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

doi:10.1016/j.jpsychores.2016.07.001

Journal of Psychosomatic Research

Volume 88, September 2016, Pages 60-67

https://doi.org/10.1016/j.jpsychores.2016.07.001 Get rights and content

Highlights

•
Doctors may be hesitant to diagnose functional somatic symptoms (FSS), due to the risk to miss a somatic disease.
•
Diagnostic tests are often ordered in patients with a low pretest probability to rule out somatic disease or to reassure the patient.
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The overall pooled proportion for misdiagnosis in patients with FSS found at diagnostic check-up is 8.8%.
•
The overall pooled proportion for misdiagnosis in patients with FSS during naturalistic follow-up is 0.5%.

Abstract

Background

Functional somatic symptoms (FSS) are bodily complaints of unclear etiology, which are (currently) not fully explained by well-recognized somatic pathology. Doctors are often hesitant to diagnose FSS, due to the risk to miss a somatic disease. The purpose of this study is to review available literature on the percentage of patients diagnosed with FSS reported to have an underlying somatic disease that explains their symptoms previously labeled as FSS.

Methods

We performed a systematic search of Medline, Embase and PsycINFO databases and reference lists of selected articles. We included studies published between January 1980 and July 2014 without language restrictions. Studies that measured the percentage of underlying somatic diseases after a diagnostic evaluation or naturalistic follow-up period in adult patients initially diagnosed with FSS were included. As primary outcome measure the weighted percentage of revised diagnoses was calculated using meta-analyses.

Results

Six diagnostic evaluation studies (total N = 1804 patients) and 16 follow-up studies (total N = 2440 patients) were included. The percentage of revised diagnosis in patients initially diagnosed with FSS was 8.8% (95% CI 1.0 to 22.2, p = 0.007) in diagnostic evaluation studies and 0.5% (95% CI 0.01 to 1.5, p = 0.03) in follow-up studies. Partially or possibly related diagnoses were rarely found. No specific somatic diagnosis seemed to be missed systematically.

Conclusions

The percentage of underlying somatic diseases in patients previously diagnosed with FSS is relatively small but unneglectable.

Introduction

Functional somatic symptoms (FSS) are bodily complaints of unclear etiology, which are (currently) not fully explained by well-recognized somatic pathology. FSS can be understood both in terms of psychological and organic aspects underlying symptom experience [1]. At the general practitioner 25–50% of the physical symptoms presented remain somatically unexplained [2], whereas these percentages vary between 37 and 66% in other specialties [3]. Costs for patients with these FSS are high [4], [5].

Patients with FSS may have long diagnostic trajectories. One reason for this delay is that doctors are often hesitant to diagnose FSS, due to the risk to miss a somatic disease. Diagnostic tests are sometimes ordered to rule out conditions with a low pretest probability or to reassure the patient. However, diagnostic tests do little to reassure these patients or resolve their FSS [6]. Furthermore, a long diagnostic trajectory withholds to inform patient timely about evidence-based psychological and physical activation treatments [7].

The degree to which the fear of missing an underlying somatic diagnosis is realistic remains unknown. In a systematic review focusing on conversion disorder, follow up revealed a missed underlying somatic disease in only 4.2% of the patients [8]. A systematic review on misdiagnoses in the more frequently occurring FSS, such as fatigue, abdominal discomfort, dizziness or syndromes such as irritable bowel syndrome (IBS), chronic fatigue syndrome (CFS) and fibromyalgia (FM), is lacking.

We conducted a systematic review and meta-analysis on how often patients initially diagnosed with FSS, have an underlying somatic disease explaining symptoms during a diagnostic evaluation or a follow-up period. In addition, we explored whether the type of symptom influences the chance of a revised diagnosis.

Section snippets

Search strategy

PRISMA guidelines were followed [9]. A systematic literature search, dating from January 1980 until July 2014 without language restrictions, was conducted in Embase, PsycINFO and Medline by two independent reviewers (E.M.E and L.M.T). Search terms were FSS terms combined with revised diagnosis terms (supplement A). Titles and abstracts were screened, after which full text was retrieved for relevant articles or articles in which relevance was doubted. Of all relevant articles, also reference

Article selection

In total, 8622 potentially relevant articles were found. After screening of titles and abstracts, 29 articles were retrieved full text (see Fig. 1a and b). Six diagnostic evaluation studies (Table 1a) and 16 follow-up studies (Table 1b) were eligible for inclusion. The median duration of follow-up was 42 months. The mean follow-up percentage was 88%, with a minimum of 70% and a maximum of 100%. After visual inspection, no specific diagnosis seemed to be missed systematically.

Diagnostic evaluation studies

Six diagnostic

Discussion

This is the first meta-analysis studying the percentage of underlying somatic diseases in patients previously diagnosed with FSS, as detected during a diagnostic evaluation or a naturalistic follow-up. The percentage of misdiagnoses in patients with FSS found at diagnostic evaluation was 8.8% and during naturalistic follow-up 0.5%. Partially or possibly related diagnoses were rarely found. No specific somatic diagnosis seemed to be missed systematically.

Before interpreting our findings, it is

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Medically unexplained physical symptoms (MUPS) are a diverse mixture of symptoms for which (currently) a medical explanation is lacking and which are extremely common in primary care [1,2]. In a small percentage of patients with MUPS a specific disorder may eventually prove to be the cause of the symptoms [3]. Although most MUPS are self-limiting, symptoms may persist and cluster.
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The cognitive behavioural intervention was effective in improving pain and physical functioning components of patients' health. It was particularly suitable for patients with symptoms that had been present for a limited number of years and with few comorbid physical diseases.
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Review articleA systematic review and meta-analysis of the percentage of revised diagnoses in functional somatic symptoms

Highlights

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Search strategy

Article selection

Diagnostic evaluation studies

Discussion

J. Psychosom. Res.

J. Psychosom. Res.

J. Psychosom. Res.

Am. J. Med.

Psychosomatics

J. Psychosom. Res.

Lancet

Psychosomatics

Gen. Hosp. Psychiatry

J. Psychosom. Res.

Soc. Sci. Med.

J. Psychosom. Res.

The irritable bowel syndrome: long-term prognosis and the physician-patient interaction

Ann. Intern. Med.

Reassurance after diagnostic testing with a low pretest probability of serious disease: systematic review and meta-analysis

JAMA Intern. Med.

Non-pharmacological interventions for somatoform disorders and medically unexplained physical symptoms (MUPS) in adults

Cochrane Database Syst. Rev.

Systematic review of misdiagnosis of conversion symptoms and “hysteria”

BMJ (Clin. Res. Ed.)

The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration

Ann. Intern. Med.

Symptoms and syndromes of bodily distress: an exploratory study of 978 internal medical, neurological, and primary care patients

Psychosom. Med.

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

Psychol. Med.

Accuracy of the clinical diagnosis of ‘psychogenic disorders’ in the presence of physical symptoms suggesting a general medical condition: a 5-year follow-up in 162 patients

Psychother. Psychosom.

Accuracy of clinical impressions: experience with patients previously diagnosed to have functional bowel syndrome

Am. J. Gastroenterol.

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