Somatization increases disability independent of comorbidity

Living with disability: patterns of health problems and symptom mediation of health consequences

BACKGROUND

People with disability experience a range of symptoms that may serve as an important linkage between disability and other health consequences. The aims of this study were to describe and compare symptom experiences of people with and without disability using a population-based sample and to test direct relationships between disability and health status and indirect effects of disability mediated through symptom experience.

METHODS

A Midwestern sample of 12,249 adults aged 40 and older responded to a cross-sectional survey. Data collected included symptom prevalence and frequencies for 21 commonly reported symptoms, self-perceived health status and physical functioning, number of medications, and demographic variables. Two mediation analyses were conducted using cumulative symptom frequency as the mediator between disability status and both self-rated health and physical functioning.

RESULTS

Adults with disability reported significantly greater prevalence and frequencies for all 21 symptoms, with pain and fatigue being the most common. The indirect effect through cumulative symptom frequency explained roughly half of the total effect of disability on general health status, and about one third of the total effect of disability on physical functioning.

CONCLUSIONS

This study found evidence supporting the diverse and significant symptom experience of people living with disability, especially for symptoms of pain and fatigue. Moreover, symptom experience was found to partially mediate the effects of disability on self-reported general health status and physical functioning. This provides support for symptoms serving as an important link to health outcomes in patients with disability.

Relations between anxiety sensitivity, somatization, and health-related quality of life in children with chronic pain

OBJECTIVE

To further understand the influence of psychological variables on pain and functioning in children with chronic pain by examining the relations between pain, anxiety sensitivity (AS), somatization, and health-related quality of life (HRQOL), and whether they vary as a function of age and gender.

METHODS

66 children (8-12 years) and adolescents (13-18 years) with chronic pain completed measures assessing pain intensity, AS (childhood anxiety sensitivity index), somatization (child somatization inventory), and HRQOL (pediatric quality of life inventory 4.0).

RESULTS

Somatization was significantly related to higher pain intensity. Somatization significantly predicted HRQOL over and above pain. AS was a significant predictor of impaired HRQOL for children and females in the sample, but not for adolescents or males.

CONCLUSION

Somatization and AS may be better predictors of HRQOL impairment than pain intensity in children with chronic pain. This may differ as a function of age and gender.

The epidemiology of multiple somatic symptoms

BACKGROUND

The risk factors for a high total somatic symptom count are unclear; and it is not known whether total somatic symptoms count is a predictor of impaired health status.

METHOD

A prospective population-based cohort study in North West England. Randomly sampled residents (1443 participants; 58% response) completed questionnaires to determine number of somatic symptoms (SSI), health status and a wide range of risk factors; 741 completed questionnaires 1 year later. We used logistic regression to identify risk factors for high SSI at follow-up and for persistently high SSI. We used ANCOVAR and multiple regression to assess whether baseline SSI predicted health status at follow-up.

RESULTS

Twenty-one percent of participants scored over 25 on the Somatic Symptom Inventory (SSI) at baseline and 14% at both baseline and follow-up. Risk factors for a persistent high SSI were: fewer than 12 years of education, separated, widowed or divorced status, reported psychological abuse during childhood, co-existing medical illnesses, anxiety and depression. In multivariate analysis baseline SSI predicted health status (SF12 physical component score and health-related quality of life (EuroQol)) 12 months later. Persistent high SSI was a clinically meaningful predictor of these outcomes.

CONCLUSIONS

Our data support a biopsychosocial approach to somatic symptoms rather than the dualistic approach of identifying "medically unexplained" symptoms. The risk factors for total somatic symptom count were those associated with psychiatric disorders including physical illness. A persistent high somatic symptom count provides a readily measured dimension of importance in epidemiology as a predictor of health status.

The prevalence of medically unexplained symptoms in primary care

OBJECTIVE

There is only a small number of studies dealing with the prevalence of medically unexplained symptoms and somatoform disorder in German primary care practices. Therefore, we aimed to study the prevalence of medically unexplained symptoms and the prevalences and comorbidities of somatoform and other mental disorders.

METHOD

In the initial stage of a two-stage prevalence study, 620 consecutive patients were first screened with a PHQ-15 questionnaire. In the second stage, 308 selected persons were then interviewed in detail.

RESULTS

Medically unexplained symptoms made up two-thirds of all reported symptoms with women, younger persons, and non-native speakers having the highest rates. The 12-months prevalences of somatoform disorders was 22.9%, for affective disorders it was 12.4%, and for anxiety disorders it was 11.4%. Somatoform disorder was comorbid with at least one other mental disorder in 43.2% of the cases. Most frequently, somatoform disorder was comorbid with anxiety or depression. 37.1% of the patients had a mental disorder.

CONCLUSION

Somatoform and other mental disorders are highly common in primary care. In order to support an adequate management of mental and somatoform disorders, general practitioners should consider the influences of gender and cultural background on the development of a mental disorder.

Neurocognitive functioning and health-related behaviours in adult survivors of childhood cancer: a report from the Childhood Cancer Survivor Study

BACKGROUND

Positive health-related behaviours are essential for the future wellbeing of childhood cancer survivors, though relatively few maintain healthy behaviours into adulthood.

METHODS

Neurocognitive function and emotional distress were examined in 6,440 adult survivors from the Childhood Cancer Survivor Study, and used to predict rates of expected health-related behaviours. Covariates included cancer diagnosis, age, sex, body mass index, insurance status, income and antidepressant medication use, and multivariable models were constructed adjusting for these factors.

FINDINGS

In multivariable regression models, survivors with neurocognitive problems in task efficiency (RR=0.77, 95% CI=0.72-0.84) were less likely to meet the Centers for Disease Control guidelines for weekly physical activity. Survivors with neurocognitive impairment were more likely to engage in general survivor care (RR=1.20, 95% CI=1.10-1.30), and less likely to engage in dental care (RR=0.92, 95% CI=0.88-0.97). Obese survivors were less likely to report receiving a bone density exam (RR=0.67, 95% CI=0.54-0.82), a mammogram (RR=0.71, 95% CI=0.57-0.89), and a skin exam (RR=0.78, 95% CI=0.68-0.89). Survivors reporting somatisation, i.e. vague physical symptoms associated with anxiety, were more likely to report receiving echocardiograms (RR=1.53, 95% CI=1.32-1.77).

INTERPRETATION

These results support the link between neurocognitive and emotional problems and health-related behaviours in adult survivors of childhood cancer. Monitoring neurocognitive and emotional outcomes may help to identify survivors at risk for poor adherence to prescribed health behaviours and health screening exams.

Prevalence and comorbidities of somatoform disorders in a rural california outpatient psychiatric clinic

OBJECTIVE

This study examines the prevalence and comorbidities of somatoform disorders in a rural setting with a diverse ethnic population.

METHOD

A retrospective chart review was conducted of active psychiatric outpatients in a clinic located in a rural community. Data abstracted included demographic variables, multi-axial diagnoses (DSM-IV-TR), length of treatment, psychotropic medications, and number of medications discontinued because of side effects. Improvement in level of function with treatment was measured by change in global assessment of functioning (GAF) scores.

RESULTS

Of 737 records reviewed, 37 (5%) contained a diagnosis of somatoform disorder. The most common comorbidities in the somatoform group were depression (P < .01), hypertension (P < .01), and arthritis (P < .05). The somatoform group was significantly more likely to have a chronic medical illness (P < .01) and history of surgeries (P < .05). The somatoform group patients' ΔGAF was one fourth the ΔGAF scores in all other psychiatric outpatients (1.41 vs 6.79, P < .01). The somatoform group changed medications more often because of side effects (1.35 times vs 0.71 times, P < .01), received a greater number of psychotropic medications (2.05 vs 1.62, P < .05), and was more likely to be taking an antidepressant (P < .05) than the nonsomatoform group.

CONCLUSION

Somatoform disorder patients had a higher prevalence of depression, chronic medical conditions, and surgeries. They responded less favorably to treatment when compared to patients without a somatoform disorder, and manifested a decreased tolerance to medication side effects. Female gender, fewer years of education, and Latino ethnicity did not increase the probability of having a somatoform disorder.

Somatic symptoms in patients with cancer experiencing pain or depression: prevalence, disability, and health care use

BACKGROUND

The adverse impact of a high somatic symptom burden is well established for primary care and other noncancer populations with chronic medical disorders.

METHODS

This study examines the impact of somatic symptom burden on disability and health care use in patients with cancer experiencing pain, depression, or both. We performed secondary analyses of baseline data from 405 patients with cancer enrolled in a telecare management trial for pain or depression. Somatic symptom burden was measured using a 22-item scale. Multivariable models were conducted to determine the association of somatic symptom burden with the Sheehan Disability Scale (SDS) score, the number of self-reported disability days in the past 3 months, and health care use. Models were adjusted for sociodemographic characteristics, medical comorbidity, and depression and pain severity.

RESULTS

Somatic symptoms were highly prevalent, with 15 of the 22 symptoms reported by more than 50% of patients. The somatic symptom burden was similar across different types and phases of cancer. The mean SDS score (scored 0-10 [not at all disabled to unable to carry out any activities]) was 5.4, and the mean number of self-reported disability days in the past 4 weeks was 16.9. In multivariable models, somatic symptom burden was associated with SDS score (P < .001) and the likelihood of at least 14 disability days in the past 4 weeks (odds ratio, 1.51; 95% confidence interval, 1.19-1.92) but not with increased health care use.

CONCLUSIONS

The somatic symptom burden is high in patients with cancer who experience pain or depression. Given the strong association with disability and the high prevalence of many types of symptoms, recognizing and managing somatic symptoms may be important in improving quality of life and functional status regardless of type or phase of cancer. Trial Registration clinicaltrials.gov Identifier: NCT00313573.

The Patient Health Questionnaire Somatic, Anxiety, and Depressive Symptom Scales: a systematic review

BACKGROUND

Depression, anxiety and somatization are the most common mental disorders in primary care as well as medical specialty populations; each is present in at least 5-10% of patients and frequently comorbid with one another. An efficient means for measuring and monitoring all three conditions would be desirable.

METHODS

Evidence regarding the psychometric and pragmatic characteristics of the Patient Health Questionnaire (PHQ)-9 depression, generalized anxiety disorder (GAD)-7 anxiety and PHQ-15 somatic symptom scales are synthesized from two sources: (1) four multisite cross-sectional studies (three conducted in primary care and one in obstetric-gynecology practices) comprising 9740 patients, and (2) key studies from the literature that have studied these scales.

RESULTS

The PHQ-9 and its abbreviated eight-item (PHQ-8) and two-item (PHQ-2) versions have good sensitivity and specificity for detecting depressive disorders. Likewise, the GAD-7 and its abbreviated two-item (GAD-2) version have good operating characteristics for detecting generalized anxiety, panic, social anxiety and post-traumatic stress disorder. The optimal cutpoint is > or = 10 on the parent scales (PHQ-9 and GAD-7) and > or = 3 on the ultra-brief versions (PHQ-2 and GAD-2). The PHQ-15 is equal or superior to other brief measures for assessing somatic symptoms and screening for somatoform disorders. Cutpoints of 5, 10 and 15 represent mild, moderate and severe symptom levels on all three scales. Sensitivity to change is well-established for the PHQ-9 and emerging albeit not yet definitive for the GAD-7 and PHQ-15.

CONCLUSIONS

The PHQ-9, GAD-7 and PHQ-15 are brief well-validated measures for detecting and monitoring depression, anxiety and somatization.

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.

[Determinants of quality of life in patients with somatoform disorders with pain as main symptom - the case for differentiating subgroups]

OBJECTIVES

What impact do the degree of somatization and the presence of a comorbid psychological disorder have on health-related quality of life in patients with pain-dominated somatoform disorders?

METHODS

282 consecutive patients (57.6 %) from a total population of N=490 patients fulfilling the criteria of somatoform pain disorders were included in the study following a thorough interdisciplinary diagnostic process at a German university hospital. Structured interviews (SKIDI and SKID-II) to assess comorbid psychological disorders as well as a structured biographical interview to assess chronification factors were conducted. We employed the Screening for Somatoform Disorders form (SOMS) to discover the extent and distribution of somatic symptoms and the SF-36 to determine the health-related quality of life.

RESULTS

The patients exhibited a multiplicity of further somatic complaints apart from pain. 69 % had a comorbid psychological disorder. The health-related physical and psychological quality of life was clearly impaired in patients with "small", "substantial" and "pronounced" somatization. Regression analysis explained 48 % of the variance of the body-related and 35 % of the variance of the psychological quality of life: Besides the extent of somatization, older age, duration of pain-associated hospitalizations and the subjective amount of occupational impairment proved to be important. With regard to the psychological (but not the somatic) health-related quality of life, the presence of a current comorbid psychological disorder was also relevant.

CONCLUSION

Patients with pain-dominated somatoform disorders are substantially impaired in their quality of life. Because 31 % of the patients with such disorders have no additional comorbid psychic disorder and the existence of a comorbid psychic disorder impacts only the psychological domain of their health-related quality of life, the results appear to strongly support maintaining the diagnostic category of somatoform disorders in ICD-11 and DSM-V. They also support the grading of the severity of the somatization similar to the grading of depressive disorders.

Body image and self-esteem in somatizing patients

AIM

The aim of the present study was to determine dissatisfaction with body appearance and bodily functions and to assess self-esteem in somatizing patients.

METHODS

Body image and self-esteem were investigated in 128 women; 34 of those had diagnosed somatoform disorders, 50 were breast cancer patients with total mastectomy surgery alone, and 44 were healthy subjects. Body image and self-esteem were assessed using the Body Cathexis Scale and Rosenberg Self-Esteem Scale.

RESULTS

The two clinical groups did not differ from one another (z = -1.832, P = 0.067), but differed from healthy controls in terms of body image (somatizing patients vs healthy controls, z = -3.628, P < 0.001; total mastectomy patients vs healthy controls, z = -3.172, P = 0.002). They also did not differ significantly in terms of self-esteem (z = -0.936, P = 0.349) when depressive symptoms were controlled. No statistically significant difference was observed between total mastectomy patients and healthy controls in terms of self-esteem (z = -1.727, P = 0.084). The lower levels of self-esteem in somatizing patients were largely mediated by depressive symptoms. Depressed and non-depressed somatizing patients differed significantly from healthy controls with respect to their self-esteem and body image.

CONCLUSIONS

Somatizing patients who were dissatisfied with their bodily functions and appearance had lower levels of self-esteem and high comorbidity of depression. In clinical practice it is suggested that clinicians should take into account psychiatric comorbidity, self-esteem, and body image in somatizing patients when planning treatment approaches.

Psychiatric issues in chronic pain

Chronic pain requires comprehensive care. While interdisciplinary approaches are recommended, the role of psychiatrists is often misunderstood. Psychiatrists should be involved with the care of patients with chronic pain as early as possible to maximize outcome. Psychiatrists offer an expertise that specifically addresses important deficiencies in the care of patients with chronic pain: 1) the lack of a detailed formulation, 2) the lumping of all psychopathology, and 3) the failure to effectively use psychopharmacologic treatments. This review provides a framework for formulating the diagnoses and treatments of patients with chronic pain.