The latent structure of medically unexplained symptoms and its relation to functional somatic syndromes

Somatic symptom distress is not related to cardioceptive accuracy

OBJECTIVE

(Cardiac) interoception was long considered a key mechanism behind symptom perception in persistent somatic symptoms (PSS). In this study, we aimed to extend earlier findings to clarify this potential interoceptive mechanisms of PSS.

METHODS

A cross-sectional sample of 251 participants (23.1% with self-reported functional somatic syndrome) completed a laboratory study with two cardioceptive accuracy tasks (Schandry task and a new cardiac signal detection task) and multiple questionnaires. Somatic symptom distress and associated constructs were assessed with the PHQ-15, as well as with a novel multidimensional questionnaire measure (HiTOP-SF1) derived from the somatoform spectrum of the Hierarchical Taxonomy of Psychopathology (HiTOP). Correlations (frequentist and Bayesian) and structural equation modelling (SEM) helped further investigate the interplay between these variables.

RESULTS

There were no significant correlations between measures of interoception and somatic symptom distress. Self-report and behavioral cardioceptive accuracy measures did not correlate significantly. No significant covariances emerged between diagnostic tools and cardioceptive accuracy; Bayesian analyses supported the lack of association between interoception and symptom perception.

CONCLUSIONS

Cardiac interoception (specifically cardioceptive accuracy) unlikely represents a key mechanism in PSS etiology. We recommend investigating other factors in PSS.

Is the rubber hand illusion associated with somatic symptom reporting?

Current approaches to somatic symptom perception conceptualize somatic symptoms partly as somato-visceral or body illusions evoked by an interaction between bottom-up (sensory) and top-down (expectations, attention) processes. Similar processes of multisensory integration are assumed to contribute to the rubber hand illusion (RHI). Findings concerning the strength and direction of associations between these two phenomena, symptom perception and the RHI, are equivocal. Individuals of a non-clinical sample (N = 63; 56% females; Mage = 20.4; SD = 1.6) completed the Patient Health Questionnaire Somatic Symptom Scale (PHQ-15) and participated in an experiment that evoked the RHI. In repeated measures analyses of variance with the PHQ-15 score as covariate, no significant interaction effects between the PHQ-15 score and indicators of the RHI, i.e., proprioceptive drift (F(1,61) < 0.001 p = 0.993, partial η2 < 0.001; BF10 = 0.307), felt body ownership(F(1,59) = 0.043, p = 0.836, partial η2 = 0,001; BF10 = 0.501), and felt body disownership (F(1,59) = 0.148, p = 0.702, partial η2 = 0.002; BF10 = 1.972) were found. Overall, frequentist and Bayesian analysis indicated that the support for a possible association between the PHQ-15 and indicators of the RHI remains inconclusive, i.e., neither the null nor the alternative hypotheses were sufficiently supported. At least in this non-clinical sample, the association between somatic symptom distress and the strength of the RHI appears so weak (perhaps non-existing), that both phenomena (somatic symptom distress and the RHI) appear distinct and largely unrelated.

Illustrating the pathway from affect to somatic symptom: the Affective Picture Paradigm

High levels of somatic symptom distress represent a core component of both mental and physical illness. The exact aetiology and pathogenesis of this transdiagnostic phenomenon remain largely unknown. The Affective Picture Paradigm (APP) represents an innovative experimental paradigm to study somatic symptom distress. Based on the HiTOP framework and a population-based sampling approach, associations between facets of somatic symptom distress and symptoms induced by the APP were explored in two studies (N1 = 201; N2 = 254) using structural equation bi-factor models. Results showed that the APP effect was significantly positively correlated with general somatic symptom distress (PHQ-15, HiTOP), cardio-respiratory symptoms (PHQ-15), as well as difficulties identifying feelings. In conclusion, negative affective cues in the APP can elicit somatic symptoms, particularly in people with higher levels of somatic symptom distress. Difficulties identifying feelings might contribute to this phenomenon. Results are compatible with a predictive processing account of somatic symptom perception.

Preliminary Validation of a General Factor Model of Chronic Overlapping Pain Conditions

Chronic overlapping pain conditions (COPCs) by definition, frequently co-occur, perhaps reflecting their shared etiologies. Their overlapping nature presents a methodological challenge, possibly masking associations between COPCs and health outcomes attributable to either general or specific processes. To address this challenge, we used population-based cohort data to evaluate the predictive validity of a bifactor model of 9 self-reported COPCs by assessing its association with incident pain-related clinical diagnoses; pain-relevant pharmacotherapy; and other health outcomes. We obtained data from a 2005 to 2006 study of Swedish adult twins linked with health data from nationwide registers through 2016 (N = 25,418). We then fit a bifactor model comprising a general COPC factor and 2 independent specific factors measuring pain-related somatic symptoms and neck and shoulder pain. Accounting for age, biological sex, and cancer, the general factor was associated with increased risk of all pain-related outcomes (eg, COPC diagnosis adjusted odds ratio [aOR], 1.71; 95% confidence interval [1.62, 1.81]), most mental health-related outcomes (eg, depression aOR, 1.72 [1.60, 1.85]), and overdose and mortality (eg, all-cause mortality aOR, 1.25 [1.09, 1.43]). The somatic symptoms specific factor was associated with pain-relevant pharmacotherapy (eg, prescribed opioids aOR, 1.25 [1.15, 1.36]), most mental health-related outcomes (eg, depression aOR, 1.95 [1.70, 2.23]), and overdose (eg, nonfatal overdose aOR, 1.66 [1.31, 2.10]). The neck and shoulder pain-specific factor was weakly and inconsistently associated with the outcomes. Findings provide initial support for the validity and utility of a general-factor model of COPCs as a tool to strengthen understanding of co-occurrence, etiology, and consequences of chronic pain. PERSPECTIVE: This article presents associations between a novel measurement model of COPCs and various health outcomes. Findings provide support for measuring pain across multiple domains rather than only measuring pain specific to one physical location in both research and clinical contexts.

Psychological Resilience to Trauma and Risk of COVID-19 Infection and Somatic Symptoms Across 2 Years

OBJECTIVE

Exposure to trauma increases the risk of somatic symptoms, as well as acute and chronic physical diseases. However, many individuals display psychological resilience, showing positive psychological adaptation despite trauma exposure. Resilience to prior trauma may be a protective factor for physical health during subsequent stressors, including the COVID-19 pandemic.

METHODS

Using data from 528 US adults in a longitudinal cohort study, we examined psychological resilience to lifetime potentially traumatic events early in the pandemic and the risk of COVID-19 infection and somatic symptoms across 2 years of follow-up. Resilience was defined as level of psychological functioning relative to lifetime trauma burden, assessed in August 2020. Outcomes included COVID-19 infection and symptom severity, long COVID, and somatic symptoms assessed every 6 months for 24 months. Using regression models, we examined associations between resilience and each outcome adjusting for covariates.

RESULTS

Higher psychological resilience to trauma was associated with a lower likelihood of COVID-19 infection over time, with one standard deviation higher resilience score associated with a 31% lower likelihood of COVID-19 infection, adjusting for sociodemographics and vaccination status. Furthermore, higher resilience was associated with lower levels of somatic symptoms during the pandemic, adjusting for COVID-19 infection and long COVID status. In contrast, resilience was not associated with COVID-19 disease severity or long COVID.

CONCLUSIONS

Psychological resilience to prior trauma is associated with lower risk of COVID-19 infection and lower somatic symptoms during the pandemic. Promoting psychological resilience to trauma may benefit not only mental but also physical health.

Exploring maladaptive cognitions and behaviors as perpetuating factors in patients with persistent somatic symptoms: a longitudinal study

OBJECTIVE

Maladaptive cognitions and behaviors may influence symptoms and impairment in patients with persistent somatic symptoms (PSS). Aims of this study were to examine: (i) whether maladaptive cognitions and behaviors are associated with symptom severity and functional health over time; (ii) if these associations are the result of changes within individuals over time or of differences between individuals; (iii) directions of changes within individuals over time.

METHODS

Longitudinal data of a heterogeneous sample of patients with PSS were analyzed (n = 322 patients enrolled in the PROSPECTS cohort study). Cognitive and behavioral responses to symptoms (CBRQ), symptom severity (PHQ-15) and physical and mental functioning (RAND-36 PCS and MCS) were assessed seven times over a five-year period (0, 6 months, 1, 2, 3, 4, 5 year). Longitudinal mixed model and hybrid model analysis with and without time-lag were applied.

RESULTS

Maladaptive cognitions and behaviors were associated with more severe symptoms and reduced physical and mental functioning over time. Both changes within individuals over time and differences between individuals were associated with higher symptom severity and reduced physical and mental functioning. The between-subject component was about twice the effect size of the within-subject component. Changes in several specific maladaptive cognitions and behaviors were associated with more severe symptoms and reduced physical and mental functioning later in time and vice versa.

CONCLUSION

This study shows that maladaptive cognitions and behaviors are associated with symptom severity and reduced physical and mental functioning over time in patients with PSS.

Somatic and psychological distress among Russian university students during the COVID-19 pandemic

OBJECTIVE

Previous studies highlighted a high prevalence of mental health issues among students during the COVID-19 pandemic, but there is no evidence from Russia. This study was aimed to examine the prevalence of somatic and psychological distress among Russian university students.

METHOD

The cross-sectional study was conducted in March-April 2021. The participants were university students from several regions of Russia (N = 1236). The Patient Health Questionnaire-15 and Depression, Anxiety, and Stress Scales-21 were used to measure the somatic and psychological distress.

RESULTS

The prevalence of somatic burden, depression, anxiety, and stress was 72.2%, 54.7%, 63.4%, and 55.4%, respectively. Somatic burden, anxiety, and stress were more frequently observed in females and students with experience of COVID-19 disease compared to males and students without experience of COVID-19 disease.

CONCLUSIONS

These data illuminate the high prevalence and potential risk factors for somatic and psychological distress among Russian university students and determine the importance of psychoeducation and preventive measures in the Russian university environment.

Categorical interoception: the role of disease context and individual differences in habitual symptom reporting

OBJECTIVE

Symptom reports correspond less to physiological dysfunction in persons with high levels of symptoms in daily life and in patients with functional somatic symptoms, suggesting poor symptom perception. In this study, we investigated whether interoception was impacted by the meaning of the context and by habitual symptom reporting.

METHODS

Eight inspiratory resistances that were equidistant in intensity were administered to healthy women (N = 124) varying in habitual symptom reporting. One group was asked to categorise them as benign sensations vs. as bodily symptoms that could suggest a disease (disease context group). Another group was asked to categorise them as low- vs. high-intensity sensations (neutral context group).

MAIN OUTCOME

Perceived differences in intensity within- vs. between-category and unpleasantness, categorisation threshold, and the reliability of categorising each stimulus were examined in relation to context (disease, neutral) and symptom reporting levels in daily life.

RESULTS

Context (neutral vs. disease) impacted intensity and unpleasantness perception. Processing of respiratory interoceptive stimulation was more detailed, elaborate, and cautious when categorising stimuli as signalling health or disease vs. as low- or high-intensity. Individual differences in habitual symptoms had no effect.

CONCLUSION

The pattern of results suggests that these categorisation effects indicate flexible, context-sensitive interoceptive processing, which may characterise healthy individuals.

Can the bodily distress syndrome (BDS) concept be used to assess functional somatic symptoms in adolescence?

OBJECTIVE

Bodily Distress Syndrome (BDS) represents a new research concept for adult patients with various functional somatic syndromes. We evaluated the utility of the BDS research concept and the associated BDS-25-checklist as a screening tool for diverse functional somatic symptoms (FSS) in adolescence by investigating: 1) the psychometric and factorial structures of the checklist, 2) symptom cluster patterns and 3) illness classification and associations with emotional psychopathology and sociodemographic factors.

METHODS

This cross-sectional study obtained data from the 16/17-year follow-up (N = 2542) of the general population Copenhagen Child Cohort 2000 (CCC2000). We used self-reported questionnaires to assess physical symptoms (the BDS-25 checklist), overall health (KidScreen), emotional psychopathology (Spence Children's Anxiety Scale; The Mood and Feelings Questionnaire), and illness worry (Whiteley-6 Index), and utilized data from Danish national registers to assess sociodemographic factors.

RESULTS

The BDS-25 checklist items displayed satisfactory psychometric data quality. Factor analyses revealed a similar four-factor model as reported in adults (factor loadings λ ≥0.5), representing distinct BDS symptom clusters: cardio-pulmonary, gastro-intestinal, musculoskeletal and general symptoms. Latent class analyses revealed a model with three latent classes, i.e. probable no to mild BDS, probable moderate, single-organ BDS and probable severe, multi-organ BDS, displaying acceptable class quality (Entropy = 0.904). Trend analyses revealed sociodemographic group differences across latent classes. Increased emotional psychopathology was associated with more pronounced BDS symptoms.

CONCLUSION

Our findings support the BDS concept with four symptom clusters and three illness severity groups (no BDS, single- organ and multi-organ BDS) to screen for FSS in adolescence.

Head-to-head comparison of somatic symptom scales: The Patient Health Questionnaire (PHQ-15) and the somatization scale of the Four-Dimensional Symptom Questionnaire (4DSQ-S)

OBJECTIVE

The goal of this study was to compare the 15-item Patient Health Questionnaire (PHQ-15) and the somatization subscale of the Four-Dimensional Symptoms Questionnaire (4DSQ-S) with respect to their latent structure and reliability, and to examine whether their scores are affected by age and gender, and whether the scales measure the same construct(s).

METHODS

The study population consisted of individuals with a tendency to experience persistent somatic symptoms, recruited in multiple healthcare settings, who completed the PHQ-15 and 4DSQ-S concurrently. We analyzed the scales' latent factor structure using confirmatory factor analysis (CFA), the scales' reliability, and differential item functioning (DIF) due to age and gender. We performed a head-to-head comparison by fitting structural equation models of the questionnaires' factors.

RESULTS

We included 234 participants. CFA showed that both questionnaires fitted a bifactor model with a general factor and four specific factors, three of which (labeled "musculoskeletal", "gastrointestinal", and "cardiopulmonary") were substantively similar. Both scales were essentially unidimensional. The reliability of the PHQ-15 and 4DSQ-S was equally high (omega 0.933 and 0.942, respectively). DIF-analysis showed minor DIF for age in one item of each questionnaire, with negligible impact on the scale score. Head-to-head comparison showed that the PHQ-15 and 4DSQ-S measured the same constructs. We present PHQ-15 - 4DSQ-S cross-walk tables.

CONCLUSIONS

Both questionnaires mainly measure a single somatic symptom burden dimension of which all symptoms (covered by the questionnaires) are adequate indicators. They do so equally accurately and they behave the same across gender and age categories.

An explanatory model of depressive symptoms from anxiety, post-traumatic stress, somatic symptoms, and symptom perception: the potential role of inflammatory markers in hospitalized COVID-19 patients

BACKGROUND

The context of the COVID-19 pandemic has harmed the mental health of the population, increasing the incidence of mental health problems such as depression, especially in those who have had COVID-19. Our study puts forward an explanatory model of depressive symptoms based on subjective psychological factors in those hospitalized for COVID-19 with and without biological markers (i.e., inflammatory markers). Therefore, we aim to evaluate the hypotheses proposed in the model to predict the presence of depressive symptoms.

METHOD

We conducted a cross-sectional study, using a simple random sampling. Data from 277 hospitalized patients with COVID-19 in Lima-Peru, were collected to assess mental health variables (i.e., depressive, anxiety, post-traumatic stress, and somatic symptoms), self-perception of COVID-19 related symptoms, and neutrophil/lymphocyte ratio (NLR) such as inflammatory marker. We performed a structural equation modeling analysis to evaluate a predictive model of depressive symptoms.

RESULTS

The results showed a prevalence of depressive symptoms (11.2%), anxiety symptoms (7.9%), somatic symptoms (2.2%), and symptoms of post-traumatic stress (6.1%) in the overall sample. No association was found between the prevalence of these mental health problems among individuals with and without severe inflammatory response. The mental health indicators with the highest prevalence were sleep problems (48%), low energy (47.7%), nervousness (48.77%), worry (47.7%), irritability (43.7%) and back pain (52%) in the overall sample. The model proposed to explain depressive symptoms was able to explain more than 83.7% of the variance and presented good goodness-of-fit indices. Also, a different performance between the proposed model was found between those with and without severe inflammatory response. This difference was mainly found in the relationship between anxiety and post-traumatic stress symptoms, and between the perception of COVID-19 related symptoms and somatic symptoms.

CONCLUSIONS

Results demonstrated that our model of mental health variables may explain depressive symptoms in hospitalized patients of COVID-19 from a third-level hospital in Peru. In the model, perception of symptoms influences somatic symptoms, which impact both anxiety symptoms and symptoms of post-traumatic stress. Thus, anxiety symptoms could directly influence depressive symptoms or through symptoms of post-traumatic stress. Our findings could be useful to decision-makers for the prevention of depression, used to inform the creation of screening tools (i.e., perception of symptoms, somatic and anxiety symptoms) to identify vulnerable patients to depression.

A unified Internet-delivered exposure treatment for undifferentiated somatic symptom disorder: single-group prospective feasibility trial

BACKGROUND

Exposure-based psychological treatment appears to have beneficial effects for several patient groups that commonly report distress related to persistent somatic symptoms. Yet exposure-based treatment is rarely offered in routine care. This may be because existing treatment protocols have been developed for specific symptom clusters or specific unwanted responses to somatic symptoms, and many clinics do not have the resources to offer all these specialised treatments in parallel. In preparation for a randomised controlled trial, we investigated the feasibility of a new and unified Internet-delivered exposure treatment (OSF.io: cnbwj) for somatic symptom disorder regardless of somatic symptom domain (e.g. cardiopulmonary, fatigue, gastrointestinal, pain), combination of unwanted emotions (e.g. anger, anxiety, fear, shame) and whether somatic symptoms are medically explained or not. We hypothesised that a wide spectrum of subgroups would show interest, that the treatment would be rated as credible, that adherence would be adequate, that the measurement strategy would be acceptable and that there would be no serious adverse events.

METHODS

Single-group prospective cohort study where 33 self-referred adults with undifferentiated DSM-5 somatic symptom disorder took part in 8 weeks of unified Internet-delivered exposure treatment delivered via a web platform hosted by a medical university. Self-report questionnaires were administered online before treatment, each week during treatment, post treatment and 3 months after treatment.

RESULTS

Participants reported a broad spectrum of symptoms. The Credibility/Expectancy mean score was 34.5 (SD = 7.0, range: 18-47). Participants completed 91% (150/165) of all modules and 97% of the participants (32/33) completed at least two exposure exercises. The average participant rated the adequacy of the rationale as 8.4 (SD = 1.5) on a scale from 0 to 10. The post-treatment assessment was completed by 97% (32/33), and 84% (27/32) rated the measurement strategy as acceptable. The Client Satisfaction Questionnaire mean score was 25.3 (SD = 4.7, range: 17-32) and no serious adverse events were reported. Reductions in subjective somatic symptom burden (the Patient Health Questionnaire 15; d = 0.90) and symptom preoccupation (the somatic symptom disorder 12; d = 1.17) were large and sustained.

CONCLUSIONS

Delivering a unified Internet-delivered exposure-based treatment protocol for individuals with undifferentiated somatic symptom disorder appears to be feasible.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04511286 . Registered on August 13, 2020.

Psychometric properties of screening questionnaires to detect depression in primary healthcare setting in rural Ethiopia

BACKGROUND

Much of the research about the validity of depression screening questionnaires is on criterion validity. Evidence is scarce on the concurrent, convergent and construct validity of these measures, particularly from low-income countries. This study aimed to evaluate the psychometric properties of depression screening questionnaires in primary healthcare (PHC) in rural Ethiopia.

METHODS

A facility-based cross-sectional study was conducted with 587 participants recruited from patients attending three PHC facilities and two 'Holy water sites' (places where religious treatment is being provided). The psychometric properties of five mental health screening questionnaires were evaluated: the nine item Patient Health Questionnaire (PHQ-9), the two item version of PHQ-9 (PHQ-2), a version of PHQ-9 with two added items of irritability and noise intolerance (PHQ-11), the Patient Health Questionnaire-15 (PHQ-15), and the World Health Organization-Five Well-being Index (WHO-5). Clinical diagnosis of depression was ascertained by psychiatrists. We analyzed data using exploratory factor analysis, Spearman's rank order correlation coefficient (Rho), the Mann Whitney test of the equality of medians, univariate logistic regression and Cronbach's alpha.

RESULTS

PHQ-9, PHQ-11 and WHO-5 were found to be unidimensional, with items in each scale highly loading onto one factor (factor loadings ranging from 0.64 to 0.87). The items of each instrument were internally consistent, with Cronbach's alpha ranging from 0.72 (PHQ-2) to 0.89 (PHQ-11). Scores for all screening scales were moderately or highly correlated with each other (Rho = 0.58 to 0.98) and moderately correlated with anxiety and disability scores. Median scores of all screening scales were significantly higher in those diagnosed with depression. The association of items measuring emotional and cognitive symptoms with the diagnosis of depression was stronger than the association with items measuring somatic symptoms. Irritability and noise intolerance had higher association with depression diagnosis than PHQ-9 items.

CONCLUSION

Emotional and cognitive symptoms are more useful than somatic symptoms to predict the diagnosis of depression in the PHC context in Ethiopia. Future research should focus on testing the unidimensionality of PHQ-9, PHQ-11 and WHO-5 using confirmatory factor analysis; establishing the criterion validity of PHQ-11 and WHO-5; and on assessing test-retest reliability of all the measures.

Assessing Somatic Symptoms With the Patient Health Questionnaire (PHQ-15) in Syrian Refugees

Somatic symptoms are common among Syrian refugees. To quantify somatic symptom load, sum score models derived from the Patient Health Questionnaire (PHQ-15) have been frequently applied without psychometric justification. Across two studies (total N = 776), we (a) tested different PHQ-15 factor solutions in Syrian refugees, (b) investigated measurement invariance (MI) of the factor solutions compared with German residents, and (c) scrutinized whether sum score models adequately represent the data and differ in associations with external validators compared with factor scores. One-factor, three-factor, four-factor, and a reduced one-factor solution all displayed acceptable to good model fit. The four-factor solution showed the best fit, enabling differential symptom analyses. Sum score models often had poor model fit, necessitating independent investigations before applying them. For all factor solutions, (partial) strict MI between residents and refugees could be established. All scoring methods displayed high and comparable associations with functional impairment, depressive, and anxiety symptoms.

Validity and utility of Hierarchical Taxonomy of Psychopathology (HiTOP): III. Emotional dysfunction superspectrum

The Hierarchical Taxonomy of Psychopathology (HiTOP) is a quantitative nosological system that addresses shortcomings of traditional mental disorder diagnoses, including arbitrary boundaries between psychopathology and normality, frequent disorder co-occurrence, substantial heterogeneity within disorders, and diagnostic unreliability over time and across clinicians. This paper reviews evidence on the validity and utility of the internalizing and somatoform spectra of HiTOP, which together provide support for an emotional dysfunction superspectrum. These spectra are composed of homogeneous symptom and maladaptive trait dimensions currently subsumed within multiple diagnostic classes, including depressive, anxiety, trauma-related, eating, bipolar, and somatic symptom disorders, as well as sexual dysfunction and aspects of personality disorders. Dimensions falling within the emotional dysfunction superspectrum are broadly linked to individual differences in negative affect/neuroticism. Extensive evidence establishes that dimensions falling within the superspectrum share genetic diatheses, environmental risk factors, cognitive and affective difficulties, neural substrates and biomarkers, childhood temperamental antecedents, and treatment response. The structure of these validators mirrors the quantitative structure of the superspectrum, with some correlates more specific to internalizing or somatoform conditions, and others common to both, thereby underlining the hierarchical structure of the domain. Compared to traditional diagnoses, the internalizing and somatoform spectra demonstrated substantially improved utility: greater reliability, larger explanatory and predictive power, and greater clinical applicability. Validated measures are currently available to implement the HiTOP system in practice, which can make diagnostic classification more useful, both in research and in the clinic.

Patients in general practice share a common pattern of symptoms that is partly independent of the diagnosis

OBJECTIVE

To describe self-reported symptoms among patients in general practice and to explore the relationships between symptoms experienced by patients and diagnoses given by general practitioners.

DESIGN

Doctor-patient questionnaires focusing on patients' self-reported symptoms during the past 7 days and the doctors' diagnoses.

SETTING

General practices in urban and suburban areas in Southeast Norway.

SUBJECTS

Forty-seven general practitioners who included 866 patients aged ≥18 years on a random day in practice.

RESULTS

The most frequently reported symptoms were tiredness (46%), lower back pain (43%), neck pain (41%), headache (39%), shoulder pain (36%), and sleep problems (35%). Women had a significantly higher prevalence than men for 16 of 38 symptoms (p < 0.05). The mean number of symptoms was 7.5 (range, 0-32; women, 8.1; men, 6.5, p < 0.05). Regression analysis showed that patients who received a social security grant had 59% more symptoms than those who were employed and that people with asthenia and depression/anxiety had 44% and 23% more symptoms, respectively than those with all other diagnoses. The patterns of symptoms reported showed similar patterns across the five most prevalent diagnoses.

CONCLUSIONS

Patients in general practice report a number of symptoms and share a common pattern of symptoms, which appear to be partly independent of the diagnoses given. These findings suggest that symptoms are not necessarily an indication of disease.KEY POINTSPatients consulting general practitioners have a high number of self-reported symptoms.The most frequent symptoms are tiredness, lower back pain, neck pain, headache, shoulder pain, and sleep problems.Patients diagnosed with asthenia and depression/anxiety report the highest number of symptoms.Selected diagnoses show similar patterns in symptom distribution.Symptoms are not necessarily an indication of disease.

Three different approaches to delimitation of functional somatic disorders: DanFunD

OBJECTIVE

The Danish Study of Functional Disorders (DanFunD) approaches functional somatic disorders (FSD) with three delimitations: Five functional somatic syndromes (FSS), Bodily Distress Syndrome (BDS), and eight data-driven symptom profiles (SP). This paper presents each delimitation and discusses optimal approaches for further original research into FSD epidemiology.

METHODS

A total of 9656 adults from the general Danish population participated in this cross-sectional study. Case assignment of the three FSD delimitations was based on self-reported symptom questionnaires. Overlap of FSS, BDS, and SP and their association with poor self-perceived health were calculated as descriptive statistics and shown with Venn diagrams. Difference in self-perceived health between participants with severe FSD were compared with participants with no FSD and calculated as risk ratios with generalized linear models with binomial family and log link.

RESULTS

We found pronounced overlaps between any FSS, BDS, and the SP with multiple symptoms as well as for multi-organ BDS and the SP with all symptoms. Symptoms and syndromes related to clusters of musculoskeletal and general symptoms contributed particularly to poor health as did multi-organ BDS and categories of SP with multiple symptoms.

CONCLUSION

Each of the three delimitations has its strengths and weaknesses, and with this study, we offer a contribution to a more valid delimitation of FSD. Future research within DanFunD and other epidemiological studies may benefit from using more than just one delimitation for capturing the diverse nature of the FSD.

Posttraumatic Stress Disorder and Persistent Somatic Symptoms During the COVID-19 Pandemic: The Role of Sense of Threat

OBJECTIVE

Persistent somatic symptoms, such as pain and fatigue, have been referred to as somatization. Somatization is commonly associated with histories of trauma and posttraumatic stress disorder (PTSD). Although previous research has demonstrated that PTSD can predict somatic problems, there has been no examination of this at the level of PTSD symptom clusters and multidimensional assessment of somatic symptoms. We examined the association between the three International Classification of Disease (11th Edition) PTSD symptom clusters (reexperiencing in the here and now, avoidance, and sense of threat), measured in relation to the COVID-19 pandemic as the stressor, and somatic symptoms while statistically adjusting for confounding variables.

METHODS

Participants were a nationally representative sample of 1041 adults from the general population of the Republic of Ireland. Physical health problems across the domains of pain, gastrointestinal, cardiopulmonary, and fatigue were assessed by the Patient Health Questionnaire, and PTSD symptoms were assessed using the International Trauma Questionnaire.

RESULTS

Sense of threat was associated with the presence of pain (β = 0.254), fatigue (β = 0.332), gastrointestinal (β = 0.234), and cardiovascular symptoms (β = 0.239). Avoidance was associated with pain (β = 0.347). Reexperiencing was not associated with any physical health variable.

CONCLUSIONS

In the context of COVID-19, the sense of threat symptoms in PTSD is most strongly related to somatic problems. Findings suggest that interventions addressing sense of threat symptoms might provide relief from somatization.

Application and validation of the bodily distress syndrome checklist in a psychosomatic outpatient sample

OBJECTIVE

The BDS checklist is a self-report measure to assess the most common somatic symptoms in functional somatic syndromes, based on the diagnostic concept of Bodily Distress Syndrome. The aim of the study was to examine the psychometric properties and validity of the BDS checklist in a psychosomatic sample and to investigate whether it is suitable to detect DSM-5 somatic symptom disorders (SSD).

METHOD

In a cross-sectional study, n = 368 patients from a psychosomatic outpatient clinic completed the BDS checklist and a semi-structured clinical interview on SSD. Item and scale characteristics and measures of reliability and validity were determined.

RESULTS

The BDS checklist showed good item characteristics and reliability (Cronbach α = 0.89). Factor analysis confirmed four symptom clusters (CFI = 0.95, TLI = 0.95, RMSEA = 0.091, 90% CI = 0.085-0.097). The BDS total score showed significant correlations with other measures of somatic symptom burden (r = 0.79, p < .001), health anxiety (r = 0.46, p < .001), depression (r = 0.45, p < .001), and general anxiety (r = 0.41, p < .001). Higher BDS checklist scores were associated with higher physical and mental health impairment and higher health care use. Diagnostic accuracy regarding somatic symptom disorder was moderate (AUC = 0.72, 95% CI: 0.67-0.77).

CONCLUSION

Findings of our study indicate that the BDS checklist is a reliable and valid measure to assess the most common somatic symptoms in a psychosomatic setting. It is however not sufficient to detect persons at risk for somatic symptom disorder. A combination with further questionnaires could probably improve diagnostic accuracy.

The BDS checklist as measure of illness severity: a cross-sectional cohort study in the Danish general population, primary care and specialised setting

OBJECTIVE

The bodily distress syndrome (BDS) checklist has proven to be useful in the diagnostic categorisation and as screening tool for functional somatic disorders (FSD). This study aims to investigate whether the BDS checklist total sum score (0-100) can be used as a measure of physical symptom burden and FSD illness severity.

DESIGN

Cross-sectional.

SETTING

Danish general population, primary care and specialised clinical setting.

PARTICIPANTS

A general population cohort (n=9656), a primary care cohort (n=2480) and a cohort of patients with multiorgan BDS from specialised clinical setting (n=492).

OUTCOME MEASURES

All data were self-reported. Physical symptoms were measured with the 25-item BDS checklist. Overall self-perceived health was measured with one item from the 36-item Short-Form Health Survey (SF-36). Physical functioning was measured with an aggregate score of four items from the SF-36/SF-12 scales 'physical functioning', 'bodily pain' and 'vitality'. Emotional distress was measured with the mental distress subscale (SCL-8) from the Danish version of the Hopkins Symptom Checklist-90. Illness worry was measured with the six-item Whiteley Index.

RESULTS

For all cohorts, bifactor models established that despite some multidimensionality the total sum score of the BDS checklist adequately reflected physical symptom burden and illness severity. The BDS checklist had acceptable convergent validity with measures of overall health (r=0.25-0.58), physical functioning (r=0.22-0.58), emotional distress (r=0.47-0.62) and illness worry (r=0.36-0.55). Acceptability was good with a low number of missing responses to items (<3%). Internal consistency was high (α ≥0.879). BDS score means varied and reflected symptom burden across cohorts (13.03-46.15). We provide normative data for the Danish general population.

CONCLUSIONS

The BDS checklist total sum score can be used as a measure of symptom burden and FSD illness severity across settings. These findings establish the usefulness of the BDS checklist in clinics and in research, both as a diagnostic screening tool and as an instrument to assess illness severity.

Mild behavioral impairment is related to frailty in non-dementia older adults: a cross-sectional study

BACKGROUND

Frailty and cognitive decline are highly prevalent among older adults. However, the relationship between frailty and mild behavioral impairment (MBI), a dementia risk syndrome characterized by later-life emergence of persistent neuropsychiatric symptoms, has yet to be elucidated. We aimed to evaluate the associations between MBI and frailty in older adults without dementia.

METHODS

In this cross-sectional study, a consecutive series of 137 older adults without dementia in the Anti-Aging Study, recruited from primary care clinics, were enrolled. Frailty was estimated using the Fried phenotype. MBI was evaluated by the Mild Behavioral Impairment Checklist (MBI-C) at a cut-off point of > 8. Cognition was assessed with the Chinese versions of the Montreal Cognitive Assessment (MoCA-BC) and Mini-mental State Examination (MMSE). Multivariable logistic regression was performed to estimate the relationship between MBI and objective cognition with frailty status.

RESULTS

At baseline, 30.7% of the older adults had frailty and 18.2% had MBI (MBI+ status). Multivariable logistic regression analysis demonstrated that compared to those without MBI (MBI- status), MBI+ was more likely to have frailty (odds ratio [OR] = 7.44, 95% CI = 1.49-37.21, p = 0.02). Frailty and MBI were both significantly associated with both MMSE and MoCA-BC score (p < 0.05).

CONCLUSIONS

Both frailty and MBI status were associated with higher odds of cognitive impairment. MBI was significantly associated with an increased risk of having frailty in the absence of dementia. This association merits further study to identify potential strategies for the early detection, prevention and therapeutic intervention of frailty.

Reliability and Validity of the Korean Version of Somatic Symptom Scale-8

OBJECTIVE

Somatic symptoms in psychiatry include underlying depression, anxiety, or other psychiatric disorders. This study aimed to conduct a validation study of a Korean version of the Somatic Symptom Scale-8 (K-SSS-8), and to utilize the K-SSS-8 effectively in clinical settings.

METHODS

For reliabilty, test-retest reliability and internal consistency were analyzed. For construct validity, exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were conducted. Known-group validity was verified, Jonckheere-Terpstra test (J-T statistic) were used.

RESULTS

Maternal Cronbach's alpha was 0.85 and r value of test-retest reliability was 0.777. In the EFA, 2-, 3- and 4-factor model showed cumulative percentile for variance of 60% or more. In the CFA, the 3-factor model was found to be the most appropriated and simplest (χ2=10.992, df=17, CFI=1.000, TLI=1.022, RMSEA=0.000). The verifying the difference in K-SSS-8 also showed significant difference. (J-T statistic=-2.510, p<0.05).

CONCLUSION

K-SSS-8 can be useful for exploring symptoms such as panic symptoms, physical pain, and physiological symptoms experienced by patients in a short time. In addition, the K-SSS-8 is expected to be very useful for determining the current severity by using the severity categories and for establish additionally required assessment plans for depression and anxiety symptoms.

Validation of the German version of the Bodily Distress Syndrome 25 checklist in a representative German population sample

OBJECTIVE

The Bodily Distress Syndrome 25 (BDS 25) checklist is a self-report instrument that can be used for case finding of a BDS in both clinical practice and research. We assessed the reliability and the internal and external validity of the German version of the BDS 25 in a sample of the general German population.

METHODS

The psychometric properties of the BDS 25 German were examined in a representative cross-sectional German population survey which included 2386 persons aged ≥14 years. Validation instruments included the Somatic Symptom Scale 8, the Giessen Subjective Complaints List 8 and the Patient Health Questionnaire 4. Participants were asked if they had been diagnosed with fibromyalgia or irritable bowel syndrome by a physician in the past.

RESULTS

The acceptance was high. Only 81 (2.3%) single items were not answered. Internal consistency was sufficiently high for all four subscales and the total score (α > 0.800). Exploratory and confirmatory factor analysis revealed clear evidence for a four-factorial structure with cardiopulmonary, gastrointestinal, musculoskeletal and general symptoms. Moderate to high correlations with other measures of somatic and psychological symptom burden were found. In latent class analysis, the model featuring three classes with no, moderate and severe BDS symptoms evinced the best model fit. Participants with self-reported fibromyalgia and irritable bowel syndrome were mainly found in the moderate and severe BDS group.

CONCLUSIONS

The BDS 25 German has excellent psychometric properties to screen for BDS in the general population.

Somatic Symptom Perception and Interoception

Abstract. Models of chronic somatic symptoms assume that abnormalities in interoception are related to the development and maintenance of symptom distress. Different models, however, disagree on the exact nature of the assumed abnormality: cognitive-behavioral models stress a hypervigilant cognitive style (predicting higher interoceptive accuracy) whereas predictive processing models assume a less detailed sensory processing (predicting lower interoceptive accuracy). This study aimed at testing the relationship between interoception and symptom perception. Using structural equation modeling, associations between cardiac interoception and symptom perception were tested in a sample of students ( n = 316) and a second heterogeneous sample ( n = 340, including 63 patients with either pathological health anxiety or a somatoform disorder according to DSM-IV). Stronger sensory symptom perceptions in the cardiorespiratory system were associated with lower interoceptive accuracy in sample 2. The findings are more in line with the predictive processing approach, suggesting less detailed and more biased interoception being associated with chronic somatic symptom distress.

Latent structure and factor invariance of somatic symptoms in the patient health questionnaire (PHQ-15)

BACKGROUND

Somatic symptoms are highly prevalent in primary care although insufficiently understood. The Patient Health Questionnaire (PHQ-15) is a valuable screening test but it has not yet been possible to unequivocally demonstrate its latent structure and measurement invariance.

METHODS

A total of 1,255 patients from 28 primary care centres suffering symptoms of anxiety, depression or somatisation participated in a clinical trial. They completed the PHQ-15 at baseline and 374 retook it at three months. Exploratory structural equation modelling (ESEM) was used to compare three models: 1) a single global factor for somatisation, 2) four specific correlated factors, and 3) a bifactor model integrating the first two models.

RESULTS

A multi-group invariance analysis of the best-fit model was performed: the bifactor model (χ²=25.17, df=23, p = 0.34, RMSEA=0.009, CFI=1.00, TLI=0.999). Strict invariance was good for both gender (RMSEA = 0.046, CFI = 0.973, TLI = 0.963) and age (RMSEA = 0.048, CFI = 0.964, TLI = 0.962). Configural and metric invariance were confirmed for moment of assessment, but scalar invariance was not.

LIMITATIONS

The two main limitations were the sample (primary care patients with emotional disorders), which was not representative of the general population, and the utilisation of ESEM (vs. confirmatory factor analysis), which did not allow a second-order factor model to be tested.

CONCLUSIONS

PHQ-15 showed a bifactor structure, providing both a single global measure of somatisation and specific measures of pain, gastrointestinal, cardiopulmonary and fatigue factors. Its factor invariance with regard to both gender and age was confirmed.

The unifying diagnostic construct of bodily distress syndrome (BDS) was confirmed in the general population

OBJECTIVES

Bodily distress syndrome (BDS) has been shown to encompass a range of functional somatic syndromes (FSS) such as irritable bowel syndrome (IBS), fibromyalgia (FM), and chronic fatigue syndrome (CFS) in clinical samples. This study aimed to explore symptom clusters and test classification of individuals with illness similar to the BDS criteria in a general population sample.

METHODS

A stratified subsample of 1590 individuals from the DanFunD part two cohort was included. Symptoms were assessed with the Research Interview for Functional somatic Disorders, performed by trained physicians. In 44 symptoms pooled from criteria of IBS, FM, CFS, and BDS, symptom clusters were explored with explorative factor analysis. Confirmation of symptom clusters of BDS in the previously described 25- and 30-item BDS checklists was performed with confirmatory factor analysis. Classification of individuals into illness groups was investigated with latent class analysis.

RESULTS

Four symptom clusters (cardiopulmonary, gastrointestinal, musculoskeletal, general symptoms/fatigue) corresponding to the BDS subtypes and their corresponding FSS were identified and confirmed. A three-class model including 25 BDS items had the best fit for dividing participants into classes of illness: One class with low probability, one class with medium probability, and one class with high probability of having ≥4 symptoms in all symptom clusters.

CONCLUSION

The BDS concept was confirmed in the general population and constitutes a promising approach for improved FSS classification. It is highly clinical relevant being the only diagnostic construct defining the complex multi-organ type.

Somatic symptoms among prison inmates: contributions of emotion regulation, dispositional mindfulness, and duration of stay in prison

PURPOSE

The modern prison system is not only a necessity to keep the public safe but also a mode of punishment for crimes. The correctional role of prisons is hampered in situations of mental illness, given that mental illness in the prison or correctional setting is a serious security risk. Few studies have given attention to the modifiable factors that may influence the mental health status of prison inmates, especially in developing countries. The purpose of this paper is to investigate emotion regulation (ER), dispositional mindfulness and duration of stay as factors in somatic symptoms among prison inmates.

DESIGN/METHODOLOGY/APPROACH

Participants were 209 prison inmates drawn from a prison in Eastern Nigeria, who completed measures of ER (cognitive reappraisal and expressive suppression), mindfulness and somatization.

FINDINGS

Results of a hierarchical multiple regression indicated that cognitive reappraisal predicted somatic complaints but it was only among older prison inmates, while expressive suppression was not a significant predictor of somatic complaints. Dispositional mindfulness was a negative predictor of somatic complaints among younger and older prison inmates. Duration of stay in prison positively predicted somatic complaints among prison inmates in emerging adulthood only (younger inmates), but not among older inmates.

RESEARCH LIMITATIONS/IMPLICATIONS

Frequent use of cognitive reappraisal strategy of ER by prisoners may not always be productive in reducing somatic complaints, and the length of time in prison may influence somatic symptoms especially for younger prisoners. The possible benefits of incorporating mindfulness-based therapies in psychosocial interventions to reduce somatic complaints in correctional settings deserves further investigation.

ORIGINALITY/VALUE

To date, there is limited research on somatic complaints of prisoners in the developing societies, particularly the psychosocial factors that may contribute to mental health problems.

Resting respiratory sinus arrhythmia moderates the association between social phobia symptoms and self-reported physical symptoms

The present study sought to investigate the association between social phobia symptoms and self-reported physical symptoms and the moderation effect of resting respiratory sinus arrhythmia (RSA) on this link. Data of 5-min resting RSA, social phobia symptoms assessed by the Social Phobia Scale, and physical symptoms assessed by the Cohen-Hoberman Inventory of Physical Symptoms were collected from 167 undergraduate students. Results indicated that higher levels of social phobia symptoms were associated with higher levels of self-reported physical symptoms. Resting RSA played the moderating role in the link between social phobia symptoms and self-reported physical symptoms, such that social phobia symptoms were positively associated with self-reported physical symptoms among individuals with low resting RSA, whereas this association was nonsignificant among individuals with high resting RSA. These findings suggest that high resting RSA as a physiological marker of better self-regulation capacity might buffer the effect of social phobia symptoms on physical health.

Why is the recognition rate of psychological distress under-estimated in general hospitals? A cross-sectional observational study in China

This study aimed to investigate the recognition rate of psychological distress in general hospitals in China and to examine the main associated factors.Using a cross-sectional study design, the questionnaires were administered to a total of 1329 inpatients from a tertiary hospital. The Patient Health Questionnaire-9 (PHQ-9), the Generalized Anxiety Disorder 7-item scale (GAD-7), the Patient Health Questionnaire (PHQ-15) and the Whiteley-7 (WI-7) were used to assess patients' mental health status. Two subjective questions were used to identify the awareness of psychological distress in patients and doctors.The frequency of psychological distress measured by the questionnaires was high in our sample (53.4%). However, the recognition rates of both patients (34.9%) and by doctors (39.1%) was low. The concordance rate between patients and doctors of whether the patient had psychological distress or not was extremely poor (Kappa = 0.089, P = .001). Factors associated with the poor concordance rate included patients' annual household income and clinically significant self-reported symptoms of anxiety and hypochondriasis.The recognition rate of psychological distress was underestimated and this may be related to a lack of awareness of mental disturbances and patients' low annual household income.

Association of Physical Morbidity and Health-Related Quality of Life in a Representative Sample of Older German People

Abstract. The association between health-related quality of life (HRQoL; Short-Form Health Survey-12; SF-12) and patient-reported morbidity-related symptoms measured by the Patient Health Questionnaire-15 (PHQ-15) is analyzed in a representative sample of older people in the general German population. Data from 1,659 people aged 60 to 85 years were obtained. Latent class analysis identified six classes of patients, which optimally categorize clusters of physical symptoms the participants reported: musculoskeletal impairments (39.8%), healthy (25.7%), musculoskeletal and respiratory/cardiac impairments (12.8%), musculoskeletal and respiratory impairments, along with bowel and digestion problems (12.9%), general impairments (4.9%), and general impairments with no bowel and digestion problems (4.8%). The participants’ SF-12 Physical Health Scores (η2 = .39) and their Mental Health Scores (η2 = .28) are highly associated with these latent classes. These associations remain virtually identical after controlling for age. The results provide evidence that profiles of patient-reported physical impairments correspond strongly with reduced HRQoL independently from aging processes.

Management of Functional Somatic Syndromes and Bodily Distress

Functional somatic syndromes (FSS), like irritable bowel syndrome or fibromyalgia and other symptoms reflecting bodily distress, are common in practically all areas of medicine worldwide. Diagnostic and therapeutic approaches to these symptoms and syndromes vary substantially across and within medical specialties from biomedicine to psychiatry. Patients may become frustrated with the lack of effective treatment, doctors may experience these disorders as difficult to treat, and this type of health problem forms an important component of the global burden of disease. This review intends to develop a unifying perspective on the understanding and management of FSS and bodily distress. Firstly, we present the clinical problem and review current concepts for classification. Secondly, we propose an integrated etiological model which encompasses a wide range of biopsychosocial vulnerability and triggering factors and considers consecutive aggravating and maintaining factors. Thirdly, we systematically scrutinize the current evidence base in terms of an umbrella review of systematic reviews from 2007 to 2017 and give recommendations for treatment for all levels of care, concentrating on developments over the last 10 years. We conclude that activating, patient-involving, and centrally acting therapies appear to be more effective than passive ones that primarily act on peripheral physiology, and we recommend stepped care approaches that translate a truly biopsychosocial approach into actual management of the patient.

A step towards a new delimitation of functional somatic syndromes: A latent class analysis of symptoms in a population-based cohort study

OBJECTIVES

The current delimitation of functional somatic syndromes (FSS) is inconsistent. We aimed to investigate somatic symptom profiles in the general adult population to contribute to a new, data-driven delimitation of FSS.

METHODS

Information on 31 self-reported somatic symptoms used in the delimitation of various FSS and bodily distress syndrome (BDS) was obtained from the DanFunD study-a population-based cohort study on 9656 adults (participation 33.6%) from Greater Copenhagen, Denmark. Latent class analysis was used to identify symptom profiles. The profiles were described by their relation with sex, age, chronic disease, self-perceived health, symptom impact, self-reported FSS, and BDS case-status.

RESULTS

Eight symptom profiles were identified. The largest profile had no symptoms (49% of the population). Three profiles were characterized by a few, specific symptoms: muscle and joint pain (17%), gastrointestinal symptoms (6%), and general symptoms (13%). Three profiles had multiple symptoms in specific combinations: musculoskeletal and general symptoms (7%); fatigue, musculoskeletal and gastrointestinal symptoms (3%); and cardiopulmonary, gastrointestinal and general symptoms (3%). Lastly, one profile (2%) had high probability of all symptoms. The last four profiles (15%) were strongly associated with BDS case-status, poor self-perceived health and high impact of symptoms. Analyses excluding persons with multi-symptomatic chronic disease showed similar results.

CONCLUSIONS

We identified eight symptom profiles characterized by specific combinations of symptoms. Four of these had multiple symptoms from several bodily systems showing large overlap with BDS, possibly indicating subtypes of FSS. The profiles contribute to a new delimitation of FSS by illustrating the importance of specific symptom combinations.

Perception of induced dyspnea in fibromyalgia and chronic fatigue syndrome

OBJECTIVE

Dyspnea perception is distorted in patients with medically unexplained dyspnea. The goals of this study were 1) to replicate these results in patients with fibromyalgia and/or chronic fatigue syndrome (CFS), and 2) to investigate predictors of distorted symptom perception within the patient group, with a focus on negative affectivity (NA), psychiatric comorbidity and somatic symptom severity.

METHODS

Seventy-three patients diagnosed with fibromyalgia and/or CFS and 38 healthy controls (HC) completed a rebreathing paradigm, consisting of a baseline (60s of room air), a rebreathing phase (150s, gradually increasing ventilation, partial pressure of CO₂ in the blood, and self-reported dyspnea), and a recovery phase (150s of room air). Dyspnea, respiratory flow and FetCO₂ levels were measured continuously.

RESULTS

Patients reported more dyspnea than HC in the recovery phase (p=0.039), but no differences between patients and HC were found in the baseline (p=0.07) or rebreathing phase (p=0.17). No significant differences between patients and HC were found in physiological reactivity. Within the patient group, the effect in the recovery phase was predicted by somatic symptom severity (p=0.046), but not by negative affectivity or by the number of psychiatric comorbidities.

CONCLUSION

This study extended earlier findings in patients with medically unexplained dyspnea to patients with fibromyalgia and CFS. This suggests that altered symptom perception is a non-symptom-specific mechanism underlying functional somatic syndromes in general, particularly in patients with high levels of somatic symptom severity. The results are discussed in a predictive coding framework of symptom perception.

Retrospective memory for symptoms in patients with medically unexplained symptoms

OBJECTIVE

Clinical assessment and diagnostic processes heavily rely on memory-based symptom reports. The current study investigated memory for symptoms and the peak-end effect for dyspnea in patients with medically unexplained symptoms and healthy participants.

METHODS

Female patients with medically unexplained dyspnea (MUD) (n=22) and matched healthy controls (n=22) participated in two dyspnea induction trials (short, long). Dyspnea ratings were collected: (1) continuously during symptom induction (concurrent with respiratory measures), (2) immediately after the experiment, and (3) after 2weeks. Symptoms, negative affect, and anxiety were assessed at baseline and after every trial. The mediating role of state anxiety in symptom reporting was assessed. The peak-end effect was tested with forced-choice questions measuring relative preference for the trials.

RESULTS

Compared to controls, dyspnea induction resulted in higher levels of symptoms, anxiety, concurrent dyspnea ratings, and minute ventilation in the patient group. In both groups, immediate retrospective ratings were higher than averaged concurrent ratings. No further increase in dyspnea ratings was observed at 2-week recall. Retrospective dyspnea ratings were mediated by both state anxiety and concurrent dyspnea ratings. Patients did not show a peak-end effect, whereas controls did.

CONCLUSION

The findings show that patients' experience of a dyspneic episode is subject to immediate memory bias, but does not change over a longer time period. The results also highlight the importance of affective state during symptom experience for both symptom perception and memory.

Comparison of the Factor Structure of the Patient Health Questionnaire for Somatic Symptoms (PHQ-15) in Germany, the Netherlands, and China. A Transcultural Structural Equation Modeling (SEM) Study

Background: Persistent somatic symptoms are associated with psychological distress, impaired function, and medical help-seeking behavior. The Patient Health Questionnaire (PHQ)-15 is used as a screening instrument for somatization and as a monitoring instrument for somatic symptom severity. A bifactorial model has been described, with one general factor and four orthogonal specific symptom factors. The objective of the present study was to assess and to clarify the factor structure of the PHQ-15 within and between different countries in Western Europe and China. Method: Cross-sectional secondary data analysis performed in three patient data samples from two Western European countries (Germany N = 2,517, the Netherlands N = 456) and from China (N = 1,329). Confirmatory factor analyses (CFA), and structural equation modeling (SEM) analysis were performed. Results: The general factor is found in every sample. However, although the outcomes of the PHQ-15 estimate severity of somatic symptoms in different facets, these subscales may have different meanings in the European and Chinese setting. Replication of the factorial structure was possible in the German and Dutch datasets but not in the dataset from China. For the Chinese dataset, a bifactorial model with a different structure for the cardiopulmonary factor is suggested. The PHQ-15 could discern somatization from anxiety and depression within the three samples. Conclusion: The PHQ-15 is a valid questionnaire that can discern somatization from anxiety and depression within different cultures like Europe or China. It can be fitted to a bifactorial model for categorical data, however, the model can only be recommended for use of the general factor. Application of the orthogonal subscales in non-European samples is not corroborated by the results. The differences cannot be ascribed to differences in health care settings or by differences in concomitant depression or anxiety but instead, a cultural factor involving concepts of disease may play a role in this as they may play a role in the translation of the questionnaire. Further research is needed to explore this, and replication studies are needed regarding the factorial structure of the PHQ-15 in China.

Die deutsche Version des „Driving Cognitions Questionnaire“ (DCQ)

Zusammenfassung. Theoretischer Hintergrund: Die Kenntnis spezifischer Kognitionen autofahrphobischer Patient_innen kann zum Verständnis der Ätiologie der Autofahrphobie sowie deren differentialdiagnostischer Abgrenzung beitragen. Die Modifikation dysfunktionaler Kognitionen bei Autofahrphobie ist zudem Ziel kognitiv-behavioraler Therapien. Bisher liegt jedoch kein deutschsprachiges Messinstrument vor, um spezifische Kognitionen bei Autofahrphobie zu erfassen, sodass die Skala „Driving Cognitions Questionnaire“ (DCQ) von Ehlers et al. (2007) ins Deutsche übersetzt wurde. Erfasst werden panikbezogene Sorgen, unfallbezogene Sorgen und Sorgen über die Bewertung durch Andere. Ziel ist eine psychometrische Validierung der deutschen Übersetzung des DCQ. Methode: Der DCQ wurde 98 ambulanten Psychotherapiepatient_innen sowie 843 Personen im Rahmen einer Online-Erhebung vorgelegt. Zur Validierung des deutschsprachigen Messinstruments wurde eine gekürzte Adaptation des „Driving Situations Questionnaire“ (DSQ) von Ehlers, Hofmann, Herda & Roth (1994) sowie das „Brief Symptom Inventory 18“ (BSI-18) von Franke et al. (2011) herangezogen. Dargestellt werden sowohl item- und skalentheoretische Befunde als auch faktorenanalytische Ergebnisse. Ergebnis: Die exploratorische Faktorenanalyse bestätigt die dreifaktorielle Struktur der Originalversion und konfirmatorisch führt ein bifaktorielles Modell zu einem guten Fit. Es liegen Belege für eine gute Reliabilität (.86 ≤ α ≤ .89) und Validität vor. Schlussfolgerung: Die deutsche Version des DCQ ist sowohl für Forschung als auch für die klinische Praxis einsetzbar und kann als Grundlage für weitere Untersuchungen in Bereichen der Klassifikation, Ätiologie und der Entwicklung von Behandlungsansätzen genutzt werden.

Prevalence and strong association of high somatic symptom severity with depression and anxiety in a Chinese inpatient population

BACKGROUND

The prevalence of the high somatic symptom severity (HSSS) and its associations with sociodemographic factors, depression, and anxiety has not been surveyed in inpatient populations at general hospitals.

METHODS

A sample including 1329 inpatients in a Chinese general hospital was surveyed using Chinese version of 15-item patient health questionnaire (PHQ-15), 9-item patient health questionnaire, and generalized anxiety disorder 7-item scale.

RESULTS

A total of 27.8% (n = 369) of the participants had HSSS (PHQ-15 ≥ 10). The multivariate regression showed that HSSS was significantly associated with depression (adjusted odds ratio [aOR], 5.219), anxiety (aOR, 5.810), or depression or anxiety (aOR, 5.338) but neither with sex, age, marital status, education status, household income, nor 7 kinds of physical disease systems.

DISCUSSION

The symptom profile and high prevalence of HSSS, and its association with clinically significant depression and anxiety in this inpatient population were mostly consistent to that documented by studies in other populations.

Systematic review of measurement properties of questionnaires measuring somatization in primary care patients

OBJECTIVE

The aim of this review is to critically appraise the evidence on measurement properties of self-report questionnaires measuring somatization in adult primary care patients and to provide recommendations about which questionnaires are most useful for this purpose.

METHODS

We assessed the methodological quality of included studies using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. To draw overall conclusions about the quality of the questionnaires, we conducted an evidence synthesis using predefined criteria for judging the measurement properties.

RESULTS

We found 24 articles on 9 questionnaires. Studies on the Patient Health Questionnaire-15 (PHQ-15) and the Four-Dimensional Symptom Questionnaire (4DSQ) somatization subscale prevailed and covered the broadest range of measurement properties. These questionnaires had the best internal consistency, test-retest reliability, structural validity, and construct validity. The PHQ-15 also had good criterion validity, whereas the 4DSQ somatization subscale was validated in several languages. The Bodily Distress Syndrome (BDS) checklist had good internal consistency and structural validity. Some evidence was found for good construct validity and criterion validity of the Physical Symptom Checklist (PSC-51) and good construct validity of the Symptom Check-List (SCL-90-R) somatization subscale. However, these three questionnaires were only studied in a small number of primary care studies.

CONCLUSION

Based on our findings, we recommend the use of either the PHQ-15 or 4DSQ somatization subscale for somatization in primary care. Other questionnaires, such as the BDS checklist, PSC-51 and the SCL-90-R somatization subscale show promising results but have not been studied extensively in primary care.

Somatic symptom profiles in the general population: a latent class analysis in a Danish population-based health survey

Purpose

The aim of this study was to identify and describe somatic symptom profiles in the general adult population in order to enable further epidemiological research within multiple somatic symptoms.

Methods

Information on 19 self-reported common somatic symptoms was achieved from a population-based questionnaire survey of 36,163 randomly selected adults in the Capital Region of Denmark (55.4% women). The participants stated whether they had been considerably bothered by each symptom within 14 days prior to answering the questionnaire. We used latent class analysis to identify the somatic symptom profiles. The profiles were further described by their association with age, sex, chronic disease, and self-perceived health.

Results

We identified 10 different somatic symptom profiles defined by number, type, and site of the symptoms. The majority of the population (74.0%) had a profile characterized by no considerable bothering symptoms, while a minor group of 3.9% had profiles defined by a high risk of multiple somatic symptoms. The remaining profiles were more likely to be characterized by a few specific symptoms. The profiles could further be described by their associations with age, sex, chronic disease, and self-perceived health.

Conclusion

The identified somatic symptom profiles could be distinguished by number, type, and site of the symptoms. The profiles have the potential to be used in further epidemiological studies on risk factors and prognosis of somatic symptoms but should be confirmed in other population-based studies with specific focus on symptom burden.

The cross-sectional relation between medically unexplained physical symptoms (MUPS) and the Cortisol Awakening Response

OBJECTIVES

We aimed to assess the cross-sectional relation between levels of cortisol and specific symptom clusters, symptom severity and duration of symptoms in patients with medically unexplained physical symptoms (MUPS).

METHODS

Baseline data of a cohort of MUPS patients were used. We chose the Cortisol Awakening Response (CAR) as a cortisol parameter, using saliva samples. We used confirmatory factor analysis for the identification of 4 specific symptom clusters: (1) gastro-intestinal symptoms; (2) pain; (3) cardio-pulmonary symptoms; and (4) fatigue. For this factor analysis we used the Physical Symptom Questionnaire (PSQ), which assesses the occurrence and frequency of 51 physical symptoms. Symptom severity was measured with the Patient Health Questionnaire-15 (PHQ-15). Duration of symptoms was based on self-reported duration of top 3 symptoms. We performed multiple linear regression to assess relations between CAR and individual factor scores on symptom clusters, symptom severity and duration of symptoms.

RESULTS

Data from 296 patients (76% female) were included in the analyses. The majority of patients suffered from symptoms in multiple organ systems. Factor analysis confirmed that the model with 4 symptom clusters fitted our data. For the total study population, we found no significant relation between CAR and participants' factor scores on any of the symptom clusters. We also found no significant relations between CAR and severity or duration of symptoms.

CONCLUSION

Our results suggest that within a heterogeneous MUPS population there is no relation between CAR and symptom severity and duration. However, more studies are needed to confirm our findings.

Multiple somatic symptoms in primary care: A field study for ICD-11 PHC, WHO's revised classification of mental disorders in primary care settings

OBJECTIVE

A World Health Organization (WHO) field study conducted in five countries assessed proposals for Bodily Stress Syndrome (BSS) and Health Anxiety (HA) for the Primary Health Care Version of ICD-11. BSS requires multiple somatic symptoms not caused by known physical pathology and associated with distress or dysfunction. HA involves persistent, intrusive fears of having an illness or intense preoccupation with and misinterpretation of bodily sensations. This study examined how the proposed descriptions for BSS and HA corresponded to what was observed by working primary care physicians (PCPs) in participating countries, and the relationship of BSS and HA to depressive and anxiety disorders and to disability.

METHOD

PCPs referred patients judged to have BSS or HA, who were then interviewed using a standardized psychiatric interview and a standardized measure of disability.

RESULTS

Of 587 patients with BSS or HA, 70.4% were identified as having both conditions. Participants had an average of 10.9 somatic symptoms. Patients who presented somatic symptoms across multiple body systems were more disabled than patients with symptoms in a single system. Most referred patients (78.9%) had co-occurring diagnoses of depression, anxiety, or both. Anxious depression was the most common co-occurring psychological disorder, associated with the greatest disability.

CONCLUSION

Study results indicate the importance of assessing for mood and anxiety disorders among patients who present multiple somatic symptoms without identifiable physical pathology. Although highly co-occurring with each other and with mood and anxiety disorders, BSS and HA represent distinct constructs that correspond to important presentations in primary care.

The relation between the patient health questionnaire-15 and DSM somatic diagnoses

BACKGROUND

Our purpose was to examine the reliability and validity of the Chinese version of the Patient Health Questionnaire-15 (PHQ-15) in Taiwan, and to explore its relation to somatoform disorders (DSM-IV) and to somatic symptom and related disorders (DSM-5).

METHODS

We recruited 471 individuals, 151 with somatoform disorders and 200 with somatic symptom and related disorders. Subjects completed the Chinese version of the PHQ-15, Beck Depression Inventory-II (BDI-II), Beck Anxiety Inventory (BAI), and received a DSM-IV- and DSM-5-based diagnostic interview. We performed exploratory factor analysis and assessed test-retest reliability, internal consistency, and correlation with BDI-II/BAI to confirm reliability and validity, and carried out ROC curve analysis to determine suitability for evaluation or screening purposes. PHQ-15 scores were compared between patients with various DSM-IV psychiatric diagnoses (such as DSM-IV somatoform disorders, panic disorder, other anxiety/depressive disorders) or no DSM-IV diagnosis and patients with DSM-5 somatic symptom and related disorders or no DSM-5 diagnosis.

RESULTS

The Chinese version identified cardiopulmonary, pain-fatigue, and gastrointestinal as major factors and had good reliability (0.803-0.930), internal consistency (0.637-0.861), and correlation coefficients with BDI-II/BAI (0.407-0.619, 0.536-0.721, respectively). The PHQ-15 scores were similar in patients with somatoform disorders and patients with panic disorder; higher in patients with somatoform disorders and panic disorder than in patients with other anxiety/depressive disorders; and significantly higher in patients with somatic symptom and related disorders than in patients without this diagnosis. The AUC of the PHQ-15 was 0.678 (cutoff 6/7) for screening somatoform disorders (DSM-IV) and 0.725 (cutoff 4/5) for screening somatic symptom and related disorders (DSM-5).

CONCLUSIONS

The Chinese version of the PHQ-15 is suitable for evaluating somatic symptom and related disorders. The preponderance of somatic symptom disorder in our sample, lack of evaluation of functional disorders, and recruitment solely from psychiatric clinics are possible limitations.

The Four-Dimensional Symptom Questionnaire (4DSQ) in the general population: scale structure, reliability, measurement invariance and normative data: a cross-sectional survey

BACKGROUND

The Four-Dimensional Symptom Questionnaire (4DSQ) is a self-report questionnaire measuring distress, depression, anxiety and somatization with separate scales. The 4DSQ has extensively been validated in clinical samples, especially from primary care settings. Information about measurement properties and normative data in the general population was lacking. In a Dutch general population sample we examined the 4DSQ scales' structure, the scales' reliability and measurement invariance with respect to gender, age and education, the scales' score distributions across demographic categories, and normative data.

METHODS

4DSQ data were collected in a representative Dutch Internet panel. Confirmatory factor analysis was used to examine the scales' structure. Reliability was examined by Cronbach's alpha, and coefficients omega-total and omega-hierarchical. Differential item functioning (DIF) analysis was used to evaluate measurement invariance across gender, age and education.

RESULTS

The total response rate was 82.4 % (n = 5273/6399). The depression scale proved to be unidimensional. The other scales were best represented as bifactor models consisting of a large general factor and one or more smaller specific factors. The general factors accounted for more than 95 % of the reliable variance of the scales. Reliability was high (≥0.85) by all estimates. The distress-, depression- and anxiety scales were invariant across gender, age and education. The somatization scale demonstrated some lack of measurement invariance as a result of decreased thresholds for some of the items in young people (16-24 years) and increased thresholds in elderly people (65+ years). The somatization scale was invariant regarding gender and education. The 4DSQ scores varied significantly across demographic categories, but the explained variance was small (<6 %). Normative data were generated for gender and age categories. Approximately 17 % of the participants scored above average on de distress scale, whereas 12 % scored above average on de somatization scale. Percentages of people scoring high enough on depression or anxiety as to suspect the presence of depressive or anxiety disorder were 4.1 and 2.5 respectively.

CONCLUSIONS

Evidence supports reliability and measurement invariance of the 4DSQ in the general Dutch population. The normative data provided in this study can be used to compare a subject's 4DSQ scores with a general population reference group.

Fibromyalgia: A Critical and Comprehensive Review

Fibromyalgia is a disorder that is part of a spectrum of syndromes that lack precise classification. It is often considered as part of the global overview of functional somatic syndromes that are otherwise medically unexplained or part of a somatization disorder. Patients with fibromyalgia share symptoms with other functional somatic problems, including issues of myalgias, arthralgias, fatigue and sleep disturbances. Indeed, there is often diagnostic and classification overlap for the case definitions of a variety of somatization disorders. Fibromyalgia, however, is a critically important syndrome for physicians and scientists to be aware of. Patients should be taken very seriously and provided optimal care. Although inflammatory, infectious, and autoimmune disorders have all been ascribed to be etiological events in the development of fibromyalgia, there is very little data to support such a thesis. Many of these disorders are associated with depression and anxiety and may even be part of what has been sometimes called affected spectrum disorders. There is no evidence that physical trauma, i.e., automobile accidents, is associated with the development or exacerbation of fibromyalgia. Treatment should be placed on education, patient support, physical therapy, nutrition, and exercise, including the use of drugs that are approved for the treatment of fibromyalgia. Treatment should not include opiates and patients should not become poly pharmacies in which the treatment itself can lead to significant morbidities. Patients with fibromyalgia are living and not dying of this disorder and positive outlooks and family support are key elements in the management of patients.

The latent structure of the functional dyspepsia symptom complex: a taxometric analysis

OBJECTIVES

Rome III introduced a subdivision of functional dyspepsia (FD) into postprandial distress syndrome and epigastric pain syndrome, characterized by early satiation/postprandial fullness, and epigastric pain/burning, respectively. However, evidence on their degree of overlap is mixed. We aimed to investigate the latent structure of FD to test whether distinguishable symptom-based subgroups exist.

METHODS

Consecutive tertiary care Rome II FD patients completed the dyspepsia symptom severity scale. Confirmatory factor analysis (CFA) was used to compare the fit of a single factor model, a correlated three-factor model based on Rome III subgroups and a bifactor model consisting of a general FD factor and orthogonal subgroup factors. Taxometric analyses were subsequently used to investigate the latent structure of FD.

KEY RESULTS

Nine hundred and fifty-seven FD patients (71.1% women, age 41 ± 14.8) participated. In CFA, the bifactor model yielded a significantly better fit than the two other models (χ² difference tests both p < 0.001). All symptoms had significant loadings on both the general and the subgroup-specific factors (all p < 0.05). Somatization was associated with the general (r = 0.72, p < 0.01), but not the subgroup-specific factors (all r < 0.13, p > 0.05). Taxometric analyses supported a dimensional structure of FD (all CCFI<0.38).

CONCLUSIONS AND INFERENCES

We found a dimensional rather than categorical latent structure of the FD symptom complex in tertiary care. A combination of a general dyspepsia symptom reporting factor, which was associated with somatization, and symptom-specific factors reflecting the Rome III subdivision fitted the data best. This has implications for classification, pathophysiology, and treatment of FD.