Comparison of screening proposals for somatization disorder empirical analyses

Screening for multiple somatic complaints in a population-based survey: does excessive symptom reporting capture the concept of somatic symptom disorders? Findings from the MONICA-KORA Cohort Study

OBJECTIVE

Excessive symptom reporting (ESR) has gained a revived attention in the conceptualization of somatic symptom disorders. We aimed to explore whether ESR captures the concept of somatic symptom disorders regardless of the patient's disease status or the degree of symptom burden.

METHODS

In three independent cross-sectional population-based samples of the MONICA/KORA Study in 1985, 1990, and 1995, somatic symptom reporting and an array of somatic and mental health features were assessed in 11,895 eligible participants. After a mean 12-year follow-up, the vital status was assessed at the end of 2002. All-cause mortality was calculated as hazard risks ratios (HRs).

RESULTS

Among all participants, a total of 1238 men and 1169 women were in the sex-specific upper quintile of the somatic symptom distribution and qualified for ESR subpopulation. ESR participants were older, on a lower educational level, and more often unemployed. They suffered more often from metabolic syndrome and chronic diseases. ESR was associated with psychological distress, negative self-perceived health, and sleeping disorders. ESR was associated with twofold more ambulant and hospital medical utilization. Survival in ESR participants was significantly reduced (HR=1.33; 95% CI=1.18-1.49; P<.001). Frequency of medical ambulatory consultations and days in hospital were higher in ESR participants, even after controlling for potential confounders.

CONCLUSION

A simple approach to screen for participants with high symptom reporting in an unselected population-based sample results in the identification of a clinically meaningful target population with high burden of physical and psychological comorbidities.

Assessment of somatoform disorders: a review of strategies and instruments

We provide an overview of methods and instruments developed for the assessment of somatoform disorders. Four diagnostic purposes have been identified: (i) classification according to a diagnostic system; (ii) screening for probable cases; (iii) dimensional measurement of syndrome severity; and (iv) assessment of associated clinical features. Existing instruments designed for each of these strategies are described, including specifications of their psychometric properties, particular features, advantages and disadvantages. A conclusion of this review is that the currently existing 'family of assessment instruments' in the field of somatoform disorders should be used to improve the comparability of scientific findings in different cultures and settings.

The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms

OBJECTIVE

Somatization is prevalent in primary care and is associated with substantial functional impairment and healthcare utilization. However, instruments for identifying and monitoring somatic symptoms are few in number and not widely used. Therefore, we examined the validity of a brief measure of the severity of somatic symptoms.

METHODS

The Patient Health Questionnaire (PHQ) is a self-administered version of the PRIME-MD diagnostic instrument for common mental disorders. The PHQ-15 comprises 15 somatic symptoms from the PHQ, each symptom scored from 0 ("not bothered at all") to 2 ("bothered a lot"). The PHQ-15 was administered to 6000 patients in eight general internal medicine and family practice clinics and seven obstetrics-gynecology clinics. Outcomes included functional status as assessed by the 20-item Short-Form General Health Survey (SF-20), self-reported sick days and clinic visits, and symptom-related difficulty.

RESULTS

As PHQ-15 somatic symptom severity increased, there was a substantial stepwise decrement in functional status on all six SF-20 subscales. Also, symptom-related difficulty, sick days, and healthcare utilization increased. PHQ-15 scores of 5, 10, 15, represented cutoff points for low, medium, and high somatic symptom severity, respectively. Somatic and depressive symptom severity had differential effects on outcomes. Results were similar in the primary care and obstetrics-gynecology samples.

CONCLUSIONS

The PHQ-15 is a brief, self-administered questionnaire that may be useful in screening for somatization and in monitoring somatic symptom severity in clinical practice and research.

Screening for high utilizing somatizing patients using a prediction rule derived from the management information system of an HMO: a preliminary study

BACKGROUND

Somatization is a common, costly problem with great morbidity, but there has been no effective screening method to identify these patients and target them for treatment.

OBJECTIVES

We tested a hypothesis that we could identify high utilizing somatizing patients from a management information system (MIS) by total number of visits and what we termed "somatization potential," the percentage of visits for which ICD-9 primary diagnosis codes represented disorders in the musculoskeletal, nervous, or gastrointestinal systems or ill-defined complaints.

METHODS

We identified 883 high users from the MIS of a large staff model HMO as those having six or more visits during the year studied (65th percentile). A physician rater, without knowledge of hypotheses and predictors, then reviewed the medical records of these patients and identified somatizing patients (n = 122) and nonsomatizing patients (n = 761). In two-thirds of the population (the derivation set), we used logistic regression to refine our hypothesis and identify predictors of somatization available from the MIS: demographic data, all medical encounters, and primary diagnoses made by usual care physicians (ICD-9 codes). We then tested our prediction model in the remaining one-third of the population (the validation set) to validate its usefulness.

RESULTS

The derivation set contained the following significant correlates of somatization: gender, total number of visits, and percent of visits with somatization potential. The c-statistic, equivalent to the area under the ROC curve, was 0.90. In the validation set, the explanatory power was less with a still impressive c-statistic of 0.78. A predicted probability of 0.04 identified almost all somatizers, whereas a predicted probability of 0.40 identified about half of all somatizers but produced few false positives.

CONCLUSIONS

We have developed and validated a prediction model from the MIS that helps to distinguish chronic somatizing patients from other high utilizing patients. Our method requires corroboration but carries the promise of providing clinicians and health plan directors with an inexpensive, simple approach for identifying the common somatizing patient and, in turn, targeting them for treatment. The screener does not require clinicians' time.

Talking tumours: histories from sequences

The history of a tumour is currently inferred from its morphology. However, progression may be variable between similar appearing tumours, and some critical events may be difficult to see. It has become increasingly apparent that histories are also written within sequences. Every tumour likely records its own progression within its genome. In the future, it may be possible to read the past based on these sequences. A critical issue is whether these autobiographies will recapitulate morphology or whether they reveal unexpected ghosts.

Health Attitude Survey. A scale for assessing somatizing patients

The authors designed an instrument, the Health Attitude Survey, to assess somatization, and administered it to over 1,000 patients attending a general medicine clinic. Within this population, a series of somatizing patients and control patients were identified for purposes of developing and testing the instrument. The 27-item scale was rapidly administered and acceptable to the patients. Based on comparisons with other measures of somatization, the instrument appeared to be a valid measure of the attitudes and perceptions of somatizing patients, and it distinguished these patients from the control subjects. The measure showed acceptable predictive value and may prove useful in clinical settings, where rapid screening is desired.

Somatization in Family Practice: Comparing 5 Methods of Classification

BACKGROUND: It has been suggested that patients with somatoform disorders are high utilizers of medical care, yet interpretation of studies has been difficult because of variant methods of diagnosis. The goal of this study was to compare 5 different methods of classification on the same group of subjects and to examine prevalence rates of somatoform disorders and medical utilization. METHOD: Subjects completed a demographic questionnaire in the physician's office and the somatization section of the Diagnostic Interview Schedule (DIS) by telephone. Subsequently, their medical charts were examined. Using the 5 methods of diagnosis, somatizers were compared with nonsomatizers for level of utilization of medical services. The setting was a medical school-based family practice residency training center. Participants were 119 patients waiting to see their family doctors. The main outcome measures were prevalence of somatization symptoms and chart information (utilization, number of health problems). RESULTS: One subject met the Diagnostic and Statistical Manual (DSM-IV)-based DIS criteria for somatization disorder. With the Bucholz modification for scoring the DIS, 10 subjects were diagnosed with somatization disorder. With the abridged Escobar criteria of 6 symptoms, 7 subjects met diagnostic criteria, while 28 met the criteria for multisomatoform disorder of 3 symptoms, as suggested by Kroenke. The diagnosis of undifferentiated somatoform disorder, requiring only 1 unexplained symptom, was obtained by 94 of the subjects. CONCLUSION: Findings from this study revealed widely divergent prevalence rates of somatoform disorders, depending on methods of diagnosis used. Correlation with rates of medical utilization is suggested as an external criterion for validating diagnostic methods.

Screening of somatization disorder: validation of the Spanish version of the Othmer and DeSouza test

The objective of this study was to validate the Spanish version of the Othmer and DeSouza Screening Test for Somatization Disorder. We have designed a validity study using the Standardized Polyvalent Psychiatric Interview, an instrument specifically designed to diagnose psychiatric morbidity in medical settings as the 'golden rule'. The control group displayed 'functional' and 'presenting' somatization. The Othmer and DeSouza Screening Test, with a threshold of three symptoms, shows 88% sensitivity, 78% specificity and a misclassification rate of 17%. It is concluded that Othmer and DeSouza's screening test, with a threshold of three symptoms, is a useful tool for the diagnosis of somatization disorder in medical and primary care settings in Spain. Discrepancies with US findings are discussed on a cross-cultural basis.

Psychiatric screening in geriatric primary care: should it be for depression alone?

Depression in the elderly is highly prevalent, associated with functional disability and increased medical costs, and treatable; however, it is infrequently recognized and treated. The Agency for Health Care Policy and Research has advocated, therefore, increased case-finding efforts for depression in primary geriatric care. Anxiety, substance, and somatoform disorders in the elderly are similarly prevalent, associated with disability and cost, treatable, and also infrequently detected and treated. We believe that psychiatric case-finding in geriatric primary care should attend to these disorders, therefore, as well as to depression. In the present study, we examined whether the association between depressive and nondepressive forms of psychopathology was similar in geriatric and nongeriatric medical patients. We also examined the relationship between each type of pathology and health care utilization and global ratings of physical and mental health. In a VA hospital general medical outpatient clinic, 508 patients completed the SCREENER, which is a brief self-report questionnaire that screens for a range of psychiatric disorders, along with a self-report questionnaire regarding subjective health and medical care utilization. Of these patients, 98% were male, and the median age was 63 years. Patients aged 63 and over were compared to younger patients. In both geriatric and younger adult patients, we found substantial comorbidity between depressive and nondepressive forms of pathology. Moreover, in both age groups, there were significant associations between both depressive and nondepressive symptoms and fair-to-poor self-rated physical and mental health and increased medical care utilization. Approximately half of the cases of nondepressive disorders in the elderly were not comorbid with depression, and thus would not have been detected by screening for depression alone. Therefore, psychiatric case finding in primary care of geriatric males should be directed at anxiety, substance, and somatoform disorders, as well as at depression, for treatment resources to be triaged to maximally decrease morbidity and cost.