Somatization in the community: relationship to disability and use of services

Racial/ethnic differences in general physical symptoms and medically unexplained physical symptoms: Investigating the role of education

OBJECTIVES

Distressing physical symptoms (e.g., back pain, nausea), many of which lack medical explanation, are a common cause for medical help seeking. However, racial/ethnic and educational differences may complicate identification and explanation of such symptoms, potentially contributing to clinician misdiagnosis and patient dissatisfaction. To better understand this issue, we examined racial/ethnic differences in general physical symptoms (GPS) and, more specifically, medically unexplained physical symptoms (MUPS) and whether differences varied by race/ethnicity and educational attainment.

METHOD

A sample of 4,864 Latino, Asian, and non-Latino White community respondents (54% female; average age of 41 years) self-reported their GPS. Two experts then rated whether endorsed symptoms were likely to have a medical basis. We assessed the associations of GPS and MUPS with race/ethnicity, age, gender, educational attainment, chronic physical conditions, and past-year psychiatric diagnoses.

RESULTS

Asian respondents reported significantly fewer GPS than non-Latino Whites, and both Asian and Latino respondents endorsed significantly fewer MUPS than non-Latino Whites. When nativity and language were each included as covariates, racial/ethnic differences in GPS count were no longer observed; however, observed differences in MUPS count remained. Educational attainment did not demonstrate a significant relationship with either GPS or MUPS. Although comorbid mental health diagnoses were significantly related to both GPS and MUPS, age, gender, and comorbid physical conditions were the only significant predictors of GPS.

CONCLUSIONS

Results from this study question existing stereotypical views of racial/ethnic differences in somatization and suggest that educational attainment does not significantly contribute to reported physical symptoms-with or without medical explanation. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Frequent attenders in general medical practice in Italy: a preliminary report on clinical variables related to low functioning

BACKGROUND

Frequent attenders (FAs), defined as patients reporting a disproportionate number of visits to general practitioners (GPs), may represent up to one-third of GP patients responsible for a high burden of care not always justified by the severity of the medical condition. The aim of this study was to explore sociodemographic and clinical characteristics of FAs of GP in Italy with particular attention to functional impairment.

METHODS

A total sample of 75 FAs (defined as individuals who had consulted GPs 15 times or more during 2015) of GPs of three primary care centers (Pisa, Livorno, and Lucca) in Italy were enrolled and assessed by sociodemographic scale, Structured Clinical Interview for DSM-5 (SCID-5), global functioning (Global Assessment of Functioning [GAF]), illness behavior and perceived health (Illness Behavior Inventory), and somatic comorbidity (Cumulative Illness Rating Scale).

RESULTS

Most of the sample were females, middle aged, married, or cohabiting, with low levels of education. One-third of FAs was low functioning (LF; GAF score <70), with no differences in the sociodemographic variables. Approximately 70.3% of the patients reported a current SCID diagnosis, in particular, major depressive disorder, somatic symptom disorders, and panic disorder, all being more frequent in LF patients. Half of the patients were taking a psychopharmacological therapy, mostly benzodiazepines (BDZs).

CONCLUSION

Most FAs were female with current medical disorders, and LF. All claimed to be worried about their own health and perceived themselves as more impaired also regarding the health perception and social role. LF patients were, or had been more likely to be under psychopharmacological treatment. FAs seem to constitute a special population that should be carefully evaluated for mental disorders and appropriate treatment.

The association between neck and shoulder discomfort-Katakori-and high somatizing tendency

Objectives: 'Katakori', discomfort or dull pain around the neck and shoulder, is common in Japan. Somatizing tendency is important in the quality of daily living. This study aimed to examine the association between disability due to Katakori and high somatizing tendency.Methods: This internet study included 34,754 Japanese adults who reported Katakori in the past four weeks. Katakori was classified into four grades: 1) no Katakori, 2) Katakori without difficulty in activities for daily living (ADL), 3) Katakori with ADL difficulty but without absence from social activities, and 4) Katakori with absence from social activities. Somatizing tendency was assessed using the Somatic Symptom Scale-8 (SSS-8). The association between a very high (SSS-8 ≥ 16) somatizing tendency and Katakori grade was examined using logistic regression adjusting for age, sex, body mass index, marital status, smoking, regular exercise, low back pain, depression, and the number of chronic conditions.Results: Katakori grade was significantly associated with a very high somatizing tendency (Odds ratio (OR)= 5.36 [4.36-6.60] in grade 4 vs. 2, and OR= 2.57 [2.30-2.89] in grade 3 vs. 2).Conclusion: When treating severe Katakori with disability, somatizing tendency should be assessed to facilitate better management.

Domain-specific associations between disability and depression, anxiety, and somatization in primary care patients

This study explores the associations between different disability domains and the most prevalent symptoms of mental disorders in primary care patients (i.e. depression, anxiety, and somatization). A total of 1241 participants from 28 primary care centres completed self-report measures of depression, anxiety, and somatization. This same sample also completed the Sheehan Disability Scale (SDS) to assess functional impairment in work, social life, and family life domains. Associations between the symptoms and each disability domain were examined using hierarchical regression analyses. Depression emerged as the strongest predictor of all three disability domains. Somatization was associated only with the work domain, and anxiety was associated only with the family life domain. Clinical symptoms explained a greater proportion of the variance than sociodemographic variables. In primary care patients, depression, anxiety and somatizations were associated with distinct domains of disability. Early provision of effective treatments in the primary care setting may be crucial to reduce the societal burden of common mental disorders.

Testing the influence of cultural determinants on help-seeking theory

Despite increased risks for mental health problems, East Asian immigrant women have the lowest overall service-utilization rates of any cultural group in the United States. Although the influence of cultural processes as the cause of low service use is widely speculated, no empirical study has tested cultural determinants (including culturally specific idioms of distress, culture-based illness interpretations, or concerns about social consequences), social contextual factors, perceived need (PN), and help-seeking (HS) behaviors. In the present study, we examined how cultural determinants, such as symptom experience, beliefs and interpretations, and perceptions about the social environment, affect PN and HS type for Japanese women living in the United States. Increasing physical symptom severity increased the predicted probability of endorsing PN. For those participants with PN, 48.6% of them used medical HS (χ2 = 11.27, p = .00), and 12.5% of them used the psychological HS (χ2 = 7.43, p = .01). Multivariate logistic regression revealed that, when PN is considered with the other cultural variables while controlling for structural variables, PN increases the odds of medical HS (OR = 2.78, 95% CI [1.0-5.8], p < .01). The odds of medical HS are also increased with higher social support (OR = 1.07, 95% CI [1.0-1.1], p < .01). Finally, the presence of interpersonal stigma beliefs decreased the odds of medical HS (OR = 2.4, 95% CI [1.1-5.3], p < .03). Clinical and research implications are discussed. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Predictors of Persistent Medically Unexplained Physical Symptoms: Findings From a General Population Study

Objective: To explore the persistency of Medically Unexplained Symptoms (MUS) and its prognostic factors in the general adult population. Knowledge of prognostic factors of MUS may indicate possible avenues for intervention development. Methods: Data were derived from the Netherlands Mental Health Survey and Incidence Study-2 (NEMESIS-2), a nationally representative face-to-face cohort study among the Dutch general population aged 18-64 years. We selected subjects with MUS at baseline and who participated at follow-up (N = 324) and reassessed those subjects for having MUS at 3 year follow-up. Logistic regression analyses were used to determine risk factors for persistency of MUS. Results: 36.4% of the subjects had persistent MUS at follow-up. In logistic regression analyses adjusted for sex and age, persistency of MUS was predicted by the number of comorbid chronic medical disorder(s), lower education, female sex, not having a paid job, parental psychopathology as well as lower functioning. In the logistic regression analysis in which all significant variables adjusted for sex and age were entered simultaneously, three variables predicted persistent MUS: parental psychopathology, the number of comorbid chronic medical disorder(s) and physical functioning, with odds ratios of 2.01 (1.20-3.38), 1.19 (1.01-1.40), and 0.99 (0.97-1.00), respectively. Conclusion: In the adult general population, MUS were persistent in over one third of the subjects with MUS at baseline. Persistency was significantly predicted by parental psychopathology, number of comorbid chronic medical disorders, and physical functioning. These findings warrant further research into early intervention and treatment options for persons with an increased risk of persistent MUS.

Long-Term Outcome of Bodily Distress Syndrome in Primary Care: A Follow-Up Study on Health Care Costs, Work Disability, and Self-Rated Health

OBJECTIVE

The upcoming International Classification of Diseases, 11th Revision for primary care use suggests inclusion of a new diagnostic construct, bodily (di)stress syndrome (BDS), for individuals with medically unexplained symptoms. We aimed to explore the long-term outcome of BDS in health care costs, work disability, and self-rated health.

METHODS

Consecutive patients consulting their family physician for a new health problem were screened for physical and mental symptoms by questionnaires (n = 1785). A stratified subsample was examined with a standardized diagnostic interview (n = 701). Patients with single-organ BDS (n = 124) and multiorgan BDS (n = 35), and a reference group with a family physician-verified medical condition (n = 880) were included. All included patients completed a questionnaire at 3, 12, and 24 months of follow-up. Register data on health care costs and work disability were obtained after 2 and 10 years of follow-up, respectively.

RESULTS

Patients with BDS displayed poorer self-rated health and higher illness worry at index consultation and throughout follow-up than the reference group (p ≤ .001). The annual health care costs were higher in the BDS groups (2270 USD and 4066 USD) than in the reference group (1392 USD) (achieved significance level (ASL) ≤ 0.001). Both BDS groups had higher risk of sick leave during the first 2 years of follow-up (RRsingle-organ BDS = 3.0; 95% confidence interval [CI] = 1.8-5.0; RRmultiorgan BDS = 3.4; 95% CI = 1.5-7.5) and substantially higher risk of newly awarded disability pension than the reference group (HRsingle-organ BDS = 4.9; 95% CI = 2.8-8.4; HRmultiorgan BDS = 8.7; 95% CI = 3.7-20.7).

CONCLUSIONS

Patients with BDS have poor long-term outcome of health care costs, work disability, and subjective suffering. These findings stress the need for adequate recognition and management of BDS.

The prevalence of medical symptoms in military aircrew

Background

The prevalence of medical symptoms in aviators has not been described in the medical literature.

Methods

An anonymous questionnaire was handed to all Israeli Air Force aviators who went through the routine yearly examination. Because only two women filled the questionnaire, we excluded them. The questionnaire contained a list of 49 symptoms and the aviators were asked to mark symptoms that were present in the last month before the examination as well as age, estimated weekly flying hours, military service status (reserve or career) and type of aircraft (jet-fighter, helicopter or transport). A general linear model was used to determine the association between age, weekly flying hours, type of aircraft and type of service with the number of symptoms. Binary logistic regression analyses was used to assess the association of these factors with lack of symptoms, and the top five ranking symptoms.

Results

Data was available for 323 male aviators. 62.5% of the aviators reported at least one symptom in the previous month. 26.9% reported three or more symptoms. 25.1% reported spinal symptoms, 22% respiratory symptoms, 21.4% fatigue, 11.5% headache and 6.5% general weakness. Career service was associated with the number of symptoms, fatigue and general weakness. Age was associated with fatigue and general weakness. Aircraft type and weekly flying hours were not associated with any symptom.

Conclusions

Medical symptoms are prevalent in military aviators. Career personnel report on medical symptoms, especially fatigue, more often than reserve personnel. Further study is warranted to examine this association.

Health care utilization in outpatients with somatoform disorders: Descriptives, interdiagnostic differences, and potential mediating factors

OBJECTIVE

Somatoform disorders are characterized by increased health care utilization producing high health costs. The aim of this study was to assess facets of and interdiagnostic differences in health care use in somatoform disorders and to examine health anxiety, symptom-related disability, depression, and phobic anxiety as potential mediating factors of the relationship between somatization and health care use.

METHOD

An outpatient sample of N=254 patients with somatoform disorders was investigated by analyzing different facets of their health care use over the last 12months. Multiple mediation analyses were applied.

RESULTS

Participants reported a mean of 28.02 doctor visits over the last year. Patients fulfilling criteria of DSM-IV somatization disorder had a significantly higher number of doctor visits than patients with undifferentiated somatoform, and somatoform pain disorder, all p≤.006. In most health care use variables, patients with comorbid mental disorders did not differ from patients without comorbidities. The mediation model on the effect of all mediator variables on the relationship between somatization and health care use reached significance (b=0.32, 95% CI: 0.0576, 0.6435). Surprisingly, specific mediator effects were found for health anxiety (b=0.06, 95% CI: 0.0004, 0.1505) and disability (b=0.18, 95% CI: 0.0389, 0.3530), but not for depression and phobic anxiety.

CONCLUSIONS

Health anxiety and symptom-related disability should be further considered when investigating potential etiological factors of increased health care use.

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.

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

Background

Medically unexplained physical symptoms (MUPS) are highly prevalent and are associated with frequent health care use (HCU). MUPS frequently co-occur with psychiatric disorders. With this study we examined the longitudinal association between MUPS and HCU over 2 years and the influence of depressive and anxiety disorders and personality traits on this association.

Methods

We analysed follow-up data from 2045 to 2981 participants from the Netherlands Study of Depression and Anxiety (NESDA), a multisite cohort study. The study population included participants with a current depressive and/or anxiety disorder, participants with a lifetime risk and/or subthreshold symptoms for depressive and/or anxiety disorders and healthy controls. HCU, measured with the Trimbos and iMTA questionnaire on Costs associated with Psychiatric illness (TIC-P), was operationalized as the number of used medical services and the number of associated contacts. MUPS were measured with the Four Dimensional Symptoms Questionnaire, depressive and anxiety disorders with the Composite International Diagnostic Interview and personality traits with the NEO Five-Factory Inventory. Measurements were taken at baseline, 1 and 2 years follow-up. We used generalized estimating equations (GEE), using HCU at all three measurements as (multivariate) outcome. GEE also takes into account the dependency of observations within participants.

Results

MUPS were positively associated with HCU over 2 years (medical services: RR 1.020, 95 % CI 1.017–1.022; contacts: RR 1.037, 95 % CI 1.030–1.044). Neuroticism and depression had the strongest influence on the associations. After adjustment for these factors, the associations between MUPS and HCU weakened, but remained significant (services: RR 1.011, 95 % CI 1.008–1.014; contacts: RR 1.023, 95 % CI 1.015–1.032).

Conclusions

Our results show that MUPS were positively associated with HCU over 2 years, even after adjusting for depressive and anxiety disorders and personality traits.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1332-7) contains supplementary material, which is available to authorized users.

Abnormal default-mode network homogeneity and its correlations with personality in drug-naive somatization disorder at rest

BACKGROUND

While the default-mode network (DMN) appears to play a crucial role in patients suffering from somatization disorder (SD), the abnormalities of the network homogeneity (NH) of the DMN in SD patients have been poorly explored. The aim of this study is to examine DMN NH using an NH approach in patients suffering from SD at rest and determine its correlations with personality as measured by the Eysenck Personality Questionnaire (EPQ).

METHODS

A total of 25 drug-naive patients with SD and 28 sex-, age-, and education-matched healthy controls underwent functional magnetic resonance imaging scans at rest. The data were analyzed by an automated NH method.

RESULTS

Patients showed increased NH in the left superior frontal gyrus and decreased NH in the bilateral precuneus. Moreover, a significantly negative correlation was observed between the NH values in the bilateral precuneus and the EPQ--Neuroticism scores.

LIMITATIONS

The present study should be considered preliminary due to a lenient, uncorrected threshold of p<0.01.

CONCLUSIONS

The results suggest that abnormal DMN NH exists in drug-naive SD and further highlight the importance of the DMN in the pathophysiology of SD.

The association between somatization and disability in primary care patients

BACKGROUND

Patient encounters for medically unexplained physical symptoms are common in primary health care. Somatization ('experiencing and reporting unexplained somatic symptoms') may indicate concurrent or future disability but this may also partly be caused by psychiatric disorders. The aim of this study was to examine the cross-sectional and longitudinal association between somatization and disability in primary care patients with and without anxiety or depressive disorder.

METHODS

Data were obtained from 1545 primary care patients, participating in the longitudinal Netherlands Study of Depression and Anxiety (NESDA). Somatization was assessed using the somatization scale of the Four-Dimensional Symptom Questionnaire (4DSQ). Disability was determined by the WHO Disability Assessment Schedule 2.0 (WHO-DAS II). The relationships between somatization and both the total and subdomain scores of the WHO-DAS II were measured cross-sectionally and longitudinally after one year of follow-up using linear regression analysis. We examined whether anxiety or depressive disorder exerted a modifying effect on the somatization-disability association.

RESULTS

Cross-sectionally and longitudinally, somatization was significantly associated with disability. Somatization accounted cross-sectionally for 41.8% of the variance in WHO-DAS disability and, longitudinally, for 31.7% of the variance in disability after one year of follow-up. The unique contribution of somatization to disability decreased to 16.7% cross-sectionally and 15.7% longitudinally, when anxiety and/or depressive disorder was added to the model.

CONCLUSION

Somatization contributes to the presence of disability in primary care patients, even when the effects of baseline demographic and health characteristics and anxiety or depressive disorder are taken into account.

Electroconvulsive therapy treatment in patients with somatic symptom and related disorders

OBJECTIVE

Medically unexplained somatic complaints are highly prevalent, and lead to significant impairment and disability. The number of effective treatment modalities for somatic symptom and related disorders (SSDs) or somatoform disorders (SDs) remains limited. To date, there is no formal indication for electroconvulsive therapy (ECT) in SSD or SD. We report on the largest case series to date regarding the effectiveness of ECT in patients with SSD and SD.

METHODS

A retrospective chart review of all patients treated with an index course of ECT at the Neuropsychiatric Program at the University of British Columbia Hospital from 2000 to 2010 was conducted. The primary outcomes consisted of changes in pseudoneurologic symptoms, pain symptoms, cardiopulmonary symptoms, and gastrointestinal symptoms. Complaints were examined pre- and post-ECT.

RESULTS

Twenty-eight participants were included in this study. Twenty-one participants received right unilateral ECT. Six received bifrontal ECT. One received bitemporal ECT. Eighteen of 21 participants reported improvement in pseudoneurologic symptoms; eleven of 14 participants reported improvement in pain symptoms; one participant reported improvement in cardiopulmonary symptoms; and one of two participants reported improvement in gastrointestinal symptoms. This paper discusses the putative mechanism of action of ECT in the treatment of SD/SSD.

CONCLUSION

This retrospective study suggests that ECT could be included as part of the existing treatment for refractory SSD and SD, particularly in refractory cases with comorbid mood disorders.

Does Integrated Behavioral Health Care Reduce Mental Health Disparities for Latinos? Initial Findings

Integrated behavioral health care (IBHC) is a model of mental health care service delivery that seeks to reduce stigma and service utilization barriers by embedding mental health professionals into the primary care team. This study explored whether IBHC service referrals, utilization, and outcomes were comparable for Latinos and non-Latino White primary care patients. Data for the current study were collected from 793 consecutive patients (63.8% Latino; M age = 29.02 years [SD = 17.96]; 35.1% under 18 years; 65.3% women; 54.3% uninsured) seen for behavioral health services in 2 primary care clinics during a 10.5 month period. The most common presenting concerns were depression (21.6%), anxiety (18.5%), adjustment disorder (13.0%), and externalizing behavior problems (9.8%). Results revealed that while Latino patients had significantly lower self-reported psychiatric distress, significantly higher clinician-assigned global assessment of functioning scores, and fewer received a psychiatric diagnosis at their initial visit compared to non-Latino White patients, both groups had comparable utilization rates, comparable and clinically significant improvements in symptoms (Cohen's d values > .50), and expressed high satisfaction with integrated behavioral services. These data provide preliminary evidence suggesting integration of behavioral health services into primary care clinics may help reduce mental health disparities for Latinos.

A randomized trial of treatments for high-utilizing somatizing patients

BACKGROUND

Somatization and hypochondriacal health anxiety are common sources of distress, impairment, and costly medical utilization in primary care practice. A range of interventions is needed to improve the care of these patients.

OBJECTIVE

To determine the effectiveness of two cognitive behavioral interventions for high-utilizing, somatizing patients, using the resources found in a routine care setting.

DESIGN

Patients were randomly assigned to a two-step cognitive behavioral treatment program accompanied by a training seminar for their primary care physicians, or to relaxation training. Providers routinely working in these patients' primary care practices delivered the cognitive behavior therapy and relaxation training. A follow-up assessment was completed immediately prior to treatment and 6 and 12 months later.

SUBJECTS

Eighty-nine medical outpatients with elevated levels of somatization, hypochondriacal health anxiety, and medical care utilization.

MEASUREMENTS

Somatization and hypochondriasis, overall psychiatric distress, and role impairment were assessed with well-validated, self-report questionnaires. Outpatient visits and medical care costs before and after the intervention were obtained from the encounter claims database.

RESULTS

At 6 month and 12 month follow-up, both intervention groups showed significant improvements in somatization (p < 0.01), hypochondriacal symptoms (p < 0.01), overall psychiatric distress (p < 0.01), and role impairment (p < 0.01). Outcomes did not differ significantly between the two groups. When both groups were combined, ambulatory visits declined from 10.3 to 8.8 (p = 0.036), and mean ambulatory costs decreased from $3,574 to $2,991 (pp = 0.028) in the year preceding versus the year following the interventions. Psychiatric visits and costs were unchanged.

CONCLUSIONS

Two similar cognitive behavioral interventions, delivered with the resources available in routine primary care, improved somatization, hypochondriacal symptoms, overall psychiatric distress, and role function. They also reduced the ambulatory visits and costs of these high utilizing outpatients.

The trade-off between costs and quality of care in the treatment of psychosomatic patients with somatoform pain disorder

BACKGROUND

The introduction of efficiency-oriented provider payment systems in inpatient mental healthcare in various Western countries may lead to the use of less healthcare resources in the treatment of patients. To avoid unintended effects on quality of care that may result from reductions in resource utilization, it is essential for decision and policy makers to know whether there is a trade-off between costs and quality of care.

AIM OF THE STUDY

The aim of this study was to investigate and quantify the relationship between costs and outcomes in psychosomatic inpatients with somatoform pain disorder.

METHODS

The inclusion criteria for patient selection (n = 101) were (i) a main diagnosis of somatoform pain disorder according to International Classification of Diseases-10 (ICD-10) [F45.4, F45.40, F45.41]; (ii) complete data on the mental component summary reflecting overall functioning of mental health (MCS-8) measured with the Short Form-8 Health Survey (SF-8) within 3 days of the admission and discharge dates; and (iii) treatment at Charité Universitaetsmedizin (Berlin, Germany) during the period January 2006-June 2010. The change in the MCS-8 score incurred over the treatment period was used as an indicator of quality of care. Treatment costs were calculated from the provider's perspective, mainly using bottom-up micro-costing. The year of valuation for cost calculation was 2008 (with no inflation adjustment); for costs provided by the accounting department for services consumed by the patient, the valuation year was based on the year of service provision. We hypothesized that the outcome 'change in MCS-8 score' was a function of the independent variable costs, patient characteristics, socio-demographic variables, pain-related variables, co-morbidities and subjective illness attribution, i.e. whether patients attributed the origin of pain mainly to a somatic cause or not. An interaction term between costs and illness attribution was included to control for the hypothesized differing effects of resource input or costs on the outcome variable conditional on patients' illness attribution. Hausman tests indicated that endogeneity was not present, thus, ordinary least squares regression (OLS) was conducted. We assessed whether the change in the MCS-8 score was clinically meaningful and perceptible by the patient, using the minimal clinical important difference (MCID). For Short Form Health Surveys, the MCID for changes in the mental component summary is typically around 3 points.

RESULTS

We found a trade-off between costs and outcome for patients without or with only minor somatic illness attribution (77 % of the sample). This patient group improved 0.4 points in outcome after every 100 <euro> increase in total costs per case (F 1,77 = 13.836, t(77) = 3.72, p = 0.0004). For patients with mainly somatic illness beliefs (23 % of the sample), we did not find a trade-off between costs and outcome.

CONCLUSION

For the majority of patients, we found a trade-off between costs and health outcome, thus, it seems advisable to carefully monitor outcome parameters when applying cost containment measures.

What do patients with medically unexplained physical symptoms (MUPS) think? A qualitative study

Context Medically unexplained physical symptoms (MUPS) are frequently encountered in family medicine, and lead to disability, discomfort, medicalisation, iatrogenesis and economic costs. They cause professionals to feel insecure and frustrated and patients to feel dissatisfied and misunderstood. Doctors seek answers for rather than with the patient. Objectives This study aimed to explore patients' explanations of the medically unexplained physical symptoms that they were experiencing by eliciting their own explanations for their complaints, their associated fears, their expectations of the consultation, changes in their ideas of causality, and the therapeutic approach that they considered would be useful. Methodology A qualitative analysis was under-taken of interviews with 15 patients with MUPS in a family medicine unit, 6 months after diagnosis. Results Experience is crucial in construction of the meaning of symptoms and illness behaviour. Many patients identify psychosocial causes under-lying their suffering. These patients received more medication and fewer requests for diagnostic examinations than they had expected. Normalisation is a common behaviour in the clinical approach. Normalisation without explanation can be effective if an effective therapeutic relationship exists that may dispense with the need for words. Listening is the procedure most valued by patients. Diagnostic tests may denote interest in patients' problems. The clinician's flexibility should allow adaptation to the patient's phases of acceptance of the significance of their physical, emotional and social problems. Conclusion Patients with MUPS have explanations and fears associated with their complaints. The patient comes to the consultation not because of the symptom, but because of what he or she thinks about the symptom. The therapeutic relationship, therapeutic listening, and flexibility should be the basis for approaching patients with MUPS. Patients do not always expect medication, although it is what they most often receive. Diagnostic tests, although used sparingly, can be a way to maintain and build a relationship. Drugs and tests can be a ritual statement of clinical interest in the patient and their symptoms.

Cognitive behavioral therapy for PTSD and somatization: an open trial

No treatment, to date, has been developed to improve both posttraumatic stress disorder (PTSD) and medically unexplained physical symptoms (MUPS), despite mounting evidence of high comorbidity between PTSD and MUPS. This study assessed the feasibility, acceptability, and treatment outcomes of an adapted cognitive behavioral therapy for PTSD and abridged somatization in a sample of eight participants. Fifteen percent of completers did not meet PTSD criteria after treatment completion and 62.5% improved their somatic symptoms. There was a significant difference between pre- and post-treatment depression symptoms, as well as in psychological and physical functioning measures. Results indicated a small to moderate effect size (d = 0.27-0.78) in PTSD severity scores, and moderate to large effect size in depression symptoms and psychosocial and physical functioning variables (d = 0.39-1.12). Preliminary evidence of acceptability indicates that the current CBT intervention may be suitable for Latinos individuals with PTSD and MUPS.

Somatic symptoms in consultation-liaison psychiatry

In medically ill patients the term 'somatic symptoms' is used to understand those symptoms which cannot be fully understood in the light of existing medical illness(es). These include a number of physical symptoms and also certain clinical syndromes such as irritable bowel syndrome, fibromyalgia, and chronic fatigue syndrome among others. However, it is increasingly recognized that such patients have larger degrees of psychological morbidities, especially depressive and anxiety disorders, and have disproportionately elevated rates of medical care utilization, including outpatient visits, hospitalizations and total healthcare costs. In view of this psychological morbidity, significant distress and functional impairment, the role of the consultation-liaison psychiatrist is prominent in the management of these patients. A consultation-liaison (CL) psychiatrist is expected to be part of the primary care team to manage patient with unexplained SS, and at the same time is expected to guide colleagues to practice a patient-centred approach to improve the outcome of patients with such symptoms. The clinical work of a CL psychiatrist involves evaluation of patients with medically unexplained symptoms for probable psychiatric disorders and treatment of psychiatric morbidity and also management of patients without psychiatric morbidity. Management strategies include reattribution, cognitive behaviour therapy and antidepressants, with each strategy showing varying degrees of success.

Desired mental health resources for urban, ethnically diverse, impoverished women struggling with anxiety and depression

Depression and anxiety are mental health issues that disproportionately affect women-particularly when access to culturally sensitive care is limited. The purpose of this study was to identify mental health concerns in three urban, ethnically diverse, underserved, and impoverished neighborhoods using the ideological perspective of community-based participatory research. In the context of long-term partnerships between a department of nursing and these neighborhoods, we recruited 61 women aged 18 to 69 years and collected data via homogeneous focus groups comprised of Black, Hispanic, and White women, respectively. We conducted five of the focus groups in English and one in Spanish. The women perceived anxiety and depression as significant concerns for themselves, their families, and their communities. They used unique community resources to manage mental health issues and desired new resources, including support groups and education.

Health care use by patients with somatoform disorders: a register-based follow-up study

OBJECTIVE

Studies have shown a greater use of medical than mental health services in patients with somatoform disorders. However, not many studies are based on structured interviews and include the entire somatoform spectrum of diagnoses. We conducted a register-based case-control study to investigate medical care use prior to and three years after diagnosis in patients with somatoform disorders.

METHODS

We included 380 patients with somatoform diagnoses (SCID-NP for DSM-IIIR) in a case-control study and compared them with 174 patients with anxiety disorders and 5540 controls from the background population. Data from the Danish National Registers were used to assess health care use in both primary and secondary care.

RESULTS

Somatoform patients incurred 2.11 (2.09-2.12) times the primary care visits of controls. They had 3.12 (3.08-3.16) times as many somatic bed-days than controls and 3.94 (3.91-3.97) as many psychiatric bed-days. Primary care use remained stable 3 years after diagnosis (p = 0.14) and the award of disability pension (p = 0.82). However, the number of somatic admissions decreased from 5.64 to 2.76 (p = 0.0004) 3 years after diagnosis. Somatization had an independent effect on health care use when controlling for psychiatric comorbidity.

CONCLUSIONS

Patients with somatoform disorders make significantly greater use of health care services than do controls and patients with anxiety. Somatoform patients made more use of psychiatric services than expected. The use of somatic health care was independent of psychiatric comorbidity. Primary care use and disability pension award were not influenced by proper diagnosing of somatoform disorders whereas number of somatic admissions were halved.

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.

Symptoms of depression in a Hispanic primary care population with and without chronic medical illnesses

OBJECTIVE

To describe somatic and psychiatric symptoms reported by Hispanic primary care patients with and without depression and/or chronic medical illnesses.

METHOD

Adult Hispanic patients (n = 104) in a Mobile Health Program in underserved southern Arizona participated in a survey conducted between September 2006 and February 2007 to obtain information about the somatic and psychiatric symptoms that they were experiencing. They were asked to rate the severity of their symptoms listed in the depression screen Personal Health Questionnaire-9 (PHQ-9), the Symptom Checklist-90-Revised (SCL-90-R), and 5 new symptoms described by patients in focus groups conducted in the first phase of the project. Patients were categorized as depressed if their PHQ-9 scores were 10 or above, and they were further categorized as having or not having chronic illnesses based on self-report. Analyses of variance were conducted for each SCL-90-R symptom dimension to compare across the 4 groups (group 1: not depressed and not medically ill; group 2: medically ill but not depressed; group 3: depressed but not medically ill; and group 4: depressed and medically ill).

RESULTS

Patients with chronic medical illnesses comorbid with depression were found to report significantly more somatic symptoms than those with only chronic medical illnesses or depression alone (P ≤ .001). They also reported significantly more psychopathology than patients with depression alone (P ≤ .05 or better).

CONCLUSIONS

Patients with medical illnesses comorbid with depression are more likely to exhibit psychopathology than patients with medical illnesses or depression alone.

Daily physical complaints and hippocampal function: an fMRI study of pain modulation by anxiety

Pain is a popular physical complaint in human. It is known that experimental anxiety modulates pain processing through hippocampal amplification, whereas it is not known whether a similar experimental reaction is related to daily physical complaints known as 'somatization'. The purpose of this study is to investigate the neural correlates of pain modulation induced by anxiety, particularly in the hippocampus, and how individual differences in this neural reaction relate to somatization. We measured neural response to noxious electrical stimulations, as well as the response to the preceding visual anticipatory cues (which induced low anxiety or high anxiety), by functional magnetic resonance imaging (fMRI). Individual daily physical symptoms were assessed by using the somatization subscale of the Symptom Checklist 90 revised (SCL-90-R). Correlation coefficients between the neural activations and the somatization scores were calculated. We found that manifestation of daily physical symptoms was related to smaller differences in hippocampus activation between high and low anxiety states, suggesting that the ability of the hippocampus to distinguish anxiety states was weakened by the chronic condition that caused the daily physical symptoms. The proper inhibition of neural activation in low anxiety states in the hippocampus and the anterior insula was observed to occur in companionship with lower daily physical complaints. These findings indicate that anxiety's alteration of the network that includes the hippocampus and that is associated with pain modulation underlies the manifestation of somatization.

Prevalence of physical symptoms and their association with race/ethnicity and acculturation in the United States

OBJECTIVE

Physical symptoms are common and a leading reason for primary care visits; however, data are lacking on their prevalence among racial/ethnic minorities in the United States. This study aimed to compare the prevalence of physical symptoms among White, Latino and Asian Americans, and examine the association of symptoms and acculturation.

METHODS

We analyzed data from the National Latino and Asian American Study, a nationally representative survey of 4864 White, Latino and Asian American adults. We compared the age- and gender-adjusted prevalence of 14 physical symptoms among the racial/ethnic groups and estimated the association between indicators of acculturation (English proficiency, nativity, generational status and proportion of lifetime in the United States) and symptoms among Latino and Asian Americans.

RESULTS

After adjusting for age and gender, the mean number of symptoms was similar for Whites (1.00) and Latinos (0.95) but significantly lower among Asian Americans (0.60, P<.01 versus Whites). Similar percentages of Whites (15.4%) and Latinos (13.0%) reported three or more symptoms, whereas significantly fewer Asian Americans (7.7%, P<.05 versus Whites) did. In models adjusted for sociodemographic variables and clinical status (psychological distress, medical conditions and disability), acculturation was significantly associated with physical symptoms among both Latino and Asian Americans, such that the most acculturated individuals had the most physical symptoms.

CONCLUSIONS

The prevalence of physical symptoms differs across racial/ethnic groups, with Asian Americans reporting fewer symptoms than Whites. Consistent with a "healthy immigrant" effect, increased acculturation was strongly associated with greater symptom burden among both Latino and Asian Americans.

Associations of physical symptoms with perceived need for and use of mental health services among Latino and Asian Americans

Although many believe that low rates of perceived mental health need and service use among racial/ethnic minorities are due, in part, to somatization, data supporting this notion are lacking. This study examined two hypotheses: (1) increased physical symptoms are associated with lower perceived need for mental health services and actual service use; and (2) physical symptoms are most strongly associated with perceived mental health need and service use among first-generation individuals. Data come from the National Latino and Asian-American Study, a nationally-representative household survey in the United States conducted from 2002 to 2003. Participants reported on the presence of fourteen physical symptoms within the past year. Perceived mental health need was present for individuals who endorsed having an emotional or substance use problem or thinking they needed treatment for such a problem within the past year. After adjusting for sociodemographic and clinical covariates, the number of physical symptoms was positively associated with perceived mental health need and service, an effect that differed by generation. Among first-generation individuals, physical symptoms were associated with increased perceived need and service use. Physical symptoms were not significantly associated with perceived need or service use among third-generation Latinos, but were associated with service use among third-generation Asian-Americans. Physical symptoms do not appear to interfere with mental health problem recognition or service use. In contrast, individuals, especially of the first-generation, with more physical symptoms were more likely to perceive need for and utilize mental health services. Our findings do not support the notion that physical symptoms account for low rates of perceived mental health need and service use among Latino and Asian-Americans.

Evaluating new proposals for the psychiatric classification of patients with multiple somatic symptoms

OBJECTIVES

The current DSM-IV classification of somatoform disorders has been criticized, and several new proposals for classification have been suggested (e.g., DSM-V work group: complex somatic symptom disorder [CSSD]). Our aim was to empirically validate and compare new proposals for the classification of people with multiple somatic complaints.

METHODS

Three hundred twenty-one participants were selected from a general population sample of more than 2500; half were selected from a subgroup with increased somatization scores (Patient Health Questionnaire 15-item somatic symptom subscale). Clinical and psychological variables and health care use were assessed with interviews and self-ratings to validate the new proposals. In addition, a high-risk group was defined to check whether new classification proposals could identify people in this a priori defined group; criteria for this high-risk group were disabling medically unexplained somatic symptoms and increased health care use. To analyze the stability of the syndromes, participants were recontacted 1 year later (completion rate, 76%).

RESULTS

The DSM-V proposal for CSSD shows good validity in the identification of people with disability and people requiring medical treatment. It is still restrictive but to a much lesser degree than the current somatization disorder: 29% of our a priori high-risk group was identified, whereas none of the participants fulfilled criteria for somatization disorder. For most proposals, the temporal stability is satisfactory yet substantially lower than expected for clinical samples. Classification criteria that include psychological features are advantageous in identifying people with health care needs.

CONCLUSIONS

Whereas some validation criteria for the new proposals (including CSSD) are satisfactory, most of the new proposals are still restrictive.

The relationship between cognitive functions, somatization and behavioural coping in patients with multiple functional somatic symptoms

BACKGROUND AND AIMS

Patients with multiple functional somatic symptoms (MFS) often express cognitive complaints. The aim of this descriptive study was to investigate whether these patients have cognitive deficits and whether the patients' cognitive functioning relates to their experience of physical and psychological distress and to their use of pain-related coping strategies.

METHODS

Neuropsychological assessment of verbal ability, psychomotor speed, attention, working memory, perceptual organization and memory, was conducted on 22 MFS patients and 27 healthy age- and gender-matched controls. Psychological distress, health anxiety, health status and pain coping were measured with questionnaires [Symptom Checklist 90-Revised (SCL-somatization, SCL-depression, SCL-anxiety), the Whiteley-7 scale, the Short Form (SF-36) and the Coping Strategies Questionnaire (CSQ)].

RESULTS

For patients, a high score on the SCL-somatization subscale was associated with poor performance on tests of attention and psychomotor speed, and with a high score on the coping scale Increasing behavioural activities. A high score on this coping scale was associated with poor performance on tests of verbal ability and executive functioning. After controlling for years of education, controls performed significantly better than patients on verbal as well as performance IQ scales but not on tests of memory.

CONCLUSION

In the present study, we found that physical complaints are related to deficits in attention and psychomotor speed. Moreover, our results suggest that poor verbal skills may play a role in the development of MFS because of an increased tendency to apply behavioural/avoidant coping strategies. We suggest that treatment of MFS should involve training of attention as well as practicing the use of cognitive coping strategies.

Distress and psychosocial needs of a heterogeneous high risk familial cancer population

In order to assess the levels of distress and psychosocial support needs of a high risk population, we undertook a study to look at both the objective and subjective levels of distress and the wants and needs of individuals from a high familial cancer risk population. Three hundred and eighteen individuals (160 affected, 158 unaffected) completed several distress and psychosocial needs questionnaires (including the Brief Symptom Inventory-18). Sixty key informants were also surveyed about their perspective on the support needs of this population. In the largely female (90%), largely HBOC syndrome group (approximately 90%), 20% had significant levels of generalized distress, with no significant differences between affected and unaffected individuals. Generalized distress was also not significantly different as a function of mutation status. Individuals who received inconclusive test results, however, were more likely to indicate somatic symptoms of distress. Those individuals who did not have social support were more likely to be those who had never had cancer and who either had a mutation, received inconclusive test results, or were not tested. Key informants were most likely to indicate that patients need more support. These results provide evidence for the importance of establishing regular psychosocial distress screening, including a focus on somatic symptoms, in such high risk populations.

Neurocognitive functioning in women presenting with undifferentiated somatoform disorders in Oman

AIM

There is a dearth of research from non-Western populations focusing on neurocognitive functioning in patients presenting with undifferentiated somatoform disorders. The aim of the present quest is to examine the presence of cognitive impairment and other health-related parameters among attendees at psychiatric settings in Oman, an Arab/Islamic country, with a diagnosis of undifferentiated somatoform disorder.

METHOD

In order to compare the performance of patients diagnosed with undifferentiated somatoform disorder (n = 20) and normal healthy subjects (n = 18) on indices of attention and concentration, tests of executive functioning, mood, somatization and vegetative functioning were carried out.

RESULTS

The performance of patients with undifferentiated somatoform disorder differed from that of normal healthy subjects on the presently operationalized indices of working memory and executive functioning, anxiety, quality of sleep and psychosomatically expressed psychological distress.

CONCLUSION

To our knowledge, this is the first study highlighting neurocognitive functioning in patients with undifferentiated somatoform disorders from a non-Western population. This type of study has the potential of shedding light on the covariates of such a debilitating and intransigent condition as undifferentiated somatoform disorder.

Assessment and further development of RDC/TMD Axis II biobehavioural instruments: a research programme progress report

A symposium was held in Toronto, 2008, in which research progress regarding the biobehavioural dimension of the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) was presented. An extended workshop was held in April 2009 in which further recommendations were made from an expert panel, using the 2008 symposium material as a base. This paper is a summary of the 2008 symposium proceedings with elaborations based on further developments. Seven studies were conducted between 2001 and 2008, in which the following were investigated: (i) basic properties of Axis II instruments, (ii) reliability and criterion validity of Axis II instruments, (iii) expansion of predictors, (iv) metric equivalence of the depression and non-specific physical symptoms subscales in the RDC/TMD, (v) laboratory investigation of oral behaviours, (vi) field data collection of oral behaviours, and (vii) functional limitation of the jaw. Methods and results for each of these studies are described. Based on the results of these studies that have been published, as well as the direction of interim results from the few studies that await completion and publication, the biobehavioural domain of the RDC/TMD, as published in 1992, is reliable and valid. These results also provide strong evidence supporting the future growth of the biobehavioural domain as the RDC/TMD matures into subsequent protocols for both clinical and research applications.

Cognitive behavioral therapy for somatoform disorders

Patients presenting with somatoform disorders often incur excessive health care charges and fail to respond to standard treatment. The purpose of this article is to provide an overview of the diagnostic criteria and demographic and clinical characteristics of each somatoform disorder and to examine the research assessing the efficacy of cognitive behavioral therapy (CBT) for each disorder. The review shows that CBT has received some empirical support for somatization, hypochondriasis, and body dysmorphic disorder. However, there are few data on the impact of treatment on health care use, especially when the cost of CBT is factored into the equation. Too few methodologically sound studies have been published on the treatment of conversion disorder or of pain disorder to make any conclusions.

Whether medically unexplained or not, three or more concurrent somatic symptoms predict psychopathology and service use in community populations

OBJECTIVES

To examine the frequency of somatic symptoms in a community population of various ethnic backgrounds and to identify correlates of these symptoms such as psychopathology, use of services, and personal distress.

METHODS

Using a 14-symptom inventory with interviewer probes for somatic symptoms, we determined the presence of general physical symptoms (GPS) in a sample of 4864 white, Latino, and Asian US community respondents. Medically "edited" verbatim interview responses were used to decide whether or not physical symptoms would qualify as medically unexplained physical symptoms (MUPS). We then assessed the association between GPS and MUPS and psychiatric disorders, psychological distress, and use of services, in both unadjusted and multivariate regression analyses.

RESULTS

One-third (33.6%) of the respondents reported at least one GPS and 11.1% reported at least one MUPS within the last year. 10.7% of respondents had three or more GPS and 1.5% had three or more MUPS. Three or more GPS and MUPS were positively associated with depressive, anxiety, and substance use disorders; service use; and psychological distress in unadjusted comparisons. In multivariate regressions, GPS persisted as a significant predictor, but there was no significant independent effect of MUPS, after controlling for GPS and other covariates.

CONCLUSIONS

Regardless of the presence or absence of medical explanations, physical symptoms are an important component of common mental disorders such as depression and anxiety and predict service use in community populations. These results suggest that three or more current GPS can be used to designate a "case" and that detailed probes and procedures aimed at determining whether or not physical symptoms are medically unexplained may not be necessary for classification purposes.

The contribution of high levels of somatic symptom severity to sickness absence duration, disability and discharge

INTRODUCTION

The primary objectives were to compare the duration of sickness absence in employees with high levels of somatic symptom severity (HLSSS) with employees with lower levels of somatic symptom severity, and to establish the long-term outcomes concerning return to work (RTW), disability and discharge. Secondary objective was to evaluate determinants of the duration of sickness absence in employees with HLSSS.

METHODS

489 sick-listed employees registered with five Occupational Health Physician (OHP) group practices were included in this study. We measured their baseline scores for somatic symptoms severity, depressive disorders, anxiety disorders, health anxiety, distress and functional impairment. The OHPs filled in a questionnaire on their diagnosis. A prospective 2-year follow-up was carried out to assess the long-term outcomes concerning sickness absence, and retrospective information was gathered with regard to sickness absence during the 12 months before the employees were sick-listed.

RESULTS

The median duration of sickness absence was 78 days longer for employees with HLSSS. They more often remained disabled and were discharged more often, especially due to problems in the relationship between the employer and the employee. HLSSS, health anxiety and older age contributed to a longer duration of sickness absence of employees.

CONCLUSION

High levels of somatic symptom severity are a determinant of prolonged sickness absence, enduring disabilities and health-related job loss. Occupational health physicians should identify employees who are at risk and adhere to guidelines for medically unexplained somatic symptoms.

Towards positive diagnostic criteria: a systematic review of somatoform disorder diagnoses and suggestions for future classification

OBJECTIVES

The classification of somatoform disorders is currently being revised in order to improve its validity for the DSM-V and ICD-11. In this article, we compare the validity and clinical utility of current and several new diagnostic proposals of those somatoform disorders that focus on medically unexplained somatic symptoms.

METHODS

We searched the Medline, PsycInfo, and Cochrane databases, as well as relevant reference lists. We included review papers and original articles on the subject of somatoform classification in general, subtypes of validity of the diagnoses, or single diagnostic criteria.

RESULTS

Of all diagnostic proposals, only complex somatic symptom disorder and the Conceptual Issues in Somatoform and Similar Disorders (CISSD) example criteria reflect all dimensions of current biopsychosocial models of somatization (construct validity) and go beyond somatic symptom counts by including psychological and behavioral symptoms that are specific to somatization (descriptive validity). Predictive validity of most of the diagnostic proposals has not yet been investigated. However, the number of somatic symptoms has been found to be a strong predictor of disability. Some evidence indicates that psychological symptoms can predict disease course and treatment outcome (e.g., therapeutic modification of catastrophizing is associated with positive outcome). Lengthy symptom lists, the requirement of lifetime symptom report (as in abridged somatization), complicated symptom patterns (as in current somatization disorder), and imprecise definitions of diagnostic procedures (e.g., missing symptom threshold in complex somatic symptom disorder) reduce clinical utility.

CONCLUSION

Results from the reviewed studies suggest that, of all current and new diagnostic suggestions, complex somatic symptom disorder and the CISSD definition appear to have advantages regarding validity and clinical utility. The integration of psychological and behavioral criteria could enhance construct and descriptive validity, and confers prospectively relevant treatment implications. The incorporation of a dimensional approach that reflects both somatic and psychological symptom severity also has the potential to improve predictive validity and clinical utility.

The outcome of health anxiety in primary care. A two-year follow-up study on health care costs and self-rated health

Background

Hypochondriasis is prevalent in primary care, but the diagnosis is hampered by its stigmatizing label and lack of valid diagnostic criteria. Recently, new empirically established criteria for Health anxiety were introduced. Little is known about Health anxiety's impact on longitudinal outcome, and this study aimed to examine impact on self-rated health and health care costs.

Methodology/Principal Findings

1785 consecutive primary care patients aged 18–65 consulting their family physicians (FPs) for a new illness were followed-up for two years. A stratified subsample of 701 patients was assessed by the Schedules for Clinical Assessment in Neuropsychiatry interview. Patients with mild (N = 21) and severe Health anxiety (N = 81) and Hypochondriasis according to the DSM-IV (N = 59) were compared with a comparison group of patients who had a well-defined medical condition according to their FPs and a low score on the screening questionnaire (N = 968). Self-rated health was measured by questionnaire at index and at three, 12, and 24 months, and health care use was extracted from patient registers. Compared with the 968 patients with well-defined medical conditions, the 81 severe Health anxiety patients and the 59 DSM-IV Hypochondriasis patients continued during follow-up to manifest significantly more Health anxiety (Whiteley-7 scale). They also continued to have significantly worse self-rated functioning related to physical and mental health (component scores of the SF-36). The severe Health anxiety patients used about 41–78% more health care per year in total, both during the 3 years preceding inclusion and during follow-up, whereas the DSM-IV Hypochondriasis patients did not have statistically significantly higher total use. A poor outcome of Health anxiety was not explained by comorbid depression, anxiety disorder or well-defined medical condition. Patients with mild Health anxiety did not have a worse outcome on physical health and incurred significantly less health care costs than the group of patients with a well-defined medical condition.

Conclusions/Significance

Severe Health anxiety was found to be a disturbing and persistent condition. It is costly for the health care system and must be taken seriously, i.e. diagnosed and treated. This study supports the validity of recently introduced new criteria for Health anxiety.

The Research Diagnostic Criteria for Temporomandibular Disorders. IV: evaluation of psychometric properties of the Axis II measures

AIMS

To evaluate the psychometric properties of the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) biobehavioral (Axis II) screening instruments.

METHODS

Participants with Axis I TMD diagnoses (n = 626) completed the Axis II instruments (Depression, Nonspecific Physical Symptoms, Graded Chronic Pain) and other instruments assessing psychological distress, pain, and disability at three study sites. Internal consistency, temporal stability, and convergent/discriminant validity of the Axis II measures were assessed. To assess criterion validity of Nonspecific Physical Symptoms and Depression instruments as screeners, 170 participants completed a structured psychiatric diagnostic interview.

RESULTS

The Axis II instruments showed very good to excellent internal consistency (Cronbach's alpha coefficients = 0.80 to 0.95). Their convergent (correlation range 0.3 to 0.9) and discriminant (range 0.0 to 0.6) validity were generally supported, although Nonspecific Physical Symptoms was more strongly associated with depressive than with somatic symptoms. Temporal stability was high for characteristic pain intensity (Lin's correlation concordance coefficient [CCC] = 0.91), interference (CCC = 0.89), and chronic pain grade (weighted kappa = 0.87), and fair to good for Depression and Nonspecific Physical Symptoms (CCC = 0.63 to 0.78). The Depression instrument normal versus moderate to severe cutoff point was good at identifying current-year depression and dysthymia diagnoses (sensitivity 87%, specificity 53%). Nonspecific Physical Symptoms did not have high utility for detecting psychiatric disorders (sensitivity 86%, specificity 31%).

CONCLUSION

The Axis-II Depression and Graded Chronic Pain instruments have clinically relevant and acceptable psychometric properties for reliability and validity and utility as instruments for identifying TMD patients with high levels of distress, pain, and disability that can interfere with treatment response and course of Axis I disorders.

Severe MUPS in a sick-listed population: a cross-sectional study on prevalence, recognition, psychiatric co-morbidity and impairment

Background

Medically unexplained physical symptoms (MUPS) have a high prevalence in the general population and are associated with psychiatric morbidity. There are indications that MUPS are an important determinant of frequent and long-term disability.

The primary objective was to assess the prevalence of MUPS in sick-listed-employees and its associations with depressive disorders, anxiety disorders, health anxiety, distress and functional impairment. Secondary objectives were to investigate the classification of the occupational health physicians (OHPs), their opinions about the causes as well as the attributions of the employee.

Methods

In a cross-sectional study of 489 sick-listed employees from 5 OHP group practices, MUPS, depressive disorders, anxiety disorders, health anxiety, distress and functional impairment were assessed with the Patient Health Questionnaire (PHQ), the Whitely Index (WI), the Four- Dimensional Symptom Questionnaire (4DSQ) and the Short-Form 36 Health Survey (SF-36).

We used a cut off score of 15 on the PHQ for the categorisation of severe MUPS.

The opinions of the OHPs were evaluated by means of a separate questionnaire with regard to the presence of employees physical symptoms, and the symptoms attributions, and the diagnoses of the OHPs.

Results

Severe MUPS had a prevalence of 15.1% in this population of sick-listed employees. These employees had 4-6 times more depressive and anxiety disorders, and were more impaired. Female gender and PHQ-9 scores were determinants of severe MUPS.

Most of the time the OHPs diagnosed employees with severe MUPS as having a mental disorder. The employees attributed their physical symptoms in 66% to mental or to both mental and physical causes.

Conclusion

The prevalence of severe MUPS is higher in long-term sick-listed employees than in the non-sick- listed working population and at least equals the prevalence in the general practice population.

Severe MUPS are associated with psychiatric morbidity and functional impairment and must therefore be specifically recognised as such. Validated questionnaires, such as the PHQ-15, are useful instruments in order to help OHPs to recognise severe MUPS.

Ethnic differences in somatic symptom reporting in children with asthma and their parents

OBJECTIVES

The purpose of this study is to examine the association between child and parent somatic symptom reporting and pediatric asthma morbidity in Latino and non-Latino white children.

METHOD

The study consists of 786 children, 7 to 15 years of age, in Rhode Island (RI) and Puerto Rico. Children's and parents' levels of general somatic symptoms were assessed with well-established self-report measures. Clinician-determined asthma severity was based on reported medication use, asthma symptom history, and spirometry results. Asthma-related health care use and functional morbidity was obtained via parent self-report.

RESULTS

Child and parent reports of general somatic symptoms were significantly related to pediatric asthma functional morbidity when controlling for poverty, parent education, child's age, and asthma severity. In controlling for covariates, Latino children in RI reported higher levels of somatic symptoms than Island Puerto Rican children, and RI Latino parents reported more somatic symptoms than RI non-Latino white parents (p < .05).

CONCLUSIONS

This study replicates and extends to children in previous research showing higher levels of symptom reporting in Latinos relative to whites. Results also provide new insight into the relation between general somatic symptom reports and pediatric asthma. Ethnic differences in somatic symptom reporting may be an important factor underlying asthma disparities between Latino and non-Latino white children.

Cognitive Behavioural Therapy for Medically Unexplained Physical Symptoms: A Pilot Study

The aim of the study was to develop a cognitive behavioural treatment model for medically unexplained physical symptoms and assess its feasibility and effect in a small sample of patients. This study was the first step in the realization of a randomized controlled trial. The study population consisted of consecutive patients presenting at a general medical outpatient clinic, whose symptoms could not be explained by objective abnormal findings. The treatment was based on a general model of the disorder, consisting of the physical symptoms, the patient's attribution and perceived control and the cognitive, behavioural, physical and social consequences. It incorporated record keeping concerning physical symptoms and emotions, identification of cognitions about the symptoms, challenging dysfunctional thoughts and behavioural experiments. At 6–months follow-up, four of the five treated patients were improved with regard to frequency and intensity of the symptoms, psychological distress and functional impairment. The improvement was sustained at 1–year follow-up.

Perceived need for care among low-income immigrant and U.S.-born black and Latina women with depression

PURPOSE

To examine perceived need for care for mental health problems as a possible contributor to ethnic disparities in receiving care among low-income depressed women.

METHODS

The role of ethnicity, somatization, and stigma as they relate to perceived need for care is examined. Participants were 1577 low-income women who met criteria for depression.

RESULTS

Compared with U.S.-born depressed white women, most depressed ethnic minority women were less likely to perceive a need for mental health care (black immigrants: OR 0.30, p < 0.001; U.S.-born blacks: OR 0.43, p < 0.001; immigrant Latinas: OR 0.52, p < 0.01). Stigma-related concerns decreased the likelihood of perceiving a need for mental health care (OR 0.80, p < 0.05). Having multiple somatic symptoms (OR 1.57, p < 0.001) increased the likelihood of endorsing perceived need.

CONCLUSIONS

Findings suggest that there are ethnic differences in perceived need for mental healthcare that may partially account for the low rates of care for depression among low-income and minority women. The relations among stigma, somatization, and perceived need were strikingly similar across ethnic groups.

Prevalence, characteristics, and attribution of somatic symptoms in Spanish patients with major depressive disorder seeking primary health care

BACKGROUND

Somatic symptoms (SS) tend to dominate clinical symptomatology in patients with depression in primary care.

OBJECTIVE

The authors performed a cross-sectional nationwide epidemiological study on 1,150 primary-care patients with major depression and evaluated the prevalence of SS and physicians' attribution of their origin.

METHOD

Patients were administered the Structured Polyvalent Psychiatric Interview.

RESULTS

Ninety-three percent of patients had at least one SS fully or partially attributed to depression, and 45% of patients had four to nine. Painful symptoms, despite being the most frequent, were the least often attributed to depression (fewer than 25% of patients with pain) and significantly more often attributed to a combined origin.

CONCLUSION

Results suggest that primary-care physicians tend to associate pain with depression to a significantly lesser extent than any other somatic symptom (e.g., cardiopulmonary or gastrointestinal). Therefore, special attention should be given to painful symptoms in order to ensure efficient management of depression in primary care.

Somatization increases disability independent of comorbidity

BACKGROUND

Somatoform disorders are an important factor in functional disability and role impairment, though their independent contribution to disability has been unclear because of prevalent medical and psychiatric comorbidity.

OBJECTIVES

To assess the extent of the overlap of somatization with other psychiatric disorders and medical problems, to compare the functional disability and role impairment of somatizing and non-somatizing patients, and to determine the independent contribution of somatization to functional disability and role impairment.

DESIGN

Patients were surveyed with self-report questionnaires assessing somatization, psychiatric disorder, and role impairment. Medical morbidity was indexed with a computerized medical record audit.

PARTICIPANTS

Consecutive adults making scheduled visits to their primary care physicians at two hospital-affiliated primary care practices on randomly chosen days.

MEASUREMENTS

Intermediate activities of daily living, social activities, and occupational disability.

RESULTS

Patients with somatization, as well as those with serious medical and psychiatric illnesses, had significantly more impairment of activities of daily life and social activities. When these predictors were considered simultaneously in a multivariable regression, the association with somatization remained highly significant and was comparable to or greater than many major medical conditions.

CONCLUSIONS

Patients with somatization had substantially greater functional disability and role impairment than non-somatizing patients. The degree of disability was equal to or greater than that associated with many major, chronic medical disorders. Adjusting the results for psychiatric and medical co-morbidity had little effect on these findings.

Psychological distress and engagement in HIV-related services among individuals seeking mental health care

In the US, HIV-related mental health care has been funded for its ability to help engage and retain individuals living with HIV into other components of HIV-related care and treatment. However, little is known empirically about the types of HIV prevention and care with which they are, or need to be, connected. To explore this, data were collected from 617 individuals upon their self-enrollment in HIV-related mental health care in a large US city with high rates of HIV infection. Nearly a third of the participants (n=195) were "minimally engaged" in care services, 53% were "moderately engaged" and 15.6% were "highly engaged". There were significant differences between level of care engagement according to one's ethnicity, X(2)(4, n=617)=38.05; p<.001; Cramer's V=.18, with African-Americans and Latinos more likely to be highly engaged in care services compared to their Caucasian counterparts. Furthermore, individuals who were highly engaged in services had significantly lower levels of depression than their less engaged peers, F(2, 614)=8.18; p<.001; eta(2)=.03. Results suggest that while ethnic minorities were engaged in a higher number of care services, they were enrolling in mental health care following enrollment in other care services. Given the numerous benefits of engaging in HIV-related mental health early in the course of infection, it is important that case managers and primary care physicians educate African-Americans and Latinos on the benefits of mental health care in order to facilitate earlier engagement in HIV-related mental health services.

Alexithymia and somatization in general population

OBJECTIVE

Even though the association between alexithymia and somatization seems plausible according to several studies with selected populations, it has not been verified in carefully controlled and nationally representative population studies. We conducted such a study to find out whether alexithymia is associated with somatization at population level.

METHODS

This study was a part of the Finnish Health 2000 Study. The nationally representative sample comprised 5129 subjects aged 30 to 97 years. Alexithymia was measured with the 20-item Toronto Alexithymia Scale (TAS-20) and somatic symptom reporting with the 12-item somatization scale derived from the Hopkins Symptom Checklist. Sociodemographic and health-related variables, including depressive and anxiety disorders, and physician verified somatic diagnoses, were treated as confounders in multivariate analyses.

RESULTS

Alexithymia was associated with somatization independently of somatic diseases, depression and anxiety and confounding sociodemographic variables. The TAS-20 factor scale "Difficulties Identifying Feelings" was the strongest common denominator between alexithymia and somatization.

CONCLUSIONS

This was the first time the independent association between alexithymia and somatization was established in a large, nationally representative nonclinical sample of both young and old adults with and without mental disorders and somatic diseases.

Mental health care preferences among low-income and minority women

Mental health care preferences are examined among 1,893 low-income immigrant and U.S.-born women with an acknowledged emotional problem (mean age = 29.1, SD = 89.6). Ethnicity, depression, somatization, and stigma are examined as they relate to mental health care preferences (medication, individual and group counseling, faith, family/friends). Seventy-eight percent of participants counseling would be helpful; 55%; group counseling; and 32% medication. Faith was cited by 81%; family and friends were endorsed by 65%. Minorities had lower odds than Whites of endorsing medication (Black immigrants: OR = 0.27, p < 0.001, U.S.-born Blacks: OR = 0.30, p < 0.001, immigrant Latinas: OR = 0.50, p < 0.01). Most minorities also had higher odds of endorsing faith compared to Whites (Black immigrants: OR = 3.62, p < 0.001; U.S.-born Blacks, OR = 3.85, p < 0.001; immigrant Latinas: OR = 9.76, p < 0.001). Being depressed was positively associated with endorsing medication (OR = 1.93, p < 0.001), individual counseling (OR = 2.66, p < 0.001), and group counseling (OR = 1.35, p < 0.01). Somatization was positively associated with endorsing medication (OR = 1.29, p < 0.05) and faith (OR = 1.37, p < 0.05). Stigma-concerns reduced the odds of endorsing group counseling (OR = 0.58, p < 0.001). Finally, being in mental health treatment was related to increased odds of endorsing medication (OR = 3.88, p < 0.001) and individual counseling (OR = 2.29, p = 0.001).