Screening for somatization and hypochondriasis in primary care and neurological in-patients: a seven-item scale for hypochondriasis and somatization

Occupational Therapy Practice in Adult Rehabilitation of Persistent Postconcussion Symptoms: A Scoping Review

IMPORTANCE

The role of occupational therapy in the rehabilitation of adults with persistent postconcussion symptoms (PPCS) following mild traumatic brain injury is an emerging practice area. Research that contributes to growing knowledge and understanding of the profession's role may increase the recognition and visibility of occupational therapy in concussion rehabilitation programs.

OBJECTIVE

To identify and categorize (using World Health Organization International Classification of Functioning, Disability and Health [WHO ICF] One-Level Classification domains) existing literature that describes occupational therapy practice (including assessments and interventions) in the rehabilitation of adults with PPCS.

DATA SOURCES

Five scientific databases (MEDLINE, Embase, Emcare, PsycINFO, and CINAHL Complete) and gray literature were searched.

STUDY SELECTION AND DATA COLLECTION

Eligibility criteria included publications between 2013 and 2023, written in English, and within the peer-reviewed literature or on specified web domains (.gov, .edu, or .org).

FINDINGS

Nineteen publications from 16 sources met eligibility criteria, consisting of quantitative studies (n = 6); case studies, series, or reports (n = 3); qualitative studies (n = 2); systematic or scoping literature reviews (n = 2); and gray literature sources (n = 3). The United States was the origin for many sources (n = 10). Assessments and interventions reported were heterogenous, mapping across 27 of the 30 WHO ICF One-Level Classifications.

CONCLUSIONS AND RELEVANCE

Evidence to inform occupational therapy practice in adult PPCS rehabilitation is limited; however, some useful information about the assessments and interventions used by occupational therapists was found. At a time when considerable advancements in concussion rehabilitation are occurring, further research on evidence-informed occupational therapy practice is required. Plain-Language Summary: This study reviewed existing evidence about the role of occupational therapy in the rehabilitation of adults with persistent postconcussion symptoms (PPCS). It identifies and methodically documents a range of occupational therapy assessments and interventions described in the literature that may be used by occupational therapists within concussion rehabilitation programs or research. The study also categorizes these by using an internationally recognized taxonomy, the World Health Organization's International Classification of Functioning, Disability and Health. The review offers a novel synthesis of published evidence to guide occupational therapy practice and inform resource allocation in concussion rehabilitation. It also highlights the need for further research about the role of occupational therapy-including both high-quality evidence of current approaches and identification of future practice opportunities-in the rehabilitation of adults experiencing PPCS following brain injury.

Short report: Early-onset health anxiety: Insights from a cross-sectional study on adults diagnosed with severe health anxiety

OBJECTIVE

The knowledge of early-onset health anxiety (HA) (i.e. onset before age 18) is limited. This retrospective study aimed to investigate 1) the age of onset of HA and 2) potential clinical factors associated with early- compared with late-onset HA in adult patients with severe HA.

METHODS

The study sample consisted of 126 adults (aged 20-60 years) diagnosed with severe HA and referred to specialized treatment. All underwent semi-structured diagnostic interviews assessing psychiatric disorders and functional somatic disorders. The interview also included a detailed illness history with a chronological listing of HA symptom onset. Self-reports were obtained on current HA symptoms, illness perceptions, and treatment expectations.

RESULTS

Early onset of HA was reported by 40 participants (32 %, 95 % CI: 24 %-41 %) with a mean age at symptom onset of 11.6 years (SD: 4.0, range: 5-17), and 23 participants reported onset before age 13 (57.5 %). Early-onset HA was significantly associated with more negative perceptions of consequences of symptoms (Cohen's d = 0.41, p = 0.04) and stronger psychological attributions (Cohen's d = 0.33, p = 0.03), and the group with early onset were more often diagnosed with severe functional somatic disorders (Cramer's V = 0.17, p = 0.06) and reported more negative treatment expectations (Cramer's V = 0.17, p = 0 0.06), although these results were non-significant.

CONCLUSION

Early onset of HA may be common and associated with more negative illness perceptions in adulthood. These results need replication but highlight the need for further research on HA in youth.

Health anxiety in cancer patients, assessed with the Whiteley Index

OBJECTIVE

Health anxiety (HA) is frequently observed in patients suffering from a severe disease such as cancer. This study aimed to test the psychometric properties of the Whiteley Index-7 (WI-7) measuring HA and to identify prognostic factors for heightened HA in cancer patients.

METHODS

A sample of 1723 cancer patients, treated in a German rehabilitation clinic, completed the Whiteley Index-7, the Generalized Anxiety Disorder screener GAD-7, the Patient Health Questionnaire PHQ-9, the Fear of Progression questionnaire FoP-Q-12, the Concerns About Cancer Recurrence questionnaire CARQ-4, and two subscales of the EORTC QLQ-SURV100.

RESULTS

The internal consistency of the WI-7 was good (Cronbach's α = 0.85), and the correlations between the WI-7 and other scales were as follows: 0.64 (GAD-7), 0.63 (PHQ-9), 0.75 (FoP-Q-12), 0.71 (CARQ-4), 0.66 (SURV-HD), and 0.75 (SURV-NHO). Women showed markedly higher levels of HA than men (effect size: d = 0.40), and patients aged 60 years and above reported lower levels of HA than younger patients (d = -0.32). Melanoma patients showed the highest HA mean score (M = 10.9), and patients receiving antibody therapy showed heightened levels of HA (M = 10.7). When considering age and sex, the effects of tumor type and treatment become smaller than in the univariate analyses.

CONCLUSION

The WI-7 is a suitable instrument for assessing HA in cancer patients. When evaluating the effects of cancer type or treatment on HA, one has to take into account the age and sex distribution. Younger patients and women deserve special attention regarding HA.

Prevalence and associated factors of health anxiety in patients with temporomandibular disorders

OBJECTIVES

To investigate the prevalence and associated factors of health anxiety (HA) in patients with Temporomandibular Disorders (TMDs) using the 8-item Whiteley Index (WI-8) scale.

MATERIALS AND METHODS

Three hundred and twenty-nine TMDs patients completed the Visual Analog Scale (VAS), WI-8, Jaw Functional Limitation Scale-8 (JFLS-8), Patient Health Questionnaire-9 (PHQ-9), and Generalized Anxiety Disorder-7 (GAD-7) scales. Clinical examinations were conducted following the Diagnostic Criteria for TMDs Axis I.

RESULTS

The prevalence of HA among TMDs patients was 18.54%. Patients with HA had higher scores of VAS-current (p = 0.026), VAS-maximum (p = 0.024), VAS-average (p = 0.030), JFLS-8 (p < 0.001), GAD-7 (p < 0.001) and PHQ-9 (p < 0.001), lower maximum mouth opening (p = 0.016), lower proportion of structure-related TMDs (p = 0.028), and higher proportion of pain-related TMDs (p < 0.001) compared to those without HA. The correlation coefficient was 0.61 (p < 0.001) between WI-8 and GAD-7 and 0.64 (p < 0.001) between WI-8 and PHQ-9.

CONCLUSION

Approximately one-fifth of patients with TMDs experienced HA. HA was associated with pain perception, functional limitations, depressive, and anxiety symptoms in individuals with TMDs. HA may contribute to heightened subjective pain experiences rather than structural changes in the TMJ.

A common metric for questionnaires on health anxiety in cancer patients

After a cancer diagnosis, life is accompanied by worries, concerns and fears that the disease will recur or worsen. These can be normal and useful reactions but may also become so severe that they interfere with everyday functioning. A challenge for patient care is that the theoretical similarity of these reactions, is not consistently conceptualized in practice, hence the empirical comparability of their measures is unclear. Here we intend to show that the theoretical similarity is also empirically justified, and we present a common metric in graphical form that allows direct comparisons between different questionnaires. A total of 1,733 cancer patients completed the Fear of Progression Questionnaire Short Form, Questionnaire on Stress in Cancer Patients-revised version, Concerns About Recurrence Questionnaire, the subscales Health Distress and Negative Health Outlook of the EORTC QLQ-SURV100, and the Whiteley Index. Using a model based on item response theory, we linked the score values of the individual questionnaires. The main outcome of this study is a diagram that can be used to convert the respective values of eight questionnaires on health anxiety to another. All instruments showed a reliability above 0.75 near the mean health anxiety level. The common metric can be used to compare measurements with these questionnaires in terms of the level of health anxiety. Additionally, the reliability of the instruments can be judged at different levels of anxiety. This allows for a better comparability of test results and facilitates communication about the results among experts and with patients.

Halifax somatic symptom disorder trial: A pilot randomized controlled trial of intensive short-term dynamic psychotherapy in the emergency department

BACKGROUND

Patients commonly present at hospital Emergency Departments (ED) with distress that meet criteria for a Somatic Symptom and Related Disorder (SSRD). Without access to effective treatment, risk of ongoing patient disability and further ED visits is high.

METHOD

This pilot trial used a randomized parallel group design to test the efficacy of Intensive Short-Term Dynamic Psychotherapy (ISTDP). ED patients who met criteria for SSRD were recruited. The effects of ISTDP plus medical care as usual (MCAU) were judged through comparison against 8 weeks of MCAU plus wait-list symptom monitoring (WL-SM). The primary outcome was somatic symptom at 8 weeks. Patients allocated to WL-SM could cross-over to receive ISTDP and 6-month follow-up data was collected. Baseline measures of patient attachment style and alexithymia were collected to examine vulnerabilities to somatic symptoms.

CLINICALTRIALS

gov: NCT02076867.

RESULTS

Thirty-seven patients were randomized to 2 groups (ISTDP = 19 and WL-SM = 18). Multi-level modelling showed that change over time on somatic symptoms was significantly greater in the ISTDP group. Between-group differences were large at 8 weeks (Cohen's d = 0.94) and increased by end of treatment (Cohen's d = 1.54). Observed differences in symptoms of depression and illness anxiety were also large, favoring ISTDP, and effects were maintained at follow-up. Patients receiving ISTDP had reduced ED service utilization at 2-year follow-up.

CONCLUSIONS

ISTDP appears an efficacious treatment for SSRD and a larger randomized trial is justified.

Can the Whiteley Index be used to assess health anxiety in adolescents from the general population?

Health anxiety (HA) is characterized by worry about being or becoming ill. The Whiteley Index (WI) is a valid and frequently used measure for HA in adults. We examined item response distribution, floor and ceiling effects, and construct validity of four different one-factor models of the WI (an 8-item model, the widely used WI-7, a revised 7-item version (WI-7-R), and a 6-item version (WI-6-R)) in a population-based sample of adolescents, using data from the 16-17-year follow-up of the Copenhagen Child Cohort 2000 (N = 2521, 16-17 years old). Females generally scored higher on all eight WI items compared to males. Construct validity was examined by confirmatory factor analysis and hypothesis testing. The WI-7-R and WI-6-R both showed acceptable fits. All four models showed good internal consistency. Hypothesis testing showed good discriminant validity, as the hypotheses on positive correlations with anxiety, depression, and physical symptoms, as well as a negative correlation with health-related quality of life, were met for both the WI-7-R and WI-6-R. We advocate for the use of the WI-6-R, which focuses on core HA symptoms and excludes items concerning physical symptoms. The overall testing supports that the WI-6-R possesses valid psychometric properties for use with adolescents in the general population.

Red State, Blue State, Purple State; Higher and Increasing Blue COVID-19 Anxiety Rate

The present study investigated COVID-19 Anxiety Scale (CAS) scores for participants from blue states, red states, and purple states across 276 days ranging from April 18, 2020 to January 23, 2021. The CAS scores increased with knowing and caring for an individual with COVID-19, following social distancing guidelines, hours talking and thinking about COVID-19, hypochondria, neuroticism, depression, anxiety, stress, negative PANAS, and time, whereas they decreased with positive PANAS. More importantly, the CAS scores were higher for participants from blue states than for participants from purple states, and the positive relation between CAS scores and time was only significant for participants from blue states. We connected media events that occurred concurrently for high CAS scores overall and for high CAS scores for participants from blue states. The spikes in CAS ratings occurred along with COVID-19 contagion, partisan reactions to protests for slain African Americans (e.g., George Floyd), and the 2020 presidential election.

Further Evidence for a Dimensional Latent Structure of Health Anxiety: Taxometric Analyses of the Whiteley Index Based on Two German Representative Samples

Health anxiety is an intricate part of illness anxiety and somatic symptom disorder. Based on convenience samples, two out of three available studies indicate that it is a dimensional rather than a categorical construct. Using two representative datasets, this study investigates whether previous results can be clarified. Conventional taxometric analyses as well as comparison curve fit indices (CCFI) profile analyses (MAMBAC and MAXSLOPE procedures) were calculated with two datasets of the German adult population assessing the Whiteley Index (WI-14, N = 2,072; WI-7, N = 2,498). Mean CCFIs indicated a dimensional structure for both the WI-7 (mean CCFI = 0.42, mean CCFI profile = 0.40) and the WI-14 (mean CCFI = 0.44, mean CCFI profile = 0.32). The results support and extend previous findings by strongly suggesting a dimensional distribution of health anxiety in the general population. Implications for research and practice comprise the adoption of a dimensional description of psychopathology as well as transdiagnostic treatment approaches.

Fear of COVID-19 predicts increases in anxiety, depressive symptoms, health anxiety, psychosocial distress, and loneliness: Findings from a prospective two-year follow-up study

The role of fear of COVID-19 in prospectively predicting changes in psychopathological symptoms during the COVID-19 pandemic remains unclear. The present data were obtained from a longitudinal non-probability sample in Germany, initially assessed at the beginning of the COVID-19 pandemic in Germany (April-May 2020) and reassessed after two years (n = 846; 83% female; mean age: 44.59 years, SD = 12.32; response rate: 19.5%). Multiple linear regressions were used to examine associations of fear of COVID-19 at baseline with depressive symptoms, anxiety, health anxiety, psychosocial distress, and loneliness controlling for (a) the respective symptom measure, and (b) all psychopathological symptoms at baseline. The data were weighted to minimize attrition and representativeness biases. Overall, loneliness decreased from the beginning of the COVID-19 pandemic until the two-year follow-up, whereas all other symptoms did not change. Fear of COVID-19 at the beginning of the pandemic predicted an increase in anxiety symptoms, health anxiety, psychosocial distress, and loneliness two years later. In addition, fear of COVID-19 predicted higher health anxiety, depressive symptoms, psychosocial distress, and loneliness, but not anxiety symptoms when controlling for all baseline symptom measures at once. Fear of COVID-19 seems to play a central role in predicting negative mental health outcomes, emphasizing the necessity of indicated prevention and intervention to decrease worry and manage anxiety, thereby reducing the negative impact on mental health caused by fear during future pandemics.

Intersectional inequalities in health anxiety: multilevel analysis of individual heterogeneity and discriminatory accuracy in the SOMA.SOC study

Background

Intersectional approaches are needed to disaggregate the complex interaction of social identities contributing to (mental) health disparities. Health anxiety represents an overlooked public mental health issue. Therefore, intersectional inequalities in health anxiety were examined using multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA).

Methods

Analyses are based on cross-sectional data of the adult population living in Germany (N = 2,413). Health anxiety was assessed with the Whiteley Index-7. Applying intersectional MAIHDA, health anxiety in the intersectional strata of gender, history of migration, and income was predicted. Discriminatory accuracy was assessed via the intra-class correlation and the proportional change in variance.

Results

Analyses revealed additive social inequalities in health anxiety with greatest impact of low income but no clear intersectional gradient. Most affected by health anxiety were females who immigrated themselves with low income, males whose parent(s) immigrated with low income, and males who immigrated themselves with medium income.

Conclusion

Intersectional approaches contribute to a more comprehensive understanding of (mental) health disparities. In addition to general efforts to counteract health inequalities, combining universal screening and targeted psychotherapeutic treatment seems promising to specifically reduce inequalities in health anxiety.

Efficacy of patient education and duloxetine, alone and in combination, for patients with multisystem functional somatic disorder: Study protocol for the EDULOX trial

BACKGROUND

Multisystem functional somatic disorder is characterized by specific patterns of persistent physical symptoms with a complex biopsychosocial etiology. The disorder can lead to disability and personal suffering. Current treatment options require specialized settings, therefore patients often wait a long time to receive specific treatment. Patient education is considered important in most treatment programs, but has only been investigated sparsely as a stand-alone treatment. Pharmacological treatment is limited to tricyclic antidepressants in low doses with no antidepressant properties. Duloxetine has been found effective in single organ functional disorders. As a treatment for multisystem functional somatic disorder, duloxetine could reduce symptoms and treat comorbid anxiety and depression. It may furthermore enhance the effect of patient education through a hypothesized effect on cognitive functioning. The purpose of the EDULOX trial is to study psycho-EDUcation and duLOXetine alone and in combination.

METHODS

This is a nested study design. The parent trial "EDULOX1" (n = 424) will compare a patient education program with enhanced usual care in an open-labelled, randomized controlled trial. In addition to this, eligible participants will furthermore receive either duloxetine or active placebo in the nested, double-blinded, randomized controlled trial, "EDULOX2" (n = 212). Patient and clinician reported outcomes will be collected through questionnaires.

CONCLUSION

The EDULOX trial may establish evidence for treatments applicable for the majority of patients with multisystem functional somatic disorder. If effective, duloxetine would be a more tolerable pharmacological treatment option that can target comorbid depression and anxiety, and potentially boost the effect of patient education. Trial registration number The study is registered at www.

CLINICALTRIALS

gov (NCT06232473) and the internal list of research projects at the Region of Central Denmark (Case number 1-16-02-305-23). Approval from the Danish Medical Research Ethics Committees (Case number: 2212291) and the Danish Medicines Agency was obtained under EudraCT Number: 2022-002780-30 and Sponsor's Protocol Code Number: 9515.

Exploring the interplay between psychotic experiences, functional somatic symptoms and health anxiety in childhood and adolescence - A longitudinal cohort study

BACKGROUND

Similarities exist between contemporary explanatory models underlying psychosis development, functional somatic symptoms, and health anxiety. The current study aimed to examine the potential interplay between psychotic experiences (and alternate measures of anomalous self-experiences and aberrant attribution of salience) and functional somatic symptoms on the outcome of health anxiety in youths.

METHODS

In a prospective general-population birth cohort, the Copenhagen Child Cohort 2000 (CCC2000), data from two time-points were available for 1122 individuals. We assessed the associations between psychotic experiences and functional somatic symptoms with health anxiety both cross-sectionally at ages 11- and 16-years, and longitudinally from age 11 to 16. Further, we examined if there was an interaction between these two domains on the outcome of health anxiety using the interaction contrast ratio.

RESULTS

Functional somatic symptoms and psychotic experiences were strongly cross-sectionally associated with health anxiety at both ages 11 and 16, even after adjustment for general psychopathology. In the longitudinal analyses, functional somatic symptoms, and psychotic experiences at age 11 were not individually associated with health anxiety at age 16 but having both functional somatic symptoms and psychotic experiences was: odds ratio 3.90, 95%CI 1.7-8.9, with suggestion of evidence for interaction beyond the additive effects. This association was attenuated after adjustment for general psychopathology: odds ratio 2.6, 95 % CI 1.0-6.4.

CONCLUSION

The strong associations between the domains support the idea of possible overlapping mechanisms underlying psychotic experiences, functional somatic symptoms, and health anxiety.

Fear of Cancer Progression: A Comparison between the Fear of Progression Questionnaire (FoP-Q-12) and the Concerns about Recurrence Questionnaire (CARQ-4)

As cancer patients often suffer from fear of cancer progression (FoP), valid screening for FoP is of high relevance. The aims of this study were to test psychometric properties of two FoP questionnaires, to determine their relationship to other anxiety-related constructs, and to analyze the impact of sociodemographic and clinical factors on the FoP. Our sample consisted of n = 1733 patients with mixed cancer diagnoses. For measuring FoP, the Fear of Progression questionnaire (FoP-Q-12) and the Concerns About Cancer Recurrence Questionnaire (CARQ-4) were used. The mean scores of the FoP-Q-12 and the CARQ-4 were 30.0 ± 10.4 and 16.1 ± 10.8, respectively, indicating relatively high levels of FoP. Both questionnaires showed excellent internal consistency coefficients, α = 0.895 and α = 0.915, respectively. The correlation between the two FoP questionnaires was r = 0.72. Female patients reported more FoP than male patients (d = 0.84 and d = 0.54, respectively). There was a nonlinear age dependency of FoP, with an increase found in the age range from 18 to 50 years and a decrease in the older age range. Radiation, chemotherapy, and antibody therapy, but not surgery, lead to an increase in FoP. Both questionnaires show good psychometric properties and can be recommended for use in an oncological routine. Female patients and patients in the middle-age range deserve special attention from healthcare providers.

Measurement properties of the Health Anxiety by Proxy Scale (HAPYS): A new questionnaire to assess parents' worries about their child's health

OBJECTIVE

Health anxiety by proxy refers to parents' excessive worries about their child's health. The Health Anxiety by Proxy scale (HAPYS) is a new self-report questionnaire to assess parents' worries and behaviors regarding their child's health. This study aimed to investigate the measurement properties of the HAPYS.

METHODS

Questionnaires were completed by 204 parents, and a HAPYS score was obtained for 200 parents: 39 parents diagnosed with health anxiety, 33 parents with different anxiety disorders, 33 parents with a Functional Somatic Disorder, and 95 healthy parents. We evaluated the following measurement properties: structural validity, reliability, convergent validity ((pain catastrophizing, parents' reports of child's emotional and physical symptoms), discriminant validity (parental reports of child's well-being), and known-groups validity (see compared groups above).

RESULTS

HAPYS demonstrated a one factor dimensionality, and excellent internal reliability (α = 0.95; CI: 0.93-0.97) and test-retest reliability after two weeks (ICC = 0.91; CI: 0.87-0.94). Convergent validity with the construct of parental catastrophizing about child pain was good (r = 0.72; CI: 0.64-0.78)). Good known-groups validity was demonstrated by the largest total HAPYS score observed in parents with health anxiety (median = 35; IQR: 9-53) and the lowest score in healthy parents (median = 9; IQR: 5-15) (p < 0.001).

CONCLUSION

The findings support that HAPYS is a useful measure of health anxiety by proxy. Future research should examine the measurement properties in larger samples and different languages with further statistical analyses of structural validity.

Translation and examination of construct validity of the Danish version of the Tampa Scale for Kinesiophobia

OBJECTIVES

This study investigates the construct validity of the Danish Tampa Scale for Kinesiophobia (TSK).

METHODS

The English 17-item scale was translated into Danish adhering to WHO's guidelines. The construct validity of the TSK was examined in a random general population sample of 4,884 18- to 72-year olds with pain within the past 4 weeks. Examination of construct validity adhered to the COSMIN checklist. Structural validity was examined by splitting the sample and conducting exploratory factor analysis on one half and confirmatory factor analysis on the other half. Convergent validity was examined through associations with self-report measures and objective physical performance tests. Reference scores for the TSK were calculated.

RESULTS

After translation, all respondents felt confident that they understood the meaning of the items. All but one found the questionnaire acceptable. The exploratory factor analysis suggested that a 1-factor 13-item version without 4 reversed items resulted in the most consistent fit across subgroups of gender, age, and severe pain report. Five different models of the TSK were tested in the confirmatory factor analysis. While none were excellent fits, both one- and two-factor models of the TSK-13 and TSK-11 were acceptable. Two-factor models marginally outperformed one-factor models on goodness of fit. There was no association between TSK scores and muscular fitness or self-reported physical activity. Cardiorespiratory fitness, self-perceived physical fitness, and self-efficacy had weak correlations with TSK scores. Scores showed modest associations with self-report measures of anxiety, illness worry, pain interference, and daily limitations.

CONCLUSIONS

Based on an overall consideration of results, we recommend using the TSK-13 as a one-dimensional construct for both research and clinical purposes pending further examinations of the TSK in clinical samples. TSK scores from the present study can serve as a standard of reference for levels of Kinesiophobia in the general population.

How do people with chronic pain explain their use, or non-use, of pain-related healthcare services? A qualitative study of patient experiences

PURPOSE

This study aims to explore how people with chronic pain explain their use or non-use of pain-related healthcare services and their expectations of the healthcare provider, and explore how explanations and expectations vary between different levels of pain-related healthcare use.

MATERIALS AND METHODS

We conducted 20 individual semi-structured interviews with purposely sampled adults between 39 and 77 years of age with chronic pain. All interviews were audio-recorded, transcribed and analysed using a thematical template analysis approach.

RESULTS

Four key drivers for pain-related healthcare use were identified: (1) the healthcare system facilitates clinical pathways, (2) appraisal of pain-related healthcare initiatives influences future use, (3) autonomy, beliefs and values determine healthcare behaviour, and (4) recommendations from others impact healthcare behaviour. Comparing explanations across different pain-related healthcare user groups (high, medium and low) showed that perceived needs, beliefs and values, and appraisal of previous healthcare experiences differed between these groups.

CONCLUSIONS

Beliefs, pain characteristics, recommendations, and the search for a diagnostic label, often initiate pain-related healthcare use. Healthcare is modified by two interconnected systems: (1) perceived needs, beliefs and values and (2) previous healthcare experiences. Differences related to these systems could explain some of the variance in pain-related healthcare use.Implications for RehabilitationDifferent use of pain-related healthcare services for people with chronic pain could be related to differences in perceived needs, beliefs and values and appraisal of previous healthcare.It may be helpful to explore the perceived needs and beliefs of those seeking healthcare due to chronic pain.Previous healthcare experiences may impact and should be explored.

Internet-Delivered Therapy for Parents With Health Anxiety by Proxy: Protocol for a Single-Case Experimental Design Study

BACKGROUND

Health anxiety (HA) by proxy is described as parents' obsessive worries that their child is severely ill although this is not medically confirmed. Research on HA by proxy suggests that it is highly distressing for the parent and that the child may be at risk of developing maladaptive symptom coping strategies. No targeted treatment for this group exists. We developed PROXY, an 8-week psychological internet-delivered treatment for parents with HA by proxy. The treatment components of PROXY are informed by cognitive behavioral therapy as well as acceptance and commitment therapy, and it was developed in collaboration with parents experiencing HA by proxy and clinical experts.

OBJECTIVE

This paper describes the protocol for a study investigating the potential effects of PROXY on parents' worries about their children's health using a single-case experimental design (SCED).

METHODS

Five parents clinically evaluated as experiencing HA by proxy will be included. A replicated randomized SCED study will be conducted in which each participant will be randomized to receive treatment after a baseline period of between 7 and 26 days (phase A). The treatment phase duration is 8 weeks for all participants (phase B), followed by a follow-up phase lasting between 14 and 33 days (phase C), ensuring that all participants remain in the study for 96 days. Participants will report daily anxiety level by SMS text message throughout the study. They will also answer self-report questionnaires, including questions on HA by proxy and own HA, 4 times during the study. Data will be submitted to structured visual analysis to inspect anxiety level, the variability of anxiety, trends, the overlap of data points among phases, when effects occur, and the consistency of data patterns across participants. Furthermore, randomization tests will be conducted for each participant to test the null hypothesis that PROXY will have no effect on participants' anxiety.

RESULTS

The recruitment of parents began in June 2022. As of March 2, 2023, a total of 4 parents have been included in the study. Data collection was expected to cease in April 2023.

CONCLUSIONS

To the best of our knowledge, this protocol describes the only study of treatment for HA by proxy. As the prevalence of this condition is still unknown, a SCED was chosen because this method allows the inclusion of very few participants while still providing information on effects and treatment courses. Conducting the study with a replicated randomized phase design enables methodologically sound testing despite the inclusion of very few participants. The results will inform researchers on individual treatment courses and effects, which may direct future research in terms of the possible mechanisms of change, ideas for how to refine the treatment content, and how the treatment may be offered to patients in the future.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04830605; https://clinicaltrials.gov/study/NCT04830605.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/46927.

Psychometric properties and psychological correlates of the COVID-19 Anxiety Syndrome Scale: A comprehensive systematic review and meta-analysis

Coronavirus disease-19 (COVID-19) has led to the demise of millions of people worldwide; additionally, it has resulted in a significant economic and mental health burden. Since the onset of the COVID-19 pandemic, various measures have been constructed to evaluate pandemic-related fear and anxiety. The COVID-19 Anxiety Syndrome Scale (C-19ASS) is a promising measure that assesses coping strategies (e.g., avoidance, checking, worrying and threat monitoring), termed 'COVID-19 Anxiety Syndrome', in response to COVID-19 fear and anxiety. The measure has been broadly welcomed, leading to its use in Brazil (Portuguese), China, Greece, Indonesia, the Philippines, Iran (Farsi), Italy, Saudi Arabia (Arabic), Turkey, the United Kingdom and the United States. To gain a better understanding of the relevance of the COVID-19 Anxiety Syndrome, we conducted a systematic review and meta-analysis to explore the psychological correlates and psychometric properties of the C-19ASS. Through the analysis of a total of 17,789 individuals (age range 19-70; female = 33%-85%), the C-19ASS demonstrated a consistent factor structure, measurement invariance across gender and acceptable reliabilities. Furthermore, a significant association with COVID-19 anxiety, depressive symptoms, generalized anxiety, health anxiety, psychological distress and functional impairment (work and social adjustment) during the COVID-19 pandemic was observed. When considering the Big Five personality traits, the C-19ASS and its subscales were only significantly and negatively associated with extraversion; only the total score on the measure was associated with neuroticism. The observed effect sizes ranged from very small to medium. Given that all included studies (K = 24) were cross-sectional, and due to the nature of the COVID-19 Anxiety Syndrome, which may well persist after the pandemic ends, it is recommended to continue screening society for the persistence of this syndrome.

Functional Somatic Disorders, Their Subtypes, and Their Association With Self-Rated Health in the German General Population

OBJECTIVE

The heterogeneous conceptualizations and classifications of persistent and troublesome physical symptoms impede their adequate clinical management. Functional somatic disorder (FSD) is a recently suggested interface concept that is etiologically neutral and allows for dysfunctional psychobehavioral characteristics as well as somatic comorbidity. However, its prevalence and impact are not yet known.

METHODS

We analyzed 2379 participants (mean age = 48.3 years, 52.5% female) from a representative German community survey using operationalized FSD criteria. These criteria defined FSD types based on somatic symptom count, type, and severity assessed by the Bodily Distress Syndrome Checklist. In addition, the associations of those types with health concerns, comorbidity, psychological distress, and self-rated health were determined.

RESULTS

There were four clearly demarcated groups with no relevant bothering symptoms, with one or with few bothering symptoms from one organ system, and with multiple bothering symptoms from at least two organ systems. Psychological distress, health concerns, and comorbidity steadily increased, and self-rated health decreased according to the number and severity of symptoms. Somatic symptom burden, health concerns, and comorbidity independently predicted self-rated health, with no interaction effect between the latter two.

CONCLUSIONS

Our data support an FSD concept with two severity grades according to persistent and troublesome symptoms in one versus more organ systems. The delimitation of subtypes with psychobehavioral characteristics and/or with somatic comorbidity seems useful, while still allowing the demarcation of a group of participants with high symptom burden but without those additional characteristics.

Social inequalities in aggravating factors of somatic symptom persistence (SOMA.SOC): study protocol for a mixed-method observational study focusing on irritable bowel syndrome and fatigue

INTRODUCTION

Some studies indicate that persistent somatic symptoms (PSS) are more prevalent among individuals with a low socioeconomic status (SES) and a migration background. However, factors explaining social inequalities in PSS are largely unknown. It is expected that aggravating factors of PSS like illness perception, illness beliefs (health literacy, stigma), illness behaviour and health anxiety may play an important role for this explanation. The SOMA.SOC study will examine social inequalities (according to SES and migration) in factors contributing to symptom persistence in irritable bowel syndrome (IBS) and fatigue.

METHODS AND ANALYSIS

The project will collect both quantitative and qualitative data. Quantitative data will be gathered via a representative telephone survey in Germany (N=2400). A vignette design will be used depicting patients varying in sex, condition (IBS/fatigue), occupational status (low/high) and migration (yes/no). In the survey, we will assess public knowledge and beliefs (eg, health literacy), attitudes (stigma) and personal experiences with the condition (eg, somatic symptom burden). Complementary, longitudinal qualitative interviews will be conducted with patients (n=32 at three time points, resulting in N=96 interviews) who will also vary according to sex, condition, occupational status and migration. Patients will be recruited from primary care practices in Hamburg. The interviews will cover origin and development of the condition, coping and help-seeking as well as social interactions and perception of the disease by others (eg, perceived stigma). SOMA.SOC is part of the interdisciplinary SOMACROSS (Persistent SOMAtic Symptoms ACROSS Diseases) research unit.

ETHICS AND DISSEMINATION

The study protocol was approved by the Ethics Committee of the Hamburg Medical Association on 25 January 2021 (reference number: 2020-10194- BO-ff). Informed consent will be obtained from all participants. The main findings will be submitted for publication in peer-reviewed journals within 12 months of study completion.

Anxiety sensitivity elevates the risk of mental health problems in employees with higher probability of contacting COVID-19 at work

Individuals with increased risk of being in contact with COVID-19 cases at work have been reported to suffer from higher fear of infection and associated mental health problems. The present study examines whether this risk is further increased by higher anxiety sensitivity (AS, i.e., fear of bodily symptoms such as breathlessness, which also are core symptoms of COVID-19) that is also known to be associated with an increased risk of psychopathology. In spring 2020, 783 German health care and social workers participated in a cross-sectional online-survey, in which anxiety sensitivity, depression, anxiety, health anxiety, fear of a COVID-19 infection as well as panic symptoms were assessed. Of these participants, 28.7% affirmed contact with COVID-19 cases, which was associated with greater fear of the virus. Individuals with high AS reported more severe anxiety, health anxiety, depressive symptoms, as well as incident and recurrent panic symptoms. Moreover, the risk association of exposure to COVID-19 cases at work with health anxiety, general anxiety, and panic symptoms was further increased by higher levels of AS. These findings suggest that especially employees with contact to COVID-19 cases who also are high in AS might profit from targeted interventions to prevent excessive fear and associated mental health problems.

Resting-state connectivity and neural response to emotional images in patients with severe health anxiety: An fMRI study

BACKGROUND

Severe health anxiety is a disorder characterized by a persistent preoccupation with one's health. In behavioral studies, biases in the processing of health-related stimuli (e.g., pictures, words) are consistently associated with health anxiety symptoms. The neural correlates of the observed behavioral abnormalities remain however poorly understood.

METHODS

In this functional magnetic resonance imaging study, 22 treatment-seeking patients with severe health anxiety and 22 control participants performed a resting-state and a picture matching task. Immediately after the resting-state, participants completed a questionnaire quantifying their thoughts and feelings during rest along several dimensions. The picture task included images of health-related and neutral scenes and of disgusted and neutral faces.

RESULTS

Compared to controls, patients with health anxiety showed increased functional connectivity in the dorsolateral prefrontal cortex within the left fronto-parietal resting-state network, which correlated positively with the self-reported thought dimensions of Self, Health Concern, and Thought Suppression. In the picture matching task, no significant group differences were found in the hypothesised regions (amygdala and insula) or at a whole-brain level in response to either health-related versus neural scenes or disgust versus neutral faces contrasts.

LIMITATIONS

A relatively small sample size and that no information about patients declining to participate was obtained.

CONCLUSIONS

Our findings suggest that behavioral biases in health anxiety may be related to aberrant left dorsolateral prefrontal cortex functional connectivity at rest. In contrast, the health anxiety patients did not show significant hyperactivations of amygdala and insula during processing of emotional stimuli, contrasting findings in other anxiety disorders.

Evidence-Based Mind-Body Interventions for Children and Adolescents with Functional Neurological Disorder

LEARNING OBJECTIVES

• Develop and implement treatment plans for children and adolescents with functional neurological disorder (FND)• Outline a plan to increase awareness and standardize the care for patients with FND using evidence-based interventions.

ABSTRACT

Functional neurological disorder (FND) in children and adolescents involves the biological embedding of lived experience in the body and brain. This embedding culminates in stress-system activation or dysregulation and in aberrant changes in neural network function. In pediatric neurology clinics, FND represents up to one-fifth of patients. Current research shows good outcomes with prompt diagnosis and treatment using a biopsychosocial, stepped-care approach. At present, however-and worldwide-FND services are scarce, the result of long-standing stigma and ingrained belief that patients with FND do not suffer from a real ("organic") disorder and that they therefore do not require, or even deserve, treatment. Since 1994, the Mind-Body Program for children and adolescents with FND at The Children's Hospital at Westmead in Sydney, Australia-run by a consultation-liaison team-has delivered inpatient care to hundreds of patients with FND and outpatient care to hundreds of others. For less-disabled patients, the program enables community-based clinicians to implement biopsychosocial interventions locally by providing a positive diagnosis (by a neurologist or pediatrician), a biopsychosocial assessment and formulation (by clinicians from the consultation-liaison team), a physical therapy assessment, and clinical support (from the consultation-liaison team and the physiotherapist). In this Perspective we describe the elements of a biopsychosocial mind-body program intervention capable of providing, as needed, effective treatment to children and adolescents with FND. Our aim is to communicate to clinicians and institutions around the world what is needed to establish effective community treatment programs, as well as hospital inpatient and outpatient interventions, in their own health care settings.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Diabetes self-management during the COVID-19 pandemic and its associations with COVID-19 anxiety syndrome, depression and health anxiety

INTRODUCTION

The effects of the COVID-19 pandemic on mental health have been profound. Mental health and diabetes self-care are inter-related. We examined whether COVID-19 anxiety, depressive symptoms and health anxiety were associated with domains of diabetes self-management and investigated whether greater COVID-19 anxiety syndrome would independently contribute to suboptimal diabetes self-care.

RESEARCH DESIGN AND METHODS

Surveys were sent to people attending diabetes clinics of three London hospitals. Participants completed the Diabetes Self-Management Questionnaire (DSMQ), the COVID-19 Anxiety Syndrome Scale (C-19 ASS), which measures perseveration and avoidant maladaptive coping behaviour, assessed with measures of co-existent depressive symptoms and anxiety, controlling for age, gender and social deprivation. Clinical data, including pre- and post-lockdown HbA_1c measures, were obtained from hospital records for 369 respondents, a response rate of 12.8%.

RESULTS

Depressive symptom scores were high. Both pre-existing health anxiety and depressive symptoms were independently linked to improvable measures of diabetes care, as was lower socio-economic rank. However, avoidant COVID-19 anxiety responses were independently associated with higher diabetes self-care scores. HbA_1c levels improved modestly over the year of UK lockdown in this cohort.

CONCLUSION

During the height of lockdown, avoidant coping behaviours characteristic of the COVID-19 anxiety syndrome may in fact work to improve diabetes self-care, at least in the short term. We recommend screening for depressive symptoms and being aware of the significant minority of people with COVID-19 anxiety syndrome who may now find it difficult to re-engage with face-to-face clinic opportunities.

Interoceptive anxiety-related processes: Importance for understanding COVID-19 and future pandemic mental health and addictive behaviors and their comorbidity

The COVID-19 pandemic is associated with an increased prevalence of mental health problems and addictive behaviors. There is a growing theoretical and empirical evidence that individual differences in interoceptive anxiety-related processes are a one set of vulnerability factors that are important in understanding the impact of pandemic-related mental health problems and addictive behavior. However, there has not been a comprehensive effort to explore this rapidly growing body of research and its implications for public health. In this paper, we discuss why interoceptive anxiety-related processes are relevant to understanding mental health and addictive behaviors during the COVID-19 pandemic. We then provide a narrative review of the available COVID-19 literature linking interoceptive fear and anxiety-related processes (e.g., anxiety sensitivity, health anxiety, and COVID-19 anxiety, fear, and worry) to mental health and addictive behaviors. We then propose a novel transdiagnostic theoretical model that highlights the role of interoceptive anxiety-related processes in mental health and addictive behavior in the context of the present and future pandemics. In the final section, we utilize this conceptualization to underscore clinical implications and provide guidance for future research initiatives in the management of COVID-19 mental health and addictive behaviors and inform the public health field for future pandemics.

Poor respiratory health outcomes associated with high illness worry and alexithymia: Eleven-year prospective cohort study among the working-age population

OBJECTIVE

Poor respiratory health outcomes have been associated with poorer physical health and higher psychological distress. The aim of this study was to investigate whether illness worry, alexithymia or low sense of coherence predict i) the onset of new respiratory disease, ii) respiratory symptoms or iii) lung function among the working-age population, independently of comorbidity mood-, anxiety, or alcohol abuse disorders.

METHODS

The study was conducted among a nationally representative sample of the Finnish population (BRIF8901) aged 30-54 years (N = 2310) in 2000-2001 and was followed up in 2011. Individuals with a diagnosed respiratory disease or a severe psychiatric disorder at baseline were excluded. Lung function was measured by a spirometry test and psychiatric disorders were diagnosed using a structured clinical interview. Structured questionnaires were used to measure self-reported respiratory symptoms and diseases, illness worry, alexithymia, and sense of coherence.

RESULTS

High illness worry predicted an 11-year incidence of asthma (OR 1.47, 95% CI 1.09-1.99, p = 0.01). Alexithymia predicted shortness of breath (OR 1.32, 95% CI 1.13-1.53, p < 0.01) and 11-year incidence of COPD (OR 2.84, 95% CI 1.37-5.88, p < 0.01), even after several adjustments for physical and mental health. Psychological dispositions did not associate with lung function in 2011.

CONCLUSIONS

In the general population, psychological factors that modify health behaviour predicted adverse respiratory health outcomes independently of lung function after 11 years of follow-up. This indicates that considering them part of personalized treatment planning is important for promoting health-related behaviour among the working-age population.

Electricians' Health After Electrical Shocks: A Prospective Cohort Study

OBJECTIVES

To examine whether demographic and health factors are associated with risk of electrical shocks and compared mental and physical health before and after an electrical shock.

METHODS

A 6-month cohort study of 6960 electricians involved weekly questionnaires regarding exposure to electrical shocks, and health. We examined the association between health and demographic factors and the risk of eventual electrical shocks and health before and after a shock.

RESULTS

Youth and poor health were associated with risk of shocks. Reporting of numbness, cramps/spasms, tremors, tinnitus, dizziness, and flashbacks increased in the week of the shock, but only tinnitus and flashbacks persisted, as other symptoms receded. Severity, high voltage, cross-body exposure, wet entry/exit points, and direct current as well as health worries and/or neuroticism increased some estimates.

CONCLUSION

Electrical shocks are common, but rarely result in health effects.

Prevalence of DSM-5 somatic symptom disorder in Chinese patients with breast cancer

OBJECTIVE

The aims of this study were to explore the frequency of somatic symptom disorder (SSD) and the relationship between SSD and somatic, psychological, and social factors in Chinese patients with breast cancer.

METHODS

This multicenter cross-sectional study enrolled 264 patients with breast cancer from 3 different departments in Beijing. The structured clinical interview for DSM-5 (SCID-5) for SSD. Standardized questionnaires and clinical data were used to compare patients with and without SSD.

RESULTS

SSD was diagnosed in 21.6% (57/264) of all enrolled patients. No differences were found between SSD patients and non-SSD patients in terms of sociodemographic characteristics and tumor-specific variables, except radiotherapy.However, patients with SSD reported higher levels of depression, anxiety and cancer-related worry. They also showed a longer duration of symptoms, greater impairment in daily life, more concern over their physical complaints and more doctor visits. In a stepwise binary logistic regression analysis, among others, higher health anxiety (WI-8, Exp(B) = 0.107, p = 0.009) and more doctor visits (OR = -1.841, p < 0.001) showed a significant association with SSD; the model explained 53.7% of the variance.

CONCLUSIONS

Similar to other physical diseases, there is a high prevalence of SSD in patients with breast cancer. SSD patients differ from non-SSD patients by exhibiting higher cancer-related emotional distress and dysfunctional illness perception and behavior. There remain substantial challenges in the diagnosis of SSD in patients with cancer and other medical conditions. This article is protected by copyright. All rights reserved.

Cost Effectiveness of Internet-Delivered Acceptance and Commitment Therapy for Patients with Severe Health Anxiety: A Randomised Controlled Trial

BACKGROUND

Health anxiety is a prevalent and debilitating disorder associated with extensive use of healthcare services and reduced quality of life (QoL). Regional variability in specialised clinics or specialist healthcare providers limits access to evidence-based treatment, which may be overcome by internet-delivered Acceptance and Commitment Therapy (iACT).

OBJECTIVE

This study investigated the cost effectiveness of iACT for severe health anxiety in adults.

METHODS

Based on a Danish randomised controlled trial (March 2016-March 2017), the economic evaluation compared costs and effects between iACT and an active control condition (iFORUM). Effectiveness was measured using self-report questionnaires. The cost analysis applied a societal perspective. Resource use and healthcare costs were extracted from the Danish National Registries. Linear regression analysis was applied using change in costs/effectiveness outcomes as the dependant variable. Time, group, and interaction between time and group were independent variables. The primary outcome was the proportion of clinically significant improvements, defined as a ≥ 25% reduction in two measures of health anxiety. The probability of cost effectiveness was presented in a cost-effectiveness acceptability curve for a range of threshold values for willingness to pay.

RESULTS

No significant differences were detected in healthcare costs between groups; however, the iACT group significantly improved in all effectiveness outcomes. The economic analysis showed that, from the healthcare perspective, iACT was associated with an incremental cost-effectiveness ratio of €33 per additional case of clinically significant improvement compared with iFORUM and that, from the societal perspective, iACT dominated iFORUM because it was more effective and less expensive.

CONCLUSIONS

We found no statistically significant differences in costs between groups; however, iACT for severe health anxiety may be cost effective, as evidenced by significant differences in effect.

TRIAL REGISTRY NUMBER

Clinicaltrials.gov, no. NCT02735434.

Detecting DSM-5 somatic symptom disorder in general hospitals in China: B-criteria instrument has better accuracy-A secondary analysis

OBJECTIVE

This study investigates the diagnostic accuracy of the PHQ-15, SSS-8, SSD-12 and Whitley 8 and their combination in detecting DSM-5 somatic symptom disorder in general hospitals.

METHODS

In our former multicenter cross-sectional study enrolling 699 outpatients from different departments in five cities in China, SCID-5 for SSD was administered to diagnose SSD and instruments including PHQ-15, SSS-8, SSD-12 and WI-8 were used to evaluate the SSD A and B criteria. In this secondary analysis study, we investigate which instrument or combination of instrument has best accuracy for detecting SSD in outpatients. Receiver operator curves were created, and area under the curve (AUC) analyses were assessed. The sensitivity and specificity were calculated for the optimal individual cut points.

RESULTS

Data from n = 694 patients [38.6% male, mean age: 42.89 years (SD = 14.24)] were analyzed. A total of 33.9% of patients fulfilled the SSD criteria. Diagnostic accuracy was moderate or good for each questionnaire (PHQ-15: AUC = 0.72; 95% CI = 0.68-0.75; SSS-8: AUC = 0.73; 95% CI = 0.69-0.76; SSD-12: AUC = 0.84; 95% CI = 0.81-0.86; WI-8: AUC = 0.81; 95% CI = 0.78-0.84). SSD-12 and WI-8 were significantly better at predicting SSD diagnoses. Combining PHQ-15 or SSS-8 with SSD-12 or WI-8 showed similar diagnostic accuracy to SSD-12 or WI-8 alone (PHQ-15 + SSD-12: AUC = 0.84; 95% CI = 0.81-0.87; PHQ-15 + WI-8: AUC = 0.82; 95% CI = 0.79-0.85; SSS-8 + SSD-12: AUC = 0.84; 95% CI = 0.81-0.87; SSS-8 + WI-8: AUC = 0.82; 95% CI = 0.79-0.84). In the efficiency analysis, both SSD-12 and WI-8 showed good efficiency, SSD-12 slightly more efficient than WI-8; however, within the range of good sensitivity, the PHQ-15 and SSS-8 delivered rather poor specificity. For a priority of sensitivity over specificity, the cutoff points of ≥13 for SSD-12 (sensitivity and specificity = 80 and 72%) and ≥17 for WI-8 (sensitivity and specificity = 80 and 67%) are recommended.

CONCLUSIONS

In general hospital settings, SSD-12 or WI-8 alone may be sufficient for detecting somatic symptom disorder, as effective as when combined with the PHQ-15 or SSS-8 for evaluating physical burden.

Psychobiological Mechanisms in Somatic Symptom Disorder and Depressive Disorders: An Ecological Momentary Assessment Approach

OBJECTIVE

Persistent somatic symptoms cause strong impairment in persons with somatic symptom disorder (SSD) and depressive disorders (DDs). Specific negative psychological factors (NPFs), such as catastrophizing, negative affectivity, and behavioral avoidance, are assumed to contribute to this impairment and may maintain symptoms via dysregulations of biological stress systems. We examined the associations between NPF and somatic symptoms in the daily life of women with SSD or DD and investigated the mediating role of psychobiological stress responses.

METHODS

Twenty-nine women with SSD and 29 women with DD participated in an ecological momentary assessment study. For 14 days, intensity of and impairment by somatic symptoms, NPF, and stress-related biological measures (cortisol, alpha-amylase) were assessed five times per day using an electronic device and saliva samples. Multilevel models were conducted.

RESULTS

The greater the number of NPF, the higher the concurrent and time-lagged intensity of and impairment by somatic symptoms in both groups (12.0%-38.6% of variance explained; χ2(12) p < .001 for all models). NPFs were associated with higher cortisol levels in women with DD and with lower levels in women with SSD (interaction NPF by group: B = -0.04, p = .042 for concurrent; B = -0.06, p = .019 for time-lagged). In women with SSD, lower cortisol levels were associated with higher intensity at the next measurement time point (group by cortisol: B = -1.71, p = .020). No mediation effects were found.

CONCLUSIONS

NPFs may be considered as transdiagnostic factors in the development and treatment of impairing somatic symptoms. Our findings will allow the development of new treatment strategies that use ecological momentary intervention approaches focusing on NPF.

Evaluation of a brief psychosocial intervention for health anxiety delivered by medical assistants in primary care: Study protocol for a pilot hybrid trial

Health anxiety is a chronic mental health condition that exerts substantial personal and economic burdens on patients, providers, and the larger healthcare system. Patients with health anxiety experience persistent worry and dread over the possibility that they are presently ill with an undetected or poorly defined physical illness or may soon become ill despite an absence of evidence and physician reassurance of wellness. A complication of health anxiety is that the sufferer frequently denies the presence of excessive anxiety, typically attributing their distress to an inability of the medical team to correctly identify the feared illness. As a result, these patients are challenging to engage in evidence-based psychosocial interventions. The present study protocol describes a psychosocial intervention based on cognitive-behavioral therapy that is adapted for delivery by Medical Assistants in the primary care setting. The rationale for this approach is that delivery by Medical Assistants has the potential to overcome barriers to engagement that prevent effective care. Moreover, deploying a task-shifted intervention relieves strain on the care team by sharing the responsibility for helping the patient manage health anxiety. The aim of this study is to demonstrate the effectiveness of this intervention and approach on health anxiety, while simultaneously collecting data on the barriers and facilitators of implementation, consistent with a hybrid type 1 study design. We will compare patient-level outcomes for participants randomized to the study intervention versus routine referral to mental health services and characterize the potential for implementation using qualitative data drawn from patient and clinical stakeholders.

Personality profiles in young adults with orthorexic eating behaviors

PURPOSE

Orthorexia nervosa (ON), defined as an excessive preoccupation with healthy eating, has gained more interest in the literature over these past few years. However, little is known about its risk and protective factors, in particular with regards to personality.

METHODS

A total of 3235 college students (10.32% men, 89.67% women) with a mean age of 21.13 (SD = 2.23) answered self-administered questionnaires assessing ON, psychopathological symptoms, and personality disorders including schizotypal, borderline, paranoid, obsessive-compulsive, and narcissistic personality. A subsample of 106 participants (91.51% women, mean age = 20.91, SD = 2.31) was selected based on the DOS cutoff score, and was then considered as the "orthorexic subsample".

RESULTS

Hierarchical cluster analysis was performed in the orthorexic subsample and led to the identification of four groups: 1-a cluster with a low level of traits (L); 2-a cluster with moderate traits and low narcissistic traits (MD); 3-a cluster with a low level of traits and moderate narcissistic traits (MN); 4-a cluster with high paranoid and narcissistic traits (PN) and a moderate level of schizotypal and borderline traits. Levels of anxiety, obsessional-compulsive, and depressive symptoms were higher in the PN and MD clusters than in the L and MN clusters. Social phobia was higher and self-esteem lower in the MD cluster and hypochondriasis was higher in the PN and MN clusters.

CONCLUSIONS

This study suggests that ON can be associated with different personality profiles, some of them displaying significant psychopathological levels. It also emphasizes the importance of taking into account personality disorder traits of young adults with orthorexic eating behaviors.

LEVEL OF EVIDENCE

Descriptive (cross-sectional) study, Level V.

Predicting PTSS in general population during COVID-19 pandemic: The mediating role of health anxiety

BACKGROUND

Despite health anxiety (HA) is associated with higher incidence of anxiety disorders, no studies have examined the association between this variable and the increased levels of Post-Traumatic Stress Symptoms (PTSS) reported during COVID pandemic.

METHODS

This study was conducted online between April and May 2020. Data were collected from 468 men and women from the Spanish general population. Sociodemographic and COVID-19-related data, health anxiety, PTSS, fear of becoming infected, social support, sleep problems and past/current psychological/psychiatric history were assessed. The mediating effect of HA when predicting PTSS was explored with mediational analyses. Moderated mediational analyses were also performed to test if receiving psychological treatment during pandemic changes the mediating effect of HA.

RESULTS

Prevalence of PTSS was higher in high-scorers in HA (p<.01). High HA was also more likely to be reported by women, individuals with sleep problems, frequently fear of getting infected, and those who have previously received psychological treatment (p<.01). HA mediates the relationship between PTSS and the following predictors of PTSS: sleep problems, psychiatric history and fear of getting infected. Being under psychological treatment did not moderate the mediating effect of health anxiety.

LIMITATIONS

Further longitudinal studies with bigger sample sizes are needed to examine the causal relationship between HA and PTSS after COVID-19 pandemic.

CONCLUSIONS

Our findings suggest that HA could influence the psychological consequences of the pandemic. Screening of HA could be useful to identify people with heightened risk of developing PTSS during pandemic.

Efficacy of internet-delivered acceptance and commitment therapy for severe health anxiety: results from a randomized, controlled trial

BACKGROUND

Health anxiety is common, disabling and costly due to patients' extensive use of health care services. Internet-delivered treatment may overcome barriers of accessibility to specialized treatment. We aimed to evaluate the efficacy of internet-delivered acceptance and commitment therapy (iACT).

METHODS

A randomized, controlled trial of iACT versus an internet-delivered discussion forum (iFORUM), performed in a Danish university hospital setting. Patients self-referred and underwent video-diagnostic assessment. Eligible patients (≥18 years) with health anxiety were randomized to 12 weeks of intervention. The randomization was blinded for the assessor. The primary outcome was between-group unadjusted mean differences in health anxiety symptoms measured by the Whiteley-7 Index (WI-7, range 0-100) from baseline to 6-month follow-up (6-MFU) using intention to treat and a linear mixed model. The study is registered at clinicaltrials.gov, number NCT02735434.

RESULTS

A total of 151 patients self-referred, and 101 patients were randomized to iACT (n = 53) or iFORUM (n = 48). A mean difference in change over time of 19.0 points [95% confidence interval (CI) 10.8-27.2, p < 0.001] was shown on the WI-7, and a large standardized effect size of d = 0.80 (95% CI 0.38-1.23) at 6-MFU. The number needed to treat was 2.8 (95% CI 1.8-6.1, p < 0.001), and twice as many patients in iACT were no longer clinical cases (35% v. 16%; risk ratio 2.17, 95% CI 1.00-4.70, p = 0.050). Adverse events were few and insignificant.

CONCLUSIONS

iACT for health anxiety led to sustained effects at 6-MFU. The study contributes to the development of easily accessible treatment options and deserves wider application.

A new measure of excessive parental worries about children's health: Development of the Health Anxiety by Proxy Scale (HAPYS)

OBJECTIVE

Health anxiety by proxy is a newly introduced term to describe parents' experience of excessive and unpleasant worries about their child's health. This article describes the development of a new measure, the Health Anxiety by Proxy Scale (HAPYS), for systematic assessment of health anxiety by proxy.

METHOD

The development of the HAPYS was performed over three phases. (1) Patients clinically assessed to have health anxiety by proxy participated in semi-structured interviews to elaborate their experience of worries regarding their child's health and their related behaviours, and to examine the face validity of items in an existing questionnaire: 'Illness Worry Scale - parent version'. (2) Based on the findings from Phase 1 the project group and a panel of experts selected and formulated questionnaire items and scoring formats. (3) The HAPYS was pilot-tested twice using cognitive interviewing with healthy parents and parents with health anxiety by proxy followed by further adjustments.

RESULTS

The final version of HAPYS consists of 26 items characteristic of health anxiety by proxy and of an impact section with five items.

CONCLUSION

Based on the pilot testing the HAPYS showed good face and content validity. It holds the potential to be a valid questionnaire to help clinicians across health care settings assess parents suffering from health anxiety by proxy.

Trajectories of Musculoskeletal Healthcare Utilization of People with Chronic Musculoskeletal Pain - A Population-Based Cohort Study

Background and Aim

Chronic musculoskeletal pain is common and associated with more general healthcare-seeking. However, musculoskeletal-related healthcare utilization is under-explored. This study aimed to explore, describe and profile trajectories of long-term musculoskeletal healthcare for people reporting chronic musculoskeletal pain.

Methods

This exploratory prognostic cohort study combined survey and national health register data from a representative group of adult Danes reporting chronic musculoskeletal pain (N = 2929). Trajectories of long-term musculoskeletal healthcare use were generated using latent class growth analysis. Types of healthcare-seeking, individual, sociodemographic, health, belief and work-related factors were used to describe and profile identified trajectories.

Results

We identified five distinct trajectories of long-term musculoskeletal healthcare utilization (low stable, low ascending, low descending, medium stable and high stable). The low stable trajectory group (no or almost no annual contacts) represented 39% of the sample, whereas the high stable trajectory group (consistent high number of annual contacts) represented 8%. Most healthcare-seeking was in primary healthcare settings (GP/physiotherapy/chiropractor). Opioid consumption was primarily in the high stable trajectory group, and surgery was rare. There were statistically significant differences across the five trajectory groups in individual, sociodemographic, health, belief and work-related profiles.

Conclusion

Long-term use of musculoskeletal healthcare services varied in this chronic musculoskeletal pain population. Almost 40% coped without seeking care, whereas 8% had consistent high use of healthcare services. Chronic musculoskeletal pain was mostly managed in primary care settings, which aligns with musculoskeletal guidelines, as did the use of pain medication and surgery. People with different musculoskeletal healthcare trajectories had different individual, sociodemographic, health, belief and work-related profiles.

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Number of musculoskeletal pain sites leads to increased long-term healthcare contacts and healthcare related costs - a Danish population-based cohort study

BACKGROUND

People with musculoskeletal pain seek more healthcare than the general population, however little is known about the long-term effect on healthcare use. The aim of this study was to examine the consequences of number of musculoskeletal pain sites on long-term care-seeking and healthcare-related costs and explore how health anxiety influences this relationship.

METHODS

We conducted a Danish population-based longitudinal cohort study of 4883 participants combining self-reported survey data from 2008 with ten-year follow-up data from national health registers. Using a causal inference framework, we examined associations between number of pain sites (range 0-7)/level of health anxiety (high/low level) and face-to-face healthcare contacts/healthcare-related costs. Data were analyzed using negative binomial regression with generalized estimating equations. Regression models were adjusted for sex, age, duration of pain, level of education, comorbidity, personality traits, risk of depression, marital status, physical job exposure, and previous healthcare utilization.

RESULTS

For each additional pain site general healthcare contacts (Incidence Rate Ratio (IRR): 1.04 (95% CI: 1.03-1.05)), healthcare-related costs (IRR: 1.06 (95% CI: 1.03-1.08) and musculoskeletal healthcare contacts (IRR: 1.11 (95% CI:1.09-1.14) increased. Those with high levels of health anxiety at baseline had a slightly higher number of general healthcare contacts (IRR 1.06 (1.01-1.11), independent of number of pain sites. However, level of anxiety did not influence the effect of number of pain sites on any healthcare use or cost outcomes.

CONCLUSIONS

We found evidence for a causal association between increasing number of pain sites and greater healthcare use and cost, and high levels of health anxiety did not increase the strength of this association. This suggests that number of pain sites could be a potential target for biopsychosocial interventions in order to reduce the need for future care-seeking.

The Validity of Somatic Symptom Disorder in Patients With Gastrointestinal Complaints

BACKGROUND AND GOAL

The current diagnostic concept of somatic symptom disorder (SSD) aims to capture psychological burden due to bodily complaints independent of the medical cause. The aim of this study was to compare patients with chronic gastrointestinal (GI) complaints with SSD (SSD+) and without SSD (SSD-) along sociodemographic, clinical, and psychological characteristics.

STUDY

This cross-sectional study included 199 patients (n=92 SSD+ and n=107 SSD-) with distressing and chronic abdominal/lower GI complaints (≥6 mo) recruited from several primary, secondary, and tertiary medical care units. SSD+ patients were separated from SSD- patients by psychobehavioral positive criteria. Psychological distress (somatization, depression, anxiety, and illness anxiety) and risk factors (adverse childhood experiences, insecure attachment, mentalizing capacity, and levels of personality functioning) were measured. Nonparametric group comparisons were performed to analyze the differences of sociodemographic, clinical, and psychological characteristics between SSD+ and SSD- patients.

RESULTS

About half of the SSD+ patients had a functional GI disorder and a third had an inflammatory bowel disease. SSD+ patients reported higher GI pain severity, higher health-related and work-related impairment, and higher psychological distress, especially illness anxiety, as well as higher mentalizing and personality functioning deficits.

CONCLUSIONS

Overall, psychobehavioral positive criteria of SSD seem to be a valid identifier of patients exhibiting a high psychological burden, independent of the medical explanation of the GI complaints. There is a substantial overlap of SSD and general mental burden, but also evidence for a specific disease entity.

Incidence and immediate consequences of electrical shocks among Danish electricians: a cohort study

OBJECTIVES

The health-related consequences of electrical shocks are mostly studied in patients from selected cohorts in hospital burn units, by making internal comparisons of subgroups, but without comparing them to unexposed individuals, or considering information regarding the preinjury health of the injured persons. Often, little is known about the details of the electrical shocks. Our purpose was to do a longitudinal study of Danish electrical workers, to monitor exposure to electrical shocks weekly over a 6-month period and to determine whether these shocks have short-term, health-related consequences.

DESIGN

Prospective cohort study with weekly measurements.

SETTING

Members of the Danish Union of Electricians.

PARTICIPANTS

Of the 22 284 invited, 6960 electricians (31%) participated in the baseline data collection, and the participation rate in the weekly follow-up ranged from 61% to 81% during the 6 month follow-up.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was an electrical shock and secondary outcomes were the immediate health-related consequences of the shocks.

RESULTS

A total of 2356 electrical shocks were reported by 1612 (23%) of the participants during the 26-week follow-up. Alternating current and voltage below 1000 V were the most common forms of electricity. In most cases, the fingers/hands were the entry and exit points, but many were unable to specify the exit point. The participants categorised 73% of the electrical shocks as 'not at all severe', and most of the shocks did not cause any immediate physical damage. However, flashbacks were more common than physical consequences. Only a few of the participants contacted health services following an electrical shock, and even fewer were absent from work.

CONCLUSION

Nearly one-fourth of Danish electricians experienced one or more electrical shocks during a 26-week period, but most of the shocks are not perceived as severe, and have only limited immediate consequences.

Psychometric Evaluation of the Whiteley Index-8 in Chinese Outpatients in General Hospitals

Background: Excessive and persistent health anxiety is a common and disabling but often unrecognized illness. Therefore, screening patients for health anxiety is recommended in primary care. The aim of the present study was to examine the psychometric properties of an updated version of the eight-item Whiteley Index (WI-8) among outpatients in general hospitals in China. Methods: The presented data were derived from a multicenter cross-sectional study. The Chinese version of the WI-8 was administered to a total of 696 outpatients. Cronbach's alpha was used to evaluate the internal consistency of the scale. The validity of the scale was evaluated based on factor analysis and correlation analyses. To assess the discriminant ability, receiver operating characteristic (ROC) analysis was conducted. Results: Cronbach's alpha was 0.937, and it decreased (0.925) after deleting the new 8th item. Factor analysis extracted one factor accounting for 69.2% of the variance. Moderate correlations were found (0.414-0.662) between the WI-8 and General Anxiety Disorder (GAD-7), Patient Health Questionnaire-9 (PHQ-9), Patient Health Questionnaire-15 (PHQ-15) and Somatic Symptom Disorder B-criteria (SSD-12). The ROC curve indicated excellent discriminatory ability to discriminate among patients with health anxiety (AUC = 0.822). Conclusions: The new WI-8 version is a reliable and valid tool to screen for health anxiety in general hospital patients. We recommend the WI-8 as a useful screening tool for health anxiety.

The COVID-19 anxiety syndrome and selective attentional bias towards COVID-19-related stimuli in UK residents during the 2020-2021 pandemic

The psychological and social effects of the COVID‐19 pandemic are pervasive, and there is potential for a long‐lasting impact on mental health. In the current study, we sought to provide, in a representative sample of UK residents during the third COVID‐19 lockdown in February 2021, further evidence for the validation of the COVID‐19 anxiety syndrome construct. We did this by evaluating the COVID‐19 anxiety syndrome against measures of personality, health anxiety and COVID‐19 anxiety in predicting levels of generalized anxiety and depression and by examining whether increased health anxiety and COVID‐19 psychological distress (COVID‐19 anxiety and COVID‐19 anxiety syndrome) scores were associated with increased attentional bias to COVID‐19‐related stimuli. A series of correlation analyses revealed that neuroticism, health anxiety, COVID‐19 anxiety and COVID‐19 anxiety syndrome scores were positively and significantly correlated with generalized anxiety and depression scores and that the perseveration component of the COVID‐19 anxiety syndrome predicted generalized anxiety and depression scores independently of age, gender, conscientiousness, openness, health anxiety and COVID‐19 anxiety. Furthermore, results indicated that only the total COVID‐19 anxiety syndrome score and the scores on the avoidance and perseveration components were positively and significantly correlated with attentional bias indices. More specifically, the general attentional bias index was only shown to be positively and significantly correlated with the total COVID‐19 anxiety syndrome score and its perseveration component, while slowed disengagement was only shown to be negatively and significantly correlated with the total COVID‐19 anxiety syndrome score and its avoidance component. The implications of these findings are discussed.

How Might We Screen for Psychological Factors in People With Pelvic Pain? An e-Delphi Study

OBJECTIVE

Persistent pelvic pain (PPP) is a complex condition often influenced by psychological factors that can alter treatment outcomes. These factors are potentially modifiable; however, currently there is no instrument to screen for them. The purpose of this study was to determine: (1) which psychological factors should be screened in individuals with PPP, and (2) the most appropriate statements to represent these psychological factors.

METHODS

The study used a focus group design followed by an electronic-Delphi (e-Delphi) process. A focus group consisting of 8 experts was conducted to determine the relevant psychological factors to screen. These results informed round 1 of the e-Delphi process, consisting of a panel of 14 pain/pelvic pain experts. The e-Delphi process consisted of 3 rounds of online surveys and 2 teleconference discussions to establish consensus on the most appropriate statement to screen for each of the psychological factors.

RESULTS

The focus group identified 13 relevant psychological factors. During the e-Delphi process, relevant screening statements were assessed using a 100-point allocation system. Experts could reword and suggest new statements. Statements were assessed for consensus and stability and were eliminated as the rounds progressed if they met the exclusion criteria. At the termination of round 3, there were 15 statements remaining.

CONCLUSION

The final list of 15 statements will assist clinicians in screening for psychological factors and is an important step for clinicians in providing psychologically informed care to people with PPP. Future research should determine the psychometric properties of the statements to determine their clinical utility as a questionnaire.

IMPACT

This study has refined a list of statements to help screen for psychological factors in individuals with PPP. Developed robustly using an e-Delphi method, this list is an important first step forward for clinicians to provide psychologically informed care to these individuals.

Continuity of health anxiety from childhood to adolescence and associated healthcare costs: a prospective population-based cohort study

BACKGROUND

Severe health anxiety (HA) is characterized by excessive and impairing worry and preoccupation with health issues and can cause increased and unnecessary medical examinations. HA in childhood and adolescence is scarcely explored, hindering the potential for prevention and early intervention.

METHODS

HA was assessed in 1,278 children/youths at two time points at ages 11 and 16 years in a general population-based birth cohort. Register-based data on costs related to nonhospital-based primary and secondary somatic health services were obtained over the follow-up period. The presence of functional somatic symptoms, emotional disorders and chronic somatic illness at baseline were included as covariates.

RESULTS

High HA (top 10% score) at age 11 predicted high HA at age 16 (relative risk [RR] 2.03, 95% CI: 1.26-3.31). The group with persistent HA was small (n = 17, 1.3%), resulting in broad confidence intervals. The statistical effect of HA at age 11 on HA at age 16 was heavily reduced after adjustment for sex and all covariates (RR: 1.49, 95% CI: 0.85-2.60). In the adjusted model, somatic illness at age 11 (RR: 1.91, 95% CI: 1.22-2.98) and female sex (RR: 3.33, 95% CI: 2.01-5.50) were independently associated with HA at age 16. Persistent HA was associated with approximately doubled healthcare costs compared to the group with consistently low HA. Incident HA at age 16 was associated with increased costs over follow-up. The increased costs were not explained by chronic somatic illness.

CONCLUSIONS

A small subgroup of children had persistent high levels of HA from late childhood to adolescence and displayed increased healthcare costs. Female sex and chronic somatic disorders at age 11 were independent risk factors of HA at age 16. These findings provide potential means of early identification and of therapeutic levers. Further intervention development and evaluation are needed.

Physical Exercise as a Resilience Factor to Mitigate COVID-Related Allostatic Overload

INTRODUCTION

The long-lasting threat of COVID-19 makes it necessary to explore strategies to improve coping skills which enable us to master a balanced life in the face of adversity.

OBJECTIVE

To unravel the most challenging aspects of COVID-19 in a nonclinical adult population and identify predictors of lost balance and consequent allostatic overload (AO). We examined the role of regular, moderate-intensity formula aerobic exercise (312 meridian exercise) in preventing allostatic overload through increasing well-being.

METHODS

An online survey was conducted to measure CO-VID-related allostatic overload according to clinimetric criteria. The Psychosocial Index (PSI), Kellner's Symptom Questionnaire (KSQ), short Depression Anxiety Stress Scales (DASS-21), Public Health Surveillance Well-Being Scale -(PHS-WB), and Whiteley-7 were used to explore mental health characteristics. Univariate statistics logistic regression analysis and a general linear model were used.

RESULTS

According to 442 valid answers, 217 adults practiced physical exercise (PE) frequently (fPE, 3-5 times/every day) while 120 did it less regularly (1-2 times/week), and 105 did not exercise/practiced irregularly (controls). Restriction-related stressors were most challenging, resulting in AO in 29% (n = 128) of the sample. The main predictors were additional stressors (p = 0.005) and anxiety symptoms (p < 0.001). The prevalence of AO was lower (p = 0.018) in the fPE group when compared to controls. KSQ distress symptoms were also lower in fPE (p < 0.0001), while total well-being was increased (p < 0.001) after adjusting for sex, age, and number of chronic diseases. According to the PHS-WB, both physical and mental well-being were higher (p = 0.003 and p = 0.004, respectively) in fPE.

CONCLUSIONS

Frequent moderate exercise is associated with better mental and physical well-being and a lower prevalence of AO.

Helpful explanatory models for somatoform symptoms (HERMES): study protocol of a randomised mixed-methods pilot trial

INTRODUCTION

Persistent somatic symptoms (PSS) are common both in the general population and primary care. They are bothersome in terms of psychological and somatic symptom burden. Health professionals often struggle with communication, as there is a lack of scientifically supported explanatory models for PSS or a focus merely on somatic aspects of the complaints, which both frustrate patients' needs. The objective of the present study is therefore to develop a psychoeducational intervention based on a current evidence-based explanatory model, to examine its feasibility and form the basis for a large-scale randomised controlled trial.

METHODS AND ANALYSIS

In a randomised controlled mixed-methods pilot trial, 75 adult psychosomatic outpatients with PSS (duration of symptoms ≥6 months) and accompanying psychological (Somatic Symptom B-Criteria Scale total score ≥18) and somatic symptom burden (Patient Health Questionnaire-15 score >10) and no prior psychosomatic treatment will be eligible. Participants will be presented with either the explanatory model without (intervention group 1, n=25) or with elements of personalisation (intervention group 2, n=25). Participants in the control group (n=25) will receive information on current PSS guidelines. Participants will be blinded to group assignment and interventions will be shown on tablet computers at the outpatient clinic. After 1 month, qualitative follow-up telephone interviews will be conducted. As primary outcomes, mean changes in psychological and somatic symptom burden will quantitatively be compared between groups, respectively. Behavioural change mechanisms and feasibility of the three interventions will be evaluated using quantitative and qualitative measures.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the medical ethics board of the Hamburg Medical Chamber (PV5653). Results from this study will be published in peer-reviewed journals and presented at national and international conferences.

TRIAL REGISTRATION NUMBER

DRKS00018803.