Quality of life in primary care patients with moderate medically unexplained physical symptoms

  • P. E. van WestrienenEmail author
  • M. F. Pisters
  • S. A. J. Toonders
  • M. Gerrits
  • N. J. de Wit
  • C. Veenhof



Medically Unexplained Physical Symptoms (MUPS) have a large impact on patient’s quality of life. Most studies have been limited to chronic MUPS and thus, little is known about moderate MUPS. Improved knowledge concerning determinants influencing quality of life in moderate MUPS patients can be helpful in managing MUPS. This study is aimed at describing the common characteristics seen in moderate MUPS patients and compare them with characteristics seen in chronic MUPS patients and general population. We also identified determinants of the physical and mental components of quality of life in moderate MUPS patients.


In a cross-sectional study, moderate MUPS patients (n = 160) were compared with chronic MUPS patients (n = 162) and general population (n = 1742) based on demographic characteristics and patient’s quality of life. Multivariable linear regression analyses were performed to identify determinants associated with a patient’s quality of life, assessed with the RAND-36.


Moderate MUPS patients experienced a better quality of life than chronic MUPS patients, but a worse quality of life as compared to the general population. Determinants associated with the physical and mental components of quality of life explain 49.1% and 62.9% of the variance, respectively.


Quality of life of patients with MUPS varies with MUPS disease stage. Based on their quality of life scores, moderate MUPS patients would be adequately distinguished from chronic MUPS patients. Half of the variance in the physical component and almost two thirds of the mental component would be explained by a number of MUPS-related symptoms and perceptions.


Medically Unexplained Physical Symptoms Primary care Quality of life SF-36 


Brief IPQ

Brief Illness Perception Questionnaire


Diagnostic and Statistical Manual of Mental Disorders


General Practitioner


Mental Component Scale


Medically Unexplained Physical Symptoms


Moderate or Vigorous Physical Activity


Numeric Rating Scale


Physical Component Scale


Preventive screening of medically unexplained physical symptoms


36-Item Short Form Health Survey


Variance of inflation factor


Four-Dimensional Symptom Questionnaire



The authors would like to thank the authors of the articles from which the data of the patients with chronic MUPS and the general population was obtained.


This work was supported by SIA-RAAK-public [Grant No. 2015-02-24P].

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (include name of committee + reference number) and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Olde Hartman, T., Blankenstein, A., Molenaar, A., Bentz van den Berg, D., Van der Horst, H., Arnold, I., et al. (2013). NHG-standaard somatisch onvoldoende verklaarde Lichamelijk Klachten (SOLK). Huisarts Wet,56(5), 222–230.Google Scholar
  2. 2.
    Landelijke Stuurgroep Multidisciplinaire Richtlijnontwikkeling in de GGZ. (2010). Multidisciplinaire Richtlijn Somatisch Onvoldoende Verklaarde Lichamelijke Klachten En Somatoforme Stoornissen (Multidisciplinary Guideline of MUPS and Somatoform Disorders). Utrecht: Netherlands Institute of Mental Health Care and Addiction and Dutch Institute of Health Care Improvement 2010.Google Scholar
  3. 3.
    Aamland, A., Malterud, K., & Werner, E. (2014). Patients with persistent medically unexplained physical symptoms: A descriptive study from Norwegian general practice. BMC Family Practice,29(15), 107. Scholar
  4. 4.
    Jackson, J., & Passamonti, M. (2005). The outcomes among patients presenting in primary care with a physical symptom at 5 years. Journal of General Internal Medicine,20(11), 1032–1037. Scholar
  5. 5.
    Smith, R., & Dwamena, F. (2007). Classification and diagnosis of patients with medically unexplained symptoms. Journal of General Internal Medicine,22(5), 685–691. Scholar
  6. 6.
    American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5) (5th ed.). Washington: American Psychiatric Press.CrossRefGoogle Scholar
  7. 7.
    Barsky, A. J., Orav, E. J., & Bates, D. W. (2005). Somatization increases medical utilization and costs independent of psychiatric and medical comorbidity. Archives of General Psychiatry,62(8), 903–910. Scholar
  8. 8.
    Verhaak, P., Meijer, S., Visser, A., & Wolters, G. (2006). Persistent presentation of medically unexplained symptoms in general practice. Family Practice,23(4), 414–420. Scholar
  9. 9.
    Zonneveld, L. N., Sprangers, M. A., Kooiman, C. G., van ‘t Spijker, A., & Busschbach, J. J. (2013). Patients with unexplained physical symptoms have poorer quality of life and higher costs than other patient groups: A cross-sectional study on burden. BMC Health Services Research,17(13), 520. Scholar
  10. 10.
    Ring, A., Dowrick, C., Humphris, G., & Salmon, P. (2004). Do patients with unexplained physical symptoms pressurise general practitioners for somatic treatment? A qualitative study. BMJ,328(7447), 1057. Scholar
  11. 11.
    Olde Hartman, T., Hassink-Franke, L., Dowrick, C., Fortes, S., Lam, C., van der Horst, H., et al. (2008). Medically unexplained symptoms in family medicine: Defining a research agenda. Proceedings from WONCA 2007. Family Practice,25(4), 266–271. Scholar
  12. 12.
    Choy, E., Perrot, S., Leon, T., Kaplan, J., Petersel, D., Ginovker, A., et al. (2010). A patient survey of the impact of fibromyalgia and the journey to diagnosis. BMC Health Services Research,26(10), 102. Scholar
  13. 13.
    Isaac, M., & Paauw, D. (2014). Medically unexplained symptoms. Medical Clinics of North America,98(3), 663–672. Scholar
  14. 14.
    Olde Hartman, T. C., Hassink-Franke, L. J., Lucassen, P. L., van Spaendonck, K. P., & van Weel, C. (2009). Explanation and relations. How do general practitioners deal with patients with persistent medically unexplained symptoms: A focus group study. BMC Family Practice,24(10), 68. Scholar
  15. 15.
    Kroenke, K., & Jackson, J. (1998). Outcome in general medical patients presenting with common symptoms: A prospective study with a 2-week and a 3-month follow-up. Family Practice,15(5), 398–403.CrossRefGoogle Scholar
  16. 16.
    Hoffman, D. L., & Dukes, E. M. (2008). The health status burden of people with fibromyalgia: A review of studies that assessed health status with the SF-36 or the SF-12. International Journal of Clinical Practice,62(1), 115–126. Scholar
  17. 17.
    Joustra, M. L., Janssens, K. A., Bültmann, U., & Rosmalen, J. G. (2015). Functional limitations in functional somatic syndromes and well-defined medical diseases. Results from the general population cohort LifeLines. Journal of Psychosomatic Research,79(2), 94–99. Scholar
  18. 18.
    Dirkzwager, A. J., & Verhaak, P. F. (2007). Patients with persistent medically unexplained symptoms in general practice: Characteristics and quality of care. BMC Family Practice. Scholar
  19. 19.
    Salaffi, F., Sarzi-Puttini, P., Girolimetti, R., Atzeni, F., Gasparini, S., & Grassi, W. (2009). Health-related quality of life in fibromyalgia patients: A comparison with rheumatoid arthritis patients and the general population using the SF-36 health survey. Clinical and Experimental Rheumatology,27(5 Suppl 56), S67–S74.PubMedGoogle Scholar
  20. 20.
    Hanssen, D. J. C., Lucassen, P. L. B. J., Hilderink, P. H., Naarding, P., & Voshaar, R. C. O. (2016). Health-related quality of life in older persons with medically unexplained symptoms. The American Journal of Geriatric Psychiatry,24(11), 1117–1127. Scholar
  21. 21.
    Fitzcharles, M. A., Rampakakis, E., Ste-Marie, P. A., Sampalis, J. S., & Shir, Y. (2014). The association of socioeconomic status and symptom severity in persons with fibromyalgia. Journal of Rheumatology,41(7), 1398–1404. Scholar
  22. 22.
    Reisine, S., Fifield, J., Walsh, S., & Dauser, D. (2004). Employment and quality of life outcomes among women with fibromyalgia compared to healthy controls. Women and Health,39(4), 1–19. Scholar
  23. 23.
    Perrot, S., Schaefer, C., Knight, T., Hufstader, M., Chandran, A., & Zlateva, G. (2012). Societal and individual burden of illness among fibromyalgia patients in France: Association between disease severity and OMERACT core domains. BMC Musculoskeletal Disorders. Scholar
  24. 24.
    Rusu, C., Gee, M. E., Lagacé, C., & Parlor, M. (2015). Chronic fatigue syndrome and fibromyalgia in Canada: Prevalence and associations with six health status indicators. Health Promotion and Chronic Disease Prevention in Canada,35(1), 3–11.CrossRefGoogle Scholar
  25. 25.
    Campos, R. P., & Vázquez, M. I. (2013). The impact of Fibromyalgia on health-related quality of life in patients according to age. Rheumatology International,33(6), 1419–1424. Scholar
  26. 26.
    van Wilgen, C. P., van Ittersum, M. W., Kaptein, A. A., & van Wijhe, M. (2008). Illness perceptions in patients with fibromyalgia and their relationship to quality of life and catastrophizing. Arthritis and Rheumatism,58(11), 3618–3626. Scholar
  27. 27.
    Soriano-Maldonado, A., Amris, K., Ortega, F. B., Segura-Jiménez, V., Estévez-López, F., Álvarez-Gallardo, I. C., et al. (2015). Association of different levels of depressive symptoms with symptomatology, overall disease severity, and quality of life in women with fibromyalgia. Quality of Life Research,24(12), 2951–2957. Scholar
  28. 28.
    Busch, A., Barber, K., Overend, T., Peloso, P., & Schachter, C. (2007). Exercise for treating fibromyalgia syndrome. Cochrane Database Systematic Review,17, 4. Scholar
  29. 29.
    Bernardy, K., Klose, P., Welsch, P., & Häuser, W. (2018). Efficacy, acceptability and safety of cognitive behavioural therapies in fibromyalgia syndrome—A systematic review and meta-analysis of randomized controlled trials. European Journal of Pain,22(2), 242–260. Scholar
  30. 30.
    Henningsen, P., Zipfel, S., & Herzog, W. (2007). Management of functional somatic syndromes. Lancet,369(9565), 946–955. Scholar
  31. 31.
    Price, J., Mitchell, E., Tidy, E., & Hunot, V. (2008). Cognitive behaviour therapy for chronic fatigue syndrome in adults. Cochrane Database Systematic Review. Scholar
  32. 32.
    Larun, L., Brurberg, K., Odgaard-Jensen, J., & Price, J. (2017). Exercise therapy for chronic fatigue syndrome. Cochrane Database Systematic Review,25, 4. Scholar
  33. 33.
    Henningsen, P. (2018). Management of somatic symptom disorder. Dialogues in Clinical Neuroscience,20(1), 23–31.PubMedPubMedCentralGoogle Scholar
  34. 34.
    van Dessel, N., den Boeft, M., van der Wouden, J. C., Kleinstäuber, M., Leone, S. S., Terluin, B., et al. (2014). Non-pharmacological interventions for somatoform disorders and medically unexplained physical symptoms (MUPS) in adults. Cochrane Database Systematic Review. Scholar
  35. 35.
    van Westrienen, P. E., Pisters, M. F., Toonders, S. A., Gerrits, M., Veenhof, C., & de Wit, N. J. (2018). Effectiveness of a blended multidisciplinary intervention for patients with moderate medically unexplained physical symptoms (PARASOL): Protocol for a cluster randomized clinical trial. JMIR Research Protocols. Scholar
  36. 36.
    Aaronson, N. K., Muller, M., Cohen, P. D., Essink-Bot, M. L., Fekkes, M., Sanderman, R., et al. (1998). Translation, validation, and norming of the Dutch language version of the SF-36 Health Survey in community and chronic disease populations. Journal of Clinical Epidemiology,51(11), 1055–1068.CrossRefGoogle Scholar
  37. 37.
    Van der Zee, K. I., Sanderman, R. (1993). Het meten van de algemene gezondheidstoestandmet de RAND-36, een handleiding (Measurement of general healthwith the RAND-36, amanual). Groningen, the Netherlands: Noordelijk Centrum voor Gezondheidsvraagstukken; 1993.Google Scholar
  38. 38.
    Van der Zee, K. I., Sanderman, R., Heyink, J. W., & de Haes, H. (1996). Psychometric qualities of the RAND 36-Item Health Survey 1.0: A multidimensional measure of general health status. International Journal of Behavioral Medicine,3(2), 104–122. Scholar
  39. 39.
    Ware, J. E. J., & Gandek, B. (1998). Overview of the SF-36 health survey and the International Quality of Life Assessment (IQOLA) Project. Journal of Clinical Epidemiology,51(11), 903–912.CrossRefGoogle Scholar
  40. 40.
    Ware, J. E. J., Gandek, B., Kosinski, M., Aaronson, N. K., Apolone, G., Brazier, J., et al. (1998). The equivalence of SF-36 summary health scores estimated using standard and country-specific algorithms in 10 countries: Results from the IQOLA Project. International Quality of Life Assessment. Journal of Clinical Epidemiology,51(11), 1167–1170.CrossRefGoogle Scholar
  41. 41.
    Dworkin, R., Turk, D., Wyrwich, K., Beaton, D., Cleeland, C., Farrar, J., et al. (2008). Interpreting the clinical importance of treatment outcomes in chronic pain clinical trials: IMMPACT recommendations. The Journal of Pain,9(2), 105–121. Scholar
  42. 42.
    Terluin, B., van Marwijk, H., Adèr, H., de Vet, H., Penninx, B., Hermens, M., et al. (2006). The Four-Dimensional Symptom Questionnaire (4DSQ): A validation study of a multidimensional self-report questionnaire to assess distress, depression, anxiety and somatization. BMC Psychiatry,22(6), 34. Scholar
  43. 43.
    De, Terluin B. (1996). Vierdimensionale Klachtenlijst (4DKL): Een vragenlijst voor het meten van distress, depressie, angst en somatisatie. Huisarts Wet,39, 538–547.Google Scholar
  44. 44.
    Terluin, B., Terluin, M., Prince, K., & van Marwijk, H. W. J. (2008). The Four-Dimensional Symptom Questionnaire (4DSQ) detects psychological problems. Huisarts Wet,51, 251–255.CrossRefGoogle Scholar
  45. 45.
    Terluin, B., Oosterbaan, D. B., Brouwers, E. P., van Straten, A., van de Ven, P. M., Langerak, W., et al. (2014). To what extent does the anxiety scale of the Four-Dimensional Symptom Questionnaire (4DSQ) detect specific types of anxiety disorder in primary care? A psychometric study. BMC Psychiatry,24(12), 121. Scholar
  46. 46.
    Broadbent, E., Petrie, K. J., Main, J., & Weinman, J. (2006). The brief illness perception questionnaire. Journal of Psychosomatic Research,60(6), 631–637. Scholar
  47. 47.
    Bussmann, H. (2013). Validation of the Active8 activity monitor: Detection of body postures and movements. Erasmus MC: Publisher.Google Scholar
  48. 48.
    Choi, L., Ward, S. C., Schnelle, J. F., & Buchowski, M. S. (2012). Assessment of wear/nonwear time classification algorithms for triaxial accelerometer. Medicine and Science in Sports and Exercise,44(10), 2009–2016. Scholar
  49. 49.
    Matthews, C. E., Chen, K. Y., Freedson, P. S., Buchowski, M. S., Beech, B. M., Pate, R. R., et al. (2008). Amount of time spent in sedentary behaviors in the United States, 2003-2004. American Journal of Epidemiology,167(7), 875–881. Scholar
  50. 50.
    Tremblay, M. S., Aubert, S., Barnes, J. D., Saunders, T. J., Carson, V., Latimer-Cheung, A. E., et al. (2017). Sedentary behavior research network (SBRN)—Terminology consensus project process and outcome. International Journal of Behavioral Nutrition and Physical Activity,14(1), 75. Scholar
  51. 51.
    Health Council of the Netherlands. (2017). Physical activity guidelines 2017. The Hague: Health Council of the Netherlands, 2017;publication no. 2017/08e.Google Scholar
  52. 52.
    Divisie Sociale en ruimtelijke statistieken Sector Sociaal-economisch totaalbeeld. (2017). Standaard onderwijsindeling 2006—Editie 2016/’17. Centraal Bureau voor de Statistiek, Den Haag/Heerlen; 2017:10–14.Google Scholar
  53. 53.
    Azur, M. J., Stuart, E. A., Frangakis, C., & Leaf, P. J. (2011). Multiple imputation by chained equations: What is it and how does it work? International Journal of Methods in Psychiatric Research,20(1), 40–49. Scholar
  54. 54.
    Miles, J., & Shevlin, M. (2001). Applying regression and correlation. A guide for students and researchers (2nd ed.). London: SAGE Publications Ltd.Google Scholar
  55. 55.
    Ware, J. E., Snow, K. K., Kosinski, M., & Gandek, B. (1993). SF-36 health survey manual and interpretation guide. Boston, MA: New England Medical Center, The Health Institute.Google Scholar
  56. 56.
    Gross, T., Morell, S., & Amsler, F. (2018). Longer-term quality of life following major trauma: Age only significantly affects outcome after the age of 80 years. Clinical Interventions in Aging,30(13), 773–785. Scholar
  57. 57.
    Togas, C., Raikou, M., & Niakas, D. (2014). An assessment of health related quality of life in a male prison population in Greece associations with health related characteristics and characteristics of detention. BioMed Research International,2014, 274804. Scholar
  58. 58.
    Lee, J. W., Lee, K. E., Park, D. J., Kim, S. H., Nah, S. S., Lee, J. H., et al. (2017). Determinants of quality of life in patients with fibromyalgia: A structural equation modeling approach. PLoS ONE,12(2), e0171186. Scholar
  59. 59.
    Poloni, N., Ielmini, M., Caselli, I., Ceccon, F., Bianchi, L., Isella, C., et al. (2018). Medically unexplained physical symptoms in hospitalized patients: A 9-year retrospective observational study. Frontiers in Psychiatry. Scholar
  60. 60.
    van der van Eck Sluijs, J. F., Ten Have, M., de Graaf, R., Rijnders, C. A. T., van Marwijk, H. W. J., & van der Feltz-Cornelis, C. M. (2018). Predictors of persistent medically unexplained physical symptoms: Findings from a general population study. Frontiers in Psychiatry. Scholar

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© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of Health Innovation and TechnologyFontys University of Applied SciencesEindhovenThe Netherlands
  2. 2.Center for Physical Therapy Research and Innovation in Primary Care, Leidsche Rijn Julius Health Care CentersUtrechtThe Netherlands
  3. 3.Physical Therapy Research, Department of RehabilitationPhysical Therapy Science and Sport, Brain Center Rudolf Magnus, University Medical Center UtrechtUtrechtThe Netherlands
  4. 4.Department of General Practice, Julius Center for Health Sciences and Primary CareUniversity Medical Center UtrechtUtrechtThe Netherlands
  5. 5.Research Group Innovation of Human Movement CareUniversity of Applied Sciences UtrechtUtrechtThe Netherlands

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