) To establish the diagnosis of MUPS or SD, the GP should follow a parallel somatic-psychosocial diagnostic step plan. 3) A Systematic Review identified Cognitive Behavioral Treatment (CBT), treatment of comorbid depressive and anxiety disorder, psychiatric consultation with a Consultation Letter to General Practitioners (GPs) and stepped care as evidence based interventions for MUPS and SD. 4) 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 reassurement 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. CONCLUSION: Disease-managament based on risk profiles, providing stepped care and case management by the GP, supported by psychiatric consultation with a consultation letter, and mental health in-patient multidisciplinary treatment for severe cases, is the recommended strategy of the Dutch Multidisciplinary Guideline for MUPS and SD.

[The Dutch multidisciplinary guideline entitled 'Medically unexplained physical symptoms and somatoform disorder']. / De Nederlandse multidisciplinaire richtlijn 'Somatisch onvoldoende verklaarde lichamelijke klachten en somatoforme stoornissen'

The Dutch multidisciplinary guideline called 'Medically unexplained physical symptoms (MUPS) and somatoform disorder' presents a disease-management approach based on three pillars: (a) maintaining patient profiles estimating the risk of iatrogenic harm as well as chronicity, (b) stepped-care treatment starting at a level appropriate for the patient's profile, and (c) the introduction of the family physician as case manager (in serious cases: the medical specialist or psychiatrist) whose task is to channel use of the health care system. Patients with a 'minor risk' profile require psycho-education and two-track treatment by the family physician. The 'moderate risk' profile is complicated by co-morbid depression, anxiety disorder or a somatic disorder; the prognosis is favourable when this co-morbidity is treated. The 'serious risk' profile is assigned to patients with long-term somatoform disorders and a history of surgery for MUPS in addition to disturbed patient-doctor relationships. Limiting iatrogenic harm is of highest priority in these patients. Implementation should focus on providing access to care as described in the guideline.

[The multidisciplinary guideline 'Diagnosis and treatment of people with whiplash-associated disorder I or II']. / De multidisciplinaire richtlijn 'Diagnostiek en behandeling van mensen met een whiplash associated disorder I of II'.

A multidisciplinary guideline for the intake and treatment of whiplash patients has been developed with regard to the impact of whiplash on public health and social security. This guideline is restricted to uncomplicated whiplash, which is defined as the sudden acceleration and deceleration of the skull with energy transfer to the neck without neurological sequelae or fractures. In whiplash victims who are not alert, have pain of the neck, diminished cervical mobility or pain on palpation of the cervical vertebrae, an X ray of the cervical spine should be carried out to exclude fractures. Following whiplash if complications have been excluded, active neck exercise treatment is the correct approach. The patient should start this as soon as possible. After uncomplicated whiplash, rest and immobilisation are undesirable.