The diagnostic challenges presented by patients with medically unexplained symptoms in general practice

Figures & data

Table I.  Characteristics of 156 somatizing patients in primary care.

		Mental disorder
	Total (n = 156)	Yes (n = 129)	No (n = 27)
Age, years (SD)	46.9 (11.1)	46.4 (11.0)	49.4 (11.8)
Women,%	81.4 (74.3–88.5)	83.7 (76.75–90.69)	70.4 (49.5–91.3)
Patients who attribute symptoms entirely to physical causes,%	30.8 (23.4–38.2)	31.8 (23.58–39.98)	25.9 (6.55–45.31)
Average number of active symptoms in the last year
Medically unexplained	11.8 (10.6–12.9)	12.1 (10.8–13.4)	10.2 (8.0–12.4)
Medically explained	2.8 (2.2–3.3)	2.8 (2.2–3.4)	2.6 (1.5–3.7)
The 10 most frequent medically unexplained symptoms,%
Headache	64.1 (56.2–72.0)	60.5 (50.8–70.1)	59.3 (35.29–83.2)
Excess gases	61.5 (51.8–71.3)	65.1 (56.4–73.8)	59.3 (38.7–79.8)
Gastric pain	60.3 (52.1–68.0)	61.2 (50.3–72.2)	63.0 (45.4–80.5)
Back pain	55.8 (46.7–64.8)	54.3 (45.2–63.3)	63.9 (39.2–86.7)
Dyspnoea	53.2 (43.9–62.5)	55.8 (46.19–65.44)	40.7 (18.41–63.07)
Palpitations	52.6 (42.8–62.3)	54.3 (43.9–64.6)	44.4 (20.0–68.9)
Articular pain	50.6 (40.8–60.4)	50.39 (39.7–61.1)	51.8 (27.6–76.1)
Pain in the lower limbs	50.6 (40.8–60.4)	51.9 (40.8–63.1)	44.4 (18.9–70.0)
Paraesthesia/numbness	48.7 (41.1–56.3)	50.4 (42.4–58.4)	40.7 (14.2–67.2)
Chest pain	46.1 (38.1–54.2)	48.8 (40.2–57.4)	33.3 (10.7–55.9)
Physical morbidity categories,%
Acute minor	43.6 (34.0–53.2)	43.4 (32.9–53.9)	44.4 (23.5–65.4)
Severe acute	36.5 (29.0–44.6)	35.7 (28.3–43.0)	40.7 (18.9–62.5)
Recurrent	45.5 (35.5–55.5)	45.7 (35.0–56.4)	44.4 (20.9–68.0)
Chronic stable	37.2 (27.5–46.8)	38.8 (28.8–48.7)	29.6 (10.0–49.2)
Chronic unstable	11.5 (5.7–17.4)	11.6 (5.4–17.8)	11.1 (0.0–24.2)
Mental disorders,%
Depression	33.3 (24.9–41.8)	40.3 (30.5–50.1)	––
Anxiety	5.8 (1.84–9.7)	7.0 (2.24–11.71)	––
Anxiety and depression	42.9 (33.2–52.7)	51.9 (41.3–62.6)	––
Comorbidity^1,%
One or more categories	97.4 (93.4–100)	100	85.2 (63.0–100)
Two or more categories	78.2 (69.8–86.6)	82.2 (74.7–89.6)	59.2 (34.3–84.2)
Three or more categories	53.2 (43.5–62.9)	58.9 (49.1–68.7)	25.9 (6.5–45.3)
Four or more categories	22.4 (15.1–29.8)	27.1 (18.2–36.1)	––
Five or more categories	5.8 (1.8–9.9)	7.0 (2.2–11.7)	––

Notes: Unless otherwise indicated, values are the mean (95% CI). ¹Calculated by adding up physical morbidity and mental health diagnoses.

Table II.  Predictive positive value of some symptoms analysed individually and as clusters.

Symptoms	n (%; CI 95%)	Positive predictive value (PPV)	IC 95% PPV
Digestive system pathology
Gastric pain	119 (76.3; 67.6–85.0)	18/119 (15.2%)	8.3%–22.0%
Vomiting	114 (73.1; 65.7–80.5)	2/12 (16.7%)	0%–41.4%
Gastric pain or vomiting	123 (78.8; 70.8–86.8)	18/123 (14.6%)	8.1%–21.2%
Cardiopulmonary disease, musculoskeletal pain or gastro-oesophageal disease
Chest pain	80 (51.3; 43.8–58.7)	21/80 (26.2%)	16.4%–36.1%
Dyspnoea	94 (60.3; 51.8–68.7)	17/94 (18.1%)	10.2%–26.0%
Palpitations	92 (59.0; 49.3–68.6)	18/92 (19.6%)	11.3%–27.8%
Chest pain or Dyspnoea or Palpitations	125 (80.1; 73.4–86.9)	26/125 (20.8%)	13.6%–28.0%
Urinary tract infection
Urinary frequency	48 (30.8; 22.9–38.7)	8/48 (16.7%)	5.7%–27.6%
Dysuria	31 (19.9; 13.3–26.5)	6/31 (19.3%)	4.6%–34.1%
Dysuria or urinary frequency	65 (41.7; 32.7–50.7)	11/65 (16.9%)	7.6%–26.3%

Figure 1.  Health-related quality of life in somatizing patients compared with a population-based community sample, patients with diabetes mellitus, and patients with chronic obstructive pulmonary disease (COPD). Abbreviations: pf = physical functioning; rp = role–physical; bp = bodily pain; gh = general health; vt = vitality; sf = social functioning; re = role – emotional; and mh = mental health.