[Hardnekkige aanhoudende lichamelijke klachten in de huisartsenpraktijk]. / Hardnekkige aanhoudende lichamelijke klachten in de huisartsenpraktijk.

BACKGROUND: In the care of patients with persevering (‘treatment-resistant’) persistant physical symptoms (PPS), problems are common. With this study, we want to identify starting points for improvement of care, including suggestions for the role of mental health care. AIM: Using the profile for persevering PPS we will estimate the prevalence, describe characteristics of this patient group and map problems encountered in their care. METHOD: Online survey in general practitioners (GPs). RESULTS: The response rate to the survey was 12.8%. The mean estimated prevalence of persevering PPS in general practice was 0.7% (corresponding to an estimated 122,500 patients throughout the Netherlands). Many patients encountered iatrogenic harm, experience societal problems and limitations in mobility and ADL independence. Although there was a general increased use of health care in these patients, some also avoided care or were under-treated. In the persistence of symptoms, patient-related factors played a role (like insisting on further somatic diagnostic tests, lack of motivation for PPS-specific treatment), but health-care related factors, like rejection for care or a lack of regional treatment options for patients with PPS, also had a causal role. CONCLUSION: Almost every GP experiences problems in the care for patients with persevering PPS. Mental health care professionals can support the GP better, by optimizing options for consultation and referral.

Development and User Experiences of a Biopsychosocial Interprofessional Online Course on Persistent Somatic Symptoms.

Background: Communication between healthcare providers and patients with persistent somatic symptoms (PSS) is frequently hampered by mutual misunderstanding and dissatisfaction. Methods: We developed an online, interprofessional course to teach healthcare providers the knowledge, skills, and attitude they need to diagnose and treat PSS in a patient-centered manner based on the biopsychosocial model. The course consisted of six modules of 45-60 min. Each module contained different types of assignments, based on six cases: videos, discussion boards, reading assignments, polls, and quizzes. For this study, we included (1) medical residents, following the course as part of their residency training, and (2) healthcare providers (general practitioners, medical specialists, physiotherapists, nurses, and psychologists), following the course as continuing vocational training. Throughout the course, participants were asked to fill out online surveys, enquiring about their learning gains and satisfaction with the course. Results: The biopsychosocial approach was integrated across the modules and teached health care workers about recent insights on biological, psychological and social aspects of PSS. In total, 801 participants with a wide variety in clinical experience started the course; the largest groups of professionals were general practitioners (N = 400), physiotherapists (N = 124) and mental healthcare workers (N = 53). At the start of the course, 22% of the participants rated their level of knowledge on PSS as adequate. At the end of the course, 359 participants completed the evaluation questionnaires. Of this group, 81% rated their level of knowledge on PSS as adequate and 86% felt that following the course increased their competencies in communicating with patients with PSS (N = 359). On a scale from 1 to 10, participants gave the course a mean grade of 7.8 points. Accordingly, 85% stated that they would recommend the course to a colleague. Conclusion: Our course developed in a co-design process involving multiple stakeholders can be implemented, is being used, and is positively evaluated by professionals across a variety of health care settings.

[Delayed diagnosis of Huntington's disease in a psychiatric setting]. / Vertraagde diagnose van de ziekte van Huntington in een psychiatrische setting.

Huntington's disease (hd) is characterised by a triad of neuropsychiatric symptoms, motor disturbances and cognitive decline. If initial symptoms are of neuropsychiatric nature they maybe misinterpreted, which can lead to delayed diagnosis. Three examples of delayed hd diagnosis in a psychiatric setting are discussed.

A systematic review and meta-analysis of the percentage of revised diagnoses in functional somatic symptoms.

BACKGROUND: Functional somatic symptoms (FSS) are bodily complaints of unclear etiology, which are (currently) not fully explained by well-recognized somatic pathology. Doctors are often hesitant to diagnose FSS, due to the risk to miss a somatic disease. The purpose of this study is to review available literature on the percentage of patients diagnosed with FSS reported to have an underlying somatic disease that explains their symptoms previously labeled as FSS. METHODS: We performed a systematic search of Medline, Embase and PsycINFO databases and reference lists of selected articles. We included studies published between January 1980 and July 2014 without language restrictions. Studies that measured the percentage of underlying somatic diseases after a diagnostic evaluation or naturalistic follow-up period in adult patients initially diagnosed with FSS were included. As primary outcome measure the weighted percentage of revised diagnoses was calculated using meta-analyses. RESULTS: Six diagnostic evaluation studies (total N=1804 patients) and 16 follow-up studies (total N=2440 patients) were included. The percentage of revised diagnosis in patients initially diagnosed with FSS was 8.8% (95% CI 1.0 to 22.2, p=0.007) in diagnostic evaluation studies and 0.5% (95% CI 0.01 to 1.5, p=0.03) in follow-up studies. Partially or possibly related diagnoses were rarely found. No specific somatic diagnosis seemed to be missed systematically. CONCLUSIONS: The percentage of underlying somatic diseases in patients previously diagnosed with FSS is relatively small but unneglectable.

Effects of adverse life events on heart rate variability, cortisol, and C-reactive protein.

OBJECTIVE: Our objective was to assess whether self-reported adverse life events during childhood or over the lifespan are associated with altered activity of the autonomic nervous system (ANS), the hypothalamic-pituitary-adrenal axis (HPA axis), and the immune system. METHOD: This study was performed in a population-based cohort of 1094 adults aged 33-79 years, 46.3% male, average age 53 (SD 11.4). Two waves of data were collected at a 2-year interval, enabling replication of the analyses. Cumulative exposure to adverse life events was assessed by means of the List of Threatening Experiences. ANS function was assessed by spectral analysis of heart rate variability in the high-frequency band (HRV-HF). HPA axis function was assessed by 24-h urinary free cortisol (24-h UFC) excretion. Inflammation was assessed by high-sensitive C-reactive protein (hsCRP). RESULTS: Multiple linear regression analyses did not reveal any significant associations, with the exception of one significant negative association between the lifetime score of adverse life events and HRV-HF ß = -0.028; P = 0.037 at baseline, but not at follow up 2 years later. CONCLUSION: In a large population-based cohort, adverse life events were not consistently associated with HRV-HF, 24-h UFC or (hsCRP).

[Development of (hypo)mania during discontinuation of venlafaxine in two patients with bipolar disorder]. / Een (hypo)manie tijdens de afbouw van venlafaxine bij twee patiënten met een bipolaire stoornis.

The scientific literature frequently warns that patients with bipolar disorder risk developing a (hypo)mania on starting a course of antidepressants. In this case report, however, two patients with bipolar disorder developed a (hypo)mania while their dosage of venlafaxine was being gradually tapered off. We discuss a pharmacodynamic explanation for the induction of (hypo)mania during discontinuation of venlafaxine. We also discuss alternative explanations, such as a venlafaxine withdrawal syndrome; induction of rapid cycling; difficulties in distinguishing an agitated depression and a dysphoric mania and the naturalistic course of a bipolar disorder.

Empirical foundations for the diagnosis of somatization: implications for DSM-5.

BACKGROUND: The aim of this study was to develop empirically validated criteria for the diagnoses of clinically relevant somatization. METHOD: This study was performed in a population-representative cohort consisting of 461 males (47.8%) and 503 females (52.2%), with an average age of 55.8 years (s.d.=11.1). Somatization, anxiety and depression were derived from the Composite International Diagnostic Interview. Mplus was used to perform confirmative factor analyses on the current DSM-IV symptom groups; on alternative symptom clusters previously suggested; and to perform latent class analysis in order to define an empirically derived cut-off for somatization. RESULTS: The existence of symptom groups as described in DSM-IV was not supported by our data, whereas a differentiation between cardiopulmonary, musculoskeletal, gastrointestinal and general somatic symptoms did fit our data. Latent class analysis revealed two classes characterized by few (n=859) and many (n=105) symptoms. The class of subjects could be approached by a simple cut-off of four functional symptoms (sensitivity 79%, specificity 98%, positive predictive value 82%, negative predictive value 97%) regardless of the number of organ systems involved. CONCLUSIONS: This study in a large population-representative cohort suggests that a simple symptom count can be used as a dimensional diagnosis of somatization. In those instances in which a categorical diagnosis is preferred, a simple cut-off of four out of 43 functional symptoms best fitted our data. We did not find any added value for incorporating the number of symptom clusters into the diagnostic criteria.

Intelligence is negatively associated with the number of functional somatic symptoms.

BACKGROUND: Functional somatic symptoms (FSS), that is, symptoms that cannot be conclusively explained by organic pathology, have a poorly understood aetiology. Intelligence was studied as a risk factor for FSS. It was hypothesised that intelligence is negatively associated with the number of FSS. To investigate the specific role of intelligence in FSS as opposed to medically explained symptoms (MES), the association of intelligence with FSS was compared with that of intelligence with MES. It was also hypothesised that lifestyle factors and socioeconomic factors mediate the relationship between intelligence and both FSS and MES, whereas psychological distress is especially important for FSS. METHODS: All analyses were performed in a longitudinal study with two measurement waves in a general population cohort of 947 participants (age 33-79 years, 47.9% male). The Generalized Aptitude-Test Battery was used to derive an index for general intelligence, and the somatisation section of the Composite International Diagnostic Interview was used to measure the number of FSS and MES. RESULTS: General intelligence was significantly associated with the number of FSS. The association of intelligence and FSS but not MES was mediated by work situation: participants of lower intelligence who reported more FSS were more often (unwanted) economically inactive. No evidence was found for a mediating role of psychological distress in the association of intelligence with FSS, even though distress was an important predictor of FSS. CONCLUSION: Intelligence is negatively associated with the number of FSS in the general population. Part of the association of intelligence with FSS is explained by a more unfavourable work situation for adults of lower intelligence.