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Mewes R. Recent developments on psychological factors in medically unexplained symptoms and somatoform disorders. Front Public Health 2022; 10:1033203. [PMID: 36408051 PMCID: PMC9672811 DOI: 10.3389/fpubh.2022.1033203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 10/18/2022] [Indexed: 11/06/2022] Open
Abstract
Somatic symptoms which are not fully explained by a medical condition (medically unexplained symptoms) have a high relevance for the public health. They are very common both in the general population and in patients in health care, and may develop into chronic impairing conditions such as somatoform disorders. In recent years, the relevance of specific negative psychological factors for the diagnosis and the stability of somatoform disorders and for the impairment by medically unexplained symptoms gained more and more attention. This resulted-among others- in core changes in the diagnostic classification criteria of somatoform disorders. Against this background, the present "Perspective" will outline recent developments and findings in the area of medically unexplained somatic symptoms and somatoform disorders. Moreover, it will lay a special focus on evidence on specific negative psychological factors that may influence the course of unexplained somatic symptoms and disorders and the impairment caused by these symptoms.
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Excessiveness in Symptom-Related Thoughts, Feelings, and Behaviors: An Investigation of Somatic Symptom Disorders in the General Population. Psychosom Med 2021; 83:164-170. [PMID: 33337595 DOI: 10.1097/psy.0000000000000903] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The diagnostic criteria of somatic symptom disorder (SSD) emphasize that somatic symptoms receive disease value once they are accompanied by excessive thoughts, feelings, or behaviors. The main objective of this study was to examine what constitutes excessiveness in psychological reactions to somatic complaints and how excessive symptom-related behavior influences self-reported health status and health care utilization. METHODS A national, representative general population survey was performed between January and March 2016 in Germany, including 2395 individuals older than 13 years. Self-report questionnaires (Somatic Symptom Scale-8, Somatic Symptom Disorder-B Criteria Scale) were used to operationalize the SSD criteria. Group differences in the daily amount of time dedicated to physical complaints were analyzed between individuals with and without SSD. Stepwise linear regression analyses were performed to predict general mental and physical health status, and health care utilization. RESULTS There was a significant effect of group (SSD yes/no) in daily time spent on symptoms, after controlling for age, sex, depression, and anxiety (F(1,2336) = 447.53, p < .001). The SSD group (n = 213) reported an average of 4 hours, whereas individuals without SSD reported 30 minutes. Results of the regression analyses showed that the combination of somatic symptoms and symptom-related psychological features is predictive of worsened self-reported physical and mental health status, and increased health care utilization. CONCLUSIONS A range of 3 to 4 hours per day spent on dealing with physical complaints seems indicative of excessiveness. If, during a clinical consultation, a patient reports such a large amount of time, a more comprehensive clinical examination of SSD should follow.
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Holtman GA, Burger H, Verheij RA, Wouters H, Berger MY, Rosmalen JG, Verhaak PF. Developing a clinical prediction rule for repeated consultations with functional somatic symptoms in primary care: a cohort study. BMJ Open 2021; 11:e040730. [PMID: 33419906 PMCID: PMC7799137 DOI: 10.1136/bmjopen-2020-040730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Patients who present in primary care with chronic functional somatic symptoms (FSS) have reduced quality of life and increased health care costs. Recognising these early is a challenge. The aim is to develop and internally validate a clinical prediction rule for repeated consultations with FSS. DESIGN AND SETTING Records from the longitudinal population-based ('Lifelines') cohort study were linked to electronic health records from general practitioners (GPs). PARTICIPANTS We included patients consulting a GP with FSS within 1 year after baseline assessment in the Lifelines cohort. OUTCOME MEASURES The outcome is repeated consultations with FSS, defined as ≥3 extra consultations for FSS within 1 year after the first consultation. Multivariable logistic regression, with bootstrapping for internal validation, was used to develop a risk prediction model from 14 literature-based predictors. Model discrimination, calibration and diagnostic accuracy were assessed. RESULTS 18 810 participants were identified by database linkage, of whom 2650 consulted a GP with FSS and 297 (11%) had ≥3 extra consultations. In the final multivariable model, older age, female sex, lack of healthy activity, presence of generalised anxiety disorder and higher number of GP consultations in the last year predicted repeated consultations. Discrimination after internal validation was 0.64 with a calibration slope of 0.95. The positive predictive value of patients with high scores on the model was 0.37 (0.29-0.47). CONCLUSIONS Several theoretically suggested predisposing and precipitating predictors, including neuroticism and stressful life events, surprisingly failed to contribute to our final model. Moreover, this model mostly included general predictors of increased risk of repeated consultations among patients with FSS. The model discrimination and positive predictive values were insufficient and preclude clinical implementation.
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Affiliation(s)
- Gea A Holtman
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Huibert Burger
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Robert A Verheij
- NIVEL, Netherlands Institute of Health Services Research, Utrecht, The Netherlands
- Tranzo Scientific Center for Care and Welfare, Tilburg School of Social and Behavioral Sciences, Tilburg University, Tilburg, The Netherlands
| | - Hans Wouters
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- General Practitioners Research Institute, Groningen, The Netherlands
| | - Marjolein Y Berger
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Judith Gm Rosmalen
- Interdisciplinary Center Psychopathology and Emotion Regulation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Peter Fm Verhaak
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- NIVEL, Netherlands Institute of Health Services Research, Utrecht, The Netherlands
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Medically Unexplained Symptoms (MUS): Faults and Implications. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16071247. [PMID: 30965593 PMCID: PMC6480347 DOI: 10.3390/ijerph16071247] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 04/03/2019] [Indexed: 12/15/2022]
Abstract
The classification of medically unexplained symptoms (MUS) could have negative consequences for patients with functional somatic syndromes (FSS). By grouping related but distinct syndromes into one label, the MUS classification fails to inform clinicians about their patients' health condition. In research settings, the MUS classification makes patient samples more heterogeneous, obstructing research into the underlying pathology of FSS. Long-term studies have shown that MUS are often appraised as medically explained symptoms at follow-up and vice versa, raising doubts about the reliability of this distinction.
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Claassen-van Dessel N, van der Wouden JC, Twisk JWR, Dekker J, van der Horst HE. Predicting the course of persistent physical symptoms: Development and internal validation of prediction models for symptom severity and functional status during 2 years of follow-up. J Psychosom Res 2018; 108:1-13. [PMID: 29602318 DOI: 10.1016/j.jpsychores.2018.02.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 02/18/2018] [Accepted: 02/20/2018] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Increased knowledge about predictors of the course of persistent physical symptoms (PPS) is needed to identify patients at risk for long-term PPS in clinical settings. Therefore, we developed prediction models for the course of PPS in terms of symptom-severity and related functional status during a 2-year follow-up period. METHODS We used data of the PROSPECTS cohort study, consisting of 325 PPS patients from several health care settings. Symptom severity (PHQ-15), physical functioning (RAND 36 PCS) and mental functioning (RAND 36 MCS) were assessed at baseline and 6, 12 and 24 months afterwards. We applied mixed model analyses to develop prediction models for all outcomes, using all follow-up measurements. Potential predictors were based on empirical and theoretical literature and measured at baseline. RESULTS For symptom severity, physical functioning and mental functioning we identified predictors for the adverse course of PPS included physical comorbidity, higher severity and longer duration of PPS at baseline, anxiety, catastrophizing cognitions, embarrassment and fear avoidance cognitions, avoidance or resting behaviour and neuroticism. Predictors of a favourable course included limited alcohol use, higher education, higher levels of physical and mental functioning at baseline, symptom focusing, damage cognitions and extraversion. Explained interpersonal variance for all three models varied between 70.5 and 76.0%. Performance of the models was comparable in primary and secondary/tertiary care. CONCLUSION The presented prediction models identified several relevant demographic, medical, psychological and behavioural predictors for adverse and favourable courses of PPS. External validation of the presented models is needed prior to clinical implementation.
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Affiliation(s)
- Nikki Claassen-van Dessel
- Department of General Practice and Elderly Care Medicine, VU University Medical Center Amsterdam, The Netherlands; Amsterdam Public Health Research Institute, Amsterdam, The Netherlands.
| | - Johannes C van der Wouden
- Department of General Practice and Elderly Care Medicine, VU University Medical Center Amsterdam, The Netherlands; Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Johannes W R Twisk
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands; Department of Health Sciences, VU University Amsterdam, The Netherlands
| | - Joost Dekker
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands; Department of Health Sciences, VU University Amsterdam, The Netherlands; Department of Rehabilitation Medicine and Department of Psychiatry, VU University Medical Center Amsterdam, The Netherlands
| | - Henriëtte E van der Horst
- Department of General Practice and Elderly Care Medicine, VU University Medical Center Amsterdam, The Netherlands; Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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Duration of untreated illness in patients with somatoform disorders. J Psychosom Res 2018; 107:1-6. [PMID: 29502757 DOI: 10.1016/j.jpsychores.2018.01.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 12/20/2017] [Accepted: 01/18/2018] [Indexed: 01/23/2023]
Abstract
OBJECTIVE A long duration of untreated mental illness (DUI) has been found to be associated with negative long-term outcomes. Although somatic symptom and related disorders are frequent in the general population and in primary care, data regarding the DUI of these disorders is scarce. The aim of this study was to investigate the DUI in patients with somatoform disorders. METHODS In a cross-sectional study, primary care patients at high risk of having a somatoform disorder were identified using the Patient Health Questionnaire (PHQ). In a second step, life-time somatoform disorder diagnosis was established using the Composite International Diagnostic Interview (CIDI). Additionally, DUI was retrospectively assessed via self-reporting and sociodemographic information was collected. Survival analysis was used to estimate the DUI and to identify patient-related predictors of DUI. RESULTS A total of 139 patients with somatoform disorders were included in the analyses. The mean DUI in these patients was 25.2years (median 23.1years). Higher education significantly predicted shorter DUI, whereas gender and age of onset were unrelated to DUI. CONCLUSIONS The results reveal a substantial delay in adequate treatment of patients with somatoform disorders. The reported DUI emphasizes the importance of improvements in the management of patients with these disorders.
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Joustra ML, Janssens KAM, Schenk HM, Rosmalen JGM. The four week time frame for somatic symptom questionnaires reflects subjective symptom burden best. J Psychosom Res 2018; 104:16-21. [PMID: 29275780 DOI: 10.1016/j.jpsychores.2017.11.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 11/04/2017] [Accepted: 11/05/2017] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Various questionnaires are available to assess somatic symptom burden, however their assessment time frames vary largely. The aim of this study was to investigate the most relevant assessment time frame for somatic symptoms by relating somatic symptom burden, with varying time frames, to quality of life (QoL) and health anxiety as indicators for clinical relevance of symptoms. METHODS This study was performed in data derived from a convenience sample of 3477 participants (age: 48.0 (SD 14.1), 66.4% female) of the Dutch research platform HowNutsAreTheDutch. Symptom burden was assessed using all items from the Patient Health Questionnaire-15 (PHQ-15) and 6 items of the Symptom Checklist-90 SOM (SCL-90 SOM). Five versions of the questionnaire were constructed, which evaluated symptom burden during the past 24h, 1week, 2weeks, 4weeks, and 3months. RESULTS Symptom burden significantly increased with each step increase in time frame until 4weeks, with no further increase when comparing 4weeks and 3months. The time frame of 4weeks provided the strongest associations between somatic symptom burden and health anxiety (B=1.635; 95%CI: 1.368 to 1.938; p≤0.001). This was also true when analysing the association between QoL and the symptom groups of musculoskeletal (B=-1.54; 95%CI: -1.93 to -1.16;p≤0.001) and gastrointestinal symptoms (B=-0.71; 95%CI: -0.96 to -0.47;p≤0.001). CONCLUSION An assessment time frame of 4weeks for somatic symptom questionnaires reflects clinically relevant somatic symptom burden in terms of QoL and health anxiety best, followed by the 3months' time frame.
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Affiliation(s)
- Monica L Joustra
- University of Groningen, University Medical Center Groningen, Interdisciplinary Center Psychopathology and Emotion regulation, The Netherlands.
| | - Karin A M Janssens
- University of Groningen, University Medical Center Groningen, Interdisciplinary Center Psychopathology and Emotion regulation, The Netherlands
| | - Hendrika M Schenk
- University of Groningen, University Medical Center Groningen, Interdisciplinary Center Psychopathology and Emotion regulation, The Netherlands
| | - Judith G M Rosmalen
- University of Groningen, University Medical Center Groningen, Interdisciplinary Center Psychopathology and Emotion regulation, The Netherlands
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Schumacher S, Rief W, Klaus K, Brähler E, Mewes R. Medium- and long-term prognostic validity of competing classification proposals for the former somatoform disorders. Psychol Med 2017; 47:1719-1732. [PMID: 28179046 DOI: 10.1017/s0033291717000149] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND DSM-5 introduced a fundamental revision of the category of somatoform disorders, which resulted in the new somatic symptom disorder (SSD) and related disorders. However, prognostic validity of SSD remains unclear, while other classification proposals, such as bodily distress disorder (BDD) or polysymptomatic distress disorder (PSDD), might be promising alternatives for the new ICD-11. Therefore, the comparison of the different approaches concerning long-term prognosis of disorder-relevant factors is of special interest. METHOD In a longitudinal design (baseline, 1-year, and 4-year follow-up), the three proposals (SSD, BDD, PSDD) were compared in an age-representative sample of the German general population (N = 321). To this end, the baseline sample was divided into three independent pairs of groups (with/without SSD, with/without BDD, with/without PSDD). It was tested how well each approach differentiated with regard to medium- and long-term healthcare utilization, number of symptoms, and impairment. RESULTS Criteria for BDD distinguished best with regard to future healthcare utilization resulting in a large-sized effect (f = 0.44) for the difference between persons with and without BDD, while SSD and PSDD revealed only medium-sized effects (f = 0.28 and f = 0.32) between subjects with and without diagnosis. The three proposals distinguished equally well with regard to future subjective impairment (between f = 0.39 and f = 0.41) and the number of reported symptoms (between f = 0.77 and f = 0.83). CONCLUSION In accordance with our data regarding prognostic validity, the current draft of the WHO group is based on the BDD proposal. However, existing limitations and weaknesses of the present proposal for the ICD-11 are further discussed.
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Affiliation(s)
- S Schumacher
- Division of Clinical Psychological Intervention,Freie Universität Berlin,Berlin,Germany
| | - W Rief
- Department of Clinical Psychology and Psychotherapy,University of Marburg,Marburg,Germany
| | - K Klaus
- Department of Clinical Biopsychology,University of Marburg,Marburg,Germany
| | - E Brähler
- Department of Medical Psychology and Medical Sociology,University of Leipzig,Leipzig,Germany
| | - R Mewes
- Department of Clinical Biopsychology,University of Marburg,Marburg,Germany
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Murray AM, Toussaint A, Althaus A, Löwe B. The challenge of diagnosing non-specific, functional, and somatoform disorders: A systematic review of barriers to diagnosis in primary care. J Psychosom Res 2016; 80:1-10. [PMID: 26721541 DOI: 10.1016/j.jpsychores.2015.11.002] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 11/05/2015] [Accepted: 11/06/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Despite their prevalence and impact on patients and the health care system, non-specific, functional, and somatoform disorders are underdiagnosed. This problem is especially problematic in primary care if we are moving towards an integrated care model. The objective of the current study was to identify and aggregate potential barriers to the diagnosis in primary care settings. METHODS Our systematic review methodology followed a pre-published protocol and was registered in PROSPERO (CRD42013002540). We combined qualitative and quantitative data from studies identified in online databases and by hand searching of reference lists. Data were synthesized in a data-driven way using a grounded-theory approach. The level of evidence and assessment of bias for the final included studies was independently conducted. RESULTS Data from n=177 full text publications were independently extracted and combined in a custom database. The final list of included studies was n=42. From these, a total of n=379 barriers were identified comprising 77 barrier-level codes, 16 thematic categories and five over-arching themes, i.e., patient-related, primary-care-practitioner related, doctor-patient interactional, situational, and conceptual and operational barriers. CONCLUSION Given the thematic range of the identified barriers, the diagnostic process of non-specific, functional, and somatoform disorders in primary care is highly complex. Individual or practice-level interventions, as well as public awareness initiatives are needed to help address the diagnostic challenges. A multi-factorial understanding of symptoms with a biopsychosocial parallel diagnostic approach should be encouraged. More direct empirical investigations are also needed.
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Affiliation(s)
- Alexandra M Murray
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf & University Hospital of Psychosomatic Medicine and Psychotherapy, Schön Clinic Hamburg Eilbek, Germany.
| | - Anne Toussaint
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf & University Hospital of Psychosomatic Medicine and Psychotherapy, Schön Clinic Hamburg Eilbek, Germany
| | - Astrid Althaus
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf & University Hospital of Psychosomatic Medicine and Psychotherapy, Schön Clinic Hamburg Eilbek, Germany
| | - Bernd Löwe
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf & University Hospital of Psychosomatic Medicine and Psychotherapy, Schön Clinic Hamburg Eilbek, Germany
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Hilderink PH, Collard R, Rosmalen JGM, Oude Voshaar RC. How does ageing affect the impact of medically unexplained symptoms and medically explained symptoms on health-related quality of life? Int J Geriatr Psychiatry 2015; 30:737-43. [PMID: 25349149 DOI: 10.1002/gps.4219] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2014] [Revised: 08/30/2014] [Accepted: 09/05/2014] [Indexed: 11/11/2022]
Abstract
BACKGROUND Physical symptoms significantly impair health-related quality of life (HRQoL), but age effects and differential effects of medically unexplained symptoms (MUS) and medically explained symptoms (MES) have hardly been examined. Our objective was to determine the effect of age on the impact of MUS and MES on HRQoL. METHODS In a population-based cohort (n = 946, aged 28-75 years), MUS and MES were measured using the Composite International Diagnostic Interview and HRQoL using the EuroQol-5 dimensions (EQ-5D). Using multiple linear regression, we regressed MUS, MES and their interaction with age on HRQoL, adjusted for socio-demographic variables and the presence of depressive and anxiety disorders. In case of significant interaction terms, age-stratified results will be presented. RESULTS In the whole study population, the association between MUS and HRQoL was stronger (β = -0.35; p < 0.001) than between MES and HRQoL (β = -0.26; p < 0.001). Adjusted for depressive and anxiety disorders, differences between these associations decline (MUS: β = -0.28, p < 0.001; MES: β = -0.25, p < 0.001). Age significantly interacted with number of MUS in explaining variance in HRQoL but not with the number of MES. The impact of MUS on HRQoL is much larger in people aged below 65 years (β = -0.39, p < 0.001) versus those aged 65 years and over (β = -0.21, p = 0.002). In the older group, the association between MUS and HRQoL lost significance when adjusted for depressive and anxiety disorders (β = -0.12 p = 0.062). CONCLUSION Our results show that age affects the association between MUS and HRQoL, which suggest that older persons cope better with MUS than younger persons.
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Affiliation(s)
| | - Rose Collard
- Radboud University Nijmegen Medical Centre, Department of Psychiatry, Nijmegen Centre for Evidence-Based Practice, Nijmegen, Netherlands
| | - Judith G M Rosmalen
- University of Groningen, University Medical Center Groningen, Groningen, Netherlands
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Lidén E, Björk-Brämberg E, Svensson S. The meaning of learning to live with medically unexplained symptoms as narrated by patients in primary care: a phenomenological-hermeneutic study. Int J Qual Stud Health Well-being 2015; 10:27191. [PMID: 25887965 PMCID: PMC4401824 DOI: 10.3402/qhw.v10.27191] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/19/2015] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Although research about medically unexplained symptoms (MUS) is extensive, problems still affect a large group of primary care patients. Most research seems to address the topic from a problem-oriented, medical perspective, and there is a lack of research addressing the topic from a perspective viewing the patient as a capable person with potential and resources to manage daily life. The aim of the present study is to describe and interpret the experiences of learning to live with MUS as narrated by patients in primary health-care settings. METHODS A phenomenological-hermeneutic method was used. Narrative interviews were performed with ten patients suffering from MUS aged 24-61 years. Data were analysed in three steps: naive reading, structural analysis, and comprehensive understanding. FINDINGS The findings revealed a learning process that is presented in two themes. The first, feeling that the symptoms overwhelm life, involved becoming restricted and dependent in daily life and losing the sense of self. The second, gaining insights and moving on, was based on subthemes describing the patients' search for explanations, learning to take care of oneself, as well as learning to accept and becoming mindful. The findings were reflected against Antonovsky's theory of sense of coherence and Kelly's personal construct theory. Possibilities and obstacles, on an individual as well as a structural level, for promoting patients' capacity and learning were illuminated. CONCLUSIONS Patients suffering from MUS constantly engage in a reflective process involving reasoning about and interpretation of their symptoms. Their efforts to describe their symptoms to healthcare professionals are part of this reflection and search for meaning. The role of healthcare professionals in the interpretative process should be acknowledged as a conventional and necessary care activity.
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Affiliation(s)
- Eva Lidén
- Institute of Health and Care Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden;
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Differential associations of specific depressive and anxiety disorders with somatic symptoms. J Psychosom Res 2015; 78:116-22. [PMID: 25524436 DOI: 10.1016/j.jpsychores.2014.11.007] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 11/07/2014] [Accepted: 11/09/2014] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Previous studies have shown that depressive and anxiety disorders are strongly related to somatic symptoms, but much is unclear about the specificity of this association. This study examines the associations of specific depressive and anxiety disorders with somatic symptoms, and whether these associations are independent of comorbid depressive and anxiety disorders. METHODS Cross-sectional data were derived from The Netherlands Study of Depression and Anxiety (NESDA). A total of 2008 persons (mean age: 41.6 years, 64.9% women) were included, consisting of 1367 patients with a past-month DSM-diagnosis (established with the Composite International Diagnostic Interview [CIDI]) of depressive disorder (major depressive disorder, dysthymic disorder) and/or anxiety disorder (generalized anxiety disorder, social phobia, panic disorder, agoraphobia), and 641 controls. Somatic symptoms were assessed with the somatization scale of the Four-Dimensional Symptom Questionnaire (4DSQ), and included cardiopulmonary, musculoskeletal, gastrointestinal, and general symptoms. Analyses were adjusted for covariates such as chronic somatic diseases, sociodemographics, and lifestyle factors. RESULTS All clusters of somatic symptoms were more prevalent in patients with depressive and/or anxiety disorders than in controls (all p<.001). Multivariable logistic regression analyses showed that all types of depressive and anxiety disorders were independently related to somatic symptoms, except for dysthymic disorder. Major depressive disorder showed the strongest associations. Associations remained similar after adjustment for covariates. CONCLUSION This study demonstrated that depressive and anxiety disorders show strong and partly differential associations with somatic symptoms. Future research should investigate whether an adequate consideration and treatment of somatic symptoms in depressed and/or anxious patients improve treatment outcomes.
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Zijlema WL, Stolk RP, Löwe B, Rief W, White PD, Rosmalen JGM. How to assess common somatic symptoms in large-scale studies: a systematic review of questionnaires. J Psychosom Res 2013; 74:459-68. [PMID: 23731742 DOI: 10.1016/j.jpsychores.2013.03.093] [Citation(s) in RCA: 141] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Revised: 03/22/2013] [Accepted: 03/23/2013] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Many questionnaires for assessment of common somatic symptoms or functional somatic symptoms are available and their use differs greatly among studies. The prevalence and incidence of symptoms are partially determined by the methods used to assess them. As a result, comparison across studies is difficult. This article describes a systematic review of self-report questionnaires for somatic symptoms for use in large-scale studies and recommends two questionnaires for use in such studies. METHODS A literature search was performed in the databases Medline, PsycINFO and EMBASE. Articles that reported the development, evaluation, or review of a self-report somatic symptom measure were included. Instrument evaluation was based on validity and reliability, and their fitness for purpose in large scale studies, according to the PhenX criteria. RESULTS The literature search identified 40 questionnaires. The number of items within the questionnaires ranged from 5 to 78 items. In 70% of the questionnaires, headaches were included, followed by nausea/upset stomach (65%), shortness of breath/breathing trouble (58%), dizziness (55%), and (low) back pain/backaches (55%). Data on validity and reliability were reported and used for evaluation. CONCLUSION Questionnaires varied regarding usability and burden to participants, and relevance to a variety of populations and regions. Based on our criteria, the Patient Health Questionnaire-15 and the Symptom Checklist-90 somatization scale seem the most fit for purpose for use in large-scale studies. These two questionnaires have well-established psychometric properties, contain relevant symptoms, are relatively short, and are available in multiple languages.
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Affiliation(s)
- Wilma L Zijlema
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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Tyrer H, Ali L, Cooper F, Seivewright P, Bassett P, Tyrer P. The Schedule for Evaluating Persistent Symptoms (SEPS): a new method of recording medically unexplained symptoms. Int J Soc Psychiatry 2013; 59:281-7. [PMID: 22433243 DOI: 10.1177/0020764012438484] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Medically unexplained symptoms are difficult to measure and in most cases the diagnosis is made either from independent data such as consultants' opinions or medical outcomes, or by proxy measures such as numbers of symptoms or consultations. A valid self-rated measure would be of value in assessing this highly prevalent condition. AIMS To describe a new scale of nine items, the Schedule for Evaluation of Persistent Symptoms (SEPS), its properties, its internal consistency, its distribution in a sample of 470 medical patients, its relationship to social functioning and health anxiety (hypochondriasis), and its construct validity by comparing its results with an independent diagnostic examination of each patient's notes two years subsequent to assessment. METHOD A prevalence study was carried out in 405 consenting medical patients in primary care, cardiology, respiratory medicine, gastroenterology and endocrine clinics, in which the SEPS scale, the Health Anxiety Inventory (HAI) and the Social Functioning Questionnaire (SFQ) were each completed. RESULTS The mean score on the SEPS scale in 470 patients was 13.4. Exploratory factor analysis revealed two main factors, one concerned focus on symptoms and the other on their attribution. Examination of all data showed a cut-off point of 14 as indicating the presence of pathological medically unexplained symptoms (MUS). Agreement between the consultants' diagnosis and pathological MUS scores was fairly good with a score of 14 or more on the SEPS showing sensitivity of 0.65 and negative predictive accuracy of 0.90. CONCLUSION It is concluded that the SEPS scale has potential value in screening patients with suspected medically unexplained symptoms.
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Affiliation(s)
- Helen Tyrer
- Centre for Mental Health, Department of Medicine, Imperial College, London, UK
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Park S, Cho MJ, Seong S, Shin SY, Sohn J, Hahm BJ, Hong JP. Psychiatric morbidities, sleep disturbances, suicidality, and quality-of-life in a community population with medically unexplained pain in Korea. Psychiatry Res 2012; 198:509-15. [PMID: 22424895 DOI: 10.1016/j.psychres.2012.01.028] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2011] [Revised: 11/16/2011] [Accepted: 01/26/2012] [Indexed: 11/26/2022]
Abstract
We examined the psychiatric morbidities, sleep disturbances, suicidality, quality-of-life, and psychological distress of community-dwelling subjects in Korea who had medically unexplained pain. A total of 6510 subjects (age 18-65 years) participated in this study. A medically unexplained pain symptom (MUS-pain) was defined as pain lasting for 6 months or longer that was sufficiently severe to cause significant distress or to materially interfere with normal activities in the previous year, and that could not be explained by a medical condition or substance use/abuse. Diagnostic assessments were based on responses to the Composite International Diagnostic Interview, which was administered by lay colleagues. The presence of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) disorders, sleep disturbances, suicidal tendency, quality-of-life issues, and psychological distress was determined in subjects with and without MUS-pain. There were significant positive associations between MUS-pain and nicotine dependence and withdrawal, alcohol dependence, major depressive disorder, dysthymic disorder, bipolar disorder, post-traumatic stress disorder, social phobia, generalized anxiety disorder, and psychotic disorder. In addition, subjects with MUS-pain reported more sleep disturbances, suicidality, psychological distress, and a poorer quality-of-life than did subjects without MUS-pain. The results of this study suggest that clinicians should carefully evaluate and treat comorbid psychiatric problems in individuals with MUS-pain.
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Affiliation(s)
- Subin Park
- Department of Psychiatry, Asan Medical Center, Ulsan University College of Medicine, Seoul, South Korea
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The Distinction Between “Medically Unexplained” and “Medically Explained” in the Context of Somatoform Disorders. Int J Behav Med 2012; 20:161-71. [DOI: 10.1007/s12529-012-9245-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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The epidemiology of multiple somatic symptoms. J Psychosom Res 2012; 72:311-7. [PMID: 22405227 DOI: 10.1016/j.jpsychores.2012.01.009] [Citation(s) in RCA: 128] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Revised: 01/12/2012] [Accepted: 01/12/2012] [Indexed: 11/24/2022]
Abstract
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.
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Reattribution reconsidered: narrative review and reflections on an educational intervention for medically unexplained symptoms in primary care settings. J Psychosom Res 2011; 71:325-34. [PMID: 21999976 DOI: 10.1016/j.jpsychores.2011.05.008] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2010] [Revised: 04/19/2011] [Accepted: 05/05/2011] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Medically unexplained symptoms (MUS) refer to bodily symptoms without a physical health explanation. In the context of MUS, reattribution is a process of attributing physical symptoms to a psychological cause. We review the use of a consultation model which employs reattribution, and which has been extensively utilised in teaching and research in primary care. METHODS Literature search for studies utilising the reattribution model. Narrative review of the results. RESULTS Data was extracted from 25 publications from 13 studies. The model has been modified over time and comparison between studies is limited by differences in methodology. The skills of the model can be acquired by training, which also improves practitioners' attitudes to MUS. However impact on clinical outcomes has been mixed and this can be explained in part from the findings of nested qualitative studies. CONCLUSIONS The reattribution model is too simplistic in its current form to address the needs of many people presenting with MUS in primary care. Reattribution of physical symptoms to psychological causes is often unnecessary. Further research is required into the effectiveness of stepped and collaborative care models in which education of primary care practitioners forms one part of a complex intervention. The consultation process is best seen as both a conversation and ongoing negotiation between doctor and patient in which there are no certainties about the presence or absence of organic pathology.
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Steinbrecher N, Hiller W. Course and prediction of somatoform disorder and medically unexplained symptoms in primary care. Gen Hosp Psychiatry 2011; 33:318-26. [PMID: 21762827 DOI: 10.1016/j.genhosppsych.2011.05.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Revised: 04/07/2011] [Accepted: 05/02/2011] [Indexed: 02/04/2023]
Abstract
UNLABELLED 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.
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Affiliation(s)
- Natalie Steinbrecher
- Department of Clinical Psychology, Johannes Gutenberg-University of Mainz, 55122 Mainz, Germany.
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Fabião C, Silva MC, Barbosa A, Fleming M, Rief W. Assessing medically unexplained symptoms: evaluation of a shortened version of the SOMS for use in primary care. BMC Psychiatry 2010; 10:34. [PMID: 20478053 PMCID: PMC2894757 DOI: 10.1186/1471-244x-10-34] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2009] [Accepted: 05/17/2010] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND To investigate the validity and stability of a Portuguese version for the Screening for Somatoform Symptoms-2 (SOMS-2) in primary care (PC) settings. METHODS An adapted version of the SOMS-2 was filled in by persons attending a PC unit. All medically unexplained symptoms were further ascertained in a clinical interview and by contacting the patient's physicians and examining medical records, attaining a final clinical symptom evaluation (FCSE). An interview yielded the diagnosis of Clinical Somatization (CS) and the diagnosis of current depressive and anxiety disorders. RESULTS From the eligible subjects, 167 agreed to participate and 34.1% of them were diagnosed with somatization. The correlation between the number of self-reported and FCSE symptoms was 0.63. After excluding symptoms with low frequency, low discriminative power and not correlated with the overall scale, 29 were retained in the final version. A cut-off of 4 symptoms gave a sensitivity of 86.0% and a specificity of 95.5% on the FCSE and 56.1% and 93.6% at self-report. Stability in the number of symptoms after 6 months was good (k = 0.57). CONCLUSIONS The 29 symptoms version of the SOMS-2 with a cut-off of 4 showed a high specificity and sensitivity, being reliable as a referral tool for further specialized diagnosis.
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Affiliation(s)
- Cristina Fabião
- Psychology Course, Department of Philosophy, Regional Centre of Portuguese Catholic University, Braga, Largo da Faculdade de Filosofia, 1, 4710 Braga Portugal.
| | - MC Silva
- Department of Population Studies, Institute for Biomedical Sciences Abel Salazar (ICBAS), University of Porto, Largo Abel Salazar, 2, 4099-003 Porto Portugal
| | - António Barbosa
- Centre of Bioethics, School of Medicine, University of Lisbon, Av. Prof. Egas Moniz, 1649-028 Lisboa Portugal
| | - Manuela Fleming
- Department of Behavioural Sciences, Institute for Biomedical Sciences Abel Salazar (ICBAS), University of Porto, Largo Abel Salazar, 2, 4099-003 Porto Portugal
| | - Winfried Rief
- Department of Clinical Psychology and Psychotherapy, Philipps University of Marburg, Gutenbergstrasse 18, 35032 Marburg Germany
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Voigt K, Nagel A, Meyer B, Langs G, Braukhaus C, Löwe B. Towards positive diagnostic criteria: a systematic review of somatoform disorder diagnoses and suggestions for future classification. J Psychosom Res 2010; 68:403-14. [PMID: 20403499 DOI: 10.1016/j.jpsychores.2010.01.015] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2009] [Revised: 01/12/2010] [Accepted: 01/14/2010] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The classification of somatoform disorders is currently being revised in order to improve its validity for the DSM-V and ICD-11. In this article, we compare the validity and clinical utility of current and several new diagnostic proposals of those somatoform disorders that focus on medically unexplained somatic symptoms. METHODS We searched the Medline, PsycInfo, and Cochrane databases, as well as relevant reference lists. We included review papers and original articles on the subject of somatoform classification in general, subtypes of validity of the diagnoses, or single diagnostic criteria. RESULTS Of all diagnostic proposals, only complex somatic symptom disorder and the Conceptual Issues in Somatoform and Similar Disorders (CISSD) example criteria reflect all dimensions of current biopsychosocial models of somatization (construct validity) and go beyond somatic symptom counts by including psychological and behavioral symptoms that are specific to somatization (descriptive validity). Predictive validity of most of the diagnostic proposals has not yet been investigated. However, the number of somatic symptoms has been found to be a strong predictor of disability. Some evidence indicates that psychological symptoms can predict disease course and treatment outcome (e.g., therapeutic modification of catastrophizing is associated with positive outcome). Lengthy symptom lists, the requirement of lifetime symptom report (as in abridged somatization), complicated symptom patterns (as in current somatization disorder), and imprecise definitions of diagnostic procedures (e.g., missing symptom threshold in complex somatic symptom disorder) reduce clinical utility. CONCLUSION Results from the reviewed studies suggest that, of all current and new diagnostic suggestions, complex somatic symptom disorder and the CISSD definition appear to have advantages regarding validity and clinical utility. The integration of psychological and behavioral criteria could enhance construct and descriptive validity, and confers prospectively relevant treatment implications. The incorporation of a dimensional approach that reflects both somatic and psychological symptom severity also has the potential to improve predictive validity and clinical utility.
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Affiliation(s)
- Katharina Voigt
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf and Schön Klinik Hamburg-Eilbek, 20246 Hamburg, Germany
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Leiknes KA, Finset A, Moum T. Commonalities and differences between the diagnostic groups: current somatoform disorders, anxiety and/or depression, and musculoskeletal disorders. J Psychosom Res 2010; 68:439-46. [PMID: 20403502 DOI: 10.1016/j.jpsychores.2010.02.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2009] [Revised: 02/02/2010] [Accepted: 02/02/2010] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To identify the similarities and differences of risk factors and correlates of different groups of people fulfilling criteria for specified diagnostic groups according to current somatoform disorder (SDs) criteria, presence of anxiety and/or depression, and self-reported musculoskeletal disorders. METHODS Participants of the Oslo-Lofoten general population cross-sectional study in 2000-2001 interviewed with the Composite International Diagnostic Interview (CIDI) somatoform section were examined by comparing similarities and differences in 8 groups identified by cross-tabulation of current SDs, anxiety and/or depression, and musculoskeletal disorders. The current SDs group was computed from the CIDI somatoform section raw data, anxiety and/or depression from the CIDI diagnostic algorithms and musculoskeletal disorders by questionnaire and self evaluation. RESULTS In the 2001 sample of 1668 (875 women and 793 men) participants, the following eight disorder groups were identified: (i) current SDs, n=49 (75.5% women) (ii) musculoskeletal (functional somatic disorders), n=327; (53.5% women) (iii) anxiety and/or depression, n=148 (73.6% women); (iv) current SDs with anxiety and/or depression, n=38 (73.7% women); (v) current SDs with musculoskeletal, n=44 (72.7% women); (vi) current SDs with anxiety and/or depression and musculoskeletal, n=34 (76.5% women); (vii) musculoskeletal with anxiety and/or depression, n=101 (66.3% women); and (viii) no disorders, n=927 (43.3% women). Commonalities and differences between current SDs, anxiety and/or depression, and musculoskeletal disorders are apparent. Impairment of outcomes and risk factor load is high in current SDs with anxiety and/or depression and musculoskeletal. CONCLUSION The data in this article could help toward the needed DSM-V and ICD-11 diagnostic revision of the SDs category.
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Affiliation(s)
- Kari Ann Leiknes
- Institute of Basic Medical Sciences, Department of Behavioural Sciences in Medicine, University of Oslo, Norway.
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Dysfunction of the hypothalamic-pituitary-adrenal axis and functional somatic symptoms: a longitudinal cohort study in the general population. Psychoneuroendocrinology 2009; 34:869-77. [PMID: 19181451 DOI: 10.1016/j.psyneuen.2008.12.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2008] [Revised: 12/24/2008] [Accepted: 12/26/2008] [Indexed: 11/23/2022]
Abstract
In persons with functional somatic symptoms (FSS), no conventionally defined organic pathology is apparent. It has been suggested that complex interactions of psychological, physiological, and social factors are involved in the etiology of FSS. One of the physiological mechanisms that may contribute to FSS is the function of the hypothalamic-pituitary-adrenal (HPA)-axis. This study investigates the association of HPA-axis function with cross-sectional presence and prospective development of FSS in the general population. This study was performed in a population-based cohort of 741 male and female adults (mean age 53.1, S.D. 10.9). Participants completed the somatization section of the Composite International Diagnostic Interview (CIDI) in which the presence of 43 FSS is surveyed. In addition to the total number of FSS, bodily system FSS clusters with musculoskeletal, gastrointestinal, cardiorespiratory, and general symptoms were constructed. HPA-axis function was assessed by measuring 24-h urinary free cortisol (24-h UFC) excretion. Follow-up measurements were performed approximately 2 years later. All analyses were adjusted for age, gender, body mass index, smoking, alcohol use, depression, exercise frequency, and urinary volume. Regression analysis detected no cross-sectional association between 24-h UFC excretion and the number of FSS (beta=-0.021, t=-0.521, p=0.603). In addition, 24-h UFC excretion was not associated with any of the bodily system FSS clusters (all p>0.050). Furthermore, 24-h UFC excretion did not predict new-onset FSS in the 2-year follow-up period (beta=0.021, t=0.566, p=0.572). We conclude that this study does not provide evidence for an association between altered HPA-axis function, as indexed by 24-h UFC, and FSS in the general population. We conclude that this study does not provide evidence for an association between altered HPA-axis function, as indexed by 24-h UFC, and FSS in the general population.
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Rask CU, Christensen MF, Borg C, Søndergaard C, Thomsen PH, Fink P. The Soma Assessment Interview: new parent interview on functional somatic symptoms in children. J Psychosom Res 2009; 66:455-64. [PMID: 19379962 DOI: 10.1016/j.jpsychores.2008.10.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2008] [Revised: 09/01/2008] [Accepted: 10/21/2008] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Medically unexplained or functional somatic symptoms (FSS) in children constitute a major clinical problem. Epidemiological studies of this phenomenon are, however, hampered by a lack of good standardized measures. The objective of this study was therefore to (1) develop a parent-report measure of FSS in children aged 5-10 years and (2) perform an initial validation. METHODS A parent interview, the Soma Assessment Interview (SAI), for FSS detection in young children was developed for lay interviewers with subsequent clinical assessment. A preliminary validation was based on interview tests of the parents of 54 children with well-defined physical disease, 59 with likely functional disorder and 105 from the community. Independent measures of the somatic complaints were completed before the interview, and children from the clinical samples were also assigned independent FSS diagnoses based on medical record review. RESULTS The Kappa value for two clinical assessors' agreement on FSS recognition was 0.86. Good discrimination was obtained between a community sample and a clinical sample with an expected high prevalence of FSS. In the former convergent validity with independent measures of somatic complaints was found. In the latter substantial agreement (89%) appeared between a medical record diagnosis of FSS and SAI detection of FSS. CONCLUSION The SAI offers comprehensive description of FSS in young children in population-based studies and may also prove useful in clinical settings. It is readily accepted and relatively quickly completed, and preliminary assessment of its validity is promising.
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Affiliation(s)
- Charlotte Ulrikka Rask
- Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Aarhus C, Denmark.
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Creed F. The outcome of medically unexplained symptoms--will DSM-V improve on DSM-IV somatoform disorders? J Psychosom Res 2009; 66:379-81. [PMID: 19379953 DOI: 10.1016/j.jpsychores.2008.10.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2008] [Revised: 10/29/2008] [Accepted: 10/29/2008] [Indexed: 10/20/2022]
Affiliation(s)
- Francis Creed
- Psychiatry Research Group, Medical School, Manchester Royal Infirmary, Manchester, England.
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Primary care consultations about medically unexplained symptoms: how do patients indicate what they want? J Gen Intern Med 2009; 24:450-6. [PMID: 19165548 PMCID: PMC2659147 DOI: 10.1007/s11606-008-0898-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2008] [Revised: 09/25/2008] [Accepted: 12/03/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Patients with medically unexplained physical symptoms (MUS) are often thought to deny psychological needs when they consult general practitioners (GPs) and to request somatic intervention instead. We tested predictions from the contrasting theory that they are transparent in communicating their psychological and other needs. OBJECTIVE To test predictions that what patients tell GPs when they consult about MUS is related transparently to their desire for (1) emotional support, (2) symptom explanation and (3) somatic intervention. DESIGN Prospective naturalistic study. Before consultation, patients indicated what they wanted from it using a self-report questionnaire measuring patients' desire for: emotional support, explanation and reassurance, and physical investigation and treatment. Their speech during consultation was audio-recorded, transcribed and coded utterance-by-utterance. Multilevel regression analysis tested relationships between what patients sought and what they said. PARTICIPANTS Patients (N = 326) consulting 33 GPs about symptoms that the GPs designated as MUS. RESULTS Patients who wanted emotional support spoke more about psychosocial problems, including psychosocial causes of symptoms and their need for psychosocial help. Patients who wanted explanation and reassurance suggested more physical explanations, including diseases, but did not overtly request explanation. Patients' wish for somatic intervention was associated only with their talk about details of such interventions and not with their requests for them. CONCLUSIONS In general, patients with medically unexplained symptoms provide many cues to their desire for emotional support. They are more indirect or guarded in communicating their desire for explanation and somatic intervention.
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Abstract
BACKGROUND To determine the prevalence, impact, and prognosis of multisomatoform disorder (MSD) over a 5-year period in a primary care population. Although somatization is prevalent in primary care, patients rarely meet Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria for somatization disorder. MSD, defined as > or = 3 bothersome, medically unexplained somatic symptoms, has been proposed as a more inclusive disorder. METHODS A total of 500 adults presenting to a primary care clinic with a physical symptom were screened with the Primary Care Evaluation of Mental Disorders. Symptom count was assessed with the Patient Health Questionnaire 15-item somatic symptom scale. Additional baseline measures included functional status and symptom characteristics. Follow-up surveys at 2 weeks, 3 months, and 5 years assessed functioning, symptom outcome, psychiatric diagnoses, and patient satisfaction. Physician surveys assessed encounter difficulty. Utilization was obtained from our health database. RESULTS MSD had an 8% prevalence at both baseline (n = 38/500) and at 5 years (n = 33/387). MSD persisted in 21% of those with MSD at baseline, and developed in 7% of those without MSD at baseline. MSD at baseline was a predictor of MSD at 5 years (relative risk (RR) = 2.7, 1.5-5.1). MSD patients were more likely to have comorbid mental disorders (RR = 1.5, 1.1-2.3) and be rated "difficult" by their clinicians (p = .02). They also reported worse functional status at all time points assessed (p < .001 for all), were less likely to experience symptom improvement, and had higher utilization rates (34.1 versus 23.1 visits; p = .006). CONCLUSIONS MSD identifies a group of patients who are less likely to experience symptom improvement and have significant functional impairment and higher utilization rates.
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Leiknes KA, Finset A, Moum T, Sandanger I. Overlap, Comorbidity, and Stability of Somatoform Disorders and the Use of Current Versus Lifetime Criteria. PSYCHOSOMATICS 2008; 49:152-62. [DOI: 10.1176/appi.psy.49.2.152] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Hong ZR, Hong SY, Han MJ, Lee HS, Gil HO, Yang JO, Lee EY, Hong SY. Clinical observation of 12 farmers who believe themselves to have suffered from chronic pesticide intoxication. Korean J Intern Med 2008; 23:1-4. [PMID: 18363272 PMCID: PMC2686957 DOI: 10.3904/kjim.2008.23.1.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
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.
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Affiliation(s)
- Zoong-Rock Hong
- Department of Internal Medicine, Soonchunhyang University Chunan Hospital, Chunan, Korea
| | - So-Young Hong
- Department of Psychology, Korea University College of Medicine, Seoul, Korea
| | - Mi-Jung Han
- Department of Psychology, Soonchunhyang University Chunan Hospital, Chunan, Korea
| | - Hae-seung Lee
- Department of Internal Medicine, Soonchunhyang University Chunan Hospital, Chunan, Korea
| | - Hyo-Ook Gil
- Department of Internal Medicine, Soonchunhyang University Chunan Hospital, Chunan, Korea
| | - Jong-O Yang
- Department of Internal Medicine, Soonchunhyang University Chunan Hospital, Chunan, Korea
| | - En-Yung Lee
- Department of Internal Medicine, Soonchunhyang University Chunan Hospital, Chunan, Korea
| | - Sae-Yong Hong
- Department of Internal Medicine, Soonchunhyang University Chunan Hospital, Chunan, Korea
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Abstract
OBJECTIVE To investigate the stability of somatoform symptoms/disorders. METHODS A literature search was done to select studies reporting data on stability of medically unexplained physical symptoms. RESULTS Whereas individual symptoms vary over time, grouping symptoms into syndromes seems to create stable features. There are substantial problems with the use of lifetime diagnosis, favoring classification approaches that require only present state symptoms. Further, doctors' ratings that symptoms are "medically unexplained" is highly problematic and reduces interrater reliability. Misdiagnoses and overlooking of organic conditions are in the same range as for other psychiatric (and many organic) disorders; therefore, this does not seem to reduce the stability of the diagnoses of somatoform disorders. CONCLUSIONS These results indicate how the classification of somatoform disorders can be improved. Some new diagnostic criteria are suggested that could be considered in the revision of Diagnostic and Statistical Manual of Mental Disorders-V (DSM-V).
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Abstract
Classification is not a trivial matter. In Burmese Days, George Orwell writes, "It is devilish to suffer from a pain that is all but nameless. Blessed are they who are stricken only with classifiable diseases! Blessed are the poor, the sick, the crossed in love, for at least other people know what is the matter with them and will listen to their belly-achings with sympathy." Patients who have somatoform disorders are particularly susceptible to this Orwellian lamentation. They are afflicted by symptoms that defy simple explanations. As detailed in this article, there is a spectrum of medical and psychiatric factors that can cause or contribute to somatic symptom burden. Research is continuing to reveal the central mechanisms that may provide a common pathway for physical and psychologic symptoms. The dualism that places some somatic symptom disorders on Axis I and others on Axis III gradually may fade in the coming decades as what the unifying causes are among common symptoms and the multicausal nature of many symptoms are discovered. Meanwhile, the classification systems should continue to operate on pragmatic principles where mechanistic explanations are lacking. This will allow grouping patients into categories that inform research, scientific and patient communication, prognostication, and clinical management. Coupling a heuristic classification system with evidence-based measures for assessing severity and monitoring treatment outcomes are important steps in the optimal care of symptomatic patients.
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Affiliation(s)
- Kurt Kroenke
- Indiana University School of Medicine, Indianapolis, IN, USA.
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Essau CA. Course and Outcome of Somatoform Disorders in Non-Referred Adolescents. PSYCHOSOMATICS 2007; 48:502-9. [DOI: 10.1176/appi.psy.48.6.502] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Leiknes KA, Finset A, Moum T, Sandanger I. Current somatoform disorders in Norway: prevalence, risk factors and comorbidity with anxiety, depression and musculoskeletal disorders. Soc Psychiatry Psychiatr Epidemiol 2007; 42:698-710. [PMID: 17598059 DOI: 10.1007/s00127-007-0218-8] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2007] [Accepted: 05/29/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND The future existence of somatoform disorders (SDs) has recently been debated. The objectives of this study were to investigate the prevalence of current SDs (defined as the presence of multisomatoform disorder [MSD] or somatoform disorders not otherwise specified [SDnos], without psychosocial impairment) and severe current SDs (MSD or SDnos with psychosocial impairment) in Norway. Differences in markers of severe current SDs, anxiety/depression and self-reported musculoskeletal disorders were explored. In addition, psychological distress and utilization of healthcare in subclasses (defined according to comorbidity with anxiety, depression and musculoskeletal disorders) of severe current SDs were examined. METHODS We interviewed 1,247 respondents using the Composite International Diagnostic Interview (CIDI) in the Oslo-Lofoten general population survey in 2000-2001. Six-month prevalence rates (%) and 95% confidence intervals (CIs) for current SDs were investigated by gender and age. Risk factors of disorders, psychological distress, healthcare utilization and use of medication were explored using logistic regression analyses. RESULTS The overall prevalence rate for severe current SDs was 10.2%. When psychosocial impairment was excluded as a criterion, the rate increased to 24.6%. Anxiety was strongly correlated with severe current SDs. Comorbidity of severe current SDs with anxiety/depression was 45%, and with musculoskeletal disorders, 43%. Analysis of healthcare utilization and use of medication showed that the presence of a comorbid psychiatric condition was more important than the presence of somatoform disorders alone. CONCLUSION Somatoform symptoms alone (with no psychiatric comorbidity) should not be considered a psychiatric disorder.
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Affiliation(s)
- Kari Ann Leiknes
- Dept. of Behavioural Sciences in Medicine, Institute of Basic Medical Sciences, University of Oslo, P.B. 1111, Blindern, 0317, Oslo, Norway.
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Lee HS, Hong SY, Hong ZR, Gil HO, Yang JO, Lee EY, Han MJ, Jang NW, Hong SY. Pesticide-initiated idiopathic environmental intolerance in South Korean farmers. Inhal Toxicol 2007; 19:577-85. [PMID: 17497536 DOI: 10.1080/08958370701271522] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
This study was designed to study patients with intolerance to pesticide smells. Ten subjects chosen were complaining of vague symptoms such as headache, dizziness, fatigue, nausea, vomiting, abdominal pain, myalgia, flu-like symptoms, etc., whenever exposed to the pesticide smells even at low intensity. To determine whether the etiology of this kind of pesticide hypersensitivity was of organic or psychiatric nature, all the subjects underwent tests as follows: complete blood cell count, urinalysis, and blood chemistry as routine tests; esophogastroduodenoscopy and abdomen ultrasonography for the gastrointestinal symptoms; chest x-ray, pulmonary function tests, and electrocardiography for the respiratory and/or cardiac symptoms; nerve conduction velocity and brain magnetic resonance imaging (MRI) for peripheral and central nerve system symptoms; and K-WAIS, Rey-Kim memory test, Rorschach, Mini Mental State Examination (MMSE), and Minnesota Multiphasic Personality Inventory (MMPI) for psychoanalysis. Of the 10 cases in which the chief complaint was headache, symptoms of two cases were caused by maxillary sinusitis. Another two showed typical multiple chemical sensitivity (MCS) or idiopathic environmental intolerance (IEI). Six out of the 10 cases, whose symptoms closely resembled the others, did not conclusively meet the criteria of classic MCS or IEI. The subjects of this case shared vague fears, both fear of pesticides and hypochondriasis. Some subjects faced financial insecurity and social uncertainty; others felt uneasy about the future of their farming life. Thus, to help verify the causes of MCS or IEI, which is strongly suggestive of pesticide smells, diagnosis needs a dual approach: on the anima and soma. Psychoanalysis can delve into the mental status of the patients to see whether the patients are aware of their symptoms. Clinical tests can see through the physical structure and functions of the organs on which patients' complaints are centered.
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Affiliation(s)
- Hae-Sung Lee
- Department of Internal Medicine, Soonchunhyang University Hospital, Cheonan, Korea
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Kroenke K, Sharpe M, Sykes R. Revising the Classification of Somatoform Disorders: Key Questions and Preliminary Recommendations. PSYCHOSOMATICS 2007; 48:277-85. [PMID: 17600162 DOI: 10.1176/appi.psy.48.4.277] [Citation(s) in RCA: 123] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
As the DSM-V process unfolds, Somatoform Disorders are a diagnostic category for which major revisions seem warranted. The Conceptual Issues in Somatoform and Similar Disorders (CISSD) project recently convened three workshops, involving 24 experts. The CISSD identified key questions related to stakeholders; terminology; appropriate axis (I versus III); medically unexplained criteria; status of functional somatic syndromes; and symptom counts, grouping, lifetime recall, and checklists. Preliminary recommendations include substantial revision of the category of Somatization Disorder, elimination of Undifferentiated Somatoform Disorder and Pain Disorder, terminology changes, and potential shifting of certain disorders to different DSM categories or axes.
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Affiliation(s)
- Kurt Kroenke
- Indiana University School of Medicine and Regenstreif Institute, Indianapolis, IN 46202, USA.
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Course and predictors of medically unexplained pain symptoms in the general population. J Psychosom Res 2007; 62:119-28. [PMID: 17270569 DOI: 10.1016/j.jpsychores.2006.08.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2006] [Revised: 08/07/2006] [Accepted: 08/24/2006] [Indexed: 01/28/2023]
Abstract
OBJECTIVE The objective of this study was to explore the course and the predictors of clinically significant medically unexplained pain symptoms (MUS-pain) within the 6 months preceding the interviews at baseline and on follow-up in the general population. METHODS A Norwegian general population study of 605 persons interviewed with the Composite International Diagnostic Interview Somatoform Section was conducted in 1989/1990 (baseline), and 421 persons (69.6% response rate; 242 women and 179 men) were reinterviewed in 2000/2001 (follow-up). Cases of recent MUS-pain compared with those at baseline were assessed on follow-up. Four blockwise logistic regression analyses were undertaken to find predictors (such as stressful life events, living alone, depression and anxiety, and physical morbidity) for recent MUS-pain in 2001. RESULTS A small "stable" group of recent MUS-pain sufferers (8% of all reinterviewed and 33.6% of those with recent MUS-pain at baseline) was evident. In this group almost all were women. In addition to female gender being a significant (P<.05) marker of recent MUS-pain (which gives a twofold-higher risk compared with men), only depression--not the occurrence of prior recent MUS-pain--remained a significant (P<.05) predictor in the final model, increasing the likelihood of having recent MUS-pain by threefold. CONCLUSION The prognosis of MUS-pain is relatively good, except for a small group (mainly women) that is prone to chronicity. Clinicians should examine for depression when confronted with MUS-pain patients and should be aware of the twofold-higher risk in women for persistent MUS-pain over a long time.
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