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This guideline should be quoted as:Olde Hartman TC, Blankenstein AH, Molenaar AO, Bentz van den Berg D, Van der Horst HE, Arnold IA, Burgers JS, Wiersma Tj, Woutersen-Koch H. NHG Guideline on Medically Unexplained Symptoms (MUS). Huisarts Wet 2013;56(5):222-30.

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M102 NHG GUIDELINE ON MEDICALLY UNEXPLAINED SYMPTOMS (MUS)

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2 huis art s & we tensch ap 56 (5) m ay 2013

NHG GUIDELINE ON MEDICALLY UNEXPLAINED SYMPTOMS (MUS)

Tim Olde Hartman, Nettie Blankenstein, Bart Molenaar, David Bentz van den Berg, Henriëtte van der Horst, Ingrid Arnold, Jako Burgers, Tjerk Wiersma, Hèlen Woutersen-Koch

mendations’). The guideline does not cover a specific symptom or illness, but does provide treatment recommen-dations for cases in which no specific somatic condition is found, the symp-toms do not disappear or are associated with functional limitations, and the patient continues to contact the gen-eral practitioner for these symptoms. The guideline does not discuss the management of specific somatoform disorders. For diagnostic and therapeu-tic recommendations for patients with hypochondriasis, we refer to the NHG Guideline on anxiety.

BackgroundExperiencing physical symptoms is a part of normal life; approximately 90% of the general population report in surveys that they have experienced at least 1 physical symptom in the past 2 weeks. Whether or not people visit their doctor for physical symptoms appears to be more strongly correlated to the significance of the symptom to them personally and their ideas concerning these symptoms, rather than the sever-ity of their symptoms. In several non-Western cultures, expressing physical symptoms is the most common method of indicating distress.2

Almost all types of symptoms that patients present to their GPs could – ei-ther quickly, or over time and after fur-ther analysis – turn out to be symptoms that cannot be (adequately) explained by a specific medical condition. Even if symptoms or combinations of symp-toms initially appear to be strongly indicative of a specific condition (for example, the combination of diarrhoea, trembling, weight loss and hot flushes is suggestive of hyperthyroidism), ad-equate examination will often reveal that the patient does not have this disease. In case of common symptoms, such as fatigue, stomach pain, back pain, dizziness and nausea, the general practitioner will often not find a dis-ease that can explain those symptoms.3

TerminologyMany terms are used to describe this large group of physical symptoms for which doctors cannot find a satisfacto-ry explanation. Historically, symptoms that regularly cluster together were frequently grouped into syndromes, such as irritable bowel syndrome (IBS), fibromyalgia and chronic fatigue syn-drome. However, many of the existing syndromes show significant overlap in their symptoms, and virtually every specialism has its own syndrome.4 This raises the question whether the clus-tering of MUS into distinct syndromes are an artefact of medical specialisa-tion and whether these symptoms are in fact different syndromes or just one.5 Furthermore, one could also group

Key messages • Medically unexplained symptoms

(MUS) are defined as physical symp-toms persisting for more than several weeks and for which adequate medi-cal examination has not revealed a condition that adequately explains the symptoms.

• Estimating the severity of MUS is based on exploration of five symp-tom dimensions, namely the somatic, cognitive, emotional, behavioural and social dimensions.

• A good doctor-patient relationship and communication are essential for the treatment of MUS.

• Management is focused on providing information and advice with a view to increasing activities in a time-contin-gent manner.

IntroductionThe NHG Guideline on MUS provides recommendations for the diagnosis and treatment of adult patients with medically unexplained symptoms (MUS). MUS is defined as physical symp-toms that have existed for more than several weeks and for which adequate medical examination has not revealed any condition that sufficiently explains the symptoms.

MUS is a working hypothesis based on the (justified) assumption that so-matic/psychological pathology has been adequately ruled out. Any change in symptoms could be a reason to revise the working hypothesis.

After formulating the working hy-pothesis, the general practitioner will estimate the severity of the MUS. This guideline distinguishes between mild, moderate and severe MUS. The severity of the MUS guides the treatment.

This guideline is based on the mul-tidisciplinary guideline on medically unexplained symptoms and somato-form disorders1 and follows as closely as possible other NHG Guidelines on symptoms and conditions that could include MUS (see ‘Diagnostic Recom-

Olde Hartman TC, Blankenstein AH, Molenaar AO, Bentz van den Berg D, Van der Horst HE, Arnold IA, Burgers JS, Wiersma Tj, Woutersen-Koch H. NHG Guideline on Medically Unexplained Symptoms (MUS). Huisarts Wet 2013;56(5):222-30

Patient contributionThe NHG Guidelines provide guidance for treatment by the GP; therefore, the GP holds a central position. However, patient factors always influence treatment. For practical reasons, this aspect is not em-phasized repeatedly in this guideline, but is mentioned explicitly at this point. Wherever possible, the GP creates a treatment plan in consultation with the patient, taking the patient’s specific situ-ation into account and acknowledging the patient’s own responsibilities, with adequate information provision being a prerequisite for success.

GP’s considerationsThe GP’s personal insight is a key aspect in all guidelines. Weighing relevant fac-tors in specific situations can justify rea-soned deviations from the treatment policy described below. Nonetheless, this guideline is meant to serve as a standard and aid.

Delegating tasksNHG Guidelines are written for GPs. This does not mean the GP must perform all tasks personally. Certain tasks may be delegated to the doctor's assistant, prac-tice support staff or practice nurse, as long as they are provided with support in the form of clear working agreements, defining the conditions under which the GP must be consulted, and as long as the GP retains quality control. As the decision on whether or not to delegate is strongly dependent on the local situations, the guidelines do not contain any concrete recommendations in this area.

3huis art s & we tensch ap56 (5) m ay 2013

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mon and have a prevalence of 2.5%.8

Doctors often indicate that immi-grant patients visit their general prac-titioner more often due to MUS than non-immigrant patients. However, this has only been confirmed for refugees. Various causes are listed for this, such as a history of violence experiences, a different perception of disease in which often no distinction is made between body and mind, and the attention, ad-vantages and (legal, social and/or soci-etal) recognition that can be obtained with physical symptoms.9

Combination with anxiety disorders and/or depressionThere is no firm association with anxi-ety disorders and/or depression for the

mild forms of MUS. In patients with se-vere forms of MUS, the risk of a depres-sion or anxiety disorder is over three times higher than in patients without MUS. More than a quarter of these pa-tients suffer from both depression and anxiety disorder.10

PathophysiologyThere is no clear explanation for the origin of MUS. Over the years, various explanatory models have been drawn up to explain the origin and persis-tence of MUS. These models are usually theoretical in nature and only based on empirical research to a limited extent.11

Every society has its own explana-tory models. Non-Western cultures of-ten do not distinguish between body

these symptoms into clusters based on localization: gastro-intestinal, cardio-pulmonary, musculoskeletal and gen-eral non-specific.6

If the MUS are not grouped into syndromes or clusters, there are also various terms to describe the separate physical symptoms, such as physically unexplained symptoms, functional symptoms, psychosomatic symptoms or somatoform symptoms.

For this guideline, we decided to adhere to the terminology in the mul-tidisciplinary guideline and to use the term medically unexplained symptoms (MUS) for physical symptoms that per-sist for more than several weeks and for which adequate medical examination has not revealed a medical condition that adequately explains the symp-toms.

This description is not very specific as far as the duration of the symptoms is concerned, as the average episode du-ration varies per type of symptoms, and also because the moment of presenta-tion to the general practitioner can vary significantly.

For some patients with physical symptoms a somatic condition can be identified, but if the symptoms are more severe or more persistent or limit functioning to a greater extent than expected based on the condition in question, they too are referred to as MUS.

MUS can be divided into mild MUS, moderate MUS and severe MUS de-pending on the duration of the symp-toms, the number of symptoms and the impact of the symptoms on daily life. This is a sliding scale of severity with-out clearly defined cut-off points.7

Epidemiological dataOccurrence of MUSThere is no ICPC code for MUS. There-fore, derived codes – for example symptom coding – must be used when studying the occurrence of MUS.

Up to 40% of the consultations in general practice concern physi-cal symptoms for which no (adequate) somatic condition can be found. Per-sistent, severe MUS are much less com-

AbstractOlde Hartman TC, Blankenstein AH, Molenaar AO, Bentz van den Berg D, Van der Horst HE, Arnold IA, Bur- gers JS, Wiersma Tj, Woutersen-Koch H. The NHG guideline medically unexplained symptoms (MUS). Huisarts Wet 2013;56(5):222-30.This guideline of the Dutch College of General Practitioners (NHG) concerns the diagnosis and manage-ment of adult patients with medically unexplained symptoms (MUS). It is based on the Dutch multidis-ciplinary guideline on MUS and somatoform disorders, and where possible refers to other guidelines produced by the College on MUS-related symptoms and disorders. The guideline is not about a specific symptom or disease, but provides tools on how to manage patients whose symptoms are persistent and lead to functional impairment, even though investigations have not identified a specific underlying medical condition. These patients continue to seek medical care.MUS is a working diagnosis based on the assumption that somatic/psychiatric pathology has been ad-equately excluded. If symptoms change, the working diagnosis may need to be revised. After establish-ing the diagnosis, the general practitioner (GP) must estimate the severity of MUS, as further manage-ment depends on symptom severity. This guideline distinguishes between mild, moderate, and severe MUS. Treatment is tailored to the individual patient. The main objectives of treatment are to define the problem in a way that is acceptable to both the patient and the doctor; to reduce unnecessary anxiety and discomfort, despite the presence of symptoms; and to improve the patient’s functioning in somatic, cognitive, emotional, behavioural, and social dimensions.Treatment proceeds in a stepwise fashion (stepped care), starting with the lightest possible effectivetreatment. In step 1, the GP treats the patient, in step 2 the GP works together with or refers the patientto other primary care professionals (e.g., physiotherapist, psychologist), and in step 3 treatment is pro-vided by multidisciplinary teams or treatment centres. If results are unsatisfactory, then treatment is intensified. If a patient presents with moderate or severe MUS, the GP can consider starting more inten-sive treatment (step 2 or even 3 if necessary) simultaneously with step 1.

Main messages • MUS is defined as physical symptoms that last for longer than a few weeks and which cannot be

satisfactorily explained after adequate medical examination. • Assessment of MUS severity is based on five dimensions of symptoms, i.e. the somatic, cognitive,

emotional, behavioural, and social dimensions. • Good doctor–patient relationship and communication are essential for the management of MUS. • Management is focused on providing information and advice with a view to increasing activities in

a time-contingent manner.


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be wary of this if alarming symptoms or changes in the pattern of symptoms occur.18 Focus on the somatic dimen-sion of the symptoms and considering physical re-examination and addition-al investigations remains important for patients with MUS. Particularly if the symptoms change. Therefore, the somatic dimension has been included in the exploration of symptoms.

Exploration of symptomsAfter forming the working hypoth-esis of MUS, the general practitioner should start additional exploration of the symptoms aimed at getting a fuller understanding of the patient and his or her MUS, identifying prognostically favourable or unfavourable factors (that inhibit recovery) and estimating the severity of the MUS. Allowing the pa-tient to speak for a few minutes with-out interruption can help to broaden the exploration of symptoms. This method can reveal relevant starting points (clues) for the treatment. They could consist of words used by the pa-tient, but also of non-verbal behaviour (body language) that is noted during the consultation.19 Explicitly asking the patient whether he or she has any specific questions also forms part of the complete exploration of symptoms.

The acronym SCEBS can assist the general practitioner in determining whether all symptom dimensions have been explored. SCEBS stands for the somatic, cognitive, emotional, behav-ioural and social dimensions.

These dimensions originate from the biopsychosocial model.11

Table 1 Guidelines about symptoms that often cannot be adequately explained in a somatic context

NHG Guideline on irritable bowel syndrome (M71)

NHG Guideline on dyspepsia (M36)

NHG Guideline on non-specific low back pain (M54)

NHG Guideline on headache (M19)

NHG Guideline on sleep problems (M23)

NHG Guideline on dizziness (M75)

anxious, whilst the doctor begins to feel powerless and irritated and is unable to come to a shared understanding of the symptoms and problems with the pa-tient. Doctors also experience (diagnos-tic) uncertainty, and (unjustly) feel that they should not show their uncertainty to patients with MUS. The doctor-pa-tient relationship is strengthened by taking the patient and his or her symp-toms seriously and by showing empa-thy. A good doctor-patient relationship results in patient satisfaction and im-proved health outcomes. By contrast, a poor doctor-patient relationship results in symptoms being reported more fre-quently and in increased consultation rates.14

DiversityThe care provider should also be open to the MUS patient’s ‘culture’ in the broadest sense of the word, regardless of whether this culture concerns the patient’s ethnicity, age, gender or socio-economic status.

A number of specific points of at-tention can be listed for immigrant patients. Firstly, the immigrant life in itself can be a stress factor. In addition, language problems and cultural differ-ences – particularly for non-Western immigrants – can place significant de-mands on the communication skills of the general practitioner.

Diagnostic guidelinesStarting point of the guideline is the situation in which the general practi-tioner becomes able to formulate the working hypothesis ‘MUS’. In other words, the guideline assumes that so-matic/psychological pathology that could be responsible for the symptoms has been reasonably ruled out in pre-ceding consultations. The general prac-titioner can use the NHG Guidelines that provide diagnostic recommenda-tions for symptoms that often do not have a somatic cause [table 1].17 MUS always remains a working hypothesis, as in a limited number of cases it could become clear over time that the symp-toms were in fact caused by somatic pa-thology. It is particularly important to

and mind. People often look for exter-nal causes of – and solutions to – their problems. Cultural differences and oth-er differences affect the applicability of some explanatory models.12

Natural course and prognosisIn 50 to 75% of people diagnosed with MUS by the general practitioner, the symptoms will decrease over the course of 12 to 15 months. However, in 10 to 30%, the symptoms will increase over time. The number of symptoms, duration and severity at presentation to the general practitioner are factors associated with a less favourable course of MUS in patients in primary care.13

A positive perception of the doctor-patient relationship (by patient and/or doctor) has a favourable effect on the prognosis of MUS.14

Factors that affect occurrence and persis-tencePsychosocial stressors (negative life events, difficult living conditions, work-related problems, stress, trauma, sexual abuse) appear to play a causal role in both explained and unexplained symptoms; on their own these factors are not a good predictor of MUS.15

Factors that play a role in MUS can be categorised into predisposing, ex-acerbating and maintaining factors. Predisposing factors are mainly suscep-tibility/nature and possibly also poor health literacy.16 Exacerbating factors vary in nature: a severe gastro-intestinal infection appears to precede the symp-toms in some people with IBS, but the symptoms can also be induced by a sig-nificant life event. Maintaining factors are often behavioural factors that can inhibit recovery, for example, reduced exercise can result in maintenance of low back pain, and continuously seek-ing help can maintain symptoms of anxiety. This causes vicious circles.

Doctor-patient relationshipThe doctor-patient relationship is often pressurised during consultations with patients with MUS. The patient often feels that he/she is not being taken se-riously, not understood and remains


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at work?The general practitioner can adjust the order of questions to account for differ-ences between a collectivistic culture and the Western individualistic cul-ture for patients with a different cul-tural background: first ask about social reactions and consequences, then ask about the patient’s own ideas, concerns and emotions.21 The use of a profes-sional interpreter – via the telephone if necessary – is recommended. Wherever possible, avoid asking a child or another family member to act as an interpreter, in order to increase the chances of un-covering psychosocial problems. Visit www.huisarts-migrant.nl for more in-formation about caring for immigrant patients with MUS.

Additional psychological disorders Based on the exploration of symptoms, the general practitioner will determine whether any additional psychological disorders are suspected. This particu-larly includes psychological disorders that affect the physical symptoms, such as depression and anxiety disorders (see the relevant NHG Guidelines).10

If there is concern about the pres-ence of a psychiatric condition (such as a somatisation disorder), the pa-tient can be referred to a psychiatrist for diagnosis. The general practitioner can also ask a psychiatrist for advice at this stage, potentially in the form of a joint consultation with the patient, the general practitioner and the psychia-trist. Preferably, the general practitio-ner should refer to a psychiatrist who works together with other therapists with experience in treating patients with MUS.

Physical examination, additional inves-tigations and diagnostic referralPhysical examination is indicated if the exploration of symptoms reveals that the symptoms have changed in nature and when alarming symptoms occur. Additional investigations or diagnostic referral to a specialist can also be con-sidered for the same reasons. For the most common symptoms, indications for referral can be found in the previ-

symptoms? Some patients become de-pressed or anxious as a result of the symptoms, whilst others feel desper-ate, despondent or rebellious.

• Is the patient very anxious about the symptoms? What exactly is he/she worried about? What is the reason for these concerns?

Symptoms and the thoughts and con-cerns about the symptoms can be asso-ciated with anxiety, fear or a depressive mood. The general practitioner can use a questionnaire as a tool to create room to discuss distress (‘being unable to cope’), anxiety and feelings of depres-sion.20

Behavioural dimensionAsk about the behavioural consequences of the symptom(s): • avoiding weight bearing or move-ment, or other avoidance behaviour;

• sick leave; • ignoring the symptom and carrying on, which causes overburdening;

• other behaviour that could inhibit the recovery.

Also focus on the help-seeking behav-iour: • Does the patient seek medical as-sistance quickly or does he/she try to solve the problems by him/herself for a long period?

• Does he/she visit different doctors/care providers for the same problem?

• What did the patient do in order to re-solve the symptoms, which measures has he/she taken?

Also look at non-verbal behaviour dur-ing the consultation (for example, a patient with back pain who does not sit upright in the chair).

Social dimensionAsk about the social consequences of the symptom(s): • What are the consequences of the symptoms on those around him/her?

• How do they respond: (overly) con-cerned, negative or supportive?

• What effect do the symptoms have on the patient’s functioning at home and

Somatic dimensionCheck the following aspects of the symptom(s): • symptom cluster (gastro-intestinal, cardio-pulmonary, musculoskeletal, general non-specific (i.e. fatigue, headache, dizziness, concentration/memory problems));

• nature, location, duration, severity and pattern of the symptoms;

• accompanying symptoms; • use of medication (including non-pre-scription treatment and potentially addictive drugs such as benzodiaz-epines and analgesics.

Focussing on the somatic aspects of the symptom demonstrates to the patient that his or her symptoms and their bur-den are recognised and taken seriously.

Cognitive dimension Ask about: • the patient’s ideas about the origin and persistence of his/her symptoms (frame of reference);

• what the patient thinks he/she can do to influence these aspects;

• why the patient thinks that he/she cannot or can no longer perform cer-tain activities or jobs;

• the patient’s expectations concern-ing the contribution by the general practitioner or other care providers in managing the symptoms.

Exploration of these aspects often al-lows the general practitioner to iden-tify certain patient perspectives that could prevent recovery: catastrophising thoughts (“I’ll never get back to work with these back issues” or “my brother/neighbour never got over this either”), disease attributions (“such severe pain must mean that my neck has been damaged in some way”), or ideas about dealing with the symptoms (“I must not bear weight on my leg until it is completely healed”).

Emotional dimensionAsk about the emotional consequences of the symptom(s): • What feelings and emotions does the patient experience as a result of the


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present before the depression or anxi-ety disorder started;

• both are of a severity that requires separate treatment.

Therapeutic recommendations

Treatment of patients with MUS re-quires an individual approach. The most important goals of the therapeu-tic recommendations are: • finding a definition of the problem that is acceptable for both the patient and the general practitioner;

• reducing unnecessary concern and functional limitations, despite the presence of symptoms;

• improving the functioning of the pa-tient in the somatic, cognitive, emo-tional, behavioural and social dimen-sions.

The treatment is a so-called ‘stepped care’ process, in which the general practitioner starts with the mildest possible effective treatment [table 2]. If this step does not provide adequate results, the treatment is intensified in step 2.26 In the event of moderate or severe MUS at first presentation, the general practitioner can consider com-bining step 1 with immediate initia-tion of more intensive treatment (step 2 or possibly step 3). Consider the patient’s ethnical-cultural background in all steps.21

STEP 1Step 1 includes a number of activi-ties that the general practitioner can spread over several consultations: (1) using the exploration of symptoms to identify and discuss the factors that could inhibit recovery, (2) education and advice (also with regard to drug treatment), (3) Formulation of a shared time-contingent plan and (4) follow-up appointments during which the general practitioner will monitor the plan and patient’s functioning. A new exploration of symptoms is performed if the recovery stagnates. As MUS al-ways remains a working hypothesis, the general practitioner will perform a new exploration of symptoms, targeted

unfavourable factors.13 Furthermore, experiencing several functional limi-tations (for example: not being able to work, loss of social activities, inability to perform family duties) is also prog-nostically unfavourable for a number of MUS.24

Evaluation of the severityBased on the outcome of the explora-tion of the prognostic factors, the gen-eral practitioner can determine the approximate location of this patient on the severity scale from mild via moder-ate to severe MUS, as explained in the introduction.

Mild MUS: • slight functional limitations; and • one or several MUS within one or two symptom clusters (gastro-intestinal, cardio-pulmonary, musculoskeletal, general non-specific (i.e. fatigue, headache, dizziness, concentration/memory problems)).

Moderate MUS: • moderate functional limitations; and • several MUS in at least three symp-tom clusters; and/or

• duration of symptoms longer than expected, depending on the normal course of the relevant symptom.

Severe MUS: • severe functional limitations; and • MUS in all symptom clusters; and/or • duration of symptoms longer than three months.

Comorbid depression and/or anxiety disorderAlthough physical symptoms accom-panying depression or an anxiety dis-order can often be explained as part of the psychiatric diagnosis, they are sometimes caused by two co-existing conditions.

Making a dual diagnosis of MUS in combination with a depression or anxi-ety disorder can be useful if: • the physical symptoms are more pro-nounced than would be consistent with depression or an anxiety disor-der;

• the physical symptom was already

ously mentioned NHG Guidelines.If the general practitioner starts to

doubt the working hypothesis of MUS due to an altered pattern of symptoms, and in order to rule out somatic pa-thology again, it is important that he/she explains thoroughly to the patient why additional investigations are be-ing performed. The same applies to a diagnostic referral to a specialist. This usually serves to further reduce the small chance of pathology. Laboratory tests performed with a low prior chance of disease have a relatively high risk of false positive test results.22

If the patient specifically asks for additional investigations or referral while there is no indication for this, the general practitioner will explain that he/she does not think additional investigations are necessary and does not expect them to provide any new findings. However, he can follow the patient’s request in order to try to reas-sure the patient. It is important in that case to explain to the patient in ad-vance what a negative test result would mean and what the next steps would be in that case.23 When referring a patient to a medical specialist at the request of the patient, it is important to formulate a clear question in the referral letter – ideally drafted by the patient and the general practitioner together – with the request that the patient be referred back to the general practitioner if no abnormalities are found. This in order to prevent the patient being passed from one specialist to the next.

EvaluationBased on the exploration of the symp-toms and the presence of any addition-al psychological problems, the general practitioner will evaluate the severity of the MUS, taking into consideration the prognostic factors.

Prognostic factorsA short duration of the symptoms, few different symptoms and few functional limitations are seen as prognostically favourable. Long persistence of symp-toms and presentation of many dif-ferent symptoms are prognostically



the general practitioner should use positive terms wherever possible. Do not say “we did not find anything”, “it’s nothing” or “we cannot find anything”, but rather say “your back is straight and can make all normal movements”.28 In contrast, for patients who have a specif-ic fear of a certain condition (for exam-ple, cancer) it is important to explain what they do not have (“you do not have lung cancer, which is what you were so afraid of”). People with limited health skills16 (among immigrants and people with low literacy skills, for instance) have little knowledge about the normal functioning of the human body. An ex-planation can help in this case.29

When providing specific and tan-gible information, the general practi-tioner can use the various explanatory models that provide recommendations for the treatment of MUS.11 Link this in with the words, images and key points that were noted during the exploratory phase. Ensure that you select a model that fits both the general practitioner and this patient, and find and use your own words when using the model.

In addition to the oral informa-tion provided, the general practitioner can refer the patient to information about MUS on the NHG public website www.thuisarts.nl or give the patient the relevant text (previously called the NHG patient letter) to take home (via the HIS or the NHG ConsultWijzer [consul-

symptoms and the fact that the patient is troubled by them.

Education and adviceEducation and explanationNext, provide the patient with targeted and tangible information that links up with the information that the gen-eral practitioner obtained during the diagnostic exploration of the somatic, cognitive, emotional, behavioural and social dimensions of the symptoms.

Avoid repeatedly reassurance of anxious patients with general state-ments. It is very important that the pa-tient’s anxiety is treated seriously and in a sensitive manner. Patients who no-tice that the doctor listens to and rec-ognises their problems feel that they are being taken more seriously and are more readily reassured.27

It is preferable to list the symptom(s) as far as possible in descriptive terms and to avoid explanations that the patient could interpret as a disease. General practitioners tend to reassure patients by telling them which severe conditions have not been found. If a pa-tient is not specifically worried about a certain condition, such an explana-tion (“you do not have lung cancer”) can cause additional anxiety. As negative explanations or normalisation have the disadvantage of making the patient feel that he/she is not being taken seriously or making the patient more anxious,

physical examination and additional investigations if changes in the symp-toms make this necessary.

Step 1 usually involves patients with MUS who experience mild functional limitations and who suffer from 1 or sev-eral symptoms in 1 or 2 symptom clusters (gastro-intestinal, cardio-pulmonary, musculoskeletal, general non-specific (i.e.: fatigue, headache, dizziness, con-centration/memory problems)).

• Conclude the exploration of symptoms and any physical examination and/or additional investigations

As part of the education process, the general practitioner will summarise the findings of the symptom explora-tion (SCEBS), the physical examination and any additional diagnostic tests. It is important to discuss clearly what was found and mention explicitly what was not found. If possible, the general practitioner should include expecta-tions or anxieties that have previously been expressed by the patient.

• Shared definition of the problemTry to come to a shared definition of the problem together with the patient, for example “your back pain started after your move, your spine has recovered, but the pain has stayed, and prevent you from performing a number of ac-tivities that you would now like to start again”. It is important to recognise the

Table 2 Overview of the step-by-step plan

Step Recommendation

Step 1Patient with mild MUS By general practitioner

Conclude exploration of symptoms and potentially perform a physical examination and/or additional investigations.Shared definition of problem, based on exploration of symptoms.Education and advice:▪ education and explanation;▪ discussion of factors that inhibit recovery; ▪ advice.Formulation of a shared time-contingent plan.Follow-up: ▪ monitor progress of plan and repeat exploration of symptoms if recovery stagnates;▪ if the symptoms change, repeat exploration of symptoms and perform a targeted physical examination and additional investigations if necessary.

Step 2Patient with moderate MUSIn collaboration with other primary care providers

Collaboration with/referral to:▪ (psychosomatic) physiotherapist or exercise therapist;▪ mental health nurse practitioner or social psychiatric nurse in primary care;▪ primary care psychologist trained in cognitive behavioural therapy.

Step 3Patient with severe MUSIn collaboration with secondary care providers

Collaboration with/referral to:▪ multidisciplinary teams/treatment centres.


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Treatment with medicationIf the general practitioner consid-ers advising pain management with over-the-counter pain medication, the working group advises short-term analgesia with acetaminophen or, as a second option (and in the absence of contra-indications), an NSAID (see the Farmacotherapeutische richtlijn Pijnbestrijding [Pharmacotherapeutic guideline on pain management] and the symptom-specific NHG Guidelines). It is preferable to reduce the pain medication gradu-ally after the acute stage, in order to prevent chronic use of pain medication and medication dependency.

Follow-up and formulation of a shared time-contingent planInstruct the patient to return in the following cases: • if there is a strong increase in the dysfunction or persistence of severe symptoms: after one week;

• if the dysfunction has not improved or is no longer improving: after two to four weeks.

At a follow-up consultation, always evaluate the previously confirmed rel-evant parts of the exploration of symp-toms and any physical examination and/or additional investigations. Check why the patient’s functioning has not improved and the symptoms have not disappeared. Always use an inventory of the functioning according to the vari-ous dimensions (SCEBS) when doing so.

During this follow-up consultation, formulate a shared plan with goals and a time schedule. This approach, which consists of a gradual (time-based) in-crease of, is preferable over a symptom-based approach (movement ‘if the pain allows’ or becoming active ‘if the fa-tigue has disappeared’) [table 3].32

Preferably the road to recovery is made tangible and illustrated with tips; the advice or exercise given should match the limitations experienced by the patient in his/her daily life. The general practitioner and the patient should agree on the time schedule for all steps in the treatment plan.

Behavioural factors, such as avoiding ac-tivities or being too active, are virtually always present with long-term MUS.31 The general practitioner explains what the effect of this behaviour is on the MUS, explores which behavioural changes the patient is motivated to make, and provides targeted and tan-gible advice.

Social factors, such as the situation in the family or at work, often determine a large portion of the burden of the symptoms. Discuss the effects of the patient’s context: support from his/her context can have a positive effect on the course, and incorrect thoughts/as-sumptions by his/her surroundings can form an inhibiting factor. If there are questions about the work situation, for example, about sick leave and possible health risks in the work place (work pressure as a factor causing MUS to persist, or attribution of symptoms to work-related factors, for example toxic substances or electromagnetic radia-tion), the general practitioner can refer the patient to an occupational health physician. The general practitioner discusses ways in which the patient can return to work and resume his/her daily activities.

AdviceWhen providing advice, the key mes-sage is that the prognosis is good, that the symptoms can vary over the course of time13 and that it is not harmful to exercise or perform activities. Experi-encing pain or fatigue does not mean that there is a disease or that damage has occurred: it is common and usu-ally goes away without intervention. The recovery will be faster if the patient gradually expands his/her activities. Advise the patient to remain active and continue with his/her daily activities – including (paid) work – as far as pos-sible. Give practical advice about this. If the patient avoids certain activities or performs too many activities and does not relax enough, this can inhibit nor-mal recovery.32

tation tool]). This patient information is based on the NHG Guideline.

Discussing factors that inhibit recoveryDiscuss the factors that can inhibit re-covery that were observed during the exploration of symptoms in the various SCEBS dimensions, and provide con-crete advice based on these factors.

Somatic factors, such as a comorbid so-matic condition or a sleep disorder, can result in persistence of MUS. If present, the general practitioner will optimise the treatment of these factors.

Cognitive factors, such as patients’ nega-tive thoughts and ideas about the symptoms, can influence recovery negatively. The general practitioner discusses the negative effects of cata-strophising beliefs such as “it will nev-er get any better” and asks the patient to consider alternatives such as replac-ing the negative thoughts with realis-tic neutral or positive thoughts like “I do have pain, but I am still able to do my job”. Challenging and adjusting such negative thoughts has a positive effect on recovery.30

Emotional factors, such as worry, fear of disease, fear of movement and hope-lessness, can make the original symp-toms worse. The general practitioner has made an inventory of these emo-tional factors in the diagnostic phase. The general practitioner uses this in-formation to provide targeted and tan-gible information and advice. If the patient is worried or afraid of disease, the general practitioner will explore what the patient is worried about and in what way he/she can be reassured. With fear of movement, the conviction that pain is a signal of a (serious) condi-tion often plays a role. In that case, the general practitioner will explain that pain usually does not indicate dan-ger or a severe condition and that this is true for the patient in this case too. For patients suffering from feelings of depression or hopelessness, the general practitioner can use the NHG Guideline on depression.



referral to secondary care providers and multidisciplinary teams or treatment centres. This involves patients with inadequate results from step 1 and 2, probably patients with severe MUS (se-vere functional limitations (including, for example, sick leave for more than 3 months) and a large number of differ-ent MUS and/or a duration of symptoms > 3 months).

In this stage, it is important that one care provider keeps control of the care provided to the patient with MUS.26 In many cases, the general practitioner is the best person for this job, but a so-cial psychiatric nurse, psychologist or occupational health physician can also fill this role.

In this step, the role of the general practitioner consists of: 1. continuing to stimulate the expan-

sion of the patient’s functioning and detecting any deterioration in his/her functioning (see step 1);

2. limiting long-term treatments and investigations that are not useful and may even be harmful;

3. if several or long-term specific and intensive treatments have not re-sulted in any further improvement: encouraging the patient to accept the status quo.

Follow-upMake regular follow-up appointments during the treatment, for example once every four to six weeks. In the event of persistent dysfunctioning without ac-tive treatment, the advice is to evaluate the situation at least once a year and to potentially offer any new treatment op-tions.

Collaboration/referralReferral for therapeutic reasons to a mono-disciplinary pain specialist is not recommended if he/she only ap-plies local invasive analgesic methods,

if the decision is made to refer. Being able to explore all symptom dimensions (SCEBS) and being able to build a safe, supportive and open relationship with the patient are required competencies.

In the primary care setting, the gen-eral practitioner can also collaborate with a (psychosomatic) physiotherapist or exercise therapist, mental health nurse practitioner, primary care social psychiatric nurse or primary care psy-chologist (trained in cognitive behav-ioural therapy). Care providers from other primary care disciplines can also be involved, depending on the local situation.

If musculoskeletal symptoms are predominant, the general practitioner will preferably refer to a physiothera-pist or exercise therapist with addi-tional specialist training (for example, in psychosomatic physiotherapy or ex-ercise therapy)34 or who has had train-ing in counselling patients with MUS.

If the general practitioner col-laborates with a mental health nurse practitioner or primary care social psy-chiatric nurse, this person can support patients in this step and offer – for ex-ample – PST (problem-solving treatment). The mental health nurse practitioner or primary care social psychiatric nurse takes over the monitoring role from the general practitioner in those cases, but the general practitioner keeps long-term control.

The general practitioner can re-fer the patient to a primary care psy-chologist for patient education and short-term supportive counselling or cognitive behavioural therapy.30 The primary care psychologist should have experience in treating patients with MUS.

STEP 3The intensification of the treatment in step 3 consists of collaboration with and

STEP 2The intensification of the treatment in step 2 consists of continuation of the treatment in accordance with step 1, and of collaboration with and referral to other primary care providers. The general practitioner implements step 2 if step 1 yields inadequate results. This usually involves patients with MUS who experience moderate functional limitations (including, for example, sick leave for more than 4 to 6 weeks) and who have several MUS in multiple symptom clusters or a symptom dura-tion longer than expected (depending on the nature and the normal course of the symptom).

Follow-upMake regular follow-up appointments if the functional limitations persist, for example once every 4 to 6 weeks. Evaluate the progress of the treatment (see ‘Collaboration/referral’ below) and the course of the symptoms together with the patient. Advise the patient to work actively on his/her recovery. Treat-ments in which the patient partici-pates actively (such as psychotherapy, psychosomatic physiotherapy and ex-ercise therapy) are more effective than passive treatments such as injections, operations and passive forms of phys-iotherapy.33

Collaboration/referralIf the patient is unable to expand his/her activities to an acceptable level because there are many inhibiting factors, the general practitioner can decide to refer the patient. In that case, the general practitioner should dis-cuss with the patient the type of ther-apy that matches his/her capabilities, wishes and needs.

A care provider with affinity and experience with – as well as specific knowledge about – MUS is preferable

Table 3 Concrete examples of time-based (desirable) and symptom-based (undesirable) advice

Desirable: time-based Undesirable: symptom-based

Activity Keep moving and expand activities back to normal in x days. Try to move if the pain/fatigue permits.

Work/daily activities Go back to work (half days if necessary) after 1 week. Go back to work as soon as the pain/fatigue allows or has disappeared.

Follow-up Return after x weeks, unless you are functioning normally again. Come back if you are not coping.


NHG guideline

© 2013 Nederlands Huisartsen Genoot-schap [Dutch College of General Practi-tioners]

tidisciplinary approach that integrates somatic, psychological and social as-pects in the treatment offers the oppor-tunity of improving the functioning in various areas. An intense physical and cognitive-behavioural rehabilitation programme promotes a return to an ac-ceptable level of activity.35 A multidisci-plinary approach allows for long-term and more specific treatments to be of-fered, either as out-patient treatment or in combination with admission.

such as denervation and injections with analgesics, corticosteroids or sclerosing agents, since these treatments are not effective when applied as monotherapy.33

If the approach in the previous steps has failed or if the evaluation immedi-ately revealed that this is a case of se-vere MUS, the general practitioner can refer for a multidisciplinary approach, in which the previously mentioned disciplines are represented and collab-orate in an integrated manner. A mul-

ation of General Practitioners]; on behalf of VAGZ: G.W. Salemink, MD, Community Medicine physician employed by Zorgver-zekeraars Nederland; on behalf of Ne-farma, Health Economy: J.J. Oltvoort, PhD; J. Stoffels, MD, PhD, general practi-tioner and retired lecturer in general practice training, UMCG; on behalf of Do-mus Medica, the Flemish GP association: Prof. A. Dirk, General Practice Medicine and Primary Health Care and employed by the Faculty of Medicine and Health Sci-ences Ghent University, Belgium; on be-half of Pharos: M. van den Muijsenbergh, MD, PhD, general practitioner and senior researcher and employed by Pharos, Na-tional Knowledge and Advisory Centre on Migrants, Refugees and Health Care Is-sues, and department of Primary Care Medicine of the UMC St. Radboud Nijme-gen and University Health Centre Heyen-dael Nijmegen, and M. Vintges, MD, PhD, physician and researcher; Y.R. Van Rood, PhD, clinical psychologist and psycho-therapist, employed by the department of Psychiatry of the LUMC. Being recorded as an expert does not mean that the expert supports every de-tail of the content in the guideline. R. Starmans and J. van Dongen – on behalf of NAS – evaluated during the commen-tary round whether the draft guideline answers the questions defined in the ba-sic plan. In September 2012, the guideline was commented on and authorised by the NHG Authorisation Committee.The search strategy used to locate the supporting literature is presented in the web version of this guideline. The proce-dures for the development of the NHG Guidelines can also be viewed in the pro-cedures book (see www.nhg.org).

Berg, T.C. Olde Hartman, A.O. Molenaar and E. Oostenberg reported no conflicts of interest. More details about this can be found on the web version of the guideline, at www.nhg.org.In June 2012, the draft guideline was sent to a number of experts for comments. A total of 14 comments were returned. The following experts returned comments: J.A.H. Eekhof, MD, PhD, general practitio-ner-epidemiologist and editor-in-chief of Huisarts & Wetenschap [General Practice & Science]; on behalf of the Dutch Associa-tion of Psychologists: C.E. Flik, clinical psychologist/psychotherapist and em-ployed by the department of Psychiatry and Psychology of the St. Antonius hospi-tal; Prof. A.L.M. Lagro-Janssen, MD, PhD, professor of Women’s Studies and Medi-cal Sciences and employed by the depart-ment of Primary Care Medicine, Women’s Studies and Medical Sciences Unit at the UMC St. Radboud Nijmegen; P. Lucassen, MD, PhD, general practitioner, senior sci-entist and employed by the department of Primary Care Medicine at the UMC St. Radboud Nijmegen; N.C. Makkes, MD, general practitioner and project leader of the ZonMw-project SOLK – Gezond geor-ganiseerd vanuit de 1e lijn [MUS – Healthily organised in primary care] (2011 to 2012), employed by general practice clinic Over-vecht, Stichting Overvecht Gezond [Foundation Overvecht Healthy]; on be-half of the Netherlands Association of In-ternal Medicine (NIV): Prof. A.C. Nieu-wenhuijzen Kruseman, MD, PhD, depart-ment of Internal Medicine at the Maas-tricht University Medical Centre; M.J.T. Oud, MD, PhD, general practitioner in Groningen; C.F.H. Rosmalen, MD, PhD, general practitioner and head of the de-partment B&O at the LHV [Dutch associ-

Guideline development methodFollowing the decision to start the devel-opment of an NHG Guideline on medically unexplained symptoms, a MUS working group started in 2009. This working group created a draft version.The working group consisted of the fol-lowing members: I.A. Arnold, MD, PhD, general practitioner in Leiderdorp; D. Bentz van den Berg, MD, general practi-tioner in Maartensdijk; A.H. Blankenstein, MD, PhD, general practitioner and head of the Department of Vocational Training for general practice of the VU University Medical Center; Prof. H.E. van der Horst, MD, PhD, general practitioner in Amster-dam and professor of general practice medicine at the VUmc; T.C. Olde Hart-man, MD, PhD, general practitioner in Nij-megen; A.O. Molenaar, MD, locum gen-eral practitioner based in De Rijp. H. Woutersen-Koch, MD, PhD, guided the working group and performed the edit-ing. She is a doctor and staff member of the Department Guideline development and Research; Tj. Wiersma, MD, PhD, was involved as a senior staff member of this department, M.M. Verduijn as a senior staff member Pharmacotherapy. E. Oostenberg, MD, was involved as staff member of the Implementation Depart-ment. In the period 2009 through 2013, none of the members of the working group re-ceived payment for an advisory role or research grants from pharmaceutical companies involved in the field of MUS. Vested interests were reported by: A.H. Blankenstein, H.E. van der Horst, and H. Woutersen-Koch. These three individuals were or are involved in research into MUS and have published on this subject. The members I.A. Arnold, D. Bentz van den



months [Melville 1987]. In an English study, gen-eral practitioners classified MUS as the reason for consultation for 19% of the consultation visitors. Based on screening instruments, 35% were found to have MUS, with 5% of these possibly suffering from a somatoform disorder [Peveler 1997]. A Dutch study found that an average of 13% of all consultations concerned at least one symptom that the general practitioners labelled as MUS [Van der Weijden 2003]. One of the highest rates of prevalence observed was in an Australian study, which showed that patients presented with MUS in 39% of the scheduled consultations in primary care [Pilowsky 1987]. Of course, the prevalence of MUS after first consultations about a symptom also differs from the prevalence for consultations due to symptoms that have existed for a longer period. For example, Verhaak et al. found a preva-lence of 2.5% for patients visiting their general practitioner frequently with MUS in Dutch gen-eral practice [Verhaak 2006]. Another cause of the variation in prevalence is a large inter-doctor variation in labelling the presented health prob-lems as ‘inadequately explained’. What one doctor deems ‘unexplained’ may have a perfectly logical explanation according to another doctor. Some doctors require a pathological or anatomical foundation before they can define a symptom as ‘explained’, whilst others are satisfied with func-tional symptoms or syndromes as an explanation.

9 Somatisation in immigrant versus non-im-migrant patients Statement based on the book Een arts van de wereld: etnische diversiteit in de medische praktijk [A global doc-tor: ethnic diversity in medical practice] [Seele-man 2005].

10 Association of MUS with anxiety disorder or depressionBoth an anxiety disorder and depression can be associated with physical symptoms. Depression and anxiety disorder can also present initially in the form of physical symptoms. In the case of de-pression, this is often in the form of fatigue and pain; anxiety disorders are often expressed in the form of shortness of breath, dizziness, palpita-tions, tingling (more generally: symptoms that present as cardio-pulmonary symptoms). How-ever, the predictive value of having physical symptoms for making the diagnosis of depres-sion or anxiety disorder is low (See the NHG Guidelines on anxiety and depression). In a sur-vey amongst 2447 patients registered at 5 general practices, 451 people reported pain at various sites in the musculoskeletal system (chronic wide-spread pain (CWP)), and 60% of them also reported persistent fatigue symptoms. A total of 809 peo-ple reported persistent fatigue, with 33% of them also reporting CWP. These combinations of fa-tigue and CWP were much more common than would be expected based on chance, particularly in people with chronic illness and/or obesity. Peo-ple with one of these two symptoms did not re-port depression or anxiety symptoms more often, whilst the combination of fatigue and CWP was associated with an increased prevalence of symp-toms of anxiety and depression [Creavin 2010].Using data from the Transition Project (16,000 patients from 10 general practitioners), Van Boven et al. examined the correlation between MUS and psychological disorders. They compared patients with new MUS (including palpitations, low back pain and headache) with patients with symptoms that are usually explained by a somatic condition (for example, enlarged lymph nodes and swollen ankles). The researchers found a statistical relationship between having MUS and an anxiety disorder or depression (OR varying from 1.7 to 5.1 for anxiety disorders, and from 1.7 to 4.2 for depres-sion). In addition, the researchers found that the predictive value of MUS for developing an anxiety disorder or depression disorder was just as low as the predictive value of explained symptoms for the development of such a disorder [Van Boven 2011].

• gastro-intestinal: stomach pain, varying pat-tern of defecation, feeling bloated/swollen ab-domen, gastro-oesophageal reflux, nausea, vomiting, borborygmi;

• cardio-pulmonary: palpitations, unpleasant sensation across the chest, shortness of breath without exertion, hyperventilation, warm or cold sweats, trembling/shaking, dry mouth, butterflies in the stomach, blushing;

• musculoskeletal: pain in arms/legs, muscle pain, joint pain, local sensation of loss of strength or weakness, back pain, pain with movement, un-pleasantly numb sensation/tingling;

• general non-specific: excessive fatigue, head-ache, dizziness, concentration problems, mem-ory problems.

The authors only counted symptoms that a person experienced as a burden. The average MUS patient had five symptoms. The more symptoms patients had, the more frequently they had a high score for distress, anxiety or depression domains on a ques-tionnaire. It made little difference whether the symptoms were located in many different clusters. The authors concluded that MUS (though they felt that bodily distress syndrome was a better name) can be viewed as one syndrome, which can be ex-pressed in various areas [Fink 2007, Fink 2010].

7 Site of somatoform disorders and epidemiol-ogy in general practiceApart from the continuum based on severity (mild, moderate and severe MUS), there are also the somatoform disorders according to the DSM.The DSM-IV-TR [American Psychiatric Associa-tion 2000] – the world’s most widely used psychi-atric classification system, which describes all psychiatric disorders – includes seven somato-form disorders. The undifferentiated somatoform disor-der and the somatoform disorder not otherwise specified are less severe – in terms of prognosis and limita-tions – than the somatisation disorder, the pain disor-der and conversion disorder; they are more common than the other somatoform disorders and do not often require a specialist approach. Hypochondria-sis and body dysmorphic disorder often result in sig-nificant suffering, but less often in severe limita-tions in functioning and require specialist treatment. Also see [Table 5].

8 Epidemiology of MUSThe large variation in observed prevalence of MUS is partly due to the definition used, the point in the symptom episode at which the diagnosis is made, and inter-doctor variation. Melville et al. found that 3% of the patients with a new symptom episode received the diagnosis of MUS after 3

Notes and literature1 Multidisciplinary guideline on medically unexplained symptoms and somatoform dis-ordersThe NHG Guideline on MUS is an expansion of as-pects from the multidisciplinary guideline on MUS and somatoform disorders [Fisher 2010] that are relevant to general practice medicine, and de-scribes how they can be applied in the general practice setting.

2 Expression of physical symptoms in non-Western culturesIn many cultures, social harmony and non-con-frontational interaction with other people take precedence over the expression of emotions. The use of metaphors and physical symptoms as a lan-guage of distress prevents the patient and those around him from feelings of shame [Kirmayer 1998]. Turkish and Moroccan individuals in par-ticular tend to focus mainly on the somatic side of their problems, in contrast to individuals from Surinam [Knipscheer 2005].

3 Absence of a medical explanation for physical symptomsQuite regularly when a person visits a doctor due to physical symptoms, the doctor is unable to find a physical cause. In about 30 to 50% of cases, the general practitioner cannot find a medical expla-nation for the symptoms [Khan 2003]. These per-centages are also high – between 40 and 60% – for the neurologist, rheumatologist, pulmonologist, gastroenterologist, cardiologist, dentist, gynae-cologist [Nimnuan 2001a] and internist [van Hemert 1996].

4 Common MUS per specialism with accompa-nying ICPC codeSee [table 4].

5 Functional syndromes: one or many?There is much discussion about the question whether functional symptoms cluster into clearly defined syndromes such as fibromyalgia, chronic fatigue syndrome or tension headache, or wheth-er these specific somatic syndromes are primarily an artefact of medical specialisation [Wessely 1999, Nimnuan 2001b, Olde Hartman 2004].

6 Clusters of medically unexplained symptomsIn an exploratory study of a group of 978 MUS pa-tients – with 701 patients originating from gen-eral practice – the symptoms experienced by these patients could be grouped in 4 clusters:

Table 4 Common MUS per specialism with accompanying ICPC code

Internal medicine Fatigue A02

Dermatology Hyperhidrosis (excessive sweating)Itching

A09.02S02

ENT Ringing of the ears/tinnitusDifficulty swallowing/globus sensation

H03D21/R21

Neurology HeadacheDizziness/vertigo/lightheadednessMuscle weakness

N01N17/01-02N18

Cardiology Cold extremitiesChest painPalpitations

K29.02K01/K02K04/K05

Pulmonology Feeling of tightness R02

Gastroenterology Stomach pain D01-02-06-08

Rheumatology Pain in muscles/joints L01-L02-L04

Psychiatry Sleep problems P06

Endocrinology Decreased appetite T03

Ophthalmology Burning eyes F05


NHG guideline

Vicious circles play an important role in maintain-ing symptoms, irrespective of the origin of the symptoms. The focus lies particularly on the in-terpretation of symptoms and the resulting dis-ease behaviour and/or help-seeking behaviour [Sharpe 1992, Speckens 2004, Van Rood 2001]. In addition, it has been shown that previous and re-peated stimuli of pain and other symptoms in the past make the central nervous system more sus-ceptible to these stimuli (sensitisation) [Rief 2007].Emotions also play an important role in physical sensations. Severe emotions are often associated with obvious, tangible physical symptoms such as becoming pale with fright or red with anger. Not being able to regulate emotions often results in physical disruption that can result in persis-tent physical symptoms. According to the psycho-analytical tradition, unexplained physical symp-toms are associated with repressed emotions. Other theories emphasise the selective percep-tion of emotions. There are indications in the lit-erature that patients with unexplained physical symptoms have difficulty recognising feelings and emotions and have difficulty distinguishing these from physical sensations (alexithymia) [De Gucht 2004, Bankier 2001].Looking at the individual development, the unex-plained physical symptoms are associated with pre-natal and post-natal experiences and experi-ences in early childhood and other early experi-ences. Since recently, there has been attention for the link between an early unsafe attachment style and later susceptibility to unexplained symptoms. The effect of early trauma, early affec-tionate neglect and early acquired methods of coping with physical symptoms make a person more susceptible to developing and maintaining unexplained physical symptoms.

12 Explanatory models and non-Western cul-turesEvery society has its own explanatory models for disease and health. The biomedical model domi-nates in Western cultures: a disease can be traced to a disorder in the body or the mind. In contrast, non-Western cultures often do not distinguish between body and mind and the causes of and so-lutions to problems are sought elsewhere (gods/spirits). For example, in Morocco, a distinction is made between disease due to natural causes (dis-ruption in the balance between warm and cold), supernatural causes (contact with djinns, de-mons that inhabit a world parallel to humans) or human causes (the evil eye, witchcraft or magic) [Borra 2003].Some Islamic patients see their symptoms as the fate that Allah has bestowed upon them and do not feel that they can actively intervene. You can-not create or earn health, it is a favour bestowed by Allah [Noordenbos 2007].

13 Course of MUSIn a meta-analysis – following an extensive search – the authors identified 6 prospective co-hort studies (with 81 to 337 patients per study) on the prognosis of MUS in a population correspond-ing to patients in primary care. The studies in-cluded in the meta-analysis revealed that the symptoms improved during the follow-up period (6 to 15 months) for 50 to 75% of the patients. Ten to 30% deteriorated during the follow-up. For most of the studies, the extent of treatment was not clear. The meta-analysis also revealed that a greater number of symptoms in the beginning resulted in a poorer prognosis. The same applies to the se-verity of the symptoms; the more severe the symptoms were at the start, the greater the chance that the symptoms will persist [Olde Hartman 2009a].In general, the majority of MUS develop in a fa-vourable manner: only 20 to 30% of the patients still experience symptoms one year after their first visit to the general practitioner [De Waal 2006].

ed with fatigue, pain and somatoform disorders. Psychological distress plays an important role in this relationship. Their hypothesis is that certain psychosocial factors combined with a chronically high level of professional stress can result in ex-periencing unexplained physical symptoms.Perceptual-cognitive perspectiveIn their somato-sensory amplification theory, Robbins and Kirmayer [Robbins 1991] describe that patients focus their attention on physical sensations. These physical sensations result in ideas and emotions in patients, resulting in phys-ical attributes [Rief 2007]. This amplifies and magnifies the initial symptoms. This results in a vicious circle of maintaining and amplifying the physical symptoms. The concept of somatic fixation also fits into this model. Somatic fixation is defined as a process of persistent inadequate coping with and response to disease, symptoms or problems by patients themselves, by their social environment or by healthcare representatives. Although the concept of somatic fixation has never been successfully operationalised for study purposes, it does have practical value in healthcare, because it indicates so clearly how symptoms are maintained by an interaction between patient, healthcare and so-cial environment [Van Eijk 1983].Neurobiological modelsThe neurosciences [Brown 2002] emphasise the complex interaction between neurobiological processes (HPA axis (hypothalamus-pituitary-adrenal axis), cytokines), environmental factors, attention and behaviour [Dantzer 2005, Kirmayer 2006]. Presumed abnormalities – for example in the limbic system – are the starting point of the-ory formation. Neural endocrinological and neu-rovegetative processes also form part of the neu-robiological approach. Psycho-immunology also emphasises the consequences of somatic illness-es on endocrine processes, immunological pro-cesses, mood and behaviour. This could explain why certain physically explained conditions do not recover despite adequate medical treatment.

11 Explanatory modelsThe various explanatory models differ in the ex-tent to which they explain physical symptoms and processes and the extent to which they take account of certain physiological, psychological and social aspects.However, pathophysiological mechanisms of var-ious symptoms are becoming increasingly clear. Research is focussing predominantly on the physiology of psychological processes. This so-mato-psychological research focuses on the phys-ical symptoms of psychological disorders (cardio-vascular or inflammatory symptoms occurring with depression) and psychological consequences of somatic conditions (effect of rheumatoid ar-thritis on ideas and personality), among other things. In this way, we are gaining increasing in-sight into the way in which somatic phenomena, ideas, emotions, behaviour and environment are linked. Biopsychosocial modelThe biopsychosocial model [Engel 1977] clearly emphasises the importance of the context of the patient. The model assumes that (perceived) health is associated with all dimensions of hu-man existence and that humans are constantly interacting with their environment. Medical schools have now incorporated this model in their curricula.Capacity/burden modelA model that expounds on the capacity/burden principle is the so-called SSSV model [De Jonghe 1997]. SSSV stands for: support, stress, strength and vulnerability. The balance between these fac-tors is important. If vulnerability and strength are unbalanced in a person, this can lead to symptoms as a result of a specific type of stress and lack of support, for instance. Stress modelDe Gucht and Fischler [De Gucht 2002] demon-strate in their ‘analysis of the relationship be-tween professional stress, psychosocial parame-ters and various dimensions of physical health’ that a high level of professional stress is correlat-

Table 5 Description of somatoform disorders and estimated prevalence in general practice [de Waal 2004]

Description Estimated prevalence in general practice

Somatisation disorder

Condition of multi-symptoms that often starts before the age of thirty, persists for a long time and is characterised by a combination of pain, gastro-intestinal, sexual and pseudo-neurological symptoms.

≤ 0.5%

Pain disorder Unexplained pain that is severe enough to limit functioning and to seek medical help. Occurrence, severity, exacerbation and persistence are linked to psychological factors. Inadequately explained pain in the presence of a somatic condition is also included in the pain disorder.

2%

Conversion disorder Unexplained symptoms or loss of function that affects random motor or sensory functions, or seizures/convulsions that suggest a neurological or other somatic condition. A link to psychological factors is deemed likely.

0.2%

Undifferentiated somatoform disorder

At least one medically unexplained physical symptom that has caused a limitation in daily life for at least six months. The functional syndromes (IBS, CFS, FM, etc.) fall into this group of undifferentiated somatoform disorders.

13%

Somatoform disorder not otherwise specified

Somatoform symptoms and syndromes that do not meet the criteria of one of the specific somatoform disorders.

Unknown

Hypochondriasis Strong preoccupation with and fear of having a serious illness, as a result of an incorrect interpretation of physical symptoms for at least six months.

1 – 5%

Body dysmorphic disorder

Preoccupation with a supposed flaw in the appearance. < 0.1%



uting role in 23% of the cases [Maarsingh 2010].Conclusion: the chance of an organic disease un-derlying symptoms previously categorised as MUS varies according to the initial symptom. This chance is very low for abdominal complaints categorised as MUS and slightly higher for fa-tigue categorised as MUS. The greatest chance of a somatic cause is present for dizziness previously categorised as MUS in elderly patients.

19 Clues/cuesThere is a long-standing tradition in primary care of paying attention to clues/cues and their sig-nificance. Recognising cues is important for the mutual understanding between doctor and pa-tient. The importance of paying attention to cues came back into fashion with the patient-centered movement at the end of the 1980s. Responding to cues presented by the patient is one of the most important tools for a successful consultation [Olde Hartman 2008].Cues are described in various ways by various au-thors:Gask en Usherwood [Gask 2002] refer to the verbal and non-verbal expressions of the patient as cues that the patient gives about psychosocial or social problems. Levinson et al. [Levinson 1997] describe cues as direct or indirect expressions that con-tain information about the lives and emotions of the patient. Balint uses the word ‘offer’ for re-marks by the patient about the importance of the symptoms and the reason for visiting the general practitioner [Balint 2000]. Branch en Malik [Branch 1993] see cues as a chance for the doctor to display empathy. It is important to detect cues and to respond at the moment that the patient ‘offers’ these cues. Not responding to cues can re-sult in the patient withholding further revela-tions. Bertakis et al. [Bertakis 1991] performed a study in which they analysed recordings of con-sultations in combination with a patient satis-faction questionnaire, and they reported a sig-nificant relationship between the reaction by the doctor to emotional cues and the extent to which the patient made further revelations. Further-more, cues also allow for a better understanding of the patient’s life and his/her thoughts and emotions. There is another benefit to recognising and exploring cues. It shows that the general practitioner is listening carefully, wants to un-derstand the significance of the symptoms for the patient and is interested in the patient. This has a favourable effect on the therapeutic relationship and thereby on disease outcomes and patient sat-isfaction. Doctors have difficulty recognising cues. Levinson et al. [Levinson 1997] examined how patients presented cues and how doctors re-sponded to them. Cues were present in more than half of the consultations (average of 2.6 cues per consultation). Patients initiated 71% of the cues themselves and 29% of the cues were initiated by the doctors as a result of asking open questions. Doctors missed out on the opportunity to respond to a cue in the majority of the consultations (79%). These consultations lasted significantly longer. Butow et al. [Butow 2002] found the same result in their study of verbal cues of cancer patients: on-cologists failed to recognise cues consistently and did not always respond to them. The consulta-tions in which oncologists did respond to cues to a greater extent did not take any longer than other consultations. Cegala [Cegala 1997] anal-ysed video recordings of consultations in primary care of 16 doctors with 32 patients, and found that doctors rarely provide information in the absence of a direct question from the patient. Conclusion: there is sufficient evidence to indi-cate that it is important to pay attention to clues/cues.

20 Questionnaires/symptom lists/detection instrumentsThere are various symptom questionnaires, such as the 4-DKL, Van Hemert’s list, the PHQ, Beck Anxiety (BAI-PC) and Beck Depression (BDI-PC).

problems and healthy children. Children with re-current abdominal complaints reported fewer negative life events than children with emotional problems. They suffered the same amount of emo-tional distress as children with a stomach condi-tion. In the 1980s, Bleijenberg [Bleijenberg 1989] examined whether patients with functional stomach symptoms could be distinguished from people with organically explained abdominal complaints based on history and psychological factors. This turned out not to be the case. A study in a tertiary care population of patients with ab-dominal complaints demonstrated that a history of sexual abuse is more common in people with IBS than in people with colitis [Drossman 1990].

16 Health literacyIt is known that low literacy is associated with a lower state of health in many areas and that this is particularly common among the elderly, ethnic minorities, people with a lower level of education and the chronically ill. The National Institutes of Health defines health literacy (health skills) as the degree to which individuals have the capacity to obtain, process and understand basic health in-formation and services needed to make appropri-ate health decisions. Therefore, according to this definition, health skills are related to the cogni-tive and functional skills for making health-re-lated decisions [Paasche-Orlow 2007].

17 Other NHG GuidelinesOther NHG Guidelines may also apply, depending on the initial symptoms, for example the NHG Guidelines on: food intolerance (M47), non-trau-matic knee problems in adults (M67), anxiety (M62), depression (M44), problematic alcohol use (M10), thyroid conditions (M31), menopause (M73), urination problems in men (M42), epicondylitis (M60), hand and wrist complaints (M91) and erec-tile dysfunction (M87).

18 The chance of a somatic condition being the cause of symptoms initially explained as MUSIBSTwo prospective studies examined how reliable the diagnosis of irritable bowel syndrome (IBS) was. Harvey et al. [Harvey 1987] monitored 104 pa-tients with IBS for 5 years. The diagnosis was found to be correct in all cases. Owens et al. [Ow-ens 1995] monitored 112 patients with IBS for an average of 29 years. Over the course of time, 3 people were diagnosed with a gastro-intestinal disease, and for 2 of the 3 cases it was very un-likely that the IBS symptoms were the result of that condition. In 1 case the symptoms of IBS were possibly related to the condition that was diagnosed at a later stage. Fatigue A prospective cohort study in Dutch general prac-tices examined the diagnoses resulting from newly presented, initially unexplained symp-toms. A total of 63 general practitioners included 444 patients (73% female, average age 43 years), primarily with symptoms of fatigue (70%). After a follow-up duration of one year, 82 patients (18%) were found to have at least one somatic compo-nent that (partially) explained the symptoms. These were mainly somatic (partial) explanations in the categories infectious/inflammatory (22% of 82), osteoarthritis/degenerative abnormalities (13%), diabetes mellitus (9%), anemia (6%), hypothy-roidism (4%), infectious mononucleosis (4%) [Koch 2009a].DizzinessA Dutch cross-sectional diagnostic study of el-derly patients who consulted their general practi-tioner due to dizziness, examined causes that could contribute to this dizziness, among other things. A total of 417 patients between the ages of 65 and 95 years were included. Cardiovascular disease was the most common contributing cause of dizziness (57%), followed by peripheral vestibular dizziness (14%) and psychiatric disease (10%). Side effects of medication played a contrib-

However, the course can also be more complex. A 1-year cohort study followed 642 patients who vis-ited their general practitioner with new-onset fatigue symptoms. Recovery was fast for 17%, slow for 25%, high fatigue scores persisted for the en-tire year for 26%, and 32% recovered quickly but suffered a relapse within a year [Nijrolder 2008].

14 Effect of doctor-patient relationship and communication on health outcomesIt is known from the literature that a good doctor-patient relationship – as well as good doctor-pa-tient communication – in general results in im-proved health outcomes, a higher level of patient satisfaction and improved compliance [Cabana 2004, Kim 2008, Nutting 2003]. In psychotherapy, this relationship is even responsible for 30% of the effect of the treatment [Lambert 2012]. In a litera-ture study on the therapeutic effect of the general practitioner-patient relationship, the investiga-tors concluded that – despite the large heteroge-neity of the studies found – general practitioners that had a warm and personal relationship with their patients were ‘more effective’ than general practitioners who kept their relationship more neutral and formal [Di Blasi 2001]. A Dutch study on the treatment of depression in primary care revealed that treatment according to the guide-line alone is insufficiently effective, but that it is effective in combination with empathy and sup-port [Van Os 2005]. Also for the treatment of IBS, a warm, empathic and trusted doctor-patient rela-tionship is more effective than the same treat-ment without such a relationship (alleviation of symptoms 61% versus 53%) [Kaptchuk 2008]. The relationship between doctor-patient commu-nication and health outcomes for the patient was examined in a systematic review of 10 RCTs and 11 controlled trials and cohort studies [Stewart 1995]. In 16 of the 21 studies, the quality of the communication had a positive effect on the health outcomes. The following communication aspects had an effect on the health outcomes:• a broad exploration of symptoms covering so-

matic, emotional and cognitive aspects and ex-pectations and the effect of the symptoms on functioning as experienced by the patient;

• a shared vision of the problem and a mutually developed treatment plan, in which the patient is given the opportunity to ask for more infor-mation and to give his/her reactions.

Aiarzaguena et al. [Aiarzaguena 2007] demon-strated in a cluster RCT that if general practitio-ners (n = 19) applied special communication tech-niques, their somatising patients (n = 76) improved significantly more in the aspects of physical health, physical pain and mental health than the patients (n = 20) of the general practitio-ners (n = 20) who applied a standard reattribution technique. The effect was present for up to 12 months. The communication techniques includ-ed that the doctor provided a physiological expla-nation (hormonal factors) and approached sensi-tive subjects indirectly. Dobkin et al. [Dobkin 2006] examined which factors predicted compli-ance – in particular regarding drug treatment – in 142 patients with fibromyalgia. Less discor-dance between doctor and patient equated to improved compliance by the patients to the pro-posed treatment and to the patient feeling better. Owens et al. [Owens 1995] used pre-defined crite-ria derived from the medical records of 112 IBS patients to demonstrate that a positive doctor-patient relationship was associated with fewer consultations during the follow-up period.Conclusion: the working group is of the opinion that there are enough indications that a good doctor-patient relationship and communication have a favourable effect on the perceived health and behaviour of patients.

15 Predictive value of psychosocial stressorsWalker [Walker 1993] compared children with ab-dominal complaints to children with organic stomach conditions, children with emotional


NHG guideline

memories, so there is no room in your head to remember things. The sadness is taking up all the space in your head and takes up a lot of en-ergy.

• The roots of a tree go deep underground. When they encounter resistance – such as a large bolder or a rock – they grow around that obsta-cle. The important thing is that the tree can continue to grow. The same applies to humans. Learn to deal with the symptoms by working around them, as the roots of a tree do. Be flexi-ble [Vloeberghs 2005].

Attention for perception regarding magic and religionMany patients use alternative medicine. In the case of immigrant patients this can include win-ti, magic, voodoo and the like, as well as the use of traditional healers (such as fqih, hoca, imam, bonoeman, lukuman). It is best that the therapist takes note of this and discusses with the client any other help or treatment that he/she is receiv-ing. It is also relevant to determine whether this alternative treatment will support and amplify the treatment that is offered or whether it will contradict the treatment [Noordenbos 2007].Effectiveness of immigrant treatment programmesAn intervention amongst female immigrants with chronic pain symptoms (n = 249) resulted in a decrease in severe pain symptoms, an increase in perceived health and a decrease in visits to the general practitioner (by 8%). The intervention con-sisted of supervised movement in a group setting for two months and a meeting with a health edu-cator speaking the same language and having the same cultural background (‘voorlichter eigen taal en cultuur’; VETC) about the relationship between stress and pain [Van Ravensberg 2008]. Recent in-dications from research show that the use of cul-tural workers in the treatment of psychosomatic symptoms result in improved perceived health compared to the standard approach by general practitioners. The culturally sensitive approach includes psycho-education with special attention for the patient’s cultural background, and immi-grant care consultants providing support in the communication between patient and general practitioner [Joosten-Van Zwanenburg 2004].

22 False positive test results with low prior risk of a somatic conditionThe VAMPIRE trial examined the diagnostic yield of blood tests in 173 patients who visited the gen-eral practitioner with new-onset unexplained symptoms of fatigue. With the limited blood tests recommended in the NHG Guideline on blood test ordering (Hb, sed. rate, glucose and TSH), a true positive test result was obtained for 6.4%, whilst 22.0% of the patients had a false positive test re-sult. A more extensive fatigue-specific panel of blood tests designed by experts (Hb, sed. rate, glu-cose, TSH as well as liver functions, creatinine, leuko-diff., ferritin, transferrin and monosticon) resulted in a true positive test result for 7.5% of the patients, but the percentage of patients with a false positive test result increased to 55.5%. The diagnoses discovered by the blood tests in the 173 patients were diabetes mellitus (4x), anemia (3x), infectious mononucleosis and hypothyroidism,

dream a lot? (dreams are important in indige-nous disease interpretations)

Turkish and Moroccan patients can have difficul-ty with the direct communication style of Dutch care providers and with discussing taboo sub-jects. They can remain passive out of respect for the care provider or because they feel that they do not have any control over the symptoms [Rabbae 2008].The order of questions (‘from the outside to the in-side’) can help to make it easier to discuss emo-tions. If unknown, first discuss the general fam-ily conditions (including country of origin) and the daily activities (work, household). Then focus on the symptoms expressed, followed by the so-cial context in which the symptoms are experi-enced (relationship to work, housing, etc.), then the relationship of the symptoms to the family and finally the patient’s own perception of the symptoms (psychological consequences, causes).Cultural barriersIf the emphasis is placed squarely on physical symptoms, bear in mind that it may be more dif-ficult for the patient to express thoughts and emotions – compared to physical symptoms – in a language that is not his/her mother tongue. It is often helpful to ask about facts first, then opin-ions and finally emotions. The patient does ex-pect questions about the various aspects of the symptoms, but more as a matter of social interest than as part of the medical diagnostic process. Particularly in the case of MUS, the general prac-titioner will have to explain clearly that he needs a lot of information in order to be able to help the patient. It is possible to discuss the psychological and social consequences of symptoms, but an ex-planation in the form of a vicious circle is often not compatible. It is often not acceptable to dis-cuss with your doctor the fact that your family is a source of stress or part of the problem, but the patient can talk about the impact of the symp-toms on the whole family. The general practitio-ner can link into this by asking which family members can become involved in the treatment as confidants. Misunderstandings in communication are even more common in contact with second-generation immigrants from non-Western cultures. The general practitioner often forgets that cultural barriers still exist if patients speak Dutch fluent-ly [Boevink 2001]. Research also shows that the chance of mutual misunderstanding between doctor and patient becomes greater if the patient belongs to a later generation of immigrants or to a partially acculturated group of immigrants from non-Western cultures. It is more important to aim for understanding than to reach an agree-ment [Harmsen 2005].ExplanationPatients of non-Western extraction have a lan-guage of distress in which the body is used to ex-press emotions and metaphors are used. This pro-tects patients and their surroundings from feelings of shame [Kirmayer 1998]. Therefore, in many cultures, information about symptoms and disease is provided with the use of metaphors:• Your head is full of unpleasant and painful

The ZonMw/NIVEL Kennissynthese ggz [Mental health care knowledge synthesis] [Zwaanswijk 2009] asked a panel of 54 primary care providers (general practitioners, social workers, primary care psychologists, social psychiatric nurses, mental health nurse practitioners) and patient representatives how these questionnaires can best be used in general practice. A total of 82% of the respondents sees support of the diagnosis as a role, if the presence of a certain condition is al-ready suspected. Questionnaires can also be used to provide an opportunity for discussion (listed by 74%) and to detect problems in high-risk groups (44%). Only 14% thinks that such an instrument can be used to detect problems in a general group of patients. In addition, it was also mentioned that questionnaires can be used to monitor the severity of patients’ symptoms during treatment or during watchful waiting.According to most respondents (76%), the number of questions that a questionnaire contains and the time that it takes to complete such an instru-ment are deciding factors for the level of applica-bility of the instrument in daily general practice. A total of 47% of the general practitioners in the panel used 1 or more questionnaires, in particu-lar for depression, anxiety and dementia. The instruments included in [table 6] are the questionnaires relevant to MUS that were evalu-ated as adequately to highly reliable and valid in the knowledge synthesis. They can all be complet-ed by the patient himself/herself. There are re-gional differences in which instrument is used. The working group has not indicated a preference in this matter.

21 Ethnic-cultural points important for com-municationIn the absence of any strong evidence, the com-ments and advice provided below were obtained from the Handleiding voor anamnestisch gesprek met migranten bij verholen psychosociale problemen [Manual for discussing the medical history with immi-grants with disguised psychosocial problems] [Limburg-Okken 1989].Method of questioning and order of questionsAn amended method of questioning is important when questioning immigrants from non-West-ern cultures. In contrast to Dutch culture, which is individualistic and in which it is somewhat more common to talk about emotions, non-West-ern cultures are often collectivistic. In collectivis-tic cultures, individuals are often expected to maintain group harmony above all else and it is not acceptable to place too much emphasis on one’s own opinion and emotions. A common question in the Netherlands, such as: “Do you have any problems?” will be answered negatively, as one does not discuss problems with people out-side the family. It is also important to word the questions as directly as possible:• When exactly did the symptoms start? What

happened on that day?• How are things at work? • What does your family think about this? (can

also express patient’s unspoken opinion)• Are you able to sleep with this illness? Do you

Table 6 Characteristics of questionnaires evaluated as adequately to highly reliable and valid

Detection of Questionnaire Number of questions

Completion time in minutes

Test characteristics Comments

Depression PHQ-9 9 5 Measures the 9 depression criteria of the DSM IV.

BDI-PC* 7 1-2 Sensitivity: 82 – 97%, specificity: 82 – 99%.

Anxiety BAI-PC* 7 1 Sensitivity 85% and specificity 80% at cut-off point 5.

Distress, depression, anxiety and somatisation

4-DKL† 50 5 – 10 Distinguishes uncomplicated stress-related problems from psychiatric conditions.

* can be ordered via www.pearson-nl.com using personal BIG number.† can be downloaded from www.emgo.nl/researchtools/4DSQ.asp or via www.spreekuurassistent.nl



and functioning apparently improving and psy-chological stress apparently decreasing [Kroenke 2007, Sumathipala 2007].Reattribution is a structured intervention in which an explanation for the mechanism of the patient’s symptoms is provided by means of nego-tiation and patient-centred communication [Lit-tle 2001]. This therapy is probably not effective, as three of the four studies show no benefits [Mor-riss 2010]. Furthermore, one RCT demonstrated that reattribution therapy by general practitio-ners was associated with a decreased quality of life [Morriss 2007].

31 Avoidance behaviour and other behavioural factorsIn the experience of the working group, behavioural factors such as avoidance or over-activity are al-most always present with long-term MUS. This has been scientifically studied and proven for fi-bromyalgia [Van Koulil 2008].

32 Time-contingent approachThe literature describes the step-by-step expan-sion of activities according to a set schedule as graded activity [Lindstrom 1992]. The care provider reaches an agreement with the patient – in ad-vance – about the exercises and activities that the patient will perform over the coming period. The starting level is determined based on the maxi-mum ability level of the patient. The exercises are not performed based on the pain (pain-based ap-proach) but are performed according to a time-based approach: the exercises are gradually in-creased in nature, duration, frequency and intensity. The therapist’s task is to schedule ac-tivities in such a way that patients who overesti-mate themselves are slowed down and patients who underestimate themselves are stimulated.For a long time it was assumed that patients with chronic non-specific lower back pain (which can also be regarded as MUS) were less physically ac-tive. Objective measurements demonstrate that there is no significant difference between the ac-tivity levels of patients with chronic non-specific low back pain and healthy individuals [Verbunt 2001]. However, a particular feature in the behav-iour of many patients with back pain is that they will systematically avoid a small number of spe-cific activities [Waddell 1993, Vlaeyen 2002]. From a behavioural therapy point of view, it is impor-tant to work towards such activities gradually in these situations. In this way, the patient is gradu-ally exposed to the situation that forms the basis of his/her dysfunction.(Also refer to the NHG Guideline on non-specific low back pain).

33 Active participationA literature review of systematic reviews and me-ta-analyses provides an overview of the results of therapeutic trials for various functional syn-dromes and diagnostic analogies of these syn-dromes [Henningsen 2007]. The authors conclude that non-drug treatments that require active participation from the patient – such as exercises and psychotherapy – appear to be more effective than passive physical treat-ments, including injections and operations, for functional somatic syndromes in general. The lit-erature review does not quantify the effects. The authors indicate that this was not feasible for the integration of so many different systematic re-views, which used such different criteria and rep-resented different interpretations in heteroge-neous clinical settings. Their overview provides empirical trends in the treatment of functional somatic syndromes in general.Conclusion: non-drug treatments that require active participation from the patient – such as exercises and psychotherapy – appear to be more effective than passive physical treatments, in-cluding injections and operations, for functional somatic syndromes in general.

disciplines play a role in this stepped-care ap-proach, their communication with each other is vitally important, as is the central role of the gen-eral practitioner as case manager. The stepped-care principle demands regular evaluation of the treatment effect if active treatment is used. How-ever, as yet, there is no empirical evidence to sup-port a stepped-care approach for MUS and so-matoform disorders [Fisher 2010].

27 Effect of blood tests and doctor-patient rela-tionship on the level of satisfaction and con-cernA cluster RCT (63 general practitioners; 498 pa-tients) revealed that patients with MUS for whom the general practitioner immediately requests blood tests are no more or less satisfied or con-cerned than patients for whom the general prac-titioner employs watchful waiting for a month. Patient satisfaction was greater and the level of concern was lower if the patient generally trusted his/her general practitioner, felt that he/she was being taken seriously, had obtained clarity about the severity of the symptom, if the option of test-ing was discussed, if the general practitioner had not created the impression that he/she did not think that the symptoms were that bad and if the general practitioner was older [Van Bokhoven 2009].

28 Ways of explaining and consequencesA focus group study amongst Dutch general prac-titioners revealed that general practitioners are aware of the importance of the way in which they explain the working hypothesis of MUS to their patients. However, they find it difficult to explain the nature and origin of the symptoms during a consultation. The general practitioners indicated that they use three methods when providing the explanation: the ‘normalisation’ of symptoms (explaining that experiencing symptoms is part of normal life), explaining that there is no disease and the use of metaphors [Olde Hartman 2009b]. However, the normalisation of symptoms and telling patients that they do not have a disease without providing a tangible explanation about how the symptoms could develop is not effective and could even lead to more help-seeking behav-iour [Salmon 1999, Dowrick 2004].

29 Anatomical knowledgeIn 2009, a cross-sectional, multiple-choice ques-tionnaire study tested the anatomical knowledge of 722 participants (598 patients from 6 different diagnostic groups and 133 people from the general population). In general, the knowledge of the anatomy was poor (average 52.5% correct, stan-dard deviation 20.1) and had not improved signifi-cantly since a previous, similar study 30 years ago. Only patients from the groups with liver dis-eases and diabetes scored higher. There was a negative correlation with age (the older the indi-vidual, the poorer the anatomical knowledge) and a positive correlation with the level of education (the higher the level of education, the better the anatomical knowledge). The authors concluded that these outcomes should have consequences for doctor-patient communication [Weinman 2009]. In the case of refugees, a lack of sufficient knowl-edge and insight into the functioning of the body and mind and the emotional charge associated with certain subjects makes it extra difficult for the care provider to explain matters in the usual manner to this group of individuals [Vloeberghs 2005].

30 Effectiveness of CBT and reattribution for MUSVarious treatments have been described for pa-tients with MUS, with quite a lot of recent re-search focussing on treatment in primary care. Some studies demonstrate that antidepressants and cognitive behavioural therapy are effective in the treatment of persistent MUS, with symptoms

thalassemia and vitamin B12 deficiency (all 1x). Two patients with mononucleosis and 1 with a dust mite allergy had a false negative test result. Patient history and physical examination were unable to predict which patients would have ab-normal blood test results [Koch 2009b].

23 Effect of additional investigations on the level of reassuranceA narrative review provided a descriptive sum-mary of RCTs that examined the effectiveness of the use of diagnostic tests as a method of reassur-ing patients. A total of 5 RCTs with 1544 patients were found. The RCTs examined various tests (ECG, X-ray examination of the lumbar spine, MRI of the brain, laboratory tests, MRI of the lumbar spine) for various symptoms (including chest pains, low back pain and headache). Of the 5 RCTs, 4 found no significant effect of the tests on the patient’s level of reassurance. One study reported a reassuring effect after 3 months, which had dis-appeared after one year. The authors of the review concluded that despite the small number of stud-ies and the heterogeneity, performing diagnostic tests hardly appears to contribute to the extent of reassurance. A clear explanation and a policy of watchful waiting can make additional diagnostic tests unnecessary. If diagnostic tests are used, it is important to provide adequate pre-test infor-mation about normal test results [Van Ravesteijn 2012].

24 Presence of functional limitations as a prognostically unfavourable factorFor the broad group of MUS patients in general, the presence of functional limitations has not been demonstrated to be a prognostically unfa-vourable factor.

25 Categorisation of MUS patients in severity classesThe categorisation of MUS patients in severity classes is based on consensus within the working group. The need for categorisation according to severity is motivated by the treatment principle of stepped care. We can distinguish between three dimensions of severity: the extent of functional limitations, the duration of the symptoms and the number of symptoms/symptom clusters in-volved.

26 Stepped careBased on a review of systematic reviews and me-ta-analyses, Henningsen et al. [Henningsen 2007] made the recommendation to implement a stepped-care approach in primary and secondary care. Stepped care is a more flexible treatment method than traditional forms of treatment. It means that various interventions of varying in-tensity are offered subsequently, depending on the effect of a previous step. Stepped-care treat-ment is based on three assumptions. The first is that the minimal interventions that are used in stepped care (for example, patient education) can have a significantly positive effect on the symp-toms that is equal to that of traditional psycho-logical treatment, at least for a number of the pa-tients. The second assumption is that the use of minimal interventions will ensure that mental health care services are used more effectively. The third assumption is that minimal interventions and the entire stepped-care approach are accept-able for both the patient and the care provider [Bower 2005]. In the case of MUS and somatoform disorders, stepped care entails opting for the mildest possible effective treatment based on the evaluation. The choice depends – among other factors – on the experiences with and effects of previous treatments and the nature and severity of the symptoms and limitations. For all these ap-proaches, it is important that an explicit goal is formulated and that monitoring of the course and the outcome of the intervention is performed. If the effect is inadequate, a subsequent (more in-tense) step in the care path is selected. As various


NHG guideline

the effectiveness of non-somatic clinical treat-ment, and the treated disorders and treatment modalities studied also vary too much to make general conclusions with a high level of evidence. An effect study (not an RCT) was performed in the Netherlands into the multidisciplinary treat-ment of severe MUS and somatoform disorders in a specialised centre for the treatment of psycho-somatic conditions [Veselka 2005]. This study formed part of the so-called STEP study (Standard Evaluation Project), a national initiative of some fifteen clinical mental health departments aimed at obtaining national figures about the ef-fectiveness and efficiency of treatment. This study evaluated intensive clinical (in-patient), multi-day or one-day multidisciplinary treat-ment. It was concluded that – in the case of severe to very severe MUS and somatoform disorders – there are strong indications that an intensive, integrative, multidisciplinary approach can be effective in achieving a reduction in symptoms, an increase in quality of life and a decrease in medical consumption.

sus 49%; p < 0.001). The other dimensions of the 4-DKL also improved significantly. The separate SF-36 (quality of life questionnaire) dimensions and the VAS scores improved significantly during the treatment (p < 0.001). After the treatment, more than 90% of the patients indicated that their health problems had improved significant-ly.Conclusion: although the level of evidence of the observational study is low – because it was unable to demonstrate that the observed difference was not the result of natural course – the working group is of the opinion that the observed effect of PSET in this group of patients (who have a poorer prognosis due to the duration of their symptoms (> 6 months)) is related to the PSET. Therefore, the working group is also of the opinion that there are strong indications for the effectiveness of PSET in patients with MUS.

35 Effectiveness of intensive rehabilitation programmesRelatively little research has been performed on

34 Effectiveness of psychosomatic exercise therapy (PSET)An observational study performed in 2010 [Van Ravensberg 2010] into the effects of the treatment by psychosomatic exercise therapists included 14 psychosomatic exercise therapists and 119 pa-tients with stress-related and/or unexplained physical symptoms. At the intake, 49% were found to have stress-related symptoms, 26% suffered from emotional exhaustion and burnout, and 24% suffered from anxiety and panic symptoms and hyperventilation. Approximately half the pa-tients (44%) had experienced symptoms for more than 6 months. Ten percent of the patients had even experienced symptoms for more than 5 years. Almost 30% of the patients had dysfunc-tional thoughts (incorrect ideas and views that inhibited recovery), and approximately half of the patients displayed dysfunctional behaviour (forc-ing themselves or over-taxing themselves). The number of patients with a distress score of more than 20 on the 4-DKL questionnaire was signifi-cantly reduced after the PSET treatment (1% ver-

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