TABLE OF CONTENTS 1 May 2001 Volume 134 Issue 9 Part 2 ( )	Previous Issue  |  Next Issue

Symptoms Research: A Fertile Field

Kurt Kroenke and Lisa Harris

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.

When Do Symptoms Become a Disease?

Robert A. Aronowitz

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.

Symptom Research on Chronic Cough: A Historical Perspective

Richard S. Irwin and J. Mark Madison

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

Peter Bytzer and Nicholas J. Talley

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: State of the Science

Philip D. Sloane, Remy R. Coeytaux, Rainer S. Beck, and John Dallara

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, Arrhythmias, and Awareness of Cardiac Activity

Arthur J. Barsky

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: Symptom and Syndrome

Simon Wessely

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.

Studying Symptoms: Sampling and Measurement Issues

Kurt Kroenke

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.

Associations of Symptoms and Health-Related Quality of Life: Findings from a National Study of Persons with HIV Infection

Karl A. Lorenz, Martin F. Shapiro, Steven M. Asch, Samuel A. Bozzette, and Ron D. Hays

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.

Health-Related Quality of Life and Health Care Costs in Severe, Refractory Irritable Bowel Syndrome

Francis Creed, Joy Ratcliffe, Lakshmi Fernandez, Barbara Tomenson, Steve Palmer, Christine Rigby, Elspeth Guthrie, Nicholas Read, and David Thompson

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.

A Review of the Evidence for Overlap among Unexplained Clinical Conditions

Leslie A. Aaron and Dedra Buchwald

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.

Measuring Patients' Expectations and Requests

Richard L. Kravitz

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.

The Effect of Unmet Expectations among Adults Presenting with Physical Symptoms

Jeffrey L. Jackson and Kurt Kroenke

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.

Physical Symptoms and Physician-Experienced Difficulty in the Physician–Patient Relationship

Steven R. Hahn

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.

Symptom Management in Older Primary Care Patients: Feasibility of an Experimental, Written Self-Disclosure Protocol

Joshua C. Klapow, Steven M. Schmidt, Lloyd Adam "Chip" Taylor, Paul Roller, Qing Li, Jaimee W. Calhoun, Jan Wallander, and James Pennebaker

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.

Stepped Care for Back Pain: Activating Approaches for Primary Care

Michael Von Korff and James C. Moore

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.

Medical Symptoms without Identified Pathology: Relationship to Psychiatric Disorders, Childhood and Adult Trauma, and Personality Traits

Wayne Katon, Mark Sullivan, and Ed Walker

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.

"Unexplained" Somatic Symptoms, Functional Syndromes, and Somatization: Do We Need a Paradigm Shift?

Michael Sharpe and Alan Carson

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.