The prevalence of somatization in primary care

Self- but not other-mentalizing moderates the association between BPD symptoms and somatic complaints in community-dwelling adolescents

OBJECTIVES

The aim of this study was to evaluate the potential moderator role of poor mentalization in the association between borderline personality disorder (BPD) traits and somatization, specifically focusing on the polarities of self- and other-mentalizing.

DESIGN

This is a cross-sectional, general population study evaluating adolescents (n = 162, 61.3% female; ages 12-18, M = 14.63, SD = 1.02). The relationship between BPD traits and somatization was evaluated with self-mentalization (attention to emotions and clarity of emotions) and other-mentalizing as moderator variables.

METHODS

One hundred sixty-two adolescents without serious mental health disorders were evaluated using self-report measures for borderline personality disorder traits (screening questionnaire for the Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II), somatic symptoms using the Somatic Symptoms Questionnaire (SSQ), self-mentalizing using the Trait Meta-Mood Scale-24 (TMMS) and other-mentalizing using the Adolescent Mentalizing Interview (AMI)). Linear regressions were conducted to test the moderation effects of self- and other-mentalizing in the relationship between BPD symptoms and somatic complaints, controlling for age and sex. Moderation analysis was conducted using PROCESS version 3.5.

RESULTS

The association between BPD symptoms and somatic complaints was moderated by a self-mentalizing dimension (emotional clarity) (b = -0.019, 95% CI = -0.0379 to -0.0002, p = .0476), but not other-mentalizing (b = 0.027, 95% CI = 0.000 to 0.053, p = .051). The effect of BPD symptoms on somatization disappears when emotional clarity is high, regardless the level of attention to emotions.

CONCLUSIONS

Self-mentalizing appears to be an adaptive skill as it attenuates the relationship between BPD traits and somatization. Specifically, emotional clarity rather than simple attention to emotions is the aspect of self-mentalizing attenuating this association. These results support that self-mentalization is an important function in the management of body-associated emotions even in non-clinical levels of BPD traits. Findings suggest that strengthening self-mentalizing skills across development might contribute to resilience and salutogenesis.

Parent perceptions of mental illness in Chinese American youth

BACKGROUND

Although parents are often the first to facilitate help-seeking in their children, parental perceptions regarding mental health serve as a significant barrier to the access of mental health services. This study examined mental health perceptions held by Chinese immigrant parents of youth.

METHODS

Eighteen parents (13 female, 5 male), who identified as having children between the ages of 13 and 21 years, participated in audio-recorded interviews using five vignettes depicting depression with and without a somatic emphasis, schizophrenia with paranoid features, attenuated psychosis syndrome, and social anxiety in youth. Questions about potential causes, likely diagnosis, and health-seeking behaviors in relation to these vignettes were asked. Interviews were analyzed for themes using a deductive-inductive hybrid approach, informed by the explanatory models that have shed light on Asian perceptions of mental illness and approaches to help-seeking.

RESULTS

While Asian groups are often considered as lacking in mental health knowledge, we found that Chinese immigrant parents were comfortable with psychological terminology as it pertained to identifying causes and describing supportive strategies and the seeking of Western-based providers. However, the majority of Chinese immigrant parent respondents did not easily note suicidality. Furthermore, respondents did not consider social anxiety as a major mental health issue among Chinese immigrant parents and attributed social anxiety to personality or cultural differences.

DISCUSSION

These findings provide an understanding of how Chinese immigrant parents conceptualize mental illness and help-seeking, which may be helpful for providers when working with Chinese immigrant parents of children that have a mental health concern.

The prevalence and predictive factors of somatization and its relationship with anxiety and depression in Iranian population

Introduction

Today mental disorders are important concerns of health care system in all countries. Among different mental disorders; depression, anxiety, and somatization are more frequent. This manuscript was conducted to evaluate the frequency of somatization symptoms, its related factors and the correlation between somatization symptoms and anxiety and depression disorders in Iranian population.

Methods

The cross-sectional study was conducted in Kerman, Iran, 2017. Participants were selected from patients who referred to the Clinics of Educational Hospitals using convenience sampling method. The PHQ-15 and HADS questionnaire were used to assess the somatization and depression and anxiety, respectively. The univariate and multivariate logistic regression was used to determine the predictive factors of somatization symptoms. The correlations between each PHQ-15 item score and anxiety and depression score were expressed.

Results

The frequency of mild, moderate and severe levels of somatization was 66.3%, 20.5% and 13.1%, respectively. Considering multivariate logistic regression analysis; age was associated with somatic symptoms, significantly. The risk of somatic symptoms was 3.4 times more in Divorced/Widowed participants than single ones (p-value: 0.035). There were significant positive correlations between anxiety and depression scores. Each additional score of anxiety and depression were associated with 1.14 times more likely (p-value: < 0.001) and 1.11 times less likely (p-value: 0.003) of having somatic symptoms, respectively.

Conclusion

The burden of somatization, depression and anxiety is high in Iranian population. Psychologists and policy-makers should consider these predictive factors for primary prevention of somatization at the personal and community level, respectively.

A Primary Care Prevention System for Behavioral Health: The Behavioral Health Annual Wellness Checkup

Behavioral health problems are involved in the majority of primary care visits. These behavior disorders (e.g., depression, anxiety, smoking, insomnia, etc.) are costly, burdensome to both the patient and the healthcare system, and result in greater medical utilization/cost and poorer future health outcomes. Integrated behavioral healthcare has been proposed as a model for more efficiently addressing the burden of behavioral health problems. While this model has demonstrated some promise in the treatment of behavioral health problems, as well as in the reduction in costs and improvement in healthcare outcomes, the primary prevention of behavioral health problems in this delivery model has been relatively neglected. The present paper discusses the potential value of incorporating the prevention of behavioral health problems into the annual physical/wellness checkup and proposes a detailed system for how this might be accomplished. Limitations, future research, and costs associated with increased prevention in a primary care context are discussed.

Satisfaction With Specific and Nonspecific Diagnoses

PURPOSE

Nonspecific upper extremity illnesses (eg,. wrist pain, forearm pain)-where no objectively verifiable pathology is detectable-are common and usually self-limiting. For some patients, a nonspecific diagnosis can contribute to mistrust and disappointment.

METHODS

This study tested the primary null hypothesis that there is no difference in mean overall satisfaction between patients given a specific compared with a nonspecific diagnosis. Second, we assessed factors associated with satisfaction and with nonspecific upper extremity diagnosis.

RESULTS

There was no significant difference between mean satisfaction with nonspecific and specific diagnoses in bivariate analysis. However, when treated as a categorical variable, 22% of the patients with a nonspecific diagnosis had a satisfaction score of 8 or lower compared with 11% of the patients given a specific diagnosis. First visit and greater pain intensity were significantly associated with a nonspecific diagnosis in bivariate analysis. In the multivariable models, no factors were independently associated with satisfaction or with nonspecific diagnoses.

CONCLUSIONS

Although nonspecific diagnoses can sometimes be frustrating for both physician and patient, in this small study using a satisfaction measure with a strong ceiling effect, they were no less satisfying to patients on average and corresponded with slightly greater pain intensity than specific diagnoses.

CLINICAL RELEVANCE

The degree to which nonspecific diagnoses (perhaps in combination with compassionate care and incremental monitoring) can be part of a satisfying treatment experience merits additional investigation.

Interprofessional care improves health-related well-being and reduces medical costs for chronic pain patients

This study evaluated whether patients with somatic symptom disorder, expressing chronic pain that could not be attributed to a medical condition, would benefit from an 8-week inpatient residence at a psychiatric ward. In the 1-year follow-up after termination the authors examined the extent to which the integrated treatment decreased patient costs. A total of 106 patients participated in the follow-up and reported a significant improvement in their general health (Cohen's d = 1.5-2.21), a decrease in impairment due to pain (d = 2.24), and a decrease in symptom severity (d = 1.29). They took fewer medications and sick days, reported fewer hospital stays and medical examinations, and consulted and changed physicians and outpatient clinics less often (d = 0.55-1.1). The average cost per patient was cut in half, down to € 80,000/$96,000 per year. From a clinical standpoint, group analysis that focused on aggression was the most effective intervention.

Mental Health in China: Stigma, Family Obligations, and the Potential of Peer Support

Some people with mental illness in China do not receive treatment. We explored how stigma and familial obligation influenced accessibility of social support for patients with depression in China and the potential acceptability of peer support programs. Semi-structured qualitative interviews were conducted with five psychiatrists and 16 patients receiving care for depression from a large psychiatric hospital in Jining, Shandong Province of China. Patients with mental illness reported barriers that prevented them from (a) receiving treatment and (b) relying on informal social support from family members, including stigma, somatization, and community norms. Circumventing these barriers, peer support (i.e., support from others with depression) was viewed by patients as an acceptable means of exchanging information and relying on others for support. Formative research on peer support programs to examine programming and activities may help reduce the burden of unmet mental health care needs in China.

Extending Cognitive-Behavioural Theory and Therapy to Medically Unexplained Symptoms and Long-Term Physical Conditions: A Hybrid Transdiagnostic/Problem Specific Approach

Medically unexplained symptoms (MUS) are not only common and distressing, but are also typically poorly managed in general medical settings. Those suffering from these problems tend to incur significantly higher health costs than the general population. There are many effective treatments for different MUS; these are almost entirely based on cognitive-behavioural approaches. However, the wide range of treatment protocols tend to be ‘syndrome specific’. As such, they do not generalise well in terms of training and application, making them expensive and difficult to disseminate, suggesting the desirability of developing a transdiagnostic approach. The general basis of such a CBT grounded transdiagnostic approach is considered, and the particular need to incorporate cognitive elements of both anxiety or health anxiety (threat) and depression (loss) is highlighted. Key empirically grounded and evidence-based processes (both specific and general) previously identified as underpinning the maintenance of MUS are delineated. The way in which these can be combined in a transdiagnostic model that accounts for most MUS presentations is presented and linked to a formulation-driven transdiagnostic treatment strategy, which is described. However, the need to take more syndrome-specific issues into account in treatment is identified, suggesting that the optimum treatment may be a hybrid transdiagnostic/specific approach with formulation, shared understanding, belief change strategies, and behavioural experiments at its heart. The generalisation of such approaches to psychological problems occurring in the context of ‘long-term conditions’ is identified as a further important development that is now within reach.

Narratives of Somatizing and Non somatizing Patients in a Primary Care Setting

Somatizing patients, who comprise approximately 20 percent of the primary care population, often present physicians with recurrent but confusing combinations of symptoms without organic explanations. Illness narratives presented during initial medical encounters with primary care physicians were examined qualitatively to determine if the narrative structure, chronological development of symptoms and temporal frame differed between somatizing and non-somatizing patients. Following a structured interview to identify somatization tendency and co-morbidities of depression and post-traumatic stress disorder, 116 patients' encounters with primary care physicians were video-recorded and transcribed. Somatizers demonstrated a narrative structure that was similar to that of non-somatizing patients, but they used a thematic rather than a chronological development of symptoms and they did not convey a clear time frame. Somatizing patients with a co-morbid psychological condition focused on concrete physical sensations, were unable to provide contextual history or chronological organization, and did not develop a temporal frame. The narratives of somatizing and non-somatizing patients differed sufficiently to warrant further research for use as a clinical aid in the diagnosis of somatization.

Psychosocial correlates, psychological distress, and quality of life in patients with medically unexplained symptoms: a primary care study in Karachi, Pakistan

OBJECTIVE

To examine the psychosocial correlates and association of psychological distress and quality of life (QOL) in patients with medically unexplained symptoms (MUS) compared to those with medically explained symptoms (MES) in a primary care setting in Karachi, Pakistan.

METHODS

A cross-sectional study of 472 patients attending GP clinics between March and August 2009 in Karachi. Participants completed questionnaires to assess demographic details, somatic symptoms, anxiety, depression, and QOL. The patients' GP recorded whether the presenting complaint was medically unexplained or medically explained.

RESULTS

MUS subjects in our study were more educated, had better social support and fewer financial problems, were less depressed and had a better QOL than subjects who had medically explained symptoms (non-MUS). Both groups (MUS and non-MUS) were comparable in terms of anxiety and number of somatic symptoms, but non-MUS subjects were more depressed than the MUS group. In a regression analysis, the number of somatic symptoms and lower levels of anxiety predicted poorer QOL in this sample. Whether these symptoms were medically explained (or not) did not seem to contribute significantly to the QOL.

CONCLUSION

Our findings confirm that even in the developing world, patients with MUS are common among primary care attendees. However, patients with MUS in urban Karachi, Pakistan may differ from Western MUS subjects in the role of stress, support, and anxiety in their presentation, and may be reflective of a conceptually different group of difficulties.

Medically unexplained symptoms

In summary, caring for patients with MUS is challenging for health care providers. Even defining somatization syndromes is complex and controversial, reflecting the medical community’s limited understanding of the pathophysiology for this group of disorders. Although risk factors for MUS have been described and are well understood, little is known about how MUS can be prevented. Uncertainty in medicine, as in any human enterprise, is a given, but the difficulties in identification and treatment of patients with MUS highlight the limitations in understanding the intersection between physical and mental health. Patients come to their physician looking for clarity, understanding, and relief of debilitating symptoms. The understanding of MUS will evolve, and perhaps an organic cause not yet understood or described may emerge to lend clarity and therapeutic opportunities to some patients with somatic disorders. In the meantime, the most powerful tools available are the ability to communicate the limits of current understanding, acknowledge the difficulties faced by patients with this disorder, and reinforce the willingness and desire of clinicians to partner with patients as the focus shifts from diagnosis to symptom management. Thus, the physician-patient relationship, still in its rightful place at the heart of the practice of medicine, lies at the center of effective treatment of patients with MUS.

Somatisation disorder and its associated factors in multiethnic primary care clinic attenders

BACKGROUND

Somatisation disorder (SD) has been reported as common in all ethnic groups, but the estimates of its prevalence have varied and the evidence for its associated factors has been inconsistent.

PURPOSE

This study seeks to determine the prevalence of SD and its associated factors in multiethnic primary care clinic attenders.

METHODS

This cross-sectional study was on clinic attenders aged 18 years and above at three urban primary care clinics in Malaysia. The operational definition of SD was based on ICD-10 criteria for SD for research, frequent attendance, and excluded moderate to severe anxiety and depression. The instruments used were the ICD-10 symptom list, the Hospital Anxiety and Depression Scale, a semi-structured questionnaire, and SF-36.

RESULTS

We recruited 1,763 patients (response rate 63.8%). The mean age of respondents was 44.7 ± 15.8 years, 807 (45.8%) were male; there were 35.3% Malay, 30.1% Chinese and 34.6% Indian. SD prevalence was 3.7%; the prevalence in Malay was 5.8%, Indian 3.0% and Chinese 2.1%. Significant associations were found between SD prevalence and ethnicity, family history of alcoholism, blue-collar workers and the physical component summary (PCS) score of SF-36. Multivariate analysis showed that SD predictors were Malay ethnicity (OR 2.7, 95% CI 1.6, 4.6), blue-collar worker (OR 2.0, 95% CI 1.2, 3.5) and impaired PCS score of SF-36 (OR 0.92, 95% CI 0.90, 0.95).

CONCLUSION

The prevalence of SD was relatively uncommon with the stringent operational criteria used. SD preponderance in blue-collar workers may be attributable to secondary gain from getting sickness certificates and being paid for time off work.

Being a botanist and a gardener: using diagnostic frameworks in general practice patients with medically unexplained symptoms

Patients with multiple medically unexplained symptoms commonly seek treatment in primary care. Many of these patients seem to have a psychological 'core' to their illness that affects the way they experience, conceptualise and communicate their distress. There is considerable debate around diagnosis for this group of patients. Existing diagnoses include somatoform disorders in psychiatry and functional disorders in the medical specialties. Some clinicians use the term 'heartsink' patients, which reflects the interpersonal frustration inherent in some therapeutic relationships. A good diagnosis should be clinically useful, helping clinicians and patients understand and manage illness. Diagnosis should also provide a reliable classification for research and evidence-based treatment. The allegory of the botanist and the gardener has been used to describe diagnosis. For the botanist, a good diagnosis produces a taxonomy that is rigorous and reliable. For the gardener, it informs the way a garden is described and understood in a specific context. Clinicians need both: a 'botanical' type of classification to bring rigour to research and therapy, and clinical 'gardening', which allows for multiple perspectives and diagnostic frameworks. Clinical reasoning is a form of research with therapeutic intent. Botany and gardening represent a mixed-methods approach that can enrich diagnosis. The challenge is to integrate multiple perspectives in clinically helpful ways that help us retain both richness and rigour.

Psychosocioeconomic study of medically unexplained physical symptoms

BACKGROUND

There is a paucity of studies done on medically unexplained physical symptoms (MUPS) in Kerala, India. The objective of this study was to examine the sociodemographic and other clinical variables associated with this condition.

MATERIALS AND METHODS

The clinical sample was taken from the General Medicine Clinic of a tertiary care hospital, in Kerala. The referred cases meeting the criteria (N=48) for medically unexplained physical symptoms were enrolled for this cross-sectional study. The medical doctor with experience in psychiatry completed the questionnaire.

RESULTS

Most of the patients were middle-aged females from rural areas. The most common symptom reported was headache. Most of the patients had symptoms for five years or more and had seen two-to-five consultants. A majority of the patients had undergone special investigations and a few had expensive and invasive investigations. Cluster C personality disorders were the most common associated personality disorders with medically unexplained physical symptoms.

CONCLUSIONS

To our knowledge this is the first psychosocioeconomic study on medically unexplained physical symptoms, done in Kerala, India. Medically unexplained physical symptoms cause loss of productivity and economic burden and are a major public health problem. Future studies are warranted focusing on non-pharmacological treatment, psycho-education on mind-body association, and medical models on specific cytokines associated with medically unexplained physical symptoms for personalized management, and to examine the effect of a combination of pharmacotherapy and cognitive behavioral therapy.

A Qualitative Study on the Attitudes and Beliefs towards Help Seeking for Emotional Distress in Omani Women and Omani General Practitioners: Implications for Post-Graduate Training

OBJECTIVES

This study aims to explore the attitudes and beliefs of Omani women attending primary health care and Omani general practitioners regarding help seeking behaviour for emotional distress. The study also intends to clarify the understanding of help seeking from both lay and professional perspectives in the context of Omani culture exploring factors related to doctors' training and health care services.

METHODS

A qualitative phenomenological study using semi-structured interviews was conducted at the Family Medicine Health Care Centre at Sultan Qaboos University Hospital. 20 lay informants (Omani women) and 10 professional informants (Omani family physicians) were interviewed.

RESULTS

Two main sets of themes are presented in this study; 1). the original themes, which are presented in the results section and represent the descriptive level of analysis, and 2). the emergent themes are presented in the discussion section and represent the interpretive level of analysis. The original themes are: a) self help, with subthemes including the role of faith, talking and distraction. b) Health care and doctors, with subthemes including: reasons for seeing a doctor, reasons for not seeing a doctor, continuity of care, doctor-patient relationship and time. c) Traditional (folk) medicine. The emergent themes are: a) Talking b) Religious faith c) Cultural beliefs and d) The doctor's role. Cultural and religious beliefs were found to shape the experience of help seeking in the study group. In addition, factors associated with doctor-patient relationship were found to play a major role in determining the help seeking behaviour of women experiencing symptoms related to psychological distress. Professional informants emphasized the role of their training, availability of supporting services, time and continuity of care. The study showed discrepancy between lay and professional informants' beliefs regarding the role of family physicians in managing mental problems.

CONCLUSION

This study recommends paying more attention to factors related to cultural beliefs, doctor-patient relationship and family physicians' role when planning health services and residency programs, and when planning research on aspects related to mental health in non-Western cultures.

Relationship Between Physical Health Status and Responses to a Psychological Distress Measure

Les données de l'enquête Santé Québec (ESQ) ont été utilisées pour examiner l'influence du statut de santé physique sur les réponses données aux items d'ordre somatique et affective-cognitive de l'inventaire de détresse psychologique (IDP) de l'ESQ. LISREL VIII a été employé pour tester un modèle explicatif de l'association entre ces variables dans trois groupes d'âge (n = 600): 18–39 ans, 40–64 ans et 65 ans et plus. Le sexe, le niveau de stress percu, le soutien social et le statut marital ont été introduits dans le modèle comme variables contrôles. Nos résultats ont montré que la composante affective-cognitive de l'IDP était le principal facteur explicatif des réponses obtenues à la composante somatique de l'échelle. Nos résultats indiquent aussi que le statut de santé physique influence directement les réponses aux items somatiques de l'IDP. Cependant, l'effet observé était similaire dans les trois groupes d'âge étudiés. Les résultats de cette étude suggèrent que l'utilisation d'une mesure de détresse psychologique comprenant des items d'ordre somatique, tel que l'IDP, entraîne une petite surestimation de la détresse psychologique dans tous les groupes d'âge. Cependant, les items somatiques n'introduisent pas un biais différentiel dans l'évaluation de la détresse psychologique des répondants en fonction dé l'âge.

Medically unexplained physical symptoms masking (cenesthopathic) schizophrenia: a case series

The authors present a case series involving four patients who were referred to a specialized somatoform disorders clinic because of chronic medically unexplained physical complaints. The patients were eventually diagnosed with cenesthopathic schizophrenia, a term that has been proposed for a type of schizophrenia in which tactile hallucinations and delusional somatosensory beliefs are prominent. Two of the four had definite responses to antipsychotic medication. All of the patients were immigrants to the United Kingdom, and cultural and language barriers were likely factors in delayed diagnoses.

Reexamining the domain of hypochondriasis: comparing the Illness Attitudes Scale to other approaches

The present study examined utility of the Illness Attitudes Scale (IAS; [Kellner, R. (1986). Somatization and hypochondriasis. New York: Praeger Publishers]) in a non-clinical college sample (N=235). Relationships among five recently identified IAS dimensions (fear of illness and pain, symptom effects, treatment experience, disease conviction, and health habits) and self-report measures of several anxiety-related constructs (health anxiety, body vigilance, intolerance of uncertainty, anxiety sensitivity, and non-specific anxiety symptoms) were examined. In addition, this study investigated the incremental validity of the IAS dimensions in predicting medical utilization. The fear of illness and pain dimension and the symptom effects dimension consistently shared stronger relations with the anxiety-related constructs compared to the other three IAS dimensions. The symptom effects dimension, the disease conviction dimension, and the health habits dimension showed incremental validity over the anxiety-related constructs in predicting medical utilization. Implications for the IAS and future conceptualizations of HC are discussed.

Tendency toward deliberate food restriction, fear of fatness and somatic attribution in cross-cultural samples

OBJECTIVE

To compare Omani and western teenagers attending schools in Muscat, Sultanate of Oman and Filipino teenagers residing in Manila, Philippines on indices of deliberate food restriction and dieting behavior.

METHODS

The sample consisted of 444 students who were assessed using the cross-culturally valid measure, Eating Attitude Test-26, a subscale of Eating Disorder Inventory to gauge the presence of the drive for thinness or 'fat phobia' and the Bradford Somatic Inventory to elicit the presence of somatization.

RESULT

Significant differences in attitudes to eating, body image and somatization between the western and non-western teenagers were found.

CONCLUSION

This paper suggests that trajectories of eating disorder, such as body image disturbances as expressed in fat phobia and somatization, tend to vary from culture to culture and underscore the view that some of the health related behavior among adolescents need to be examined within socio-cultural contexts.

Classification and diagnosis of patients with medically unexplained symptoms

Patients with medically unexplained symptoms (MUS) have little or no demonstrable disease explanation for the symptoms, and comorbid psychiatric disorders are frequent. Although common, costly, distressed, and often receiving ill-advised testing and treatments, most MUS patients go unrecognized, which precludes effective treatment. To enhance recognition, we present an emerging perspective that envisions a unitary classification for the entire spectrum of MUS where this diagnosis comprises severity, duration, and comorbidity. We then present a specific approach for making the diagnosis at each level of severity. Although our disease-based diagnosis system dictates excluding organic disease to diagnose MUS, much exclusion can occur clinically without recourse to laboratory or consultative evaluation because the majority of patients are mild. Only the less common, "difficult" patients with moderate and severe MUS require investigation to exclude organic diseases. By explicitly diagnosing and labeling all severity levels of MUS, we propose that this diagnostic approach cannot only facilitate effective treatment but also reduce the cost and morbidity from unnecessary interventions.

Characteristics of telephone calls in a psychiatric outpatient practice

OBJECTIVE

The goal of this study was to document the volume and characteristics of telephone calls from patients in an outpatient psychiatric clinic.

METHODS

Telephone calls from a psychiatric resident's patients were logged over a 6-month period. Information collected included sex of the caller, reason for the call, deemed importance of the call, primary psychiatric diagnosis, and insurance type.

RESULTS

A total of 291 calls occurred during the 6-month period, with an average of 2.4 calls per work day. The physician deemed 1.5% of calls to be an emergency and 15% to be urgent. Of the resident's total case load of 115 patients over the 6 month period, 29% (n = 33) of patients never made physician-patient telephone contact. Female patients were significantly more likely to call than males. Requests for medication refills were the most frequent type of call (38%). The mean number of calls per patient in the caseload was significantly different across diagnostic groups, with patients with personality disorders and anxiety spectrum disorders making more calls than other groups. There was no significant difference in the volume of telephone calls between patients with private health insurance and those without.

CONCLUSION

This study may be of particular interest to physicians and managed care systems who are interested in reimbursement for telephone psychiatry. This study confirms and extends the previously reported association between certain psychiatric disorders (personality disorders, anxiety spectrum disorders) and relative frequency of telephone calls to the physician. In addition, the high volume of calls for prescription refills is an important issue in telephone management.

Alexithymia and somatosensory amplification in functional dyspepsia

Somatosensory amplification is the tendency to report somatic sensations as intense and disturbing. Alexithymia is a personality construct characterized by difficulty recognizing emotions and a tendency to focus on external events and bodily sensations. The association of somatosensory amplification and alexithymia with functional symptoms was assessed in 111 patients with functional dyspepsia and 53 healthy comparison subjects. The subjects completed several assessment instruments, including the Somatosensory Amplification Scale and the 20-Item Toronto Alexithymia Scale. The patients with dyspepsia had modestly higher scores on measures of alexithymia (especially difficulty identifying feelings) and somatosensory amplification. Alexithymia and somatosensory amplification may play important roles in symptom generation and perception in a subset of patients with functional dyspepsia, but the importance of these constructs in this patient population appears less than previously reported.

Cognitive-behavioural therapy for patients with multiple somatoform symptoms--a randomised controlled trial in tertiary care

OBJECTIVE

(a) To evaluate the effect of a cognitive-behavioural inpatient treatment and (b) to analyse the differential efficacy of an additional ("soma") group management training of somatisation.

METHODS

The final sample consisted of 191 patients with somatisation syndrome (patients with at least eight DSM-IV somatoform symptoms). Patients were randomly assigned to (I) "standard treatment + soma" or (II) "standard treatment + relaxation training." A waiting control group consisted of 34 patients. All patients were diagnosed with a structured clinical interview for DSM-IV and received an interview on medical consulting behaviour and questionnaires concerning somatoform symptoms, general psychopathology, subjective health status, and life satisfaction.

RESULTS

Results show high impairment of the sample prior to treatment. At the 1-year follow-up, all outcome criteria were significantly reduced. The differential effect of the additional soma treatment was significant only for a reduction of visits to the doctor. Greatest longitudinal effect sizes were found for the reduction of somatoform symptoms.

CONCLUSION

Considering the subjects' high initial impairment, the outcome results are encouraging. The specific effect on health care use highlights the socioeconomic relevance.

Severe health anxiety: Why it persists and how to treat it

Hypochondriasis (HA) involves the fear of serious illness despite appropriate reassurances. Because HA is associated with patients' personal suffering and clinical management problems, it is important for clinicians to be knowledgeable about current conceptual and treatment approaches to this problem.

Somatization and mental health: a comparative study of the idiom of distress hypothesis

Somatization is the expression of physical symptoms in the absence of medically explained physical illness. As a disproportionate response to psychosocial distress, somatization is usually correlated with depression. According to the idiom of distress hypothesis, the association of somatization and mental health is mitigated when somatizing indirectly expresses, and is understood by others as, emotional distress. Theory and data suggest that collectivistic societies such as South Korea (S.K.), unlike individualistic societies like the U.S. (U.S.), employ an idiom of distress. Multiple measures of physical and mental health were administered to a random sample of S.K. (n=220) and U.S. (n=215) adults. Measurement structures of physical health and mental health were comparable between samples. Individuals in both samples somatized the same number of symptoms, although the U.S. adults expressed those symptoms more frequently. Findings supported the idiom of distress hypothesis. Bivariate and multivariate analyses revealed that the relationship of somatization with mental health depends on culture. Also, the disparity in mental health was greatest and favored the U.S. adults at low levels of somatization, but the disparity in mental health between countries disappeared as somatization increased.

Group therapy for somatization disorders in primary care: maintenance of treatment goals of short cognitive-behavioural treatment one-and-a-half-year follow-up

OBJECTIVE

The objective of this study was to evaluate the maintenance of treatment goals of a short cognitive-behavioural group treatment programme for the management of somatization disorders in primary care.

METHOD

In a previous controlled 6-month follow-up study, patients with somatization disorders (n=32) improved with respect to illness and somatic preoccupation, hypochondriasis, and medication usage. In the present report the same group of patients were also investigated one-and-a-half year after initial treatment.

RESULTS

The long-term follow-up manifested maintained improvement with respect to hypochondriasis. There was additional reduction of anxiety and psychosocial preoccupation, whereas somatization and depression-anxiety scores improved progressively.

CONCLUSION

A short cognitive-behavioural group treatment of psychosomatic patients can be useful in primary care and may manifest maintained or progressive beneficial outcome.

Using nurse practitioners to implement an intervention in primary care for high-utilizing patients with medically unexplained symptoms

Patients with medically unexplained symptoms (MUS) often are a source of frustration for clinicians, and despite high quality biomedical attention and frequent diagnostic tests, they have poor health outcomes. Following upon progress in depression treatment approaches, we developed a multidimensional treatment protocol for deployment by primary care personnel. This multi-faceted intervention for MUS patients emphasized cognitive-behavioral principles, the provider-patient relationship, pharmacological management, and treating comorbid medical diseases. We deployed it in an HMO using nurse practitioners (NP) to deliver the intervention to 101 patients, while 102 controls continued to receive medical care from their usual primary care physician. Successful deployment of the intervention required training the NPs, continuing support for the NPs in their management of this difficult population, and establishing strong communication links with the HMO. This paper addresses the practical considerations of using primary care personnel to implement a complex intervention in primary care, and it includes a discussion of special challenges encountered as well as solutions developed to overcome them.

The somatization in primary care study: a tale of three diagnoses

Somatization is a common phenomenon that has been defined in many ways. The two most widely used diagnoses, Somatization Disorder (SD) and Abridged Somatization Disorder (ASD), are based on lifetime unexplained symptoms. However, reports indicate instability in lifetime symptom recall among somatizing patients. Multisomatoform disorder (MSD) is a new diagnosis based on current unexplained symptoms. To understand how knowledge about SD and ASD translates to MSD, we examined the diagnostic concordance, impairment and health care utilization of these groups in a sample from the Somatization in Primary Care Study. The diagnostic concordance was high between MSD and SD, but lower between MSD and ASD. All three groups reported considerable physical impairment (measured using the PCS subscale of the SF-36). The mental health (MCS) scores for the three groups were only slightly lower than those of the general population. Over the course of one year, physical functioning fell significantly for all three groups. Mental functioning did not change significantly for any of the three groups over this period. Utilization patterns were very similar for the three groups. The high prevalence, serious impairment, and worsening physical functioning over the course of one year suggest the importance of developing interventions in primary care to alleviate the impaired physical functioning and reduce utilization in somatizing patients. MSD should be a useful diagnosis for targeting these interventions because it identifies a sizable cohort of somatizing patients reporting impairment of comparable severity to full SD, using a more efficient diagnostic algorithm based on current symptoms.

A contemporary conceptual model of hypochondriasis

Hypochondriasis (HC), which involves preoccupation with the fear of having a serious illness despite appropriate medical examination, is often encountered in medical settings. The most conspicuous feature of this disorder is seeking excessive reassurance from physicians, medical references, or self-inspection; however, many patients also fear they will receive upsetting information if evaluated and thus avoid consultations and remain preoccupied with physiologic events, believing they are physically ill. Thus, HC causes personal suffering for the patient and practical and cost management problems for professionals across fields of clinical practice. The past 2 decades have seen considerable improvement in the understanding and treatment of HC. In this article, we review a contemporary conceptual model of HC and an effective form of treatment called cognitive-behavioral therapy that is derived from this model. Recommendations for presenting this conceptualization to patients and encouraging proper treatment are also discussed.

Health concerns of university women with a history of child physical and sexual maltreatment

Three health symptom checklists were used to measure physical health concerns among university women in relation to prior child physical maltreatment (CPM) (20%, n = 153) and child sexual abuse (CSA) (19%, n = 143). A history of CPM was related to all three general areas of health concerns as well as to many of the specific subscales comprising the measures (e.g., muscular-skeletal symptoms and gynerological problems), whereas an interaction between CSA and CPM was linked to greater premenstrual distress subscale scores (particularly emotional and behavioral symptoms). Overall, although CSA was not related to health symptoms, within the CSA subgroup, greater duration and severity of CSA was predictive of higher premenstrual distress even after controlling for CPM. This study emphasizes the need for greater awareness of the physical health-related correlates of both physical and sexual maltreatment in childhood and their associated implications for women's health care needs.

Physical symptoms, posttraumatic stress disorder, and healthcare utilization of women with and without childhood physical and sexual abuse

For four groups of women: no abuse, physical abuse alone, combined sexual and physical abuse, and unclear about memories of abuse, we examined the associations between childhood sexual and physical abuse, chronic physical symptoms in adulthood, PTSD, and health care utilization. Of a randomly selected sample of 600 adult femalc members of a health maintenance organization, 86 (14%) chose to participate. Women with a history of physical and sexual abuse in childhood reported significantly more cardiovascular, immune, musculoskeletal, neurologic, and reproductive symptoms than those without this history. While the Sexual/Physical Abuse group had the most chronic physical symptoms, medical visits, emergency room visits, prescriptions, and severe PTSD, the Unclear Memory group consistently ranked second on these same measures--higher than either Controls or the Physical Abuse group. Findings underscore the importance of screening for trauma history among patients seen in medical clinics, and the importance for psychotherapists of attending to patients' physical as well as psychological symptoms of childhood trauma.

Medically unexplained symptoms in an urban general medicine practice

The authors investigated the prevalence of multiple medically unexplained symptoms (MMUS) as identified by primary care physicians (PCPs) in a systematic sample of 172 patients. Patients were from a university-affiliated urban primary care practice serving a low-income population. Patients with a history of MMUS were older (mean: 57.2 vs. 53.0 years), more likely to be female (90.5% vs. 72.3%), and less likely to be married or living with a partner (14.4% vs. 36.2%) than those without MMUS. Patients with MMUS had over twice the rate of any current psychiatric disorder, almost two-and-a-half times the rate of any current anxiety disorder, and greater functional impairment. These data suggest that patients with MMUS are as common in urban primary care clinics as in more affluent clinics and reinforce the need for PCPs to screen these patients for common and treatable psychiatric conditions.

Resource utilization of patients with hypochondriacal health anxiety and somatization

OBJECTIVES

To examine the resource utilization of patients with high levels of somatization and health-related anxiety.

DESIGN

Consecutive patients on randomly chosen days completed a self-report questionnaire assessing somatization and health-related, hypochondriacal anxiety. Their medical care utilization in the year preceding and following completion of the questionnaire was obtained from an automated patient record. The utilization of patients above and below a predetermined threshold on the questionnaire was then compared.

PATIENTS AND SETTING

Eight hundred seventy-six patients attending a primary care clinic in a large, urban, teaching hospital.

OUTCOME MEASURES

Number of ambulatory physician visits (primary care and specialist), outpatient costs (total, physician services, and laboratory procedures), proportion of patients hospitalized, and proportion of patients receiving emergency care.

RESULTS

Patients in the uppermost 14% of the clinic population on somatization and hypochondriacal health anxiety had appreciably and significantly higher utilization in the year preceding and the year following completion of the somatization questionnaire than did the rest of the patients in the clinic. After adjusting for group differences in sociodemographic characteristics and medical comorbidity, significant differences in utilization remained. In the year preceding the assessment of somatization, their adjusted total outpatient costs were $1,312 (95% CI $1154, $1481) versus $954 (95% CI $868, $1057) for the remainder of the patients and the total number of physician visits was 9.21 (95% CI 7.94, 10.40) versus 6.33 (95% CI 5.87, 6.90). In the year following the assessment of somatization, those above the threshold had adjusted total outpatient costs of $1,395 (95% CI $1243, $1586) versus $1,145 (95% CI $1038, $1282), 9.8 total physician visits (95% CI 8.66, 11.07) versus 7.2 (95% CI 6.62, 7.77), and had a 24% (95% CI 19%, 30%) versus 17% (95% CI 14%, 20%) chance of being hospitalized.

CONCLUSIONS

Primary care patients who somatize and have high levels of health-related anxiety have considerably higher medical care utilization than nonsomatizers in the year before and after being assessed. This differential persists after adjusting for differences in sociodemographic characteristics and medical morbidity.

Vulvar vestibulitis: a multi-factorial condition

OBJECTIVE

To study differences in somatic symptoms and personality dimensions between women with vulvar vestibulitis and a non-symptomatic control group.

DESIGN

A case-control study conducted in 1998.

SETTING

Two clinics in northern Sweden.

SAMPLE

Thirty-eight women, 18-25 years of age, suffering from vulvar vestibulitis, and 70 healthy controls.

METHODS

The women completed two questionnaires: the temperament and character inventory to study personality aspects, and the Giessen subjective complaints list, which is a checklist of subjective bodily complaints.

RESULTS

Regarding personality aspects the women with vulvar vestibulitis scored significantly higher than the control group, on exclusively one out of seven subscales of the temperament and character inventory (i.e. harm avoidance). This trait is considered to be partly inherited and stable throughout life, and to give the person a tendency to react to problems with pessimistic thoughts, increased anxiety and fatigue. On the Giessen subjective complaints list the women with vestibulitis reported a significantly higher number of somatic complaints in several areas.

CONCLUSIONS

The findings that women suffering from vulvar vestibulitis have more bodily complaints than the controls is interpreted as an indication of a psychosomatic element in their illness, which could be primary or secondary. Furthermore, these women are characterised by a particular personality trait, and it is suggested that this trait might influence their experience and management of pain and stress. A multi-factorial origin of vulvar vestibulitis is advocated and a multimodal interdisciplinary treatment approach is suggested. To elucidate further the mechanisms behind this health problem, prospective controlled studies are urgently needed.

Somatization: a debilitating syndrome in primary care

Somatization is a significant problem for clinical medicine. Unlike somatization disorder, which is relatively rare, abridged somatization, a less severe form of somatization, is prevalent in primary care clinics. The authors examined the clinical status and functioning of patients diagnosed with a depression or anxiety disorder comorbid with abridged somatization and compared them with patients diagnosed with a depression or anxiety disorder alone. The authors examined severity of physical functioning and psychopathology in relation to diagnostic status. Patients diagnosed with both abridged somatization and a depression or anxiety disorder were more physically impaired and more anxious than those diagnosed with a depression or anxiety disorder alone. The results suggest that abridged somatization frequently coexists with depression and anxiety and thus complicates the presentation of these disorders.