ABSTRACT

The PhD dissertation emanates from the Research Unit for Functional Disorders, Aarhus University Hospital, and consists of three original articles and two chapters from a published treatment manual on treatment of patients with somatization or functional somatic symptoms (FSS) in general practice. The study includes development of cognitive therapeutic inspired treatment models for use in general practice by family general practitioners (GPs). The Extended Reattribution and Management (TERM) Model is evaluated in general practice in a pragmatic randomised controlled trial with intervention on the doctor level and the effect measured at patient level. Forty GPs were randomised for control or a 24-hour intensive skills-training programme (TERM Model). A total of 1785 consecutive patients from these practices were followed for two years with patient questionnaires, GP evaluation and health care costs derived from the national health care registers. A stratified sample of 701 patients underwent a diagnostic interview with the Schedules of Clinical Assessment in Neuropsychiatry. The prevalence was estimated to 36% of patients consulting their GP for a new illness problem and the comorbidity of other psychiatric illness was about one third. This underscores the necessity of teaching doctors to treat somatoform disorders on its own and not only the frequent accompanying depression or anxiety disorder. For all patients with functional somatic symptoms, the physical functioning, measured with Short Form-36, increased significantly more in the intervention group than among controls, whereas illness worry (hypochondriasis) was worsened for the most chronic group. The GPs changed consultation behaviour after intervention, significantly more often discussing non-physical topics and more often planning scheduled follow-up appointments. In spite of a reduction of health care costs amounting to 2010 Danish kroner (= 271 Euro) per patient with FSS per year, the reduction was not statistically significant because of large variation. In order to avoid inducing iatrogenic harm and a patient odyssey through the health care system, diagnoses of FSS should be made with positive criteria rather than as done presently as an exclusion diagnosis (medically unexplained symptoms). These positive criteria are still very insufficiently defined. Research on valid positive criteria is called for as is research on methods of preventing chronification.