An international study comparing the effect of medically explained and unexplained somatic symptoms on psychosocial outcome

The framework for systematic reviews on psychological risk factors for persistent somatic symptoms and related syndromes and disorders (PSY-PSS)

Introduction

Numerous psychological factors are believed to play a pivotal role in the development and maintenance of persistent somatic symptoms (PSS) in all fields of medicine. However, very few of these factors have been empirically investigated in relation to PSS. The aim of this study is firstly to propose a framework and define search terms for systematic reviews on the empirical evidence and diagnostic value of psychological risk factors for PSS and PSS-related outcomes (PSY-PSS). Secondly, the application of the framework is illustrated using the example of a systematic review on the relevance of psychological factors in somatic symptom disorders (SSD; DSM-5) and bodily distress disorders (BDD; ICD-11).

Methods

Following a narrative review approach, two comprehensive lists of search terms to identify studies in (1) relevant patient groups with PSS and (2) relevant psychological factors were generated by reviewing the current literature and employing an iterative process of internal revision and external expert feedback.

Results

We identified 83 relevant symptoms, syndromes and disorders for which we defined a total of 322 search terms (list 1). We further comprised 120 psychological factors into 42 subcategories and 7 main categories (list 2). The introduced lists can be combined to conduct systematic reviews on one or more specific psychological factors in combination with any symptom, syndrome or disorder of interest. A protocol of the application of this framework in a systematic review and meta-analysis on psychological etiological factors of SSD and BDD is presented following the PRISMA guidelines.

Discussion

This framework will help to gather systematic evidence on psychological factors in order to improve the understanding of the etiology of PSS, to refine future diagnostic conceptualizations of PPS, and to develop optimized mechanism-based interventions for individuals with PPS and related syndromes and disorders.

The Amplification of Symptoms in the Medically Ill

The mechanism of symptom amplification, developed in the study of somatization, may be helpful in caring for patients with symptoms that, while they have a demonstrable medical basis, are nonetheless disproportionately severe and distressing. Amplified medical symptoms are marked by disproportionate physical suffering, unduly negative thoughts and concerns about them, and elevated levels of health-related anxiety. They are accompanied by extensive and sustained illness behaviors, disproportionate difficulty compartmentalizing them and circumscribing their impact, and consequent problems and dissatisfaction with their medical care. A distinction has long been made between "medically explained" and "medically unexplained" symptoms. However, a more comprehensive view of symptom phenomenology undermines this distinction and places all symptoms along a smooth continuum regardless of cause: Recent findings in cognitive neuroscience suggest that all symptoms-regardless of origin-are processed through convergent pathways. The complete conscious experience of both medically "explained" and "unexplained" symptoms is an amalgam of a viscerosomatic sensation fused with its ascribed salience and the patient's ideas, expectations, and concerns about the sensation. This emerging empirical evidence furnishes a basis for viewing persistent, disproportionately distressing symptoms of demonstrable disease along a continuum with medically unexplained symptoms. Thus, therapeutic modalities developed for somatization and medically unexplained symptoms can be helpful in the care of seriously ill medical patients with amplified symptoms. These interventions include educational groups for coping with chronic illness, cognitive therapies for dysfunctional thoughts, behavioral strategies for maladaptive illness behaviors, psychotherapy for associated emotional distress, and consultation with mental health professionals to assist the primary care physician with difficulties in medical management.

Are Anxious and Depressive Symptoms Associated with Gastrointestinal Symptoms in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL)?

Psychological distress is common among non-Hispanic/Latino adults with gastrointestinal (GI) symptoms. Heartburn and acid regurgitation symptom prevalence, and their relationship with anxious and depressive symptoms, was examined in 16,415 Hispanic Community Health Study/Study of Latinos participants aged 18-74 from 4 US cities (Bronx, NY; Chicago, IL; Miami, FL; San Diego, CA). Complex survey logistic regression models were used to test relations between GI, anxious, and depressive symptoms. 10.1% (95% confidence interval [CI] = 9.4, 10.8) and 8.9% (95% CI = 8.3, 9.5) of the overall sample (estimates are weighted and adjusted for age and body mass index) respectively self-reported heartburn and acid regurgitation at least several times/week within the past year. Adults who reported GI symptoms several times/week or more also self-reported higher psychological distress compared to adults who reported GI symptoms less frequently. For one standard deviation higher in anxious symptoms (5.6 units), GI prevalence odds were respectively 1.14 (95% CI = 1.10, 1.17) and 1.14 (95% CI = 1.09, 1.18) for heartburn and acid regurgitation. GI prevalence odds (heartburn = 1.14, 95% CI = 1.11, 1.18; acid regurgitation = 1.15, 95% CI = 1.10, 1.18) were similar for one standard deviation higher in depressive symptoms (5.9 units). Demographic, health, and clinical characteristics did not significantly attenuate relationships between GI and psychological distress symptoms. Psychological distress is related to GI symptoms in US Hispanics/Latinos.

Identifying clusters of health symptoms in deployed military personnel and their relationship with probable PTSD

OBJECTIVE

Among military personnel posttraumatic stress disorder is strongly associated with non-specific health symptoms and can have poor treatment outcomes. This study aimed to use machine learning to identify and describe clusters of self-report health symptoms and examine their association with probable PTSD, other psychopathology, traumatic deployment exposures, and demographic factors.

METHOD

Data were from a large sample of military personnel who deployed to the Middle East (n = 12,566) between 2001 and 2009. Participants completed self-report measures including health symptoms and deployment trauma checklists, and several mental health symptom scales. The data driven machine learning technique of self-organised maps identified health symptom clusters and logistic regression examined their correlates.

RESULTS

Two clusters differentiated by number and severity of health symptoms were identified: a small 'high health symptom cluster' (HHSC; n = 366) and a large 'low health symptom cluster' (LHSC; n = 12,200). The HHSC had significantly higher proportions of (Gates et al., 2012 [1]) scaled scores indicative of PTSD (69% compared with 2% of LHSC members), Unwin et al. (1999a) [2] scores on other psychological scales that were indicative of psychopathology, and (Graham et al., n.d. [3]) deployment trauma. HHSC members with probable PTSD had a stronger relationship with subjective (OR 1.25; 95% CI 1.12, 1.40) and environmental (OR 1.08; 95% CI 1.03, 1.13) traumatic deployment exposures than LHSC members with probable PTSD.

CONCLUSION

These findings highlights that health symptoms are not rare in military veterans, and that PTSD is strongly associated with health symptoms. Results suggest that there may be subtypes of PTSD, differentiated by health symptoms.

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.

Evaluating challenges for improving medically unexplained symptoms in US military veterans via provider communication

OBJECTIVES

Medically unexplained symptoms (MUS) are common, with particularly high rates observed in military veterans. Effective patient-provider-communication is thought to be a key aspect of care; however there have been few empirical studies on the association between communication and outcomes for patients with MUS. We evaluate whether discussing veterans' MUS-illness representations and good interpersonal skills have the potential to promote MUS-treatment adherence and improvement.

METHODS

Veterans experiencing MUS (n=204) reported on their primary care providers' communication about illness representations and interpersonal skills; correlation, regression, and bootstrap-mediation analyses were conducted to test hypotheses regarding veteran-reported outcomes. Main outcomes included satisfaction with the provider, MUS-treatment adherence, intentions to adhere, and expectations for MUS improvement.

RESULTS

Veterans reported infrequent discussion of MUS illness representations but high degrees of provider interpersonal skills. Communication regarding patients' illness representations and treatment expectations was significantly related to treatment adherence and adherence intentions; provider interpersonal skills were not. Both were related to veteran satisfaction.

CONCLUSIONS AND PRACTICE IMPLICATIONS

Providers' interpersonal skills may be important in chronic illness contexts, such as MUS, by contributing to satisfaction with the provider. The current study suggests that providers may better promote MUS-treatment adherence through discussing MUS illness representations and treatment expectations.

High healthcare utilization near the onset of medically unexplained symptoms

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Burden and risk factors for gastrointestinal symptom distress in HIV patients in the modern antiretroviral era

In the modern antiretroviral (ARV) era, there is limited knowledge about the prevalence and risk factors for HIV patient-reported gastrointestinal (GI) symptoms (diarrhoea/soft stool, nausea/vomiting, bloating/painful abdomen, loss of appetite, and weight loss/wasting) and distress. We prospectively analysed data (2007-2014) on distressing GI symptoms from the Ontario HIV Treatment Network Cohort Study, which follows people attending HIV clinics. Using generalized estimating equations with a logit link, we estimated the associations of psychosocial, demographic, behavioural, and clinical factors with each GI symptoms compared to asymptomatic and non-bothersome symptoms. Among 1532 included participants, 80.4% were male, mean age was 45 years, and 64.6% reported being men who have sex with men. Most were Caucasian (56.3%), a median time since HIV diagnosis of 9.8 years (interquartile range (IQR): 4.1-16.9), and 83.1% were on ARV. More than two-thirds (68.7% (95% confidence intervals (CI): 63.1% to 69.2%)) reported one or more symptoms with a median of 1.2 (IQR: 0-1.7). The proportion remained stable over time since HIV diagnosis and ARV initiation. Risk factors varied for multivariable models. A strong association with Centre for Epidemiologic Studies Depression scale scores of ≥23 was found for all symptoms. Adjusted odds ratios (95% CI) were 1.72 (1.39-2.12), 2.95 (2.33-3.72), 2.20 (1.81-2.68), 4.97 (3.99-6.19), and 2.98 (2.52-3.82) for diarrhoea, nausea/vomiting, bloating, loss of appetite, and weight loss, respectively. With the exception of bloating, odds were significantly lower for those on ARV containing integrase inhibitors and greater for patients reporting current cannabis use. GI symptoms in the modern ARV era are highly prevalent and may arise as a common pathway of distress in response to psychosocial vulnerabilities, regardless of the stage of diagnosis. These findings support the need for integrated approaches to address psychological and physical distress in HIV disease.

An experimental paradigm to repeatedly induce somatic symptoms

OBJECTIVE

Experimental research in the field of medically unexplained physical symptoms (MUPS) is rare. We examined a method of script driven imagery in terms of manipulating the intensity of the symptom, the impairment by the symptom and the symptom tolerance. Additionally, we identified relevant predictors for the efficacy of symptom induction.

METHODS

We assessed the most impairing symptom in 48 subjects suffering from multiple, chronic MUPS and a severe physical illness that 48 age-matched healthy controls suffered from in the past. An individual script including thoughts and sensations accompanying the symptom was recorded. During the experiment, participants were exposed to the script repeatedly and then rated the intensity of, impairment by and tolerance of the symptom on a visual analog scale (VAS).

RESULTS

A mixed model repeated-measures-ANOVA revealed a significant main effect for the factor time (pre- and post-induction assessment; p<.001) but not for group (MUPS- vs. control-groups; p=.159-.314) indicating that the manipulation of all VASs was effective for both groups. The interaction time×group was significant for tolerance and post-hoc analyses showed no significant reduction for tolerance in the MUPS-group. The number of somatic symptoms and endurance behavior predicted higher induction efficacy in the MUPS-group for intensity. For healthy controls, endurance behavior and pain-persistence were associated with lower induction efficacy for all VAS.

CONCLUSION

Script-driven imagery could be a promising research procedure in the field of MUPS. It could be used to investigate short term effects of psychological interventions as well as physiological and cognitive processes accompanying symptom manipulation.

Psychiatric Comorbidity in Alcohol Dependence

We review our clinical studies of psychiatric comorbidity in short-term and long-term abstinent and in treatment naïve alcoholics (STAA, LTAA and TNA). TNA ypically have less severe alcoholism than treated abstinent samples and evidence less severe psychiatric disturbance. Lifetime psychiatric diagnoses are the norm for STAA and LTAA but not for TNA. Individuals with alcohol and drug use disorders show greater antisocial personality disturbance, but do not show differences in the mood or anxiety domains or in borderline personality disorder (BPD) symptoms. The studies show that alcoholics can achieve and maintain abstinence in the face of ongoing mood, anxiety, or BPD problems. By contrast, for ASPD, LTAA essentially stop current antisocial behaviors in all seven domains of antisocial behaviors. We believe that ongoing antisocial behavior is not consistent with maintaining abstinence, and that LTAA modify their antisocial behavior despite continued elevated social deviance proneness and antisocial dispositionality. Abstinent individuals without lifetime psychiatric disorders and TNA show more (subdiagnostic threshold) psychiatric symptoms and abnormal psychological measures than non-alcoholic controls in the mood, anxiety, BPD, and antisocial domains. In summary, our studies show that although LTAA have achieved multi-year abstinence, they still report significant psychological distress compared to NAC. We believe this distress may negatively affect their quality of life. This suggests the importance of developing effective care models to address comorbid mental health problems in LTAA. We also show that antisocial personality disorder symptoms decline to the levels seen in normal controls, and that excluding individuals from research with a psychiatric diagnosis does not control for subdiagnostic psychiatric differences between alcoholics and controls.

Medically Unexplained Symptoms: an acceptable term?

BACKGROUND

The term 'Medically Unexplained Symptoms' (MUS) is used by health professionals and researchers to refer to persistent bodily complaints, including pain and discomfort.

AIMS

This study explores the views held by a lay sample on the clinical terminology used to describe 'MUS', to ascertain reasons for particular preferences and whether preferences differ between individuals who experience more somatic symptoms.

DESIGN AND METHODS

A sample (n = 844) of healthy adults completed an online survey, which included a questionnaire measuring somatic symptoms (Patient Health Questionnaire-15 (PHQ-15)) and a question about their preferences for terminology used to describe MUS.

RESULTS

Of 844 participants, 698 offered their preferences for terminology. The most popular terms were 'Persistent Physical Symptoms' (20%) and 'Functional Symptoms' (17%). 'MUS' (15%), 'Body Distress Disorder' (13%) and 'Complex Physical Symptoms' (5%) were less popular. And 24% indicated no preference, but high PHQ-15 scorers were more likely to express preferences than low scorers.

CONCLUSION

Persistent Physical Symptoms and Functional Symptoms are more acceptable to this sample of healthy adults than the more commonly used term 'MUS'.

Psychological and behavioral variables associated with the somatic symptom severity of general hospital outpatients in China

OBJECTIVE

In high-income countries, the number and severity of somatic symptoms - irrespective of etiology--are associated with adverse psychobehavioral and functional characteristics. This study aimed to assess these key features among Chinese general hospital outpatients with high levels of somatic symptoms.

METHODS

This multicenter, cross-sectional study evaluated four outpatient departments of internal medicine and Traditional Chinese Medicine in Beijing and Kunming and enrolled a total of 281 consecutive patients. The patients answered questionnaires concerning somatic symptom severity [Patient Health Questionnaire (PHQ-15)], illness perception (Brief Illness Perception Questionnaire), illness behavior (Scale for the Assessment of Illness Behavior), emotional distress (Hospital Anxiety and Depression Scale) and health-related quality of life (12-Item Short Form Health Survey). Subsamples reporting high scores of somatic symptom severity (PHQ-15 ≥10, SOM+) versus low scores (PHQ-15 <10, SOM-) were compared.

RESULTS

Twenty-eight percent (79/281) of all outpatients showed high somatic symptom severity. The strongest correlations between high somatic symptom severity and psychobehavioral variables were found for high emotional distress, female gender, living alone, low physical quality of life and high dysfunctional illness behavior. The proportion of the explained variance was 36.1%.

CONCLUSION

In Chinese outpatients, high somatic symptom severity is frequent and associated with psychobehavioral characteristics. With the PHQ-15 cutoff of 10, SOM+ patients could be differentiated from SOM- patients using these characteristics.

Multiple symptoms and medically unexplained symptoms--closely related concepts in general practitioners' evaluations. A linked doctor-patient study

OBJECTIVES

Symptoms for which doctors cannot find a clear medical explanation, medically unexplained symptoms (MUS), represent a challenge in medical practice. Recent proposals to define this phenomenon are based on patients' symptom count, without distinguishing between medically explained and unexplained symptoms. We describe how general practitioners (GPs) evaluate multiple and medically unexplained symptoms, and how these dimensions are interconnected. Furthermore, we explore how the number of patient-reported symptoms is associated with the two axes.

METHODS

A multi-centre, doctor-patient-linked cross-sectional study in general practice. GPs rated consecutive patients along two 11 point ordinal scales assessing multiple (Multi-scale) and medically unexplained symptoms (MUS-scale). Patients completed a questionnaire addressing 38 symptoms experienced during the previous week and 866 linked questionnaires were available for analysis.

RESULTS

GPs used the whole range of the scales, rating only a minority of the patients as "0 (not at all)". The two scales were highly correlated (r=0.80), with a quadratically weighted kappa of 0.73, reflecting substantial agreement between the scales. MUS-scores were highest in middle age. There was a tendency that Multi-scores increased with age and that correlations between the scales decreased with age, in both sexes, although partly non-significant. The number of patient-reported symptoms was moderately correlated with the two scales.

CONCLUSION

Multisymptomatology captures MUS as a continuous construct to a great degree in GPs' clinical evaluations, although the two cannot be regarded as the same phenomenon. Patient-reported symptoms seem to be a less valid proxy for MUS.

Somatic symptoms in consultation-liaison psychiatry

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

Symptom load and functional status: results from the Ullensaker population study

Background

There is evidence to support that the number of self-reported symptoms is a strong predictor of health outcomes. In studies examining the link between symptoms and functional status, focus has traditionally been on individual symptoms or specific groups of symptoms. We aim to identify associations between the number of self-reported symptoms and functional status.

Methods

A questionnaire was sent to people in seven age groups (N = 3227) in Ullensaker municipality in Southern Norway. The Standardised Nordic Questionnaire and the Subjective Health Complaints Inventory were used to record 10 musculoskeletal symptoms and 13 non-musculoskeletal symptoms, respectively. Four COOP-WONCA charts were used to measure functional status.

Results

We found a strong linear association between the number of self-reported symptoms and functional status. The number of symptoms explained 39.2% of the variance in functional status after adjusting for the effects of age and sex. Including individual symptoms instead of only the number of symptoms made little difference to the effect of musculoskeletal pain but affected the influence of non-muscular symptoms. Including even minor problems captured substantially more of the variance in functional status than including only serious problems.

Conclusions

The strong association between the number of symptoms and functional status, irrespective of type of symptom, might indicate that the symptoms share some common characteristics. The simple act of counting symptoms may provide an approach to study the relationships between health and function in population studies and might be valuable in research on medically unexplained conditions.

Relationship of somatic symptoms with depression severity, quality of life, and health resources utilization in patients with major depressive disorder seeking primary health care in Spain

OBJECTIVE

To investigate the relationship between the characteristics of somatic symptoms and depression severity, quality of life (QOL), and health resources utilization in patients with major depressive disorder (MDD) in primary care setting.

METHOD

This cross-sectional, nationwide epidemiologic study, carried out in 1150 primary care patients with DSM-IV-defined MDD, evaluated the characteristics of somatic symptoms by means of the Standardized Polyvalent Psychiatric Interview. Depression severity and QOL were evaluated by means of the Zung Self-Rating Depression Scale (SDS) and the Physical and Mental Component Summaries of the Medical Outcomes Study 12-item Short-Form Health Survey. Health resources utilization was measured in terms of doctor consultations and hospitalizations. The associations were assessed by means of adjusted analyses. The study was carried out from April 2004 to July 2004.

RESULTS

Disability associated with somatic symptoms and number of somatic symptoms were strongly associated with increased depression severity (2.45 and 0.29 increase in SDS score, respectively) and health resources utilization (odds ratios of 1.42 and 1.04, respectively). Associated disability, frequency, and persistence during leisure time of somatic symptoms were strongly associated with poorer QOL. In contrast, we found a weaker relationship between duration and intensity of somatic symptoms and depression severity, QOL, and health resources utilization.

CONCLUSIONS

Of the studied somatic symptom characteristics, somatic symptom-associated disability and number of somatic symptoms are strongly associated with increased depression severity and health resources utilization, as well as with decreased QOL. Our results may help physicians identify relevant characteristics of somatic symptoms to more effectively diagnose and treat depression in primary care patients.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Role of mental health professionals in the management of functional somatic symptoms in primary care

Functional somatic symptoms associated with persistent frequent attendance is emotionally demanding, costly and intractable to treat. Such patients are hard to engage in practice and research by mental health professionals, whose main role may be indirect training, supporting and advising primary care professionals rather than direct patient care.

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.

Association of somatic symptoms with depression and anxiety in clinical patients of general hospitals in Guangzhou, China

OBJECTIVES

In high-income countries, depression and anxiety are reported to be common reasons for patients visiting nonpsychiatric services. This study aimed to assess the rate of depression and anxiety, and their associations with somatic symptoms, in patients presenting to clinics of general hospitals in Guangzhou, China.

METHODS

In a hospital-based cross-sectional study of 2408 randomly selected clinical patients from 15 general hospitals, we assessed depression and anxiety via the Hospital Anxiety and Depression Scale (HADS), somatic symptoms via the Patient Health Questionnaire 15-Item Somatic Symptom Severity Scale (PHQ-15) and patients' view of the impact of somatic symptoms on their life, job and social relationships. Multiple logistic models were used to analyze the association of somatic symptoms with depression and anxiety, the underlying physical diseases and the self-rated somatic symptoms' impact on social functions.

RESULTS

Of the participants, 454 (19.0%) reported moderate to high somatic symptoms (PHQ-15 score ≥ 10), 367 (15.2%) had depression (HADS-D score ≥ 7), 167 (6.9%) had anxiety (HADS-A score ≥ 10), and 125 (5.2%) had both depression and anxiety (HADS-D ≥ 7 and HADS-A ≥ 10). Patients with depression and anxiety had higher somatic symptoms and rated these symptoms as having a greater negative impact on their social functions. Relevant to other systemic diseases, only digestive system disease was associated with higher somatic symptoms and self-rated negative social impact, and great negative emotions. Stepwise multiple logistic analyses demonstrated that female sex and depression and anxiety were the main factors for the high somatic symptoms of the population.

CONCLUSIONS

Among patients who visit hospital clinics in Guangzhou, China, somatic complaints are highly associated with depression and anxiety, and rarely associated with their underlying medical diseases. The findings indicate the importance of recognizing and managing depression and anxiety for these patients.

Noninvasive radioelectric asymmetric brain stimulation in the treatment of stress-related pain and physical problems: psychometric evaluation in a randomized, single-blind placebo-controlled, naturalistic study

Background

The aim of this study was to investigate the effects of noninvasive radioelectric asymmetric conveyer brain stimulation (REAC-BS) on pain and physical problems, a measurement cluster of the Psychological Stress Measure (PSM) test. When the symptoms of pain and physical problems do not respond to various therapeutic approaches such as medication, physiotherapy, and psychotherapy, they are often called medically unexplained symptoms. As such, these symptoms are reported to be a response to stressful situations or emotional states, often unknown to patients themselves. To explore the effectiveness of noninvasive radioelectric brain stimulation in the amelioration of symptoms of pain and physical problems, we administered a neuropsychophysical optimization protocol using a REAC device.

Methods

The PSM, a self-administered questionnaire, was used to measure psychological stress and pain and physical problems in a group of 888 subjects. Data were collected immediately prior to and following a 4-week REAC treatment cycle.

Results

There was a significant reduction in scores measuring subjective perceptions of stress for subjects treated with one cycle of neuropsychophysical optimization REAC-BS. At the end of the study, the number of treated subjects reporting symptoms of stress-related pain and physical problems on the PSM test was significantly reduced, whereas there was no difference in placebo-treated subjects.

Conclusion

One cycle of neuropsychophysical optimization REAC-BS appears to reduce subjective perceptions of stress as measured by the PSM, particularly on the pain and physical problems cluster.

Do gastrointestinal complaints increase the risk for subsequent medically certified long-term sickness absence? The HUSK study

Background

Gastrointestinal complaints are very common in the general population and very often co-occur with common mental disorders. We aimed to study the prospective impact of gastrointestinal complaints on long term sickness absence, and address the contribution from co-occurring common mental disorders and other somatic symptoms.

Method

Health data on 13 880 40-45 year olds from the Hordaland Health Study (1997-99) were linked to national registries on sickness absence. As part of a wider health screening, gastrointestinal complaints were ascertained. Participant's anxiety and depression, and the presence of other somatic symptoms were evaluated. In Cox regression models, we predicted sickness absences over an average 5.4 years follow-up, with adjustment for confounders, anxiety and depression and other somatic symptoms.

Results

After adjusting for gender, level of education and smoking, those reporting GI complaints had higher risk for later sickness absence (HR = 1.42, 95% CI 1.34-1.51). GI complaints were associated with both anxiety (OR = 3.66, 95% CI 3.31-4.04) and depression (OR = 3.28, 95% CI 2.89-3.72), and a high level of other somatic symptoms (OR = 8.50, 95% CI 7.69-9.40). The association of GI complaints was still independently associated with future sickness absence (HR = 1.17, 95% CI 1.10-1.16) adjusting for mental illness and other somatic symptoms.

Discussion

Sickness absence is a complex behavioural outcome, but our results suggest GI complaints contribute by increasing the risk of long term sickness absence independently of comorbid mental illness and presence of other somatic symptoms. Occupational consequences of illness are important, and should also be addressed clinically with patients presenting with GI complaints.

Course and prediction of somatoform disorder and medically unexplained symptoms in primary care

THEORY/OBJECTIVE: Somatoform disorder (SFD) is associated with considerable psychosocial impairment. However, only a few studies have dealt with the course of this clinical subgroup. Therefore, the objective was to identify predictors for the various courses of SFD and medically unexplained symptoms (MUS).

METHOD

We screened 620 consecutive patients in primary care using the Patient Health Questionnaire (PHQ-15). Afterwards, 308 patients were studied in more detail using a diagnostic interview and a set of questionnaires. One year later, we were able to interview 277 participants a second time.

RESULT

After 1 year, 48.8% of the respondents had a remitted SFD. The following variables proved to be significant predictors of MUS: current depressive episode, negative life events, number of MUS at baseline, attributional style, autonomic sensations and catastrophizing cognitions. The course of SFD could be predicted through current depressive or anxiety disorder, negative life events, functional disability and attributional style.

CONCLUSION

Somatoform disorder has a favorable course. The predictors of the courses of SFD and MUS we found can be integrated into previous explanatory models. The coping with MUS or SFD can be seen as a mediating factor.

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.

Unexplained somatic symptoms during major depression: prevalence and clinical impact in a national sample of Italian psychiatric outpatients

BACKGROUND

The aim of this study was to explore the prevalence and impact of unexplained somatic symptoms during major depression.

SAMPLING AND METHODS

A total of 560 consecutive outpatients with a major depressive episode according to the DSM-IV (text revision) were evaluated in 30 psychiatric facilities throughout Italy. 'Unexplained' somatic symptoms were evaluated using the 30-item Somatic Symptoms Checklist (SSCL-30). Somatic symptoms were considered explained if they were best accounted for as coming from a concomitant physical illness or side effects. Patients evaluated their own mood symptomatology using the Zung questionnaires for depression and anxiety and the Hypomania Checklist-32.

RESULTS

According to the SSCL-30, only 90 subjects (16.1%) had no unexplained somatic symptoms, while 231 (41.3%) had 1-5 unexplained symptoms and 239 (42.7%) had more than 5. Asthenia was the most commonly observed unexplained somatic symptom (53% of patients). Unexplained somatic symptoms were more common in females and among those suffering from major depression and depression not otherwise specified rather than in patients with recurrent major depression and bipolar disorders. No relationship between unexplained somatic symptoms and hypomanic features was observed.

CONCLUSIONS

The presence of a large number of unexplained somatic symptoms is associated with more severe depression and higher rates of misdiagnosis and inappropriate treatment.

Interventions for anxiety in the critically ill: a guide for nurses and families

Anxiety is a common feeling for patients and families during the critical care experience. As anxiety for critically ill patients presents increased risks for morbidity and mortality, it is imperative that nurses strive to identify unrelieved anxiety early to prevent adverse events. Alleviating anxiety experienced by families as a result of the critical care experience involves providing assurance, allowing them to remain near the patient, providing accurate and current information, providing for their comfort, and projecting a supportive attitude. As constant care providers, nurses can have the greatest impact on creating an environment that is safe, healing, and humane for critically ill patients and their families.

Psychiatric comorbidity in older long-term abstinent alcoholics

BACKGROUND

We compared 89 older abstinent alcoholics (OAA, mean abstinence of 14.8 years), to 53 age and gender-comparable older non-alcoholic controls (ONC) with regard to lifetime and current psychiatric diagnoses, lifetime psychiatric symptom counts, and psychological measures in the mood, anxiety, and externalizing disorder domains. We compared these findings with our previously reported results in analogous middle-aged samples (MAA versus MNC).

METHODS

The methods used were the same as in our previous study of MAA versus MNC.

RESULTS

OAA had more lifetime psychiatric and mood disorder diagnoses than ONC. They also had more lifetime symptoms and psychological test evidence of psychiatric disorder in all domains. However, OAA were less different from ONC than were MAA from MNC on most psychiatric and psychological measures. In both studies, differences between alcoholics and controls were dramatically larger in the externalizing compared with the mood and anxiety domains, and there was little evidence that psychiatric comorbidity measures impacted abstinence duration.

CONCLUSIONS

The finding that OAA had less psychiatric illness than MAA may involve a combination of selective survivorship, selection bias, and cohort differences. Although selection bias may be present in clinical studies of samples of any age, it is a more potent problem in older samples. However, given these potential biases, our results underestimate psychiatric comorbidity in OAA, strengthening our finding of increased psychiatric disorder in OAA versus ONC.

Taking consultation-liaison psychiatry into primary care

Up to 50% of patients seen in primary care have mental health problems, the severity and duration of their problems often being similar to those of individuals seen in the specialized sector. This article describes the reasons, advantages, and challenges of collaborative or shared care between primary and mental health teams, which are similar to those of consultation-liaison psychiatry. In both settings, clinicians deal with the complex interrelationships between medical and psychiatric disorders. Although initial models emphasized collaboration between family physicians, psychiatrists, and nurses, collaborative care has expanded to involve patients, psychologists, social workers, occupational therapists, pharmacists, and other providers. Several factors are associated with favorable patient outcomes. These include delivery of interventions in primary care settings by providers who have met face-to-face and/or have pre-existing clinical relationships. In the case of depression, good outcomes are particularly associated with approaches that combined collaborative care with treatment guidelines and systematic follow-up, especially for those with more severe illness. Family physicians with access to collaborative care also report greater knowledge, skills, and comfort in managing psychiatric disorders, even after controlling for possible confounders such as demographics and interest in psychiatry. Perceived medico-legal barriers to collaborative care can be addressed by adequate personal professional liability protection on the part of each practitioner, and ensuring that other health care professionals with whom they work collaboratively are similarly covered.

Gastrointestinal symptoms in primary care: prevalence and association with depression and anxiety

OBJECTIVE

Results from general population studies suggest a relationship between gastrointestinal (GI) symptoms, depression, and anxiety. However, no primary care study has investigated this issue. This study investigates the prevalence of GI symptoms in primary care and their association with depression and anxiety.

METHOD

Within a cross-sectional survey, 2091 consecutive patients from 15 primary care clinics in the United States completed self-report questionnaires regarding GI symptoms [15-item Patient Health Questionnaire (PHQ-15)], anxiety [seven-item Generalized Anxiety Disorder Scale (GAD-7)], and depression (PHQ-8). Of those, 965 randomly selected patients additionally underwent a criterion standard diagnostic telephone interview (Structured Clinical Interview for DSM-IV) for the most common anxiety disorders.

RESULTS

A total of 380 [18% (95% CI, 16.3% to 19.3%)] patients reported to be substantially bothered by at least one GI symptom in the previous 4 weeks. The prevalence of severe levels of depression (PHQ-8 score > or =15) was nearly fivefold in patients with GI symptoms compared to patients without GI symptoms (19.1% vs. 3.9%; P<.001), and the prevalence of severe levels of anxiety (GAD-7 score > or =15) was nearly fourfold in patients with GI symptoms compared to patients without GI symptoms (19.4% vs. 5.6%; P<.001). Similarly, with each additional GI symptom, the odds for an interview-based diagnosis of specific anxiety disorders increased significantly: For example, compared to patients with no GI symptom, the odds ratio (OR) (95% CI) for generalized anxiety disorder in patients with one GI symptom was 3.7 (2.0 to 6.9); in patients with two GI symptoms, OR=6.5 (3.1 to 13.6); and in patients with three GI symptoms, OR=7.2 (2.7 to 18.8).

CONCLUSION

GI symptoms are associated significantly with depression and anxiety in primary care. It is suggested to screen as a routine for anxiety and depression in patients with GI symptoms and, if indicated, to initiate specific treatment.

Clinical observation of 12 farmers who believe themselves to have suffered from chronic pesticide intoxication

BACKGROUND/AIM

We assessed twelve cases of suspected chronic pesticide intoxication, with medically unexplained physical symptoms.

METHODS

Complete blood cell count (CBC), blood chemistry, routine urinalysis, chest X-ray, ECG, gastrofiberscopy, abdominal ultrasonography, neuroselective sensory nerve conduction threshold, and psychological assessment were performed on 12 farmers who believe themselves to have suffered from chronic pesticide intoxication.

RESULTS

No specific abnormalities were observed on CBC, routine urinalysis, chest X-ray, ECG, gastroscopy, abdominal ultrasonography, or peripheral nerve conduction velocity test. They persistently manifested helplessness, depression, and anxiety. The results of both psychological assessment and general physical examination revealed the following clinical features: depression (8 cases), multiple chemical hypersensitivity syndrome (2 cases), alcoholism (1 case), and religious preoccupation (1 case).

CONCLUSION

In those living in the western rural area of South Korea, depression is a prominent ongoing presentation in pesticide-exposed farmers, in addition to unexplainable physical symptoms.