Table of Contents

Symptoms are the principal reason for clinic visits in about half of all outpatient encounters, yet biomedical research has typically focused on specific diseases rather than generic symptoms. The papers in this supplement are intended to serve as an introduction and a stimulus to the field of symptoms research.

Although biological and clinical factors set some boundaries for which symptoms might plausibly be linked in a disease concept, social influences largely explain which symptom clusters have made it as diseases.

This review provides a perspective on how research on the management of cough has evolved, looks at key methodologic lessons from this research and how they may relate to the management of other symptoms, identifies important methodologic challenges, and lists important unanswered questions.

Dyspepsia is a poor guide to the nature of “disturbances” in the gut. Use of an age threshold and alarm features to identify patients who require further investigation to rule out structural disease seems to be valid. Lack of validated outcome measures has hampered clinical studies of dyspepsia and has produced complex measures that combine symptoms or other indirect indicators of outcome into a general score.

Dizziness causes considerable morbidity and utilization of health services. Investigators would benefit from use of consistent criteria to describe dizziness symptoms and establish diagnoses. Investigation of the effects of testing and treatment should focus on morbid or life-threatening diagnoses. In the elderly, a function-oriented approach should be studied. Alternative therapies for chronic and recurrent dizziness merit investigation.

Palpitations are significantly less likely to be related to demonstrable cardiac arrhythmias in patients who somatize more and have more health-related anxiety and psychiatric distress. However, accurate awareness of arrhythmias is not associated with accurate awareness of resting heartbeat, and many heart transplant recipients are accurately aware of their resting heartbeat. Little is still known about symptom perception, processing, and reporting.

Chronic fatigue and the chronic fatigue syndrome present problems in definition and measurement. Social, behavioral, and psychological variables are important in both chronic fatigue and the chronic fatigue syndrome. Interventions that address these general variables are often more successful than interventions directed at specific causes.

Physical symptoms account for more than half of all outpatient visits, but the specific causes and treatments of many common symptoms are often not well established. Because clinical research has primarily targeted specific diseases, symptoms-based research is still an emerging field of scientific inquiry, and optimal methods are still being developed. This paper considers eight important issues in sampling and measurement of symptoms.

In this prospective cohort study, several HIV symptoms, including nausea, persistent cough, difficulty breathing, and diarrhea, were associated with more disability days, worse quality of life, or both. Targeting specific symptoms may improve health-related quality of life and reduce disability.

In this cross-sectional survey, both abdominal and psychological symptoms were independently associated with impaired health-related quality of life in patients with severe irritable bowel syndrome. Optimal treatment is likely to require a holistic approach. Since health care and loss of productivity costs are not clearly associated with irritable bowel syndrome symptoms, alleviation of them will not necessarily lead to reduced costs.

In this literature review, substantial overlap was found among unexplained clinical conditions such as fibromyalgia, the irritable bowel syndrome, and tension headache. Most studies are limited by methodologic problems, such as case definition and selection and recruitment of case-patients and controls.

The literature supports the conclusion that patients' expectations are wide ranging, can be measured, and have potentially important clinical consequences. Learning to elicit, evaluate, and understand patients' expectations will be a major task for clinicians and policymakers.

In this prospective cohort study, patients who sought care for physical symptoms and did not leave the encounter with an unmet expectation were found to be more likely to be satisfied with their care and to have less worry about serious illness. Diagnostic and prognostic information are particularly valued by patients and may be associated with greater improvement in symptoms and functional status 2 weeks after the visit.

The association between physical symptoms and physician-experienced difficulty in the clinical encounter is due in part to the association between patients' physical symptoms and mental disorders, but symptoms also contribute independently to difficulty. The independent component of symptom-associated difficulty may be due to 1) differences between patient and physician in expectations about treatment and 2) the part that symptoms play in conferring the “sick role” on a patient.

This study evaluated the feasibility of adapting an experimental written self-disclosure protocol for the primary care setting, with the goal of reducing symptoms. Patients and providers reported high levels of satisfaction with the protocol, but reductions in symptoms were minimal for both groups. The reduction in use of outpatient services and associated costs was twice as great in the treatment group.

The authors propose a stepped-care approach that provides a framework for 1) sequencing progressively more intensive interventions and 2) coordinating the efforts of primary care physicians, allied health professionals, behavioral health clinicians, and patients to improve functional outcomes in patients with back pain.

The substantial functional impairment, distress, and costs associated with medical symptoms without identified pathology suggest that research studies promoting a better understanding of the biopsychosocial cause of these symptoms may yield pragmatic, cost-effective approaches to treatment in medical settings.

In the past 100 years, a “mental” explanation for medically unexplained functional or somatization symptoms has predominated. A paradigm shift is proposed in which unexplained symptoms are remedicalized around the notion of a functional disturbance of the nervous system and treatments currently considered “psychiatric” are integrated into general medical care.