Measurement and assessment of somatic symptoms

Symptoms of Depression, Anxiety, and Stress in Students in Albania

Depression, anxiety and stress are increasingly concerning phenomena in our society, with serious consequences on physical and mental health. The repercussions may be particularly devastating in particular population subgroups, such as female university students. The purpose of this study was to determine the levels of depression, anxiety, and stress among university students in Tirana. A cross-sectional study was conducted with a random sample of 570 students from the university students in Tirana. Information was collected on socio demographic and academic characteristics; symptoms of depression, anxiety, and stress. Female students manifest more symptoms of depression compared to male students. The higher level of symptoms of depression, anxiety and stress was found in the first academic years. Students with somatic disease exhibit higher scores compared to the rest of students. These findings highlight the need to adopt measures that address mental health, especially major depression, in female university students. Identifying the most frequent symptoms and finding a series of increased-risk and protective factors adds evidence to the existing scientific literature and allows efforts to be directed towards those experiences that are most frequent in female university students.    

Validation of the Chinese version of the Somatic Symptom Scale-8 in patients from tertiary hospitals in China

OBJECTIVE

To validate the Chinese language version of the Somatic Symptom Scale-8 (SSS-8) in a sample of outpatients attending tertiary hospitals in China.

MATERIALS AND METHODS

A Chinese language version of the SSS-8 was completed by outpatients (n = 699) from psychosomatic medicine, gastroenterology/neurology, and traditional Chinese medicine clinics of nine tertiary hospitals between September 2016 and January 2018 to test the reliability. The Patient Health Questionnaire-15 (PHQ-15), the Somatic Symptom Disorder-B Criteria Scale (SSD-12), the Patient Health Questionnaire-9 (PHQ-9), the General Anxiety Disorder-7 (GAD-7) scale, the Medical Outcome Study 12-item Short Form Health Survey (SF-12) and the World Health Organization Disability Assessment Schedule (WHO DAS 2.0) were rated to test construct validity. The criterion validity was tested by using the Semi-structured Clinical Interview for DSM-5 (Research Version) (SCID-5-RV) for somatic symptom disorder (SSD) as the diagnostic gold standard to explore the optimal cutoff score of the SSS-8.

RESULTS

The average age of the recruited participants was 43.08 (±14.47). 61.4% of them were female. The internal consistency derived from the sample was acceptable (Cronbach α = 0.78). Confirmatory factor analyses resulted in the replication of a three-factor model (cardiopulmonary symptoms, pain symptoms, gastrointestinal and fatigue symptoms) (comparative fit index = 0.95, Tucker-Lewis index = 0.92, root mean square error of approximation = 0.10, 90% confidence interval = 0.08-0.12). The SSS-8 sum score was highly associated with PHQ-15 (r = 0.74, p < 0.001), SSD-12 (r = 0.64, p < 0.001), GAD-7 (r = 0.59, p < 0.001), and PHQ-9 (r = 0.69, p < 0.001). The patients with more severe symptoms showed worse quality of life and disability The optimal cutoff score of SSS-8 was 9 (sensitivity = 0.67, specificity = 0.68).

CONCLUSION

Our preliminary assessment suggests that the Chinese language version of the SSS-8 has reliability and validity sufficient to warrant testing further in research and clinical settings.

The ambivalence about accepting the prevalence somatic symptoms in PTSD: Is PTSD a somatic disorder?

This study examined the prevalence of somatic symptoms in post-traumatic stress disorder (PTSD) in a population-based military sample (N = 14,445). Descriptive statistics explored somatic symptom endorsement in the entire sample. A latent class analyses was conducted on participants with a posttraumatic stress checklist (PCL) score ≥29 (n = 2433), with class differentiated by somatic symptom endorsement.Multinomial logistic regression explored correlates of latent class. Somatic disorder was more prevalent in probable-PTSD (59.6%) and subsyndromal-PTSD (26.5%) than no-PTSD (5.0%) groups, supporting an intersection of pathophysiological processes between somatic and PTSD symptoms. A 3-class solution of Syndromal (26.7%),Psychological (17.7%), and Somatic (55.5%) classes provided the optimal representation of latent somatic symptom typologies in probable PTSD and subsyndromal PTSD. Differences between classes on key characteristics supported potentially meaningful class distinctions. Class was not predicted by number of deployments nor whether a member had ever deployed. However, class was predicted by life-time trauma, indicating that the PTSD somatic symptom relationship is not confined to combat related PTSD or the effect of toxic exposures on deployment, but that pre-existing pathophysiology related to life-time trauma may drive the relationship.The high degree of coincidence between PTSD and somatic symptoms and the high prevalence of somatic distress in the Syndromal and Somatic classes support somatic symptoms are a ubiquitous aspect of the clinical presentation and should be considered a central characteristic of PTSD and therefore included in the diagnostic criteria, as suggested by the original formulations of PTSD.

Development of the psychosomatic symptom scale (PSSS) and assessment of its reliability and validity in general hospital patients in China

OBJECTIVES

To develop and verify the Psychosomatic Symptom Scale (PSSS) among psychosomatic patients and the cut-off value of PSSS in distinguishing psychosomatic patients from health controls.

METHODS

The PSSS was drafted by an expert workgroup. 996 patients and 366 controls from 14 general hospitals in China were recruited to complete PSSS, Patient Health Questionnaire-15 (PHQ-15) and Symptom Checklist-90 (SCL-90). Student's t-test, Kruskal-Wallis test, Cronbach's α, Spearman's correlation, and confirmatory factor analysis (CFA) were used to verify the PSSS. Receiver operating characteristic (ROC) analyses were used to determine the cut-off value.

RESULTS

Cronbach α of PSSS was 0.907. The PSSS was significantly correlated with SCL-90 somatization subscale (r = 0.682, P < 0.001) and PHQ-15 (r = 0.724, P < 0.001). CFA supported the theoretical two-factor structure of the PSSS, with comparative fit index (CFI) = 0.979, Tucker-Lewis index (TLI) = 0.977, root mean square error of approximation (RMSEA) = 0.039 (90% CI: 0.035-0.042), and standardized root mean residual (SRMR) = 0.054. As the sum score of PSSS was significantly higher in female, cut-off values were determined as 11 in females and 10 in males respectively.

CONCLUSIONS

The PSSS is a reliable and valid instrument for measuring psychosomatic symptoms.

The associations between psychological distress and health-related quality of life in patients with non-cardiac chest pain

Background

Recurrent chest pain episodes with no clear explanation may affect patients’ psychological wellbeing and health-related quality of life (HRQoL) negatively. Despite the fact that a significant amount of patients with non-cardiac chest pain (NCCP) might have a history of Cardiac Disease (CD), there is today a lack of knowledge on how CD influences the association between psychological wellbeing and HRQoL in patients with NCCP. Therefore, the aim of this study is to describe HRQoL in patients with NCCP, with or without history of CD, and to explore the association between HRQoL and cardiac anxiety, depressive symptoms, fear of body sensations and somatization.

Methods

Five hundred fifty-two patients discharged with NCCP from four hospitals in Southeast Sweden completed the EQ-5D, Cardiac Anxiety Questionnaire, Patient Health Questionnaire-9, Body Sensations Questionnaire, and Patient Health Questionnaire-15.

Results

Fifty precent reported at least moderate problems regarding pain/discomfort and 25% reported at least moderate problems in the HRQoL dimensions mobility, usual activities, and anxiety/depression. Patients with NCCP and history of CD reported significantly lower HRQoL (p ≤ 0.05) compared to patients with NCCP without CD. In the total study population, cardiac anxiety, depressive symptoms, and somatization had weak significant negative associations (beta = 0.187–0.284, p < 0.001) with HRQoL. In patients with history of CD, the association between depressive symptoms and HRQoL was moderate (beta = − 0.339, p < 0.001), compared to weak association in patients without CD (beta = − 0.193, p < 0.001). On the other hand, the association between cardiac anxiety and HRQoL was weak in both patients with history of CD (beta = − 0.156, p = 0.05), and in those without (beta = − 0.229, p < 0.001).

Conclusions

Patients with NCCP, in particular those with history of CD, reported low levels of HRQoL, which was associated with psychological distress. This should be considered when developing psychological interventions aiming to improve HRQoL in patients with NCCP.

Resting-State Functional Connectivity Between Centromedial Amygdala and Insula as Related to Somatic Symptoms in Depressed Patients: A Preliminary Study

OBJECTIVE

Somatic symptoms are prevalent in patients with depression. The centromedial amygdala (CMA) is a key brain region that mediates autonomic and somatic responses. Abnormal function in the CMA may contribute to the development of somatic symptoms in depressed patients.

METHODS

We compared the resting-state functional connectivity (RSFC) based on the seed of the left and right CMA between 37 patients with depression and 30 healthy controls. The severity of depressive and somatic symptoms was assessed using the Hamilton Depression Rating Scale (HDRS) and the 15-item somatic symptom severity scale of the Patient Health Questionnaire (PHQ-15). Correlation analysis was performed to investigate the relationship between the RSFC and clinical variables (HDRS and PHQ-15) in depressed patients.

RESULTS

Compared with healthy controls, patients with depression exhibited decreased RSFC between the CMA and insula, and superior temporal gyrus. In addition, functional connectivity between the left CMA and left insula was negatively correlated with PHQ-15 (r = -0.348, p = .037) in depressed patients. No significant relation was found between the RSFC and HDRS in depressed patients.

CONCLUSIONS

Functional connectivity between the CMA and insula is reduced in depressive patients, which is associated with the severity of somatic symptoms. Our findings may provide a potential neural substrate to interpret the co-occurrence of depression with somatic symptoms.

Somatic symptom disorder in the general population: Associations with medical status and health care utilization using the SSD-12

OBJECTIVE

Somatic Symptom Disorder (SSD) is characterized by excessive thoughts, feelings, and behaviors associated with physical symptoms. DSM-5 criteria for SSD focus on these psychological features (criterion B) rather than the presence or absence of an identifiable medical disorder. This study examines the role of medical disorder in the assessment of SSD and associations of SSD with health care utilization.

METHOD

Participants (N = 448, mean age 46.7 ± 16.9 years, 53.8% women) were recruited from the general community and completed the SSD-12 to quantify DSM-5 Criterion B for SSD. Participants also provided demographic and medical background information.

RESULTS

The SSD-12 total score was elevated in individuals with a major medical disorder (N = 97: cardiovascular disease, cancer, pulmonary disease or other: SSD-12 = 11.6 ± 8.8), and also among those with medical conditions commonly treated in primary care (N = 46: e.g., migraine, asthma: SSD-12 = 8.3 ± 7.1), compared to those free of these disorders (SSD-12 = 5.8 ± 7.0), which remained significant in age- and sex-adjusted models. Normative values are reported. High SSD-12 scores (≥15) were associated with more health care utilization (adjusted OR primary care visits = 3.35, 95%CI = 1.64-6.87).

CONCLUSIONS

The SSD-12 is a useful tool for the assessment of SSD. Medical comorbidity is associated with higher SSD-12 scores. Future studies are needed to determine whether SSD is more common in medical patients or whether correction of normative values is needed for screening purposes.

Characteristics of undiagnosed diseases network applicants: implications for referring providers

BACKGROUND

The majority of undiagnosed diseases manifest with objective findings that warrant further investigation. The Undiagnosed Diseases Network (UDN) receives applications from patients whose symptoms and signs have been intractable to diagnosis; however, many UDN applicants are affected primarily by subjective symptoms such as pain and fatigue. We sought to characterize presenting symptoms, referral sources, and demographic factors of applicants to the UDN to identify factors that may determine application outcome and potentially differentiate between those with undiagnosed diseases (with more objective findings) and those who are less likely to have an undiagnosed disease (more subjective symptoms).

METHODS

We used a systematic retrospective review of 151 consecutive Not Accepted and 50 randomly selected Accepted UDN applications. The primary outcome was whether an applicant was Accepted, or Not Accepted, and, if accepted, whether or not a diagnosis was made. Objective and subjective symptoms and information on prior specialty consultations were collected from provider referral letters. Demographic data and decision data on network acceptance were gathered from the UDN online portal.

RESULTS

Fewer objective findings and more subjective symptoms were found in the Not Accepted applications. Not Accepted referrals also were from older individuals, reported a shorter period of illness, and were referred to the UDN by their primary care physicians. All of these differences reached statistical significance in comparison with Accepted applications. The frequency of subspecialty consults for diagnostic purposes prior to UDN application was similar in both groups.

CONCLUSIONS

The preponderance of subjective and lack of objective findings in the Not Accepted applications distinguish these from applicants that are accepted for evaluation and diagnostic efforts through the UDN. Not Accepted applicants are referred primarily by their primary care providers after multiple specialist consultations fail to yield answers. Distinguishing between patients with undiagnosed diseases with objective findings and those with primarily subjective findings can delineate patients who would benefit from further diagnostic processes from those who may have functional disorders and need alternative pathways for management of their symptoms.

TRIAL REGISTRATION

clinicaltrials.gov NCT02450851 , posted May 21st 2015.

The associations between psychological distress and healthcare use in patients with non-cardiac chest pain: does a history of cardiac disease matter?

BACKGROUND

Psychological distress such as somatization, fear of body sensations, cardiac anxiety and depressive symptoms is common among patients with non-cardiac chest pain, and this may lead to increased healthcare use. However, the relationships between the psychological distress variables and healthcare use, and the differences in relation to history of cardiac disease in these patients has not been studied earlier. Therefore, our aim was to explore and model the associations between different variables of psychological distress (i.e. somatization, fear of body sensations, cardiac anxiety, and depressive symptoms) and healthcare use in patients with non-cardiac chest pain in relation to history of cardiac disease.

METHODS

In total, 552 patients with non-cardiac chest pain (mean age 64 years, 51% women) responded to the Patient Health Questionnaire-15, Body Sensations Questionnaire, Cardiac Anxiety Questionnaire, Patient Health Questionnaire-9 and one question regarding number of healthcare visits. The relationships between the psychological distress variables and healthcare visits were analysed using Structural Equation Modeling in two models representing patients with or without history of cardiac disease.

RESULTS

A total of 34% of the patients had previous cardiac disease. These patients were older, more males, and reported more comorbidities, psychological distress and healthcare visits. In both models, no direct association between depressive symptoms and healthcare use was found. However, depressive symptoms had an indirect effect on healthcare use, which was mediated by somatization, fear of body sensations, and cardiac anxiety, and this effect was significantly stronger in patients with history of cardiac disease. Additionally, all the direct and indirect effects between depressive symptoms, somatization, fear of body sensations, cardiac anxiety, and healthcare use were significantly stronger in patients with history of cardiac disease.

CONCLUSIONS

In patients with non-cardiac chest pain, in particular those with history of cardiac disease, psychological mechanisms play an important role for seeking healthcare. Development of interventions targeting psychological distress in these patients is warranted. Furthermore, there is also a need of more research to clarify as to whether such interventions should be tailored with regard to history of cardiac disease or not.

Somatic symptom disorder was common in children and adolescents attending an emergency department complaining of pain

AIM

The aim of this study was to quantify the prevalence of somatic pain in a paediatric emergency department (ED).

METHODS

We conducted a prospective observational study using patients admitted to the ED of an Italian children's hospital between December 2014 and February 2015. We enrolled children aged 7-17 who turned up at the ED complaining of pain. Patients and parents were asked to fill in a questionnaire to allow the analysis of the patients' medical history and provide contact details for follow-up. We divided the enrolled patients into four groups: post-traumatic pain, organic pain, functional pain and somatic pain. The questionnaire was used to define pain characteristics and to generate an impairment score.

RESULTS

Of the 713 patients who met inclusion criteria, 306 (42.9%) were enrolled in the study. Of these, 135 (44.0%) suffered from post-traumatic pain, 104 (34.0%) from organic pain, 41 (13.4%) from functional pain and 26 (8.6%) from somatic pain. Somatic pain patients had endured pain longer, had missed more school days and had suffered severe functional impairment.

CONCLUSION

This study highlighted that somatic pain was a significant contributor to paediatric emergency room visits and should be suspected and diagnosed in children reporting pain.

On somatic symptoms measurement: the scale for assessment of somatic symptoms revisited

BACKGROUND

Scale for assessment of somatic symptoms (SASS) has been widely used for assessing somatic complaints since many years. With impending changes in the classificatory system on somatoform disorders, we re- assessed the test-retest reliability and inter-rater reliability of SASS.

MATERIALS AND METHODS

SASS was administered twice with a gap of 24 h on 20 subjects for test retest reliability. Two clinicians assessed inter-rater reliability on 20 subjects. Kendall tau B and Cronbach's alpha were calculated from the data.

RESULTS

All of the items except burning sensation, weakness of mind and trembling had strong correlation with values >±0.40 on both test retest and inter-rater reliability; burning sensation and trembling were not reported by any subject. On inter-rater reliability the items constipation, diarrhea, lack of libido weren't scored by any subjects. Cronbach's alpha for test retest was 0.982 and 0.840 indicating good internal consistency.

CONCLUSION

Majority of the symptoms in SASS had high correlation in both test retest reliability as well as inter-rater reliability, however few items needs revision.

Somatic symptoms, perceived stress and perceived job satisfaction among nurses working in an Indian psychiatric hospital

BACKGROUND

High stress perception by nurses caring for psychiatric patients can lead to somatic symptoms which impact on their job satisfaction perception.

OBJECTIVE

To assess and correlate the level of somatic symptoms, perceived stress and perceived job satisfaction among the subjects.

DESIGN

The authors used a descriptive correlation design to invite 150 nurses of both genders working for more than one year with psychiatric patients. The Scale for Assessment of Somatic Symptoms (Chaturvedi et al., 1987) and a Visual Analogue Scale (VAS) for stress and job satisfaction perception were used to collect data.

RESULTS

The nurses (128) reported mainly pain related (4.87±2.97) somatic symptoms. Somatic symptoms positively correlated (r=0.302) with stress perception and negatively correlated (r=-0.231) with perceived job satisfaction, while perceived stress and perceived job satisfaction were negatively correlated (r=-0.460, p=0.000).

CONCLUSION

The results indicate a need for stress management interventions.