The outcome of neurology outpatients with medically unexplained symptoms: a prospective cohort study

Abstract

Background: In a previous cross sectional study of 300 consecutive new attenders at neurology outpatient clinics, 90 were detected with symptoms that were rated as "not at all" or only "somewhat" explained by organic disease. Objective: To report a follow up study of this cohort. Methods: Patients were reinterviewed by telephone eight months after their initial assessment. They were asked to rate their overall improvement on a clinical global improvement scale, and their health status on the medical outcome short form 36 item scale (SF-36). The PRIME MD interview was administered to determine psychiatric diagnoses. Neurological and primary care records were reviewed for any changes in diagnostic opinion during the follow up period. Results: Of the 90 eligible patients, 66 (73%) participated in follow up. Among these, five (8%) rated themselves as "much worse," four (6%) as "somewhat worse," 27 (40%) as "just the same," 15 (23%) as "somewhat better," and 15 (23%) as "much better." There were no cases in which an organic cause for the presenting complaint was uncovered during the follow up period. Poorer physical function at baseline was the only predictor of poorer outcome at follow up. Conclusions: Over half the patients who presented to neurologists with symptoms that were rated as largely or completely medically unexplained had not improved eight months later. In no case was a disease explanation for the original presenting symptoms subsequently identified.

Neurology out-patients with symptoms unexplained by disease: illness beliefs and financial benefits predict 1-year outcome

“…This has especially been the case for patients who have been referred to specialist medical services (Couprie et al 1995 ;Barsky et al 1996 ;Vercoulen et al 1996 ;Crimlisk et al 1998 ;Carson et al 2003). However, we know little about what patient characteristics predict poor outcome.…”

“…Symptoms that are considered by the assessing doctors to be ' not at all ' or only ' somewhat ' explained by disease account for about a third of new out-patient visits to secondary medical care services, such as neurology out-patient clinics. They often do not improve after the specialist consultation (Carson et al 2003) and may become associated with chronic disability (Carson et al 2000 ;Kroenke, 2003). However, we know relatively little about which patient characteristics predict a poor post-consultation outcome for these patients.…”

“…Based on previous reports of predictors of subjective outcome in other similar symptomatic conditions, we hypothesized that the following variables would predict poor outcome : greater number of physical symptoms (Speckens et al 1996b) ; poorer physical functioning (Carson et al 2003) ; greater emotional distress (Bombardier & Buchwald, 1995) ; general worry about health (Kroenke & Jackson, 1998) ; the belief that they would not recover (Mondloch et al 2001) ; the belief that the symptoms were not affected by psychological factors (Vercoulen et al 1996) ; and being in receipt of illnessrelated financial benefits (Atlas et al 2006). …”

Medically unexplained symptoms and the disease label

“…Yet, studies propose that anywhere from 10 to 35 per cent of primary consultations fail to alleviate the presenting complaint (Peveler et al, 1997;Feder et al, 2001;Sharpe and Carson, 2001;Reid et al, 2002;Carson et al, 2003).…”

What Are We Communicating When We Present the Diagnosis of PNES?

“…Somatic symptoms disorders exist in every discipline of medicine and comprise a substantial percentage of medical visits, clinical testing, and disability contributing to the high cost of healthcare and human suffering (1). Medically "unexplained" symptoms are seen in about one-third of outpatient neurology visits with nearly one-fifth of these formally diagnosed with functional neurologic symptoms (2).…”