The association between medically unexplained physical symptoms and health care use over two years and the influence of depressive and anxiety disorders and personality traits: a longitudinal study

The Impact of Depression, Anxiety and Personality Disorders on the Outcome of Patients with Functional Limb Weakness - Individual Patient Data Meta-Analysis

OBJECTIVE

Psychiatric comorbidities such as depression, anxiety, and personality disorders are common in patients with functional limb weakness/paresis (FND-par). The impact of these conditions on the prognosis of FND-par has not been systematically reviewed. The aim of this study was to identify a potential prognostic effect of comorbid depression, anxiety, and/or personality disorder on prognosis in patients with FND-par.

METHODS

A systematic review was performed to identify studies that reported measures of baseline depression, anxiety, and/or personality disorder, and physical disability. An individual patient data meta-analysis was subsequently performed.

RESULTS

Eight studies comprising 348 individuals were included (7 prospective cohorts; 1 case-control study). There was heterogeneity in sample size, follow-up duration, and treatment modality. Depression and anxiety were present in 51.4% and 53.0% of FND-par patients, respectively. In individuals whose FND-par improved, there was no significant difference between those with versus without depression (52.6% vs 47.4%, p = 0.69) or those with versus without anxiety (50.3% vs 49.7%, p = 0.38). Meta-analysis showed no clear impact of baseline depression or anxiety per se [pooled OR for depression 0.85 (95%CI 0.50-1.45; p = 0.40) and anxiety 0.84 (95%CI 0.51-1.38; p = 0.91)]; and of depression or anxiety severity [pooled OR for depression 1.23 (95%CI 0.63-2.39; p = 0.91) and anxiety 1.40 (95%CI 0.70-2.78; p = 0.58)] on FND-par outcome. Insufficient data were available to assess the impact of personality disorders.

CONCLUSION

We found no evidence that depression or anxiety influenced outcome in FND-par. Large-scale, prospective studies in FND-par, and other FND subtypes, are needed to fully contextualize the impact of concurrent mental health concerns on outcomes.

Survey of Health Literacy Among Japanese Outpatients with Mental Illness

Purpose

Low health literacy has been associated with adverse outcomes in health maintenance and the course of chronic physical illness. In particular, anxiety disorders can also affect one's physical health, causing issues including cardiovascular, respiratory, gastrointestinal and immune system disorders. However, there are no reports on physical health literacy among Japanese patients with mental illness.

Patients and Methods

A patient background questionnaire, the Japanese version of the Ten-Item Personality Inventory, and the Japanese version of the Health Literacy Scale (HLS-EU-Q47; European Health Literacy Survey Questionnaire) were distributed face to face to 1000 psychiatric outpatients. A total of 785 valid responses including 211 patients with schizophrenia, 261 patients with mood disorders, and 234 patients with anxiety disorders were obtained by mail.

Results

Health literacy was "limited" in 52% of patients with schizophrenia, 51% of those with mood disorders, and 38% of those with anxiety disorders. Among patients with mood disorders, there were no differences between those with major depressive disorder and those with bipolar disorder. Anxiety disorders were associated with higher health literacy than schizophrenia and mood disorders (odds ratio (OR) 1.85, 95% confidence interval (95% CI) 1.07, 3.34), and in terms of personality, neuroticism (OR 0.85, 95% CI 0.75, 0.97) and openness (OR 0.85, 95% CI 0.74, 0.98) were associated with limited health literacy, while agreeableness (OR 1.36, 95% CI 1.18, 1.57) and extraversion OR 1.34, 95% CI 1.17, 1.52) were associated with higher health literacy.

Conclusion

The results of this study indicate limited health literacy in patients with mental illness, in particular, limited health literacy in outpatients with schizophrenia and mood disorders. In addition, gender and some personality traits were associated with physical health literacy. Based on these results, physical health education should be individualized.

The Doctor Is In(ternet): The Mediating Role of Health Anxiety in the Relationship between Somatic Symptoms and Cyberchondria

Cyberchondria is a dysfunctional behavioral pattern characterized by an excessive and anxiety-amplifying engagement in searching for reassuring health information on the Internet. Research demonstrated that somatic symptoms and health anxiety might foster maladaptive health-related behaviors, such as cyberchondria. However, the relationships between somatic symptoms, health anxiety, and cyberchondria have been scarcely examined. Accordingly, this study aimed to test the mediating effect of health anxiety on the association between somatic symptoms and cyberchondria. Four hundred and thirty-one adults from the community (158 males, 36.66%), aged between 18 and 74, were recruited via an online survey. Participants completed self-report measures of somatic symptoms, health anxiety, and cyberchondria. A mediation analysis demonstrated that the severity of somatic symptoms predicted increased levels of cyberchondria and that health anxiety partially mediated this association. Therefore, interventions aimed at decreasing health anxiety may also play a role in decreasing the risk of developing cyberchondria.

Type D Personality and Big Five Personality Traits and the Risk of Breast Cancer: A Case-Control Study

OBJECTIVE

The goal of this study is to establish the differences in Type D personality and Big five personality traits between a group of newly diagnosed breast cancer patients and a group of controls.

METHODS

A comparative study of breast cancer patients and women without previous history of cancer was carried out. We used Type D Scale-14 as an instrument for the assessment of the type-D personality pattern and NEO-FFI for the assessment of the Big Five personality traits. Conditional logistic regression models were used to estimate odds ratios and 95% confidence intervals were applied for breast cancer by personality trait factors.

RESULTS

Negative affectivity (NA) (OR = 4.45 95% CI: 1.96-10.61), neuroticism HIGH (OR = 3.97, 95% CI: 1.08-15.81), openness to experience HIGH (OR = 3.47 95% CI: 1.11-11.49), were associated factors significantly related to an increased risk of breast cancer, whereas Social Inhibition (SI) was associated factor with a decreased risk of breast cancer (OR = 0.40 95% CI: 0.16-0.92).

CONCLUSIONS

This was the first case-control study which analyzed NA and SI traits in breast cancer patients. SI as a breast-cancer risk decreasing factor might indicate that expressing negative emotions is not always a healthy mechanism of their regulation.

The randomized clinical trial results of the anxiety treatment in patients with somatoform dysfunction and neurotic disorders

The existing treatments for somatoform dysfunction (SfD), reaction to severe stress (RSS), and adjustment disorders (AjD) are insufficiently effective and safe. Anxiolytic drug Tenoten proved effective in clinical trials (CT). The aim of this multicenter double-blind placebo-controlled randomized CT was to investigate the safety and efficacy of Tenoten in the treatment of anxiety in adults with SfD, RSS, AjD and other neurotic disorders (oNDs). 390 adult patients with SfD, RSS and AjD or oNDs with the Hospital Anxiety and Depression scale-anxiety (HADS-A) score ≥ 11 were randomized into 4 groups (n = 127 in Tenoten group 1 (4 tablets/day); n = 131 in Tenoten group 3 (8 tablets/day), n = 132 in combined Placebo group 2 + 4). The changes from baseline in the mean Hamilton Anxiety Rating Scale (HAM-A) score in groups 1 and 3 after 12 weeks were the primary outcome. The decrease of the HAM-A score from 18.81 ± 5.81 to 7.26 ± 4.63 (in group 1) and from 18.38 ± 4.3 to 6.40 ± 4.02 (in group 3) was observed post-treatment (p_{group 1/placebo} = 0.0055, p_{group 3/placebo} < 0.0001). Overall, 46 adverse events (28 in the Tenoten groups and 18 in the Placebo) were reported without any difference between the study groups. Tenoten performed significantly more effective than placebo in the anxiety treatment of adults with SfD, RSS, AjD and oNDs (clinicaltrials.gov NCT03036293).

Psychopathology and Somatic Complaints: A Cross-Sectional Study with Portuguese Adults

(1) Background: Functional somatic symptoms (FSS) are physical symptoms that cannot be fully explained by medical diagnosis, injuries, and medication intake. More than the presence of unexplained symptoms, this condition is associated with functional disabilities, psychological distress, increased use of health services, and it has been linked to depressive and anxiety disorders. Recognizing the difficulty of diagnosing individuals with FSS and the impact on public health systems, this study aimed to verify the concomitant incidence of psychopathological symptoms and FSS in Portugal. (2) Methods: For this purpose, 93 psychosomatic outpatients (91.4% women with a mean age of 53.9 years old) and 101 subjects from the general population (74.3% women with 37.8 years old) were evaluated. The survey questionnaire included the 15-item Patient Health Questionnaire, the 20-Item Short Form Survey, the Brief Symptom Inventory, the Depression, Anxiety and Stress Scale, and questions on sociodemographic and clinical characteristics. (3) Results: Increases in FSS severity were correlated with higher rates of depression, anxiety, and stress symptoms. The findings also suggest that increased rates of FSS are associated with lower educational level and female gender. (4) Conclusion: Being aware of the relationship between FSS and psychopathological symptoms and the need to explore psychosocial issues during clinical interviews may favor early detection of these cases. The early detection of mental disorders is essential for individuals’ adherence to treatments, reflecting on healthcare costs.

Validation of the Four-Dimensional Symptom Questionnaire (4DSQ) in a mental health setting

Mental health problems are highly prevalent in primary care. Validated tools to detect mental disorders in general practice are needed. The Four-Dimensional Symptom Questionnaire (4DSQ) was designed to help GPs differentiating between psychological distress and psychopathological conditions (depression, anxiety, somatization). The aim of the current study was to examine psychometric properties of the 4DSQ in a mental health setting. Reliability, factorial, construct, and criterion validity of the English translation of the 4DSQ were analyzed in an American sample of 159 patients attending a psychotherapy outpatient clinic. Measurement equivalence across languages was determined by analyzing differential item functioning (DIF) and differential test functioning (DTF) in the American sample and a Dutch mental health sample, matched by age and sex. A confirmatory factor analysis confirmed all 4DSQ subscales to be unidimensional. All 4DSQ subscales revealed excellent reliability (Cronbach's alpha and McDonald omega ≥.90) and high correlations with a symptom distress subscale of an instrument that is commonly used to monitor psychotherapy progress, the Outcome Questionnaire-45. Eight items were flagged with DIF. The Depression subscale was free of DIF. DTF analyses showed an impact of DIF on scale level for the lower cutoff score of the Distress scale. The 4DSQ Distress score was the best predictor of a mood disorder diagnosis and the Anxiety score outperformed other 4DSQ scales to predict an anxiety disorder. In conclusion, the 4DSQ demonstrates excellent reliability and validity in a mental health setting. Further research is needed to determine reliable cutoff values on 4DSQ subscales to predict psychiatric diagnoses.

Excessiveness in Symptom-Related Thoughts, Feelings, and Behaviors: An Investigation of Somatic Symptom Disorders in the General Population

OBJECTIVE

The diagnostic criteria of somatic symptom disorder (SSD) emphasize that somatic symptoms receive disease value once they are accompanied by excessive thoughts, feelings, or behaviors. The main objective of this study was to examine what constitutes excessiveness in psychological reactions to somatic complaints and how excessive symptom-related behavior influences self-reported health status and health care utilization.

METHODS

A national, representative general population survey was performed between January and March 2016 in Germany, including 2395 individuals older than 13 years. Self-report questionnaires (Somatic Symptom Scale-8, Somatic Symptom Disorder-B Criteria Scale) were used to operationalize the SSD criteria. Group differences in the daily amount of time dedicated to physical complaints were analyzed between individuals with and without SSD. Stepwise linear regression analyses were performed to predict general mental and physical health status, and health care utilization.

RESULTS

There was a significant effect of group (SSD yes/no) in daily time spent on symptoms, after controlling for age, sex, depression, and anxiety (F(1,2336) = 447.53, p < .001). The SSD group (n = 213) reported an average of 4 hours, whereas individuals without SSD reported 30 minutes. Results of the regression analyses showed that the combination of somatic symptoms and symptom-related psychological features is predictive of worsened self-reported physical and mental health status, and increased health care utilization.

CONCLUSIONS

A range of 3 to 4 hours per day spent on dealing with physical complaints seems indicative of excessiveness. If, during a clinical consultation, a patient reports such a large amount of time, a more comprehensive clinical examination of SSD should follow.

Framing the process in the implementation of care for people with generalized anxiety disorder in primary care: a qualitative evidence synthesis

Background

Generalized anxiety disorder (GAD) is one of the most common mental disorders in primary care (PC). GAD has low remission and high relapse rates over long follow-up periods. Qualitative evidence was synthesized to understand the implementation of care and treatment options for people with GAD in PC.

Methods

Research published from 2008 to September 2020 was searched in five databases (MEDLINE, EMBASE, CINAHL, WOS and PsycArticles). Studies that used qualitative methods for data collection and analysis to investigate the implementation of care and treatment options for people with GAD in PC and outpatient settings were included. Non-qualitative studies, mixed methods studies that did not separately report qualitative findings and studies in languages other than English or Spanish were excluded. We used the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) framework to assess the overall confidence in the findings.

Results

The results with a moderate level of confidence showed that the trajectory of care for people with GAD in PC and outpatient settings is long and fluctuates over time, involving multiple difficulties in accessing and maintaining initial treatment or successive treatment options. In addition, there are wide variations in the preferences for and acceptability of different treatment options. The results with a high level of confidence indicated that more information on GAD and its treatment options is needed for PC practitioners, GAD patients and their carers. The results with a low level of confidence suggested that patients use antidepressants for longer than recommended and that the interruption of treatment is not usually planned.

Conclusions

Initial resistance to new treatments among people with GAD can make access and adherence to treatment difficult. Improving care may require patients to be informed of possible trajectories in stepped care pathways before the initiation of treatment so they are aware that they may need to try a number of options until the most effective treatment for them is found. Increased awareness of and information materials on GAD may facilitate both appropriate diagnosis and long-term care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-020-01307-6.

Personality, Healthcare Use and Costs-A Systematic Review

BACKGROUND

Thus far, there is a lack of a systematic review synthesizing empirical studies that analyze the link between personality factors and healthcare use (HCU) or costs. Consequently, the purpose of our systematic review is to give an overview of empirical findings from observational studies examining the association between personality factors and HCU or costs.

METHODS

PubMed, PsycINFO, and NHS EED (NHS Economic Evaluation Database) were searched. Observational studies examining the association between personality factors and HCU costs by using validated tools were included. Two reviewers performed study selection and data extraction and evaluated the study quality. Findings were synthesized qualitatively.

RESULTS

In total, n = 15 studies (HCU, n = 14; cost studies, n = 1) were included in the final synthesis. A few studies point to an association between conscientiousness and HCU (with mixed evidence). Some more evidence was found for an association between higher agreeableness, higher extraversion, and higher openness to experience and increased HCU. The majority of studies analyzed found a link between higher neuroticism and increased HCU.

CONCLUSION

Personality factors, and particularly neuroticism, are associated with HCU. This knowledge is important to manage healthcare use. However, future research based on longitudinal data and studies investigating the link between personality characteristics and costs are required.

Assessing measurement equivalence of the Danish and Dutch Four-Dimensional Symptom Questionnaire using differential item and test functioning analysis

Aims: The Dutch Four-Dimensional Symptom Questionnaire (4DSQ) measures distress, depression, anxiety and somatisation, facilitating the distinction between stress-related problems and psychiatric disorder in primary and occupational health care. The aim of the study was to examine the measurement equivalence across the Danish and Dutch 4DSQ. Methods: Danish 4DSQ data were obtained from a cohort of Danish citizens on sick leave for mental-health problems. Dutch 4DSQ data were obtained from a cohort of Dutch employees on sick leave and a cohort of general practice attenders suspected of having mental-health problems. The study samples were matched on age and sex. The 4DSQ scales were assessed for essential unidimensionality using confirmatory factor analysis. Measurement equivalence of the 4DSQ across the groups was assessed using differential item and test functioning (DIF and DTF) analysis. Results: The study groups each consisted of 1363 people (63% female, M_age=42 years). The 4DSQ scales proved essentially unidimensional. DIF was detected in 20 items. In terms of Cohen’s effect size, DIF was mostly small or moderate. In terms of effect size, the mean effect on the scale score (DTF) was negligible. Nevertheless, it is recommended to adjust some of the cut-off points for two Danish 4DSQ scales to retain the meaning of these cut-off points in Dutch respondents. Conclusions:The Danish version of the 4DSQ measures the same constructs as the original Dutch questionnaire. Twenty items functioned differently in Danish respondents than in Dutch respondents, but this had only a small impact on the scale scores.

Medically unexplained symptoms: time to and triggers for diagnosis in primary care consultations

BACKGROUND

It is currently not known when in the consultation GPs label symptoms as medically unexplained and what triggers this.

AIM

To establish the moment in primary care consultations when a GP labels symptoms as medically unexplained and to explore what triggers them to do so.

DESIGN AND SETTING

This was a qualitative study. Data were collected in the Netherlands in 2015.

METHOD

GPs' consultations were video-recorded. GPs stated whether the consultation was about medically unexplained symptoms (MUS). The GP was asked to reflect on the video-recorded consultation and to indicate the moment when they labelled symptoms as MUS. Qualitative interviewing and analysis were performed to explore the triggers GPs perceived that caused them to label the symptoms as MUS.

RESULTS

A total of 43 of the 393 video-recorded consultations (11%) were labelled as MUS. The mean time until GPs labelled symptoms as medically unexplained was about 4 minutes for newly presented symptoms and 2 minutes for symptoms for which the patients had already visited the GP before. GPs were triggered to label symptoms as MUS in the consultation by: the way patients presented their symptoms; the symptoms not fitting into a specific pattern; patients attributing the symptoms to a psychosocial context; and a discrepancy between symptom presentation and objective findings.

CONCLUSION

Most GPs labelled the presented symptoms as medically unexplained soon after the start of the consultation. GPs are triggered to label symptoms as medically unexplained by patients' symptom presentation, symptom patterns, and symptom attribution. This suggests that non-analytical reasoning was a central component in their thought process.

Medically unexplained physical symptoms in patients visiting the emergency department: an international multicentre retrospective study

OBJECTIVE

The objective of this study was to assess the incidence and characteristics of patients presenting with physical symptoms that remain medically unexplained at the emergency department (ED).

PATIENTS AND METHODS

A retrospective chart study was carried out in three hospitals in The Netherlands and Belgium. All patients (age > 18 years) visiting the ED in 4 selected weeks in 2013 at the Erasmus University Medical Center (Erasmus MC) in Rotterdam, The Netherlands, and 1 selected week in 2013 at the Haaglanden Medical Center, Westeinde HMC in The Hague, The Netherlands, and the University Hospital Ghent (UZG), Belgium, were included. Descriptive statistics were used for data analysis.

RESULTS

A total of 2869 patients (Erasmus MC 1674, HMC 691, UZG 504) were included. Medically unexplained physical symptoms in the emergency department (EDMUPS) were present in 13.4% of all ED visits (Erasmus MC 12.5%, HMC 18.7%, UZG 9.1%). No EDMUPS were identified in trauma patients. When excluding trauma patients, EDMUPS were present in 18.5% (Erasmus MC 16.8%, HMC 26.5%, UZG 13.3%) of the visits. The characteristics of patients with and without EDMUPS differed significantly; patients with EDMUPS were more often younger, female, self-referred, frequent visitors, were prescribed less medication and more often had a psychiatric disease. Dutch and Belgian Hospital differed in the distribution of patients in triage categories and in the incidence of psychiatric illnesses.

CONCLUSION

Physical symptoms remain unexplained in a significant number of patients at the time of ED assessment.

Explanation of somatic symptoms by mental health and personality traits: application of Bayesian regularized quantile regression in a large population study

BACKGROUND

Somatic syndrome is one of the remarkably prevalent issues in primary health care and subspecialty settings. We aimed to elucidate multidimensional associations between somatic symptoms with major mental problems and personality traits in the framework of the quantile regression model with a Bayesian approach.

METHODS

A total of 4763 employees at Isfahan University of Medical Sciences and Health Services in Isfahan province, Iran, filled out four validated questionnaires including Hospital Anxiety and Depression Scale (HADS), NEO Questionnaire, General Health Questionnaire (GHQ) and PHQ-15 for somatic symptom severity. In addition, Functional Gastrointestinal Disorders (FGIDs) were determined using Rome IV criteria. Exploratory Factor Analysis (EFA) and Bayesian regularized quantile regression with adaptive LASSO penalization were applied for reduced dimension of somatic symptoms and variable selection and parameter estimation, respectively.

RESULTS

The 25 major somatic symptoms were grouped into four factors including general, upper gastrointestinal, lower gastrointestinal and respiratory by EFA. Stress, depression, and anxiety had significant effects on all of the four extracted factors. The effect of anxiety in each four extracted factors was more than stress and depression. Neuroticism and agreeableness had significant effects on all of the four extracted factors, generally (p < 0.05).

CONCLUSIONS

Given the high prevalence of somatic symptoms and psychosomatic complaints in correlation with the diverse range of mental co-morbidities, developing more detailed diagnostic tools and methods is crucial; nonetheless, it seems that providing better interdisciplinary approaches in general medical practice is groundwork.

Deficient head motor control in functional dizziness: Experimental evidence of central sensory-motor dysfunction in persistent physical symptoms

Understanding the mechanisms of symptoms that are insufficiently explained by organic dysfunction remains challenging. Recently, it has been proposed that such "functional symptoms" are based on erroneous sensory processing in the central nervous system (CNS), with internal expectations dominating sensory inputs. In a pilot study, we used a head motor control set-up to assess the interplay between sensory input and expectation on the example of patients with functional dizziness. Eight patients and 11 age-matched healthy controls performed large active eye-head gaze shifts towards visual targets in the natural situation and with the head moment of inertia 3.3-fold increased. The latter induces head oscillations and the expected sensory outcome of the movement, estimated in the CNS, does not match the actual sensory input. Head oscillations were assessed in patients and in healthy subjects and compared to prior results from patients with organic disease (vestibular loss and cerebellar ataxia). Head oscillations in patients with functional dizziness were different from those of healthy subjects (F(1,17)=27.26, P<0.001, partial η²=0.62), and similar to those of patients with cerebellar ataxia, and with vestibular loss (F(2,19)=0.56, P=0.58). Even in the natural, unweighted, condition, head oscillations were higher in functional dizziness patients than in healthy subjects (P=0.001). Since an extensive work-up failed to demonstrate any explanatory peripheral vestibular, motor, or cerebellar organic dysfunction, these motor control deficits are a first indication of erroneous interplay between expectations and sensory input in the CNS that could account for persistent physical symptoms.

Efficacy of a guided internet-based intervention (iSOMA) for somatic symptoms and related distress in university students: study protocol of a randomised controlled trial

INTRODUCTION

Persistent and distressing somatic symptoms are common in younger age cohorts such as university students. However, the majority does not receive adequate psychosocial care. Internet-based and mobile-based interventions may represent low threshold and effective extensions to reduce somatic and associated mental symptom severity. The planned study aims to investigate the feasibility and efficacy of an internet-based intervention in reducing somatic and psychological symptoms in an international population of university students with somatic symptom burden.

METHODS AND ANALYSIS

This parallel two-armed randomised controlled trial evaluates an 8-week guided intervention, including web-based consecutive modules based on cognitive behavioural therapy (CBT) principles against a waitlist control group. Guidance will be provided by trained psychologists with weekly written supportive feedback. As part of the 'Studicare' project, the present study aims to recruit n=154 university students indicating somatic symptom burden at baseline in German-speaking universities. Self-report assessments will take place at baseline and after intervention completion (8, 16 weeks after randomisation). The primary outcome will be the severity of somatic symptoms and associated mental distress. Secondary outcomes include depression, (health) anxiety, disability, intervention satisfaction and adherence.

ETHICS AND DISSEMINATION

Ethics approval has been granted. Results from this study will be published in peer-reviewed journals and presented at international conferences.

TRIAL REGISTRATION NUMBER

DRKS00014375; Pre-results.

The association between patients' expectations and experiences of task-, affect- and therapy-oriented communication and their anxiety in medically unexplained symptoms consultations

Background

It is unknown whether patients with medically unexplained symptoms (MUS) differ from patients with medically explained symptoms (MES) regarding their expectations and experiences on task‐oriented communication (ie, communication in which the primary focus is on exchanging medical content), affect‐oriented communication (ie, communication in which the primary focus is on the emotional aspects of the interaction) and therapy‐oriented communication (ie, communication in which the primary focus is on therapeutic aspects) of the consultation and the extent to which GPs meet their expectations.

Objective

This study aims to explore (a) differences in patients’ expectations and experiences in consultations with MUS patients and patients with MES and (b) the influence of patients’ experiences in these consultations on their post‐visit anxiety level.

Study design

Prospective cohort.

Setting

Eleven Dutch general practices.

Measurements

Patients completed the QUOTE‐COMM (Quality Of communication Through the patients’ Eyes) questionnaire before and after the consultation to assess their expectations and experiences and these were related to changes in patients’ state anxiety (abbreviated State‐Trait Anxiety Inventory; STAI).

Results

Expectations did not differ between patients with MUS and MES. Patients presenting with either MUS or MES rated their experiences for task‐related and affect‐oriented communication of their GP higher than their expectations. GPs met patients’ expectations less often on task‐oriented communication in MUS patients compared to MES patients (70.2% vs 80.9%; P = ˂0.001). Affect‐oriented communication seems to be most important in reducing the anxiety level of MUS patients (β −0.63, 95% Cl = −1.07 to −0.19).

Discussion

Although the expectations of MUS patients are less often met compared to those of MES patients, GPs often communicate according to patients’ expectations. Experiencing affect‐oriented communication is associated with a stronger reduction in anxiety in patients with MUS than in those with MES.

Conclusion

GPs communicate according to patients’ expectations. However, GPs met patients’ expectations on task‐oriented communication less often in patients with MUS compared to patients with MES. Experiencing affect‐oriented communication had a stronger association with the post‐consultation anxiety for patients with MUS than MES.

Medically unexplained physical symptoms in patients attending a medical outpatient clinic in a tertiary hospital in North India

OBJECTIVE

Medically unexplained physical symptoms (MUPS) are commonly seen across health care settings. Earlier studies have focussed on prevalence, cost-utilization and burden. Data from India is scarce. Patients with persistent MUPS have more impairment and psychological distress. This study was designed to assess psychological morbidity, health anxiety (HA), somatic symptom load, disability, quality of life (QOL) in patients with persistent MUPS presenting to a general medical outpatient service and compare it with patients with medically explained physical symptoms (MEPS).

METHODS

The study was conducted in the outpatient service of the Department of Internal Medicine in a tertiary hospital in North India. Persistent MUPS was defined as physical symptoms of at least 3 months duration leading to dysfunction and with no identifiable medical cause. 70 patients with persistent MUPS and MEPS each were recruited. Psychiatric morbidity was assessed using the Mini International Neuropsychiatric interview, somatic symptom load with Patient Health Questionniare-15 (PHQ-15), HA with Whiteley Index, disability with WHODAS 2.0 and QOL with WHOQOL-Bref.

RESULTS

Both the groups were comparable on socio-demography and length of symptoms. Prevalence of psychiatric disorders and HA was significantly greater in MUPS. Patients with persistent MUPS had significantly more health care utilization, number and burden of somatic symptoms, greater disability and worse QOL.

CONCLUSIONS

Patients with persistent MUPS have a different profile when compared to MEPS. There is a need to screen and identify patients with MUPS and manage them keeping in mind the psychological factors and chronic nature and number of symptoms.

High healthcare utilization near the onset of medically unexplained symptoms

OBJECTIVE

Patients with medically unexplained syndromes (MUS) often do not receive appropriate healthcare. A critical time for effective healthcare is the inception of MUS. The current study examined data from a prospective longitudinal study of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) soldiers to understand the relationship of increasing physical symptom burden to healthcare utilization.

METHODS

Data was examined from a prospective study of OEF/OIF soldiers assessed before and one year after deployment (n=336). Physical symptom burden was measured with the Patient Health Questionnaire (PHQ-15). Analyses were conducted with polynomial regression and response surface analysis (RSA).

RESULTS

Increases in physical symptom burden predicted greater healthcare utilization one year after deployment: primary care practitioner (slope=-0.26, F=4.07, p=0.04), specialist (slope=-0.43, F=8.67, p=0.003), allied health therapy (e.g., physical therapy) (slope=-0.41, F=5.71, p=0.02) and mental health (slope=-0.32, F=4.04, p=0.05). There were no significant difference in utilization between those with consistently high levels and those with increases in physical symptom burden.

CONCLUSION

This is the first prospective study to examine, and show, a relationship between onset of clinically significant physical symptoms and greater healthcare utilization. Our data suggest that patients with increasing physical symptom burden have the same level of healthcare as patients with chronic physical symptom burden. Needed next steps are to better understand the quality of care at inception and determine how to intervene so that recommended approaches to care are provided from the onset.

The Somatic Symptom Disorder - B Criteria Scale (SSD-12): Factorial structure, validity and population-based norms

PURPOSE

The Somatic Symptom Disorder - B Criteria Scale (SSD-12) assesses the psychological features of DSM-5 Somatic Symptom Disorder (SSD). The present study investigates the dimensionality and psychometric properties in a general population sample and provides norm values.

METHOD

Test dimensionality was evaluated via confirmatory factor analysis and nonparametric item response theory. Correlational analyses and logistic regression models based on related measures (SSS 8, PHQ-2, GAD-2, Health Care Utilization) were used to derive predictive validity. Age and gender specific norms were derived via quantile regression.

RESULTS

The SSD-12 has good item characteristics and excellent reliability (Cronbach's α=0.95). Confirmatory factor analyses revealed a high correlation between the three proposed psychological subscales interpreted as cognitive, affective and behavioral aspects, indicating a general factor model of the SSD-12 in the general population (n=2362, CFI=0.99, TLI=0.998, RMSEA=0.09, 90% CI: 0.09-0.1). SSD-12 total sum-score was significantly associated with somatic symptom burden (r=0.73, p<0.001), general anxiety (r=0.63, p<0.001) and depressive symptoms (r=0.64, p<0.001). Patients with a higher SSD-12 symptom burden reported higher general physical and mental health impairment and a significantly higher health care use.

CONCLUSION

The SSD-12 is a reliable and valid self-report measure of the psychological characteristics of DSM-5 Somatic Symptom Disorder. The provided norms enable researchers and clinicians to compare SSD-12 scores with reference values of a general population sample.

Familial liability to psychosis is a risk factor for multimorbidity in people with psychotic disorders and their unaffected siblings

BACKGROUND

Multimorbidity may impose an overwhelming burden on patients with psychosis and is affected by gender and age. Our aim is to study the independent role of familial liability to psychosis as a risk factor for multimorbidity.

METHODS

We performed the study within the framework of the Genetic Risk and Outcome of Psychosis (GROUP) project. Overall, we compared 1024 psychotic patients, 994 unaffected siblings and 566 controls on the prevalence of 125 lifetime diseases, and 19 self-reported somatic complaints. Multimorbidity was defined as the presence of two or more complaints/diseases in the same individual. Generalized linear mixed model (GLMM) were used to investigate the effects of gender, age (adolescent, young, older) and familial liability (patients, siblings, controls) and their interactions on multimorbidity.

RESULTS

Familial liability had a significant effect on multimorbidity of either complaints or diseases. Patients had a higher prevalence of multimorbidity of complaints compared to siblings (OR 2.20, 95% CI 1.79-2.69, P<0.001) and to controls (3.05, 2.35-3.96, P<0.001). In physical health multimorbidity, patients (OR 1.36, 95% CI 1.05-1.75, P=0.018), but not siblings, had significantly higher prevalence than controls. Similar finding were observed for multimorbidity of lifetime diseases, including psychiatric diseases. Significant results were observed for complaints and disease multimorbidity across gender and age groups.

CONCLUSION

Multimorbidity is a common burden, significantly more prevalent in patients and their unaffected siblings. Familial liability to psychosis showed an independent effect on multimorbidity; gender and age are also important factors determining multimorbidity.

Is uncertain vulvovaginal candidiasis a marker of vulvodynia? A study in a Dutch general practice research database

Background

A recent Dutch study in general practice showed a clear relationship between the diagnosis of vulvovaginal candidiasis (VVC) and symptoms suggestive of provoked vulvodynia (PVD). PVD accounts for the largest group of vulvar pains, but is often not recognised by GPs.

Aim

To investigate whether diagnostic uncertainty about VVC in general practice could also point to the diagnosis of PVD, and whether and how this diagnostic uncertainty affects management.

Design & setting

An observational study in 2014 in Dutch general practices of the NIVEL Primary Care Database.

Method

Women with an uncertain diagnosis of VVC were distinguished from those with certain VVC based on the occurrence of recurrent episodes and persisting complaints, despite treatment. Factors known to be associated with PVD were hypothesised to be more prevalent in women with uncertain VVC. Data on symptom management by GPs were collected.

Results

In total 7066 women with VVC or uncertain VVC were included. Uncertain VVC was found to account for 28% of these patients. Compared to VVC, the group uncertain VVC included significantly more women with female genital symptoms, tiredness, irritable bowel syndrome (all P<0.001), feeling anxious, reduced sexual desire, depressive disorder, relationship problems, and micturition symptoms (all P<0.05). Compared to VVC, the group uncertain VVC included significantly higher mean numbers of telephone consultations (P<0.001), more referrals to gynaecology (P = 0.009), and higher mean numbers of prescriptions per patient (P<0.001).

Conclusion

This study's findings indicate that uncertain VVC could be a marker of PVD. GPs might reconsider their diagnostics and management when women present recurrent and persistent vulvovaginal complaints, especially if accompanied by dyspareunia, functional syndromes, micturition symptoms, and psychological conditions.

Functional urological disorders: a sensitized defence response in the bladder-gut-brain axis

Functional urological and gastrointestinal disorders are interrelated and characterized by a chronic course and considerable treatment resistance. Urological disorders associated with a sizeable functional effect include overactive bladder (OAB), interstitial cystitis/bladder pain syndrome (IC/BPS), and chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). Poor treatment outcomes might be attributable to untreated underlying psychological and psychiatric disorders, as the co-occurrence of functional urological and gastrointestinal disorders with mood and anxiety disorders is common. The hypothetical bladder-gut-brain axis (BGBA) is a useful framework under which this interaction can be studied, suggesting that functional disorders represent a sensitized response to earlier threats such as childhood adversity or previous traumatic events, resulting in perceived emotional and bodily distress - the symptoms of functional disorders. Psychological and physical stress pathways might contribute to such alarm falsification, and neuroticism could be a risk factor for the co-occurrence of functional disorders and affective conditions. Additionally, physical threat - either from external sources or internal sources such as infection - might contribute to alarm falsification by influencing body-brain crosstalk on homeostasis and, therefore, affecting mood, cognition, and behaviour. Multidisciplinary research and an integrated care approach is, therefore, required to further elucidate and remediate functional urological and gastrointestinal polymorphic phenotypes.