title: The challenge of diagnosing non-specific, functional, and somatoform disorders: A systematic review of barriers to diagnosis in primary care.
abstract: OBJECTIVE
  Despite their prevalence and impact on patients and the health care system, non-specific, functional, and somatoform disorders are underdiagnosed. This problem is especially problematic in primary care if we are moving towards an integrated care model. The objective of the current study was to identify and aggregate potential barriers to the diagnosis in primary care settings.
  
  
  METHODS
  Our systematic review methodology followed a pre-published protocol and was registered in PROSPERO (CRD42013002540). We combined qualitative and quantitative data from studies identified in online databases and by hand searching of reference lists. Data were synthesized in a data-driven way using a grounded-theory approach. The level of evidence and assessment of bias for the final included studies was independently conducted.
  
  
  RESULTS
  Data from n=177 full text publications were independently extracted and combined in a custom database. The final list of included studies was n=42. From these, a total of n=379 barriers were identified comprising 77 barrier-level codes, 16 thematic categories and five over-arching themes, i.e., patient-related, primary-care-practitioner related, doctor-patient interactional, situational, and conceptual and operational barriers.
  
  
  CONCLUSIONS
  Given the thematic range of the identified barriers, the diagnostic process of non-specific, functional, and somatoform disorders in primary care is highly complex. Individual or practice-level interventions, as well as public awareness initiatives are needed to help address the diagnostic challenges. A multi-factorial understanding of symptoms with a biopsychosocial parallel diagnostic approach should be encouraged. More direct empirical investigations are also needed.
authors.affiliation: Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf & University Hospital of Psychosomatic Medicine and Psychotherapy, Schön Clinic Hamburg Eilbek, Germany. Electronic address: a.murray@uke.de.
authors.forename: Alexandra M
authors.initials: AM
authors.lastname: Murray
authors.affiliation: Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf & University Hospital of Psychosomatic Medicine and Psychotherapy, Schön Clinic Hamburg Eilbek, Germany.
authors.forename: Anne
authors.initials: A
authors.lastname: Toussaint
authors.affiliation: Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf & University Hospital of Psychosomatic Medicine and Psychotherapy, Schön Clinic Hamburg Eilbek, Germany.
authors.forename: Astrid
authors.initials: A
authors.lastname: Althaus
authors.affiliation: Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf & University Hospital of Psychosomatic Medicine and Psychotherapy, Schön Clinic Hamburg Eilbek, Germany.
authors.forename: Bernd
authors.initials: B
authors.lastname: Löwe
mesh_terms: D006801:Humans; D015995:Prevalence; D011320:Primary Health Care; D013001:Somatoform Disorders / Q000175:diagnosis* / Q000628:therapy
keywords: Barriers; Diagnosis; Functional disorder; Medically unexplained symptoms; Primary care; Recognition; Somatoform disorder; Systematic review