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APPENDIX A Population and Need-Based Prevention of Unexplained Physical Symptoms in the Community CharIes C. Engel, Jr., and Wayne ]. Katon SYNOPSIS How might military medicine respond to existing research on the epide- miology, burden, natural history, and management of medically unexplained physical symptoms (MUPS) in primary care and the general population? This review of extensive published research suggests that MUPS are pervasive and contribute substantially to physical, social, occupational, and organizational im- pairment, psychosocial distress, unnecessary health care utilization and expen- ditures, and adverse health care outcomes. These studies suggest that the natural history of MUPS is influenced by a number of predisposing, precipitating, and perpetuating factors and that certain prognostic factors may help clinicians and policy makers estimate the outcomes and population needs. We use the epidemiology of MUPS and the basic principles of population- based health care to construct an efficient MUPS prevention strategy that em- phasizes a continuum of care. In the absence of randomized trial evidence of efficacy for any single multifaceted continuum of MUPS care, the prevention program suggested is conservative and reasonably achievable, lends itself to subsequent evaluation and improvement, and calls for a multifaceted, well- inte~rated stenned care management anoroach involving ~7 , ~ ~ ~7 ~ ~ Charles C. Engel, Jr., M.D., M.P.H., is Chief of the Gulf War Health Center at Walter Reed Army Medical Center in Washington, D.C., and Assistant Professor of Psy- chiatry at the Department of Psychiatry of the Uniformed Services University in Be- thesda, Maryland. Wayne J. Katon, M.D., is Professor and Vice-Chair, Department of Psychiatry and Behavioral Sciences at the University of Washington School of Medicine. The views expressed by Doctor Engel in this article are his own and do not reflect the official policy or position of the Department of the Army, the Department of Defense, or the U.S. Government. 173

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174 STRATEGIESTOPROTECTTHEHEALTHOFDEPLOYED U.S. FORCES . broad-based and low-intensity educational interventions delivered to every member of the military services and perhaps their family members; . primary care-based collaborative and interdisciplinary practice teams that aim to improve short- and long-term health behaviors using a variety of behav- ioral strategies including education; . information systems that use expert systems to process and feed back data obtained by using a health care-based health information system and a popula- tion survey-based health data monitoring system; . specialized, multimodal services available for the intensive multidisci- plinary management of disabling and otherwise treatment-refractory MUPS; and . development of a "center of excellence" to lead clinical, research, and educational efforts related to MUPS in the military. We suggest that future improvement efforts target military clinicians, military health care delivery, the military work environment, and existing methods for compensating and returning ill personnel to work. No matter the overall process and structure of care provided for individuals with MUPS, physicians are urged to practice "person-centered" rather than "dis- ease-centered" care. They cannot ignore their place as consultants to real people in real predicaments who are attempting to make difficult decisions potentially affecting their future health, career, relationships, and status. Hadler has stated that the role of physicians, "should be more than that of concerned citizens or even of patients' advocates; tto that] we can add the perspective of students of the human predicament."58 The expanded notion of ill health as a human pre- dicament is especially apropos in occupational and military medicine settings. Occupational and military physicians treat diseases, but of equal import is their obligation to study and prepare the workplace so those workers with illness- related work limitations can eventually make a successful return to productivity. Eventually, we are impressed that military medicine's innovations in this area may provide an important model for civilian health care organizations seeking solutions to the difficult challenge of MUPS. UNDERSTANDING MEDICALLY UNEXPLAINED PHYSICAL SYMPTOMS The absence of a discerned cause for physical symptoms is best viewed through the lens of the scientific uncertainty necessarily involved in any one-to- one doctor-patient visit. We will use "MUPS" in reference to health care use for physical symptoms that are not clinically explained by a medical etiology. MUPS can be broken down into a four-part process. First, an individual must experience the symptom. In a simplified way, this might be viewed as the bio- logical part of the process. Presumably, for one to perceive a symptom, some neurophysiological event must bring it to awareness. The second step is cogni- tive, or related to how we think about the symptom. The person perceiving a

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APPENDIX A 175 symptom overlays some knowledge, biases, or beliefs that he or she has about the symptom and its cause, assigning it a level of medical importance. We do not seek care for most of the symptoms we experience, partly because we assign them some relatively low level of medical significance. When we seek care, we are taking a third and behavioral step that is mediated by our belief in the symptom's significance. The fourth and final step is the purview of the clinician: he or she must de- cide the extent to which symptoms are explained by the patient's medical diag- noses. This is one of the most problematic aspects of MUPS. There is a clear potential for doctor-patient conflict in this formulation. Differing clinician and patient explanations for MUPS may be one of the most important contributors to the frustration that these symptoms create for clinicians 97 ~54 and the dissatis- faction with care that many affected patients describe. Add some reason for doctor-patient mistrust, and the relationship can become outwardly adversarial and result in mutual rejection. In occupational settings like the military, clinicians must provide care within the context of competing and sometimes unacknowledged obligations. The clinician is committed to the welfare of the employer, who is both paying the clinician's salary and providing medical benefits for the patient. This same clinician has a simultaneous duty to the health and well-being of the patient. Under these circumstances, the patient may fear that the clinician is being co- erced to deny the reality of the medical problem in service to the employer's financial or political interests. The patient may feel that the clinician is more interested in keeping the patient on the job than in providing treatment. Alterna- tively, the clinician may suspect that the patient is exaggerating health concerns to obtain benefits. Conflicts such as these heighten doctor-patient mistrust, dampen rapport, and diminish the chance of a productive clinical encounter. Symptom-based disorders are diagnoses based upon patient-reported physical symptoms rather than specific findings on clinical examination or diagnostic test- ing. Symptom-based disorders seldom offer clinicians and patients more than a label. In most instances, the prognosis, treatment, and factors that determine dis- ability are remarkably similar across different symptom-based disorders. Observed differences are typically small and are attributable to differences in severity, the number of other symptoms involved with the syndrome, or differences in loss of functioning due to symptom location (e.g., lower-extremity joint pain impedes walking, whereas headache pain does not). The names of symptom-based disor- ders are usually based on hypothesized etiology (e.g., chronic Lyme disease), pu- tative triggers (e.g., multiple chemical sensitivity), a central descriptive feature (e.g., chronic fatigue syndrome), or body region (e.g., temporomandibular disor- der). Labels often use complicated terminology (e.g., fibromyalgia or myalgic encephalomyelitis) that suggests to patients, doctors, and the public that the syn- drome is better understood than it actually is. Therefore, we will use the term symptom-based disorder to signify syndromes that are clinically diagnosed almost exclusively by using patients' verbal descriptions. Table A-1 displays some com- mon examples of symptom-based disorders and illustrates that clinicians in nearly

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176 STRATEGIESTOPROTECTTHEHEALTHOFDEPLOYED U.S. FORCES every specialty encounter them. Symptom-based disorders overlap extensively, manifest remarkably similar pathophysiology, risk factors, clinical course, and prognosis, and respond to similar rehabilitative treatment approaches.~723 54 67 ~8 ~58 Historically, physicians have tended to categorize MUPS and symptom-based disorders as psychiatric symptoms on the basis of exclusion. It seems most logical that only some MUPS are psychiatric in their origin. TABLE A-1 Some Symptom-Based Diagnoses and the Specialties that Commonly Diagnose and Encounter Them Specialty Clinical Syndrome Specialty Clinical Syndrome Orthopedics Low back pain Patellofemoral syndrome Dentistry Temporomandibular dysfunction Gynecology Chronic pelvic pain Rheumatology Fibromyalgia Premenstrual syndrome Myofascial syndrome Siliconosis Ear-Nose- Idiopathictinnitus InternalMedicine Chronic fatigue syn Throat drome Neurology Idiopathic dizziness Infectious Diseases Chronic Lyme disease Chronic headache Chronic Epstein-Barr virus Chronic brucellosis Chronic candidiasis Urology Chronic prostatitis Gastroenterology Irritable bowel syn Interstitial cystitis drome Urethral syndrome Gastroesophageal reflux Anesthesiology Chronic pain syndromes Physical Medicine Mild closed head in Jury Cardiology Atypical chess pain Occupational Multiple chemical Idiopathic syncope Medicine sensitivity Mitral valve prolapse Sick building syn drome Pulmonary Hyperventilation syn- Military Medicine Gulf War Syndrome drome Endocrinology Hypoglycemia Psychiatry Somatoform disorders

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APPENDIX A 177 EPIDEMIOLOGY OF SYMPTOMS AND SYMPTOM-BASED DISORDERS Prevalence in the Community and Primary Care Review of the epidemiology of unexplained physical symptoms necessarily involves discussion of the epidemiological literature on somatization and the somatoform disorders (e.g., conversion disorder, somatization disorder, or pain disorder). The central feature in the somatoform disorders, however, is the pres- ence of MUPS. The absence of test abnormalities or objective physical exami- nation findings means that a psychiatric etiology is presumed but that the actual etiology is a matter of debate. We advocate an Theoretical, nonetiological, and phenomenological understanding of MUPS since this formulation is intellectu- ally honest and maximally acceptable to those affected. Population-based surveys have shown that 85 to 95 percent of community respondents experience at least one physical symptom every 2 to 4 weeks al- though relatively few of these symptoms are reported to physicians. The population-based Epidemiologic Catchment Area Study examined 13,538 re- spondents from four U.S. communities and found that 25 percent reported chest pain, 24 percent reported abdominal pain, 23 percent reported dizziness, 25 per- cent reported headache, 32 percent reported back pain, and 25 percent reported fatigue.9~ Thirty-one percent of symptoms were medically unexplained, and the type of symptom was unrelated to the absence of explanation. Eighty-four per- cent of symptoms caused respondents to seek health care, take a medicine, or curtail activities.9~ Over 4 percent of people had a lifetime history of multiple, chronic, unexplained symptoms and an exacerbation within the past year.38 ~42 Other studies have shown that MUPS are associated with a high proportion of populationwide disability and health care utilization, largely because they are so common.3974 For example, the 1989 National Ambulatory Medical Care Sur- vey estimated that physical symptoms account for 57 percent of all U.S. ambu- latory care visits including some 400 million clinic visits per annum.~27 Kroenke and Mangelsdorff90 reviewed the medical records of 1,000 primary care-internal medicine patients over a 3-year period and determined the incidence, diagnostic findings, and outcomes of 14 common symptoms. At least one common symp- tom was present in 38 percent of patients, and only 16 percent of symptoms were felt to have an organic cause. Symptomatic patients were monitored for an average of 11 months, and for 47 percent of patients the symptom persisted throughout the follow-up period. Two-thirds of symptoms were evaluated be- yond the initial history and physical examination, but only approximately 1 in 10 evaluations resulted in an organic diagnosis not apparent at the index visit. Subsequently, Kroenke et alps completed an off~ce-based survey of 410 primary care-internal medicine patients to determine the prevalence and adequacy of therapy for 15 common symptoms. Eighty-two percent of patients had one or more symptoms, and in 77 percent one or more of these symptoms had been reported to patients' physicians. However, only 39 percent of patients with fa

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178 STRATEGIESTOPROTECTTHEHEALTHOFDEPLOYED U.S. FORCES fugue, dyspnea, dizziness, insomnia, sexual dysfunction, depression, and anxiety reported any noticeable response to treatment. Most other primary care research suggests that etiologies are unknown for at least 25 to 30 percent of patients with either painful or nonpainful physical symptoms.87 92 93 An extensive scientific literature has shown that MUPS are strongly and consistently associated with psychosocial distress, psychiatric disorders, de- creased quality of life, and increased health care utilizations ~8 25 38 39 56 76 90 92 ~29 ~35 Depression and anxiety are consistently associated with MUPS across many studies that have used wide-ranging methodologies including cross- sectional ~35 case-control,73 82 ~40 ~52 ~56 and longitudinal designs35 Some evi- dence suggests that associated high health care utilization leads to more harm and patient dissatisfaction than benefit.86 ~45 Natural History of MUPS MUPS are characteristically chronic and intermittently relapsing, although the natural history is reasonably variable in severity and periodicity. Factors responsible for variability in clinical outcomes may be classified as predispos- ing, precipitating, and perpetuating factors. Predisposing factors are characteristics of individuals that render them more vulnerable to MUPS and related morbidity. Important predisposing factors are heredity;~36 ~62 neurophysiological, neurotransmitter, and autonomic nervous system factors;4 3~ 44 52 55 83 ~44 early life adversity (e.g., child maltreatment);3 26 68 8598~52~53~55 chronic medical illness;2~266~2~47 or chronic distress or mental illness.3470 Predisposing factors may be either intrinsic (i.e., innate to the indi- vidual) or acquired (i.e., obtained during lifetime exposure or experience). A precipitating factor is essentially a "straw that breaks the camel's back," initiating an acute episode of MUPS and related morbidity. Factors that precipi- tate MUPS include biological stressors,~5 ~34 psychosocial stressors,27-29 acute psychiatric disorders, and epidemic health concerns.~4 2~ 24 62 69 ~39 Perpetuating factors are those that maintain, exacerbate, or prolong symp- toms, distress, and disability after they occur. Perpetuating factors may occur independently of the original precipitants. They include harmful illness beliefs (beliefs that lead to a maladaptive response to the symptoms),~32 labeling effects (i.e., the adverse effects associated with viewing oneself as ill),406063 ~06 misin- formation,~ 7 ~6 ~00 ~30 ~33 workplace and compensation factors, 59 ~28 ~4~ and social support factors.~07 Prognostic Factors: Prediction of Outcomes and Assessment of Future Needs MUPS occur along a spectrum of severity and prognosis74 ranging from mild and transient to chronic and disabling. Prognostic factors are individual, environ

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APPENDIX A 179 mental, or population characteristics that may be used to predict symptom out- comes and estimate future treatment and resource needs. The prognostic spectrum of MUPS includes acute, recurrent, and chronic subtypes. Acute MUPS occurs in the absence of a previous pattern or history of MUPS and lasts a few months at most, and associated disability is often temporally associated with an acutely stressful life event. Recurrent MUPS is characterized by alternating symptomatic, asymptomatic, and mildly symptomatic periods. Chronic MUPS is a pattern of persistent unexplained physical symptoms associated with chronic disability, high health care utilization, and persistent problems with coping. Empirically evaluated prognostic indicators for MUPS include (1) prior level of health care use, (2) psychiatric factors, (3) physical symptom factors, and (4) factors related to functioning. A high level of previous health care use suggests that a poor long-term outcome characterized by chronic MUPS is rela- tively likely.78 ~36 A large number of prospective studies have consistently found that the presence of stressors, distress, and psychiatric disorders, especially when they are chronic, predict persistent MUPS and related disability.9 ~3 22 29 57 65~05~09~9~26 A higher number of comorbid physical symptoms ("symptom count"~53 and longer symptom durational 22 89 95 ~48 also predict a poor outcome. Past poor functioning including occupational functioning suggests a poor prog- nosis.37 50 94 A patient's historical level of functioning can serve as a marker for a myriad of issues that diminish the amount of reserve that an individual can muster when symptoms worsen. PREVENTION OF SYMPTOMS AND SYMPTOM-BASED DISORDERS The epidemiology of MUPS suggests that those individuals afflicted with the mysterious "Gulf War Syndrome" may represent only the most disabled, symptomatic, and distressed of ill Gulf War veterans. For each veteran who seeks care for Gulf War-related health concerns, there may be several others with fewer physical symptoms. In a less protean manner, perhaps, these indi- viduals' symptoms are reducing their capacity to function, increasing their use of health care, and heightening their health-related worries. Left unmanaged, these milder syndromes may become subject to the adverse influences of the previously described predisposing, precipitating, and perpetuating factors. Is it possible to prevent MUPS? Resources are limited, and the scope of the problem is wide. The success of any program of prevention will depend on the degree of effectiveness of existing interventions and the resources required to deliver them. It may be feasible to significantly reduce the organizational impact of MUPS among military personnel by using a coordinated combination of population-based and need-based strategies. We recommend the adoption of a "population-based health care" model that uses a stepped-care approach (Figure A-1) to achieve maximum overall efficiency and effectiveness.

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180 Preevent Prevention Postevent Prevention Workplace risk communica tion Workplace screening ~ \ Workplace edu- . Workplace cation education Family educat Family edu- . ion cation Public service announce- meets .^ STRATEGIESTOPROTECTTHEHEALTHOFDEPLOYED U.S. FORCES Intensive Programs Multispecialty care: 1 ) 1 0- to 1 5- week outpati- ent <2) 3-week in- patient Collaborative Primary Care '' Integrated pat- tern of care Clinical risk communicat Primary Care on ~ ~ Care-based: Care-based . 1 ) education screening . 2) physical re Clinical risk . activation communicat- . 3) problem ion . solving Tracking Tracking Tracking Tracking Tracking Vulnerability Precipitating Symptoms and Chronicity Disability Factors Health Concerns FIGURE A-1 A stepped-care approach to the population management of medically unexplained physical symptoms. Advantages of Population-Based Intervention Rosen has noted, "a large number of people exposed to a small risk may generate many more cases than a small number exposed to a high risk" (p. 24~. Similarly, a large number of people exposed to a low-intensity preventive inter- vention can have a very large population effect (i.e., the effect of prevention summed across every person experiencing the intervention). Figure A-2 uses

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APPENDIX A 25 20 au Q ~15 En 10 5 O EMPHASIS: EMPHASIS: POPULATION UNMET NEEDS .~ - - ~ - Before After - 20 A cr '\` ~Disability _. ~t ' At/' do-- ~- - 10 Q _~~ ~,y~ ~-5 ~ ~ '; ;'' i ~'2"~ I- ~ 1 1 my, ..... 0 1 2 3 4 5 6 181 7 8 9 10 11 12 13 14 15 16 Symptom Count - lo FIGURE A-2 Contrasting the population-based and needs-based approaches to reducing morbidity related to medically unexplained physical symptoms. Since disability (right vertical axis) is closely related to symptom count, population interventions that reduce symptoms a small amount per individual ("Before" = before intervention; "After" = after intervention) can prevent extensive disability when benefits are summed across the population. More intensive needs-based interventions can assist the relatively few indi- viduals with repeated health care visits, multiple symptoms, and high levels of disability. Units of disability are hypothetical. hypothetical data to illustrate that there is a graded and threshold-free relation- ship between symptom count and disability. Therefore, even among relatively healthy individuals, a small intervention benefit results in a small average indi- vidual improvement in functional status. Figure A-2 also shows that most of the population experiences relatively few symptoms and consequently little disabil- ity related to MUPS. When small reductions in individual disability occur across an entire population, the resulting societal benefits may be large and meaningful. For the majority of people, MUPS come and go, usually without so much as a physician consultation. If these people are encouraged to seek health care for MUPS, it may increase the chance of long-term disability. This increase in dis- ability may occur via mechanisms such as unnecessary worry, unnecessary avoid- ance of physical and social activities, unnecessary treatment, adverse effects of treatment, and provider errors.42 "Medicalization" of otherwise minor and transient symptoms may also occur. This is a process similar to labeling, wherein the act of visiting a doctor for a symptom imbues the symptom with catastrophic meaning, thereby setting up a self-fulf~lling expectation of future disability.

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182 STRATEGIES TO PROTECT THE HEALTH OF DEPLOYED U.S. FORCES In sum, population-based approaches to MUPS have the advantages of uni- versal exposure to an intervention and summation of the benefit per individual across an entire population. Since many individuals who would never have be- come ill necessarily receive intervention, population-based interventions must have a lower potential for harm than most interventions employed for the sick. Advantages of Need-Based Intervention Interventions that target the whole population can seldom address the unmet needs of the important minority suffering from many symptoms and extensive disability. Rosen described health care-based preventive approaches as "the high risk strategy" because the effort is to identify individuals at especially high health risk or with especially great need for health care. The time-limited nature of clinical practice requires that providers rapidly recognize patients who require special attention. In essence, the clinician must identify and dichotomously de- lineate people lying along the continuum of disability severity as either ill or not ill. The point at which people are deemed ill is more or less arbitrary but neces- sary to operationalize so that the process of care can proceed unhindered. Using the hypothetical data from Figure A-2, for example, the "cutoff point" for identi- f~cation of individuals in need of clinical care is set at 10 symptoms. This artificial dichotomy leads to the specific advantages and disadvantages of health care-based prevention strategies. The primary advantage is that inter- vention can be matched to the unique needs of a relatively few seriously ill indi- viduals, an approach that is attractive and sensible to both ill patients and their providers. Another advantage is that intervention aimed at the ill is minimally intrusive or harmful for those who are not ill. Riskier, more intensive, or more invasive interventions may be justified for "high risk" or ill individuals because of the comparatively large potential for individual benefit and the reduced so- cietal cost conferred by limiting the intervention to a few. On the other hand, clinical strategies contribute disappointingly little to any overall reduction of population disability. This is because only a very small pro- portion of society is ever exposed to a clinically based intervention that targets an ill or needy population. For example, Figure A-2 suggests that relatively few individuals have 10 or more symptoms, and many who have fewer than 10 symptoms will manifest significant disability and unmet needs that would not be addressed by a clinical intervention. In sum, the population-based and need-based prevention approaches both offer important advantages and suffer from unique limitations. The best ap- proach to the prevention of MUPS therefore involves some combination of population-based and need-based prevention, intervention, and management.

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APPENDIX A 183 Population-Based Care: Matching Resources to Needs Population-based care aims to improve health outcomes through carefully structured clinical services linked through primary care to a population-based prevention plan. Population-based care is the development and implementation of a detailed plan that covers all people in a defined population who, despite population-based prevention, have developed a chronic or recurrent health con- dition or concern. Important symptoms are identified, a mechanism to track out- comes is devised, and a deliberate matching of appropriate resources to patients with unmet needs occurs.~5~ Katon and colleagues have described how population-based care can re- duce the prevalence of depression, and we advocate an analogous approach for MUPS. Critical is an understanding that various health care settings see different clinical populations with contrasting levels of MUPS severity and duration. More severely ill populations are encountered as the setting shifts from the community into higher levels of health care (e.g., tertiary care and inpatient hospital). This is clearer when one considers the dynamics of illness in populations. Consider that the point prevalence (P) of some illness (i) is roughly equal to its incidence (Ii) times its average duration (Di): Pi _ Ii ~ Di.~25 For intermittently relapsing illnesses such as MUPS, the duration of symptomatic illness can be approximated as the number of symptom episodes (N) times the average dura- tion per symptom episode (De) Given some assumptions (beyond the scope of this discussion), the following can be shown: Pi Ii * De * Ni This equation predicts that groups with more frequently episodic MUPS or MUPS of longer episode duration are overrepresented in populations because these characteristics elevate prevalence. The incidence of brief, nonrecurrent MUPS (e.g., acute back pain with a rapid resolution) may be relatively high compared with that of chronic MUPS. Even so, the long symptom duration and large number of episodes among those few individuals with an incident case of MUPS who develop chronic MUPS ensure that those with chronic MUPS are disproportionately represented in the population at any point in time. This over- representation of those with chronic and recurrent MUPS versus those with brief and acute MUPS is greater in specialty care than primary care and greater in referral facilities than local facilities. This occurs because local care and lower- intensity levels of care serve to "filter out" healthy and transiently ill individu- als. Hence, the prevalence of chronic and recurrent illness is least in the general population, the greatest in specialty and tertiary referral settings, and intermedi- ate in local and primary care settings. The equation presented above suggests that the societal or organizational burden of MUPS may be reduced in at least three ways: . incidence reduction or prevention of illness onset (primary prevention),

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202 STRATEGIES TO PROTECT THE HEALTH OF DEPLOYED U.S. FORCES cat conditioning and endurance that occurs in response to persistent physical symptoms and resulting deactivation requires time and a graduated program to reverse. Abrupt and haphazard return of personnel to full physical duties and the expectation that they will immediately perform at the same levels as others in their unit will commonly produce failure and an increased sense of defeat for the worker. In contrast, a rapid return of workers to their full levels of supervisory and other nonphysical roles is indicated to reinforce organizational expectations that a rapid return to productivity is expected. Likewise, worker productivity helps bolster self-esteem and a sense of accomplishment. Obstacles to Specialized Services The greatest obstacle to the development of specialized care for patients with MUPS is the perception on the part of adminis- trators, policy makers, and clinicians that MUPS are neither disabling nor impor- tant. Although explanations of"stress" or "somatization" for unexplained physical symptoms serve an important clinical purpose for many MUPS patients, they are often used to minimize the needs of affected patients. Another barrier at present is the lack of an institutionalized niche for specialized care for MUPS, especially after combat and deployments. Both primary and tertiary care of MUPS is, as we have shown, interdisciplinary and requires the collaboration of many clinicians such as generalists, psychiatrists, psychologists, physiatrists, anesthesiologists, nurses, social workers, physical therapists, occupational therapists, and dietitians. In the current health care environment, each of these clinicians is responsible to a department head, and departments are demarcated along specialty lines. Interdis- ciplinary care of MUPS is a lesser priority for each of these departments than ill- nesses that fall more clearly within their specialty purview. When competing clini- cal demands are high, the argument that patients with MUPS suffer more from "nothing" than "something" seems compelling organizationally. Another important obstacle to intensive models of MUPS care is the con- ventional sense that such care is too costly. Currently, it is not known whether the extra costs associated with appropriate intervention are offset by longer-term decreases in health care use and improvements in occupational functioning. Most patients referred to intensive MUPS care, however, are using unusually large amounts of health care and are functioning poorly, so the potential for gains appears to be great. Left untreated, patients with MUPS remain costly to society. For the military, MUPS seem certain to occur after future wars, and excellence in this aspect of patient care may pay public relations dividends as well as improve the care of affected veterans. Further research on the cost- effectiveness of specialized services for patients with treatment-refractory MUPS is needed to rigorously examine these issues. CONCLUSIONS Hadler58 has described four major areas in which occupational physicians might contribute to the care of workers: clinical, educational, research, and pol

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APPENDIX A 203 icy making. We adhere to his comprehensive outline and offer our own thoughts and a few of his in concluding this review of MUPS and their relevance for the military and perhaps other employers. First, physicians caring for workers with MUPS must foster improved worker adaptation to illness as the worker experiences it. Hadler has urged physicians to try to understand the "sociopolitical arena" in which illness occurs. We urge clini- cians to go several steps further and design a system of care that is responsive to people and their subjective health concerns rather than diseases per se. Second, physicians caring for workers with MUPS must develop appropri- ate educational experiences for other providers and for affected workers and their significant others. Clinician education should emphasize the psychosocial and behavioral contexts of illness and disability rather than only simplistic bio- medical perspectives. Providers must become more sophisticated regarding the ways that environmental factors may shape behavioral responses to symptoms and to ill health. Third, physicians caring for workers with MUPS must develop short-, in- termediate-, and long-term clinical research and policy research agendas with explicit goals and objectives. These research agendas must address important military health practice and policy questions. Research into biological mecha- nisms, although important for understanding one basis of unexplained symp- toms, is costly. History suggests that mechanistic research is slow to yield im- mediate answers of importance to workers, patients, and organizations. Rather, epidemiological research is necessary to aid policy makers' attempts to compre- hend the societal and military burdens of MUPS and the historical relevance of MUPS to diverse deployments. Hadler has recommended research on the im- pact of job demands on physical and emotional health and workers' health per- ceptions, and this remains an area of need. Where, how, and why veterans with postdeployment health concerns seek their care and their satisfaction with that care is currently completely unknown within the military and is of great impor- tance to prevention, treatment, and risk communication efforts. Fourth, we suggest that physicians and policy makers move as rapidly as possible toward population-based models of health care and create system in- centives for local-level development of novel interdisciplinary approaches to MUPS, interventions that span the spectrum of precare, primary care, collabora- tive primary care, and intensive specialty care. Physicians and policy makers must consider human factors whenever they are engaged in workplace structure and task design, since in the end, new technologies are effective only if the peo- ple who operate them are functioning well. Physicians and policy makers should carefully consider the impact of the prevailing military and U.S. Department of Veterans Affairs disability compensation system on incentives for workers to improve their health. Given the necessary breadth of efforts to prevent MUPS in the military, we suggest the development of a "center of excellence" to lead clinical, research, and educational efforts related to MUPS in the military. A center of excellence could initiate and monitor efforts to implement clinical, educational, and re

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204 STRATEGIES TO PROTECT THE HEALTH OF DEPLOYED U.S. FORCES search agendas pertaining to MUPS. When appropriate, the center could provide input to military policy makers interested in ensuring that they consider the im- pact of MUPS as they design, monitor, and adjust military health policy. A cen- ter of excellence would centralize U.S. Department of Defense responsibility in this arena and enhance organizational accountability. Eventually, military medi- cine's innovations may provide an important model for civilian health care or- ganizations seeking solutions to the difficult challenge of medically unexplained physical symptoms. REFERENCES Abbey SE, Garf~nkel PK. Neurasthenia and chronic fatigue syndrome: The role of culture in the making of a diagnosis. American Journal Or Psychiatry 1991; 148~124:1638-46. Adler RH, Zlot S. Hurny C, Minder C. Engel's "Psychogenic Pain and the Pain Prone Patient:" A retrospective, controlled clinical study. Psychosomatic Medicine 1989;51~14:87-101. Alexander RW, Bradley LA, Alarcon GS, et al. Sexual and physical abuse in 7. 8. 9. women with f~bromyalgia: Association with outpatient health care utilization and pain medication usage. Arthritis Care Research 1998;11~24:102-15. Almy TP. Experimental studies on the irritable colon. American Journal oiMedi- cine 1951;10:60-7. Andersen SM, Harthorn BH. Changing the psychiatric knowledge of primary care physicians. The effects of a brief intervention on clinical diagnosis and treatment. General Hospital Psychiatry 1 990; 1 2~34: 1 77-90. 6. Anderson IS, Ferrans CE. The quality of life of persons with chronic fatigue syn drome. Journal of Nervous and Mental Disease 1997; 185~64:359-67. Angell M. Breast implants protection or paternalism? New England Journal Or Medicine 1992;326~254: 1695-6. Barsky AJ, Delamater BA, Clancy SA, Antman EM, Ahern DK. Somatized psychi atric disorder presenting as palpitations. Archives Or Internal Medicine 1996; 156(10):1102-8. Beitman BD, Kushner MG, Basha I, Lamberti J. Mukerji V, Bartels K. Follow-up status of patients with angiographically normal coronary arteries and panic disor der. JAMB 1991;265~124:1545-9. Bergdahl J. Anneroth G. Perris H. Cognitive therapy in the treatment of patients with resistant burning mouth syndrome: A controlled study. Journal Or Oral Pa thology and Medicine 1995 ;24~5) :213-5. 11. Bigos SJ, Battle MC, Spengler DM, et al. A prospective study of work perceptions and psychosocial factors affecting the report of back injury. Spine 1991;16~14:1-6. 12. Blumer D, Montouris G. Hermann B. Psychiatric morbidity in seizure patients on a neurodiagnostic monitoring unit. Journal of Neuropsychiatry and Clinical Neuro- sciences 1995;7~44:445-56. 13. Bombardier CH, Buchwald D. Outcome and prognosis of patients with chronic fatigue vs. chronic fatigue syndrome. Archives ofInternal Medicine 1995;155~194: 2105-10. 14. Boxer PA. Indoor air quality: A psychosocial perspective. Journal of Occupational Medicine 1990;32~54:425-8.

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206 STRATEGIESTOPROTECTTHEHEALTHOFDEPLOYED U.S. FORCES Engel CC Jr., Liu X, Miller R. et al. A 3-week intensive outpatient behavioral medicine intervention for veterans with persistent, unexplained post-war symptoms (slide presentation). The Society of Behavioral Medicine, 19th Annual Scientific Sessions, New Orleans, 1998. 36. Engel CC Jr., Roy M, Kayanan D, Ursano R. Multidisciplinary treatment of per- sistent symptoms after Gulf War service. Military Medicine 1998;163~44:202-8. Engel CC Jr., von Korff M, Katon WJ. Back pain in primary care: Predictors of high health-care costs. Pain 1996;65~2-34:197-204. 38. Escobar JI, Golding JM, Hough RL, Karno M, Burnam MA, Wells KB. Somatiza- tion in the community: Relationship to disability and use of services. American Journal o/Public Health 1987;77~74:837-40. 39. Escobar JI, Rubio-Stipec M, Canino GJ, Karno M. Somatic symptom index (SSI): A new and abridged somatization construct. Journal of Nervous and Mental Dis- eases 1989;177~34:140-6. 40. Feinstein AR. Nosologic Challenges of Diagnostic Criteria for a "New Illness." Conference on Federally Sponsored Gulf War Veterans' Illnesses Research: June, 1998; Pentagon City, Va. 41. Feldman RM, Soskolne CL. The use of nonfatiguing strengthening exercises in post-polio syndrome. Birth Defects Original Article Series 1987;23~44:335-41. 42. Fisher ES, Welch HG. Avoiding the unintended consequences of growth in medical care: How might more be worse? JAMS 1999;281~54:446-53. 43. Flor-H, Fydrich T. Turk DC. Efficacy of multidisciplinary pain treatment centers: A meta-analytic review. Pain 1992;49:221-30. 44. Flor-Henry P. Fromm-Auch D, Tapper M, Schopflocher D. A neuropsychological study ofthe stable syndrome of hysteria. Biological Psychiatry 1981;16~74:601-26. Frank JW, Brooker AS, DeMaio SE, et al. Disability resulting from occupational low back pain. Part II: What do we know about secondary prevention? A review of the scientific evidence on prevention after disability begins. Spine 1996;21~244: 2918-29. 46. Frost H. Klaber Moffett JA, Moser JS, Fairbank JC. Randomised controlled trial for evaluation of fitness programme for patients with chronic low back pain. BMJ 1 995 ;3 1 0~6973 ): 1 5 1-4. Frost H. Lamb SE, Klaber Moffett JA, Fairbank JC, Moser JS. A fitness pro- gramme for patients with chronic low back pain: 2-year follow-up of a randomised controlled trial. Pain 1998;75~2-34:273-9. 48. Fulcher KY, White PD. Randomised controlled trial of graded exercise in patients with the chronic fatigue syndrome. BMJ 1997;314~70954:1647-52. 49. Gallagher TH, Lo B. Chesney M, Christensen K. How do physicians respond to patient's requests for costly, unindicated services? Journal Or General Internal Medicine 1997;12~114:663-8. 50. Gatchel RJ, Polatin PB, Kinney RK. Predicting outcome of chronic back pain using clinical predictors of psychopathology: A prospective analysis. Health Psychology 1995;14~54:415-20. 51. Goldberg D. Reasons for misdiagnosis. Sartorius N. Goldberg D, de Girolamo G. Costa e Silva J-G, Lecrubier Y. Wittchen U., Editors. Psychological Disorders in General Medical Settings. Lewiston, N.Y.: Hogrefe and Huber; 1990:139-45. 52. Goldenberg DL. Fibromyalgia syndrome. An emerging but controversial condition. [Review]. JAMS 1987;257~204:2782-7.

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APPENDIX A 207 53. Goldman SL, Kraemer DT, Salovey P. Beliefs about mood moderate the relation ship of stress to illness and symptom reporting. Journal Psychosomatic Research 1996;41(2): 1 15-28. 54. Gomborone JE, Gorard DA, Dewsnap PA, Libby GW, Earthing MJ. Prevalence of irritable bowel syndrome in chronic fatigue. Journal of the Royal College o/Physi cians of London 1996;30~64:512-3. 55. Gordon E, Kraiuhin C, Kelly P. Meares R. Howson A. A neurophysiological study of somatization disorder. Comprehensive Psychiatry 1986;27~4) :295-3 01. 56. Gureje O. Von Korff M, Simon GE, Gater R. Persistent pain and well-being: A World Health Organization study in primary care. JAMA 1998;280~24:147-51. 57. Gwee KA, Graham JC, McKendrick MW, et al. Psychometric scores and persis tence of irritable bowel after infectious diarrhoea. Lancet 1996; 347~89954:150-3. 58. Hadler NM. Occupational illness. The issue of causality. Journal of Occupational Medicine 1984;26~84:587-93. 59. Hadler NM. If you have to prove you are ill, you can't get well. Spine 1996;21~204: 2397-2400. 60. Hadler NM. Fibromyalgia, chronic fatigue, and other iatrogenic diagnostic algo rithms. Do some labels escalate illness in vulnerable patients? [see comments]. [Re view] [46 reds]. Postgraduate Medicine 1997;102~24:161-2, 165-6, 171-2 passim. 61. Hahn SR, Thompson KS, Wills TA, Stern V, Budner NS. The difficult doctor-pa tient relationship: Somatization, personality and psychopathology. Journal of Clinical Epidemiology 1994;47~64:647-57. Hall EM, Johnson JV. A case study of stress and mass psychogenic illness in indus trial workers. Journal of Occupational Medicine 1989;3 1~34:243-50. 63. Haynes RB, Sackett DL, Taylor DW, Gibson ES, Johnson AL. Increased absentee ism from work after detection and labeling of hypertensive patients. New England Journal Medicine 1978;299~144:741-4. 64. Hellman CJ, Budd M, Borysenko J. McClelland DC, Benson H. A study of the effectiveness of two group behavioral medicine interventions for patients with psy chosomatic complaints. Behavioral Medicine 1990;16~44:165-73. Hotopf M, Mayou R. Wadsworth M, Wessely S. Temporal relationships between physical symptoms and psychiatric disorder. Results from a national birth cohort. British Journal o/Psychiatry 1998;173:255-61. 66. Hotopf M, Mayou R. Wessely S. Childhood risk factors for adult medically unex plained symptoms: Results from a prospective cohort study. 44th Annual Meeting ofthe Academy ofPsychosomatic Medicine 1998. 67. Hyams KC. Developing case definitions for symptom-based conditions: The prob lem of specificity. Epidemiological Reviews 1998;20~24: 148-56. 68. Irwin C, Falsetti SA, Lydiard RB, Ballenger JC, Brock CD, Brener W. Comorbid ity of posttraumatic stress disorder and irritable bowel syndrome. Journal oiClini cal Psychiatry 1996;57~124:576-8. 69. Johanning E, Auger PL, Reijula K. Building-related illnesses. New England Jour nal Medicine 1998;338~154:1070; discussion 1071. 70. Kaplan DS, Masand PS, Gupta S. The relationship of irritable bowel syndrome (IBS) and panic disorder. Annals Clinical Psychiatry 1996;8~24:81-8. Kashner TM, Rost K, Smith GR, Lewis S. An analysis of panel data. The impact of a psychiatric consultation letter on the expenditures and outcomes of care for pa tients with somatization disorder. Medical Care 1992;30~94:811-21. Kates N. Psychiatric consultation in the family physician's office. Advantages and hidden benefits. General Hospital Psychiatry l988;10~64:431-7.

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208 STRATEGIES TO PROTECT THE HEALTH OF DEPLOYED U.S. FORCES Katon W. Hall ML, Russo J. et al. Chest pain: Relationship of psychiatric illness to coronary arteriographic results. American Journal Medicine 1988;84~14:1-9. Katon W. Lin E, Von Korff M, Russo J. Lipscomb P. Bush T. Somatization: A spectrum of severity. American Journal o/Psychiatry 1991;148~14:34-40. Katon W. Robinson P. Von Korff M, et al. A multifaceted intervention to improve treatment of depression in primary care. Archives Or General Psychiatry 1996; 53(104:924-32. 76. Katon W. Russo J. Chronic fatigue syndrome criteria. A critique of the requirement for multiple physical complaints. Archives of Internal Medicine 1992;152~84:1604-9. 77. Katon W. Von Korff M, Lin E, Bush T. Ormel J. Adequacy and duration of antide- pressant treatment in primary care. Medical Care 1992;30~14:67-76. Katon W. Von Korff M, Lin E, et al. Distressed high utilizers of medical care. DSM-III-R diagnoses and treatment needs. General Hospital Psychiatry 1990; 12(64:355-62. 79. Katon W. Von Korff M, Lin E, et al. A randomized trial of psychiatric consultation with distressed high utilizers. General Hospital Psychiatry 1992;14~24:86-98. 80. Katon W. Von Korff M, Lin E, et al. Collaborative management to achieve treat- ment guidelines. Impact on depression in primary care. JAMS 1995;273~134:1026- 31. 81. Katon W. Von Korff M, Lin E, et al. Population-based care of depression: Effective disease management strategies to decrease prevalence. General Hospital Psychiatry 1997;19~34: 169-78. 82. Katon WJ, Buchwald DS, Simon GE, Russo JE, Mease PJ. Psychiatric illness in patients with chronic fatigue and those with rheumatoid arthritis. Journal oiGen- eral Internal Medicine 1991 ;6~44:277-85. 83. Katon WJ, Sullivan M. Antidepressant treatment of functional somatic symptoms. Mayou RA, Bass C, Sharpe M, Editors. Treatment of Functional Somatic Symp- toms. New York: Oxford University Press; 1995. 84. Kirmayer LJ, Robbins JM. Three forms of somatization in primary care: Preva- lence, co-occurrence, and sociodemographic characteristics. Journal of Nervous and Mental Disease 1991; 1 79( 1 1 ):647-55. 85. Koss MP, Koss PG, Woodruff WJ. Deleterious effects of criminal victimization on women's health and medical utilization. Archives of Internal Medicine 1991; 151~24:342-7. 86. Kouyanou K, Pither CE, Wessely S. Iatrogenic factors and chronic pain. Psycho- somatic Medicine 1 997;59~64:597-604. 87. Kroenke K. Symptoms in medical patients: An untended field. American Journal of Medicine 1992;92~1A):3S-6S. 88. Kroenke K, Arrington ME, Mangelsdorff AD. The prevalence of symptoms in medical outpatients and the adequacy of therapy. Archives of Internal Medicine 1990;150(84:1685-9. 89. Kroenke K, Jackson JL, Chamberlin J. Depressive and anxiety disorders in patients presenting with physical complaints: Clinical predictors and outcome. American Journal Medicine 1997; 1 03~54:339-47. 90. Kroenke K, Mangelsdorff AD. Common symptoms in ambulatory care: Incidence, evaluation, therapy, and outcome. American Journal Medicine 1989;86~34:262-6. 91. Kroenke K, Price RK. Symptoms in the community. Prevalence, classification, and psychiatric comorbidity. Archives of Internal Medicine 1 993; 1 53 (2 1 ~ :2474-80.

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APPENDIX A 209 92. Kroenke K, Spitzer RL, deGruy FV3rd, et al. Multisomatoform disorder. An alter- native to undifferentiated somatoform disorder for the somatizing patient in pri- mary care. Archives General Psychiatry 1997;54~44:352-8. 93. Kroenke K, Spitzer RL, Williams JB, et al. Physical symptoms in primary care. Predictors of psychiatric disorders and functional impairment. Archives of Family Medicine 1994;3~94:774-9. 94. Kroenke K, Wood DR, Mangelsdorff AD, Meier NJ, Powell JB. Chronic fatigue in primary care. Prevalence, patient characteristics, and outcome. JAMS 1988;260~74: 929-34. Lembo T. Fullerton S. Diehl D, et al. Symptom duration in patients with irritable bowel syndrome. American Journal oiGastroenterology 1996;91~54:898-905. 96. Lidbeck J. Group therapy for somatization disorders in general practice: Effective- ness of a short cognitive-behavioural treatment model. Acta Psychiatrica Scandi- navica 1997;96~14:14-24. 97. Lin EM, Katon W. Von Korff M, et al. Frustrating patients: Physician and patient perspectives among distressed high users of medical services. Journal General Internal Medicine 1991;6~34:241-6. 98. Linton SJ. A population-based study of the relationship between sexual abuse and back pain: Establishing a link. Pain 1997;73~14:47-53. 99. Loeser ID, Egan KJ, Editors. Managing the Chronic Pain Patient: Theory and Practice at the University Or Washington Multidisciplinary Pain Center. New York: Raven Press; 1989. 100. Loeser ID, Sullivan M. Doctors, diagnosis, and disability: A disastrous diversion. Clinical Orthopaedics and Related Research 1997~3364:61-6. 101. Marks IN, Goldberg DP, Hillier VF. Determinants of the ability of general practi- tioners to detect psychiatric illness. Psychological Medicine 1979;9~24:337-53. 102. Marple RL, Kroenke K, Lucey CR, Wilder J. Lucas CA. Concerns and expectations in patients presenting with physical complaints. Frequency, physician perceptions and actions, and 2-week outcome. Archives of Internal Medicine 1997;157~134: 1482-8. 103. McCain GA, Bell DA, Mai FM, Halliday PD. A controlled study of the effects of a supervised cardiovascular fitness training program on the manifestations of primary f~bromyalgia. Arthritis and Rheumatism 1988;31~94:1135-41. 104. McCully KK, Sisto SA, Natelson BH. Use of exercise for treatment of chronic fatigue syndrome. Sports Medicine 1996;21~14:35-48. 105. McDonald AJ, Bauchier PAD. Non-organic gastro-intestinal illness: A medical and psychiatric study. British Journal o/Psychiatry 1980; 136: 1276-83. 106. Meador CK. The art and science of non-disease. New England Journal Medicine 1965;272:92. 107. Murray J. Corney R. Not a medical problem? An intensive study of the attitudes and illness behaviour of low attenders with psychosocial difficulties. Social Psy- chiatry and Psychiatric Epidemiology 1990;25~34:159-64. 108. National Institute of Mental Health. Mental disorder and primary medical care: An analytical review of the literature. DHEW Publication No. (ADM) 78-661. Wash- ington, D.C.: Superintendent of Documents, U.S. Government Printing Office 1979. 109. Neitzert CS, Davis C, Kennedy SH. Personality factors related to the prevalence of somatic symptoms and medical complaints in a healthy student population. British Journal Or Medical Psychology 1997;70(Pt. 1):93-101. 110. Newham D, Edwards RH. Effort syndromes. Physiotherapy 1979;65~24:52-6.

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210 STRATEGIESTOPROTECTTHEHEALTHOFDEPLOYED U.S. FORCES 111. Noyes R. Reich J. Clancy J. O'Gorman TW. Reduction in hypochondriasis with treatment of panic disorder. British Journal o/Psychiatry 1986;149:631-5. 112. Oltson M. Primary care patients who refuse specialized mental health services. Archives of Internal Medicine 1991; 15 1~14: 129-32. 113. Orleans CT, George LK, Houpt JL, Brodie HK. How primary care physicians treat psychiatric disorders: A national survey of family practitioners. American Journal o/Psychiatry 1985; 142(1):52-7. 114. Ormel J. Giel R. Medical effects of nonrecognition of affective disorders in pri- mary care. Sartorius N. Goldberg D, de Girolamo G. Costa e Silva J-G, Lecrubier Y. Wittchen U., Editors. Psychological Disorders in General Medical Settings. Lewiston, N.Y.: Hogrefe and Huber; 1990: 146-58. 115. Ormel J. Koeter MW, van den Brink W. van de Willege G. Recognition, manage- ment, and course of anxiety and depression in general practice. Archives General Psychiatry 1991;48~84:700-6. 116. Ormel J. van den Brink W. Giel MWJ, van der Meer K, van de Willige G. Wilmink FW. Recognition, management and outcome of psychological disorders in primary care: A naturalistic follow-up study. Psychological Medicine 1990;20:909-23. 117. Payne A, Blanchard EB. A controlled comparison of cognitive therapy and self- help support groups in the treatment of irritable bowel syndrome. Journal of Con- sulting and Clinical Psychology 1 995 ;63 (54: 779-86. 118. Plesh O. Wolfe F. Lane N. The relationship between f~bromyalgia and temporo- mandibular disorders: Prevalence and symptom severity. Journal oiRheumatology 1996;23~114:1948-52. 119. Potts SG, Bass CM. Psychological morbidity in patients with chest pain and normal or near- normal coronary arteries: A long-term follow-up study. Psychological Medicine 1995;25~24:339-47. 120. Quill TE. Somatization disorder. One of medicine's blind spots. JAMA 1985; 254~214:3075-9. 121. Richard K. The occurrence of maladaptive health-related behaviors and teacher- related conduct problems in children of chronic low back pain patients. Journal r Behavioral Medicine 1988;11:107-116. 122. Robins LN. Psychiatric epidemiology. Archives r General Psychiatry 1978;35: 697-702. 123. Rose G. The Strategy o/Preventive Medicine. New York: Oxford University Press; 1992. 124. Rost K, Kashner TM, Smith RGJ. Effectiveness of psychiatric intervention with somatization disorder patients: Improved outcomes at reduced costs. General Hos- pital Psychiatry 1994;16~64:381-7. 125. Rothman KJ, Greenland S. Measures of disease frequency. Rothman KJ, Greenland S. editors. Modern Epidemiology. 2nd ed. Philadelphia: Lippincott-Raven Publish- ers; 1998. 126. Russo J. Katon W. Clark M, Kith P. Sintay M, Buchwald D. Longitudinal changes associated with improvement in chronic fatigue patients. Journal o/Psychosomatic Research 1998;45~1 Spec. No.~:67-76. 127. Schappert SM. National Ambulatory Medical Care Survey: 1989 Summary. Vital Health Statistics 1992; 13 ~ 110) 1-80. 128. Schrader H. Obelieniene D, Bovim G. et al. Natural evolution of late whiplash syndrome outside the medicolegal context. Lancet 1996;347~90104: 1207-11. 129. Schweitzer R. Kelly B. Foran A, Terry D, Whiting J. Quality of life in chronic fatigue syndrome. Social Science and Medicine 1995;41~104: 1367-72.

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