Somatization and health anxiety as predictors of health care use

The Relation of Health Anxiety to Treatment Utilization Among Patients with Substance Use Disorders: The Moderating Role of Racial/Ethnic Background

Background: Although health anxiety is broadly related to the overutilization of healthcare, limited research has examined this relation among individuals with substance use disorders (SUDs), or the extent to which racial/ethnic differences influence this relationship. Objectives: The purpose of the current study is to examine the moderating role of racial/ethnic minoritized background in the relationship between health anxiety and treatment utilization among individuals with SUDs. In the present study, patients with SUDs receiving residential treatment in Mississippi (N=118; 62% racial/ethnic minoritized status, 35.6% White) completed a measure of health anxiety and answered questions about past mental health, physical health, and substance use treatment. Regression models examined whether racial/ethnic minoritized status (White vs. racial/ethnic minoritized status) moderated the relation of health anxiety to treatment utilization among patients with SUDs. Treatment utilization was examined by asking whether participants had seen a doctor or mental health provider, engaged in substance use treatment, or alcohol treatment prior to their current treatment (dichotomous), as well as the number of times they had engaged in each treatment (physical health, mental health, substance use, and alcohol treatment) in the past year (continuous). Results: Results revealed that the facets of health anxiety involving concerns about pain and disease phobia were positively associated with treatment utilization, but only among racial/ethnic minoritized participants, with concerns about pain positively associated with self-reported physical health treatment utilization (OR=0.70, 95% CI=0.50; 0.97) and disease phobia positively associated with past mental health (B = 0.36, p = 0.023) and alcohol use treatment (B=-0.23, p=.009). Conversely, disease phobia was related to less prior alcohol use treatment among White participants (B=-0.23, p=.009). Conclusions: Overall, among patients in residential treatment for SUDs, racial/ethnic minoritized participants with SUDs reported more health anxiety compared to white participants, and certain facets of health anxiety (i.e., concerns about pain and worry about severe illness) were linked to heightened treatment utilization among racial/ethnic minoritized individuals.

Health anxiety, death anxiety and coronaphobia: Predictors of postpartum depression symptomatology during the COVID-19 pandemic

OBJECTIVE

To determine levels of postpartum depression symptoms and possible relevant predictors, such as death anxiety, health anxiety, and coronavirus-related anxiety.

DESIGN

Cross-sectional web-based survey using quantitative methods.

SETTING

Exclusively online recruiting via social media and unpaid cross-posting conducted during the third wave of the COVID-19 pandemic in Romania.

PARTICIPANTS

Women were eligible to take part in the study if they were mothers over the age of 18 and had a baby aged between 4 weeks - 12 months of age; 1024 women were included in the final sample.

MEASUREMENTS AND FINDINGS

Health anxiety, death anxiety, coronavirus-related anxiety, and postpartum depression symptoms were measured using validated instruments. Current depression symptomatology was 67.6%, 26.7% scored above the cut-off for high health anxiety, 1% for coronavirus-related anxiety, and 62.7% for death anxiety. Significant predictors for depressive symptomatology were breastfeeding, history of depression, family income, number of children, health anxiety, death anxiety, and coronavirus anxiety. Further, hierarchical multiple regression analysis indicated that death anxiety, health anxiety, and coronavirus anxiety predicted postpartum depression symptoms over and above socio-demographic factors.

KEY CONCLUSIONS

Supported by previous studies, our results suggest that postpartum depression symptomatology levels during the COVID-19 pandemic are high and that they are predicted by health and death anxiety, which are also increased during the pandemic.

IMPLICATION FOR PRACTICE

The findings provide information to identify the risk for depression symptoms in postpartum mothers during acute public health situations.

Somatization in Adolescents With Persistent Symptoms After Concussion: A Retrospective Chart Review

OBJECTIVE

After concussion, approximately 30% of adolescents experience symptoms that persist beyond 1 month postinjury. For some, these symptoms affect functioning, development, and quality of life. Somatization, where psychological distress contributes to physical symptoms, may contribute to persistent symptoms after concussion in some adolescents. Understanding how clinicians identify somatization in adolescents with persistent symptoms after concussion in practice is a critical next step in improving our understanding, identification, and subsequent treatment of somatization in this patient population. To address this, the investigators assessed and compared characteristics of adolescents with persistent symptoms after concussion with and without clinician-identified somatization.

METHODS

Participants were adolescents (N=94) referred for persistent symptoms after concussion to a specialty youth concussion clinic between January 2016 and May 2018. A retrospective chart review extracted demographic and injury characteristics, symptoms after concussion, school attendance, premorbid experiences, mental health, and medical service use. Participants with physician-identified somatization were compared with those without physician-identified somatization on these measures.

RESULTS

Adolescents with identified somatization had more severe and atypical neurological and psychiatric symptoms after concussion and more postinjury impairment in school attendance, were more likely to have a history of premorbid chronic pain or medically unexplained symptoms, and obtained more neuroimaging and health care after injury compared with those unaffected by somatization. They did not differ in mood or anxiety symptom self-reports.

CONCLUSIONS

This study identified characteristic differences and similarities in adolescents with and without clinician-identified somatization after a prolonged concussion recovery. These findings have the potential to improve clinical identification of somatization in youths following a concussion and may aid in treatment among this demographic group.

Somatic symptom disorder: a scoping review on the empirical evidence of a new diagnosis

BACKGROUND

In 2013, the diagnosis of somatic symptom disorder (SSD) was introduced into the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This review aims to comprehensively synthesize contemporary evidence related to SSD.

METHODS

A scoping review was conducted using PubMed, PsycINFO, and Cochrane Library. The main inclusion criteria were SSD and publication in the English language between 01/2009 and 05/2020. Systematic search terms also included subheadings for the DSM-5 text sections; i.e., diagnostic features, prevalence, development and course, risk and prognostic factors, culture, gender, suicide risk, functional consequences, differential diagnosis, and comorbidity.

RESULTS

Eight hundred and eighty-two articles were identified, of which 59 full texts were included for analysis. Empirical evidence supports the reliability, validity, and clinical utility of SSD diagnostic criteria, but the further specification of the psychological SSD B-criteria criteria seems necessary. General population studies using self-report questionnaires reported mean frequencies for SSD of 12.9% [95% confidence interval (CI) 12.5-13.3%], while prevalence studies based on criterion standard interviews are lacking. SSD was associated with increased functional impairment, decreased quality of life, and high comorbidity with anxiety and depressive disorders. Relevant research gaps remain regarding developmental aspects, risk and prognostic factors, suicide risk as well as culture- and gender-associated issues.

CONCLUSIONS

Strengths of the SSD diagnosis are its good reliability, validity, and clinical utility, which substantially improved on its predecessors. SSD characterizes a specific patient population that is significantly impaired both physically and psychologically. However, substantial research gaps exist, e.g., regarding SSD prevalence assessed with criterion standard diagnostic interviews.

Health anxiety is an important driver of healthcare use

Background

Healthcare use is increasing, and health anxiety (HA) is recognized as an important associated factor. Previous research on the association between HA and healthcare use has mostly explored HA as a dichotomous construct, which contrasts the understanding of HA as a continuous construct, and compared healthcare use to non-use. There is a need for studies that examine the association between healthcare use and the continuum of HA in a general population.

Aim

To explore the association between HA and primary, somatic specialist and mental specialist healthcare use and any differences in the association by level of healthcare use.

Methods

This study used cross-sectional data from the seventh Tromsø study. Eighteen thousand nine hundred sixty-seven participants aged 40 years or older self-reported their primary, somatic specialist and mental specialist healthcare use over the past 12 months. Each health service was categorized into 5 groups according to the level of use. The Whiteley Index-6 (WI-6) was used to measure HA on a 5-point Likert scale, with a total score range of 0–24. Analyses were conducted using unconstrained continuation-ratio logistic regression, in which each level of healthcare use was compared with all lower levels. Morbidity, demographics and social variables were included as confounders.

Results

HA was positively associated with increased utilization of primary, somatic specialist and mental specialist healthcare. Adjusting for confounders, including physical and mental morbidity, did not alter the significant association. For primary and somatic specialist healthcare, each one-point increase in WI-6 score yielded a progressively increased odds ratio (OR) of a higher level of use compared to all lower levels. The ORs ranged from 1.06 to 1.15 and 1.05 to 1.14 for primary and somatic specialist healthcare, respectively. For mental specialist healthcare use, the OR was more constant across levels of use, ranging between 1.06 and 1.08.

Conclusions

In an adult general population, HA, as a continuous construct, was significantly and positively associated with primary, somatic specialist and mental healthcare use. A small increase in HA was associated with progressively increased healthcare use across the three health services, indicating that the impact of HA is more prominent with higher healthcare use.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07529-x.

The relationship of cortical activity induced by pain stimulation with clinical and cognitive features of somatic symptom disorder: A controlled functional near infrared spectroscopy study

OBJECTIVE

The neurobiological correlates of Somatic Symptom Disorder (SSD) introduced in the DSM-5 has been the focus of a limited investigation. We aimed to examine the cortical response to painful stimuli and its relationship to symptom severity as well as cognitive and psychological characteristics in proposed models of somatoform disorders.

METHODS

We measured hemodynamic responses by 52-channel functional near-infrared spectroscopy. We compared the cortical response to painful stimuli in index patients with SSD (N = 21) versus age, and gender matched healthy control subjects (N = 21). We used brush stimulation as the control condition. We analyzed the relationship of cortical activity with SSD symptom severity as well as somatosensory amplification (SSA), alexithymia, dysfunctional illness behaviour, worry, and neuroticism.

RESULTS

Patients with SSD had higher somatic symptom severity, SSA, alexithymia, neuroticism, illness-related worry, and behaviour. Somatic symptom severity was predicted by a model including SSA and subjective feeling of pain in the index patients. Activity in the left-angular and right-middle temporal gyri was higher in the SSD subjects than the controls during pain stimulation. Positive correlations were detected between mean pain threshold levels and left middle occipital gyrus activity, as well as between SSA-scores and right-angular gyrus activity during pain condition in the index patients with SSD.

CONCLUSION

We present the first evidence that representation of pain in terms of cortical activity is different in subjects with SSD than healthy controls. SSA has functional neuroanatomic correlates and predicts symptom severity in SSD and therefore is involved as a valid intermediate phenotype in SSD pathophysiology.

Personality, Healthcare Use and Costs-A Systematic Review

BACKGROUND

Thus far, there is a lack of a systematic review synthesizing empirical studies that analyze the link between personality factors and healthcare use (HCU) or costs. Consequently, the purpose of our systematic review is to give an overview of empirical findings from observational studies examining the association between personality factors and HCU or costs.

METHODS

PubMed, PsycINFO, and NHS EED (NHS Economic Evaluation Database) were searched. Observational studies examining the association between personality factors and HCU costs by using validated tools were included. Two reviewers performed study selection and data extraction and evaluated the study quality. Findings were synthesized qualitatively.

RESULTS

In total, n = 15 studies (HCU, n = 14; cost studies, n = 1) were included in the final synthesis. A few studies point to an association between conscientiousness and HCU (with mixed evidence). Some more evidence was found for an association between higher agreeableness, higher extraversion, and higher openness to experience and increased HCU. The majority of studies analyzed found a link between higher neuroticism and increased HCU.

CONCLUSION

Personality factors, and particularly neuroticism, are associated with HCU. This knowledge is important to manage healthcare use. However, future research based on longitudinal data and studies investigating the link between personality characteristics and costs are required.

Is severity a clinically meaningful specifier of somatic symptom disorder?

OBJECTIVE

Few existing studies have investigated the clinical relevance of Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) somatic symptom disorder (SSD) severity rated by clinicians. We examined the association of SSD severity with psychiatric and medical comorbidity, psychological features and help-seeking attitude and behaviours.

METHODS

A total of 123 patients with SSD were prospectively recruited and completed several types of self-report instrument. Information about medical comorbidity and healthcare use was gathered from the participants and medical record review. Common comorbid psychiatric diagnoses of SSD were assessed by psychiatrists. Group differences of patients with SSD of varying severity were assessed with ANOVA and chi-square tests. Multiple linear regression models were used to examine the relationships between SSD severity and psychological features.

RESULTS

Prevalence of medical comorbidity and comorbid psychiatric diagnoses of SSD was not significantly different among patients with varying SSD severity. Patients with severe SSD had the highest Patient Health Questionnaire-15 (PHQ-15), Health Anxiety Questionnaire (HAQ), Beck Depression Inventory-II (BDI-II) and Beck Anxiety Inventory (BAI) scores. Help-seeking behaviour was not associated with SSD severity. After controlling for demographic variables, the associations between 'severe SSD' and the PHQ-15, HAQ, BDI-II and BAI scores were significant.

CONCLUSION

SSD severity rated by clinicians was not associated with comorbid medical or psychiatric diagnoses. Compared to patients with mild/moderate SSD, patients with severe SSD not only had higher somatic distress and health anxiety but also higher levels of anxiety/depression. However, SSD severity was not associated with help-seeking attitude and behaviour.

Medically Unexplained Symptoms and Antecedent Sexual Abuse: An Observational Study of a Birth Cohort

OBJECTIVE

Medically unexplained symptoms (MUS) are common and associated with high consumption of health care resources. Cross-sectional studies in selected and clinical populations show consistent linkages between history of childhood sexual abuse (CSA) and presentation with MUS and somatization. However, there are almost no well-controlled prospective studies in population samples.

METHODS

Data were gathered in a longitudinal study of a New Zealand birth cohort born in 1977. Hospital e-record data for the period 2008-2015 (age, 30-38 years) were searched for a subsample of 408 study participants who were resident in one District Health Board region, and details of MUS contacts were recorded. Retrospective reports of CSA (<16 years) were obtained at ages 18 and 21 years. Associations between CSA and MUS were sequentially adjusted using logistic regression methods for both childhood confounders assessed before age 16 years and potential mediating mental health/family context up to age 30 years.

RESULTS

Twenty (4.9%) participants were classified as having MUS, of whom 11 had a history of CSA. Severe CSA involving attempted/completed sexual penetration was strongly associated with risk of MUS (odds ratio = 11.6, 95% confidence interval = 4.3-31.7, p < .001). A substantial association remained after statistically adjusting for confounding and mediating mental health/family context (adjusted odds ratio = 5.1, 95% confidence interval = 1.2-21.3, p = .024). This strong association was specific to severe CSA (as opposed to childhood physical abuse) and to MUS rather than medically explained symptoms.

CONCLUSIONS

CSA involving attempted/completed penetration was strongly associated with attendance at secondary level care for MUS. Implications for prevention and treatment of MUS are discussed.

The mediating effect of health anxiety in the relationship between functional somatic symptoms and illness behavior in Chinese inpatients with depression

BACKGROUND

Functional somatic symptoms in depression disorder may cause inappropriate illness behavior hindering the treatment process. Health anxiety may play a role in this relationship, but few studies have examined it. The current study aimed to investigate the role of health anxiety in the relationship between functional somatic symptoms and illness behavior in patients with depression.

METHODS

The present study recruited 323 hospitalized patients with depression to complete the Patient Health Questionnaire-15, Whiteley-Index-7, and Scale for the Assessment of Illness Behavior, then constructed a structural equation model to examine whether health anxiety mediated the relationship between functional somatic symptoms and illness behavior.

RESULTS

The results showed significant correlations between any two of the three variables of interest. More importantly, health anxiety played a partially mediating role (42.86%) in the relationship between functional somatic symptoms and illness behavior. Further analysis suggested that elderly patients reached higher health anxiety than younger patients when their functional somatic symptoms were mild.

CONCLUSIONS

These results highlight that health anxiety may mediate the influence of functional somatic symptoms on illness behavior. The implications of assessing and intervening in health anxiety in patients with depression were discussed.

Characteristics of Elderly Frequent Attendees in Slovene Family Medicine Practices - a Cross-sectional Study

Introduction:

Frequent attendance in family medicine practices is associated with elderly patients and those with chronic diseases. Longstanding frequent attendees have more social and psychiatric problems, medically unexplained conditions, and chronic diseases, and are prescribed more psychotropic drugs and analgesics.

Aim:

To fill the lack of data on the factors associated with frequent attendance at family medicine practices by the elderly.

Methods:

Forty family physicians (FPs) participated in this cross-sectional study in 2017 and randomly recruited up to 20 of their patients; 624 patients were recruited. From the patients’ health records, the FPs collected demographic data, lifestyle factors, all the patients’ diagnoses, all the drugs prescribed in the previous 12 months, multi-morbidity (CIRS-G index), the quality of life index (EQ-5D) and the number of visits to the family medicine practice in the previous 12 months. The Self-Rating Depression Scale was administered to the patients. Statistical analysis was carried out using the IBM SPSS 20.0 package, with appropriate non-parametric tests (Mann-Whitney U test, chi-square test) to check significant differences between groups of patients. Multivariate modelling was carried out to evaluate the associations between the number of visits to the FP and independent variables.

Results:

The number of prescribed drugs (p=0.026), haematological problems (p=0.005) and genitourinary problems (p=0.001) were associated with frequent attendance. Patients with borderline depression were approximately three times more likely to be frequent attendees than non-depressed patients.

Conclusion:

Polypharmacy, haematological and genitourinary problems are associated with frequent attendance in elderly patients. Further longitudinal studies are required to validate our findings.

Management of somatic symptom disorder

This review paper gives an overview of the management of somatic symptom disorder. It starts with a description of the clinical problem of patients with persistent bodily distress, discusses classificatory, epidemiological, and etiological issues and then describes the evidence and practical principles of dealing with these patients who are often seen as "difficult" to treat. It is concluded that the best-suited approach is stepped care with close cooperation of primary care, a somatic specialist, and mental health care professionals operating on the basis of a biopsychosocial model of integrating somatic as well as psychosocial determinants of distress and therapeutic factors.

Assessing the relationship between fear of cancer recurrence and health care utilization in early-stage breast cancer survivors

PURPOSE

The purpose of this study was to determine whether fear of cancer recurrence (FCR) is associated with greater health care utilization (HCU) in early-stage breast cancer survivors.

METHODS

Three hundred early-stage breast cancer survivors diagnosed within the past 7 years reported on FCR as well as calls and visits to oncology providers and primary care providers during the preceding 3 months. Participants also reported on use of mental health services and psychotropic medications since diagnosis. Structural equation modeling was used to create a latent FCR factor and evaluate this factor as a predictor of various HCU outcomes controlling for age at diagnosis, years since diagnosis, generalized anxiety, objective risk of recurrence, and number of comorbidities.

RESULTS

FCR predicted more visits to both oncology providers (RR = 1.53, p = .002) and primary care providers (RR = 1.31, p = .013), as well as more phone calls to oncology providers (RR = 2.08, p = .007). FCR was not a significant predictor of phone calls to primary care providers (RR = 1.39, p = .054), utilization of mental health treatment (OR = 1.27, p = .362), or use of psychotropic medications (OR = 1.37, p = .178).

CONCLUSIONS

FCR was associated with increases in some types of HCU, which may reflect excessive medical reassurance-seeking and lead to unnecessary medical costs.

IMPLICATIONS FOR CANCER SURVIVORS

FCR is a serious concern that warrants greater attention to reduce distress-related health care utilization. Utilization of mental health services to address FCR may represent higher-value health care.

Behavioral Health of Gulf Coast Residents 6 Years After the Deepwater Horizon Oil Spill: The Role of Trauma History

OBJECTIVE

The purpose of this study was to examine the associations between oil spill exposure, trauma history, and behavioral health 6 years after the Deepwater Horizon oil spill (DHOS). We hypothesized that prior trauma would exacerbate the relationship between oil spill exposure and behavioral health problems.

METHODS

The sample included 2,520 randomly selected adults in coastal areas along the Gulf of Mexico. Participants reported their level of oil spill exposure, trauma history, depression, anxiety/worry, illness anxiety, and alcohol use.

RESULTS

Individuals with more traumatic experiences had a significantly higher risk for all measured behavioral health problems after controlling for demographic factors and DHOS exposure. Those with higher levels of DHOS exposure were not at greater risk for behavioral health problems after controlling for prior trauma, with the exception of illness anxiety. There was no evidence that trauma history moderated the association between DHOS exposure and behavioral health.

CONCLUSIONS

Findings suggest that trauma exposure may be a better indicator of long-term behavioral health risk than DHOS exposure among disaster-prone Gulf Coast residents. DHOS exposure may be a risk factor for illness anxiety but not more general behavioral health concerns. Trauma history did not appear to exacerbate risk for behavioral health problems among Gulf residents exposed to the DHOS. (Disaster Med Public Health Preparedness. 2019;13:497-503).

Management of Functional Somatic Syndromes and Bodily Distress

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

The combination of health anxiety and somatic symptoms: a prospective predictor of healthcare usage in primary care

Extant research provides equivocal conclusions if the combined presentation of health anxiety with severe somatic symptoms confers risk for greater future primary care usage. The present study further examined the combination of health anxiety and somatic symptoms as a predictor of healthcare usage in primary care. Using a prospective longitudinal design, a large sample (N = 530) of patients presenting for treatment at a community health center completed self-report measures assessing health anxiety and somatic symptom severity. A medical record review at the time of questionnaire administration and 1 year following that administration was completed to assess the frequency of medical visits during the preceding and subsequent year. As expected, the interactive effect between health anxiety and somatic symptom severity predicted greater subsequent year medical visits. Covariates included preceding year medical visits, sociodemographic variables, body mass index, smoking status, and depressive symptom severity. Simple effects indicated that health anxiety predicted greater subsequent year medical visits when coupled with relatively severe, but not mild, somatic symptoms. Assessing health anxiety and somatic symptom severity in primary care settings could be important for identifying individuals at risk for future frequent healthcare visits and who may benefit from intervention.

The Heterogeneity of Illness Behaviors in Patients with Medically Unexplained Physical Symptoms

PURPOSE

To investigate the heterogeneity of illness behavior in patients with medically unexplained physical symptoms (MUPS), we clustered patients in regard to their degree of engaging in different aspects of illness behavior and identified related variables with these behaviors.

METHOD

A sample of N = 224 patients attending treatment in primary care with a history of MUPS (at least two symptoms) was investigated by analyzing different aspects of illness behavior with the self-reported number of doctor visits during the last 6 months and the Scale for the Assessment of Illness Behavior (SAIB; e.g., expression of symptoms).

RESULTS

Two distinct clusters were identified by cluster analysis: a low (n = 106) and a high (n = 118) illness behavior clusters. The high illness behavior cluster exhibited a significantly higher rate of health anxiety than the low illness behavior cluster. Regression analysis revealed a particular effect of sex in the high illness behavior cluster: whereas being male was associated with increased illness behavior as measured by the SAIB, being female was linked to a higher number of doctor visits. Increased health anxiety was associated with the SAIB illness behavior in both clusters. Depression and anxiety did not show incremental associations with all aspects of illness behavior.

CONCLUSION

Knowledge of the pattern of illness behavior in patients with MUPS enables us to improve psychological treatments that directly address specific aspects of illness behavior or health anxiety. Differences between sexes in illness behaviors require more differentiated consideration in future research.

Psychiatric conditions and general practitioner attendance prior to HPV vaccination and the risk of referral to a specialized hospital setting because of suspected adverse events following HPV vaccination: a register-based, matched case-control study

AIM

No association between human papilloma virus (HPV) vaccination and numerous diseases has been found. Still, a large number of Danish women are reporting suspected adverse events. Other factors may play a role, and the aim of this study is to examine the association between psychiatric conditions, general practitioner (GP) attendance and indicators of psychological symptoms prior to HPV vaccination and the risk of referral to an HPV center following vaccination.

STUDY DESIGN AND SETTING

Register-based, matched case-control study. Cases were identified from five Danish, regional HPV centers, and health data for cases and controls were obtained from national registries.

PARTICIPANTS

Cases were defined as women referred to an HPV center between January 1, 2015 and December 31, 2015 (n=1,496). Each case was matched with five controls on age, region and time of first vaccine registration. The total study population consisted of 8,976 women.

RESULTS

Overall, women above 18 years who had been referred to an HPV center were more likely to have used psychiatric medication (odds ratio [OR]: 1.88 [95% CI 1.48-2.40]) or to have been hospitalized because of a psychiatric disorder within 5 years prior to the first vaccine registration (OR: 2.13 [95% CI 1.59-2.86]). Specifically, referred women were more likely to have used antipsychotics, antidepressants, attention deficit hyperactivity disorder (ADHD) medication or anxiolytics, and to have been hospitalized for affective disorders or anxiety, but not to have been hospitalized for schizoid, ADHD or eating disorders. In addition, they were more likely to have had talk therapy or psychometric test performed prior to vaccination (OR: 1.72 [95% CI 0.1.35-2.18] and OR: 1.67 [95% CI 1.30-2.13], respectively). Referred women of all ages had higher use of GP before vaccination. Population attributable fraction analyses indicated that psychiatric medication, hospitalization due to a psychiatric disorder and use of talk therapy, or psychometric test "explained" 13%, 10%, 12% and 11% of the referrals, respectively. Results did not change substantially when adjusted for potential confounders.

CONCLUSION

Women referred to HPV centers because of suspected adverse events after vaccination more often had preexisting psychiatric conditions, psychological symptoms or frequent GP attendance prior to HPV vaccination.

Long-Term Outcome of Bodily Distress Syndrome in Primary Care: A Follow-Up Study on Health Care Costs, Work Disability, and Self-Rated Health

OBJECTIVE

The upcoming International Classification of Diseases, 11th Revision for primary care use suggests inclusion of a new diagnostic construct, bodily (di)stress syndrome (BDS), for individuals with medically unexplained symptoms. We aimed to explore the long-term outcome of BDS in health care costs, work disability, and self-rated health.

METHODS

Consecutive patients consulting their family physician for a new health problem were screened for physical and mental symptoms by questionnaires (n = 1785). A stratified subsample was examined with a standardized diagnostic interview (n = 701). Patients with single-organ BDS (n = 124) and multiorgan BDS (n = 35), and a reference group with a family physician-verified medical condition (n = 880) were included. All included patients completed a questionnaire at 3, 12, and 24 months of follow-up. Register data on health care costs and work disability were obtained after 2 and 10 years of follow-up, respectively.

RESULTS

Patients with BDS displayed poorer self-rated health and higher illness worry at index consultation and throughout follow-up than the reference group (p ≤ .001). The annual health care costs were higher in the BDS groups (2270 USD and 4066 USD) than in the reference group (1392 USD) (achieved significance level (ASL) ≤ 0.001). Both BDS groups had higher risk of sick leave during the first 2 years of follow-up (RRsingle-organ BDS = 3.0; 95% confidence interval [CI] = 1.8-5.0; RRmultiorgan BDS = 3.4; 95% CI = 1.5-7.5) and substantially higher risk of newly awarded disability pension than the reference group (HRsingle-organ BDS = 4.9; 95% CI = 2.8-8.4; HRmultiorgan BDS = 8.7; 95% CI = 3.7-20.7).

CONCLUSIONS

Patients with BDS have poor long-term outcome of health care costs, work disability, and subjective suffering. These findings stress the need for adequate recognition and management of BDS.

Health care utilization in outpatients with somatoform disorders: Descriptives, interdiagnostic differences, and potential mediating factors

OBJECTIVE

Somatoform disorders are characterized by increased health care utilization producing high health costs. The aim of this study was to assess facets of and interdiagnostic differences in health care use in somatoform disorders and to examine health anxiety, symptom-related disability, depression, and phobic anxiety as potential mediating factors of the relationship between somatization and health care use.

METHOD

An outpatient sample of N=254 patients with somatoform disorders was investigated by analyzing different facets of their health care use over the last 12months. Multiple mediation analyses were applied.

RESULTS

Participants reported a mean of 28.02 doctor visits over the last year. Patients fulfilling criteria of DSM-IV somatization disorder had a significantly higher number of doctor visits than patients with undifferentiated somatoform, and somatoform pain disorder, all p≤.006. In most health care use variables, patients with comorbid mental disorders did not differ from patients without comorbidities. The mediation model on the effect of all mediator variables on the relationship between somatization and health care use reached significance (b=0.32, 95% CI: 0.0576, 0.6435). Surprisingly, specific mediator effects were found for health anxiety (b=0.06, 95% CI: 0.0004, 0.1505) and disability (b=0.18, 95% CI: 0.0389, 0.3530), but not for depression and phobic anxiety.

CONCLUSIONS

Health anxiety and symptom-related disability should be further considered when investigating potential etiological factors of increased health care use.

The overlap of somatic, anxious and depressive syndromes: A population-based analysis

OBJECTIVE

The comorbidity of somatic, anxious and depressive syndromes occurs in half of all primary care cases. As research on this overlap of syndromes in the general population is scarce, the present study investigated the prevalence of the overlapping syndromes and their association with health care use.

METHOD

A national general population survey was conducted between June and July 2012. Trained interviewers contacted participants face-to-face, during which, individuals reported their health care use in the previous 12months. Somatic, anxious and depressive syndromes were assessed using the Somatic Symptom Scale-8 (SSS-8), Generalized Anxiety Disorder-2 (GAD-2) and Patient Health Questionnaire-2 (PHQ-2) respectively.

RESULTS

Out of 2510 participants, 236 (9.4%) reported somatic (5.9%), anxious (3.4%) or depressive (4.7%) syndromes, which were comorbid in 86 (3.4%) cases. The increase in the number of syndromes was associated with increase in health care visits (no syndrome: 3.18 visits vs. mono syndrome: 5.82 visits vs. multi syndromes: 14.16 visits, (F_(2,2507)=149.10, p<0.00001)). Compared to each somatic (semi-partial r²=3.4%), anxious (semi-partial r²=0.82%) or depressive (semi-partial r²=0.002%) syndrome, the syndrome overlap (semi-partial r²=6.6%) explained the greatest part of variance of health care use (_{change_in}R²⁼11.2%, _{change_in}F_(3,2499)=112.81, p<0.001.) CONCLUSIONS: The overlap of somatic, anxious and depressive syndromes is frequent in the general population but appears to be less common compared to primary care populations. To estimate health care use in the general population the overlap of somatic, anxious and depressive syndromes should be considered.

Portuguese validation of the Short Health Anxiety Inventory: Factor structure, reliability, and factor invariance

The Short Health Anxiety Inventory is a brief instrument to assess health anxiety widely used across countries; however, no validated version is available for Portuguese-speaking population. Factorial structure, reliability, and equivalency factor with the Spanish version were analyzed with Portuguese adolescents aged 14-18 years. A Portuguese adolescent cohort ( N = 629) and a comparative Spanish adolescent cohort ( N = 1502) were evaluated. The original two-factor version was the best fitting model for the Portuguese version. The reliability was excellent. Complete measurement invariance across both countries was supported. The Portuguese version of the Short Health Anxiety Inventory is a valid screening inventory to assess health anxiety in adolescents.

Functional (psychogenic) dizziness

Functional and psychiatric disorders that cause vestibular symptoms (i.e., vertigo, unsteadiness, and dizziness) are common. In fact, they are more common than many well-known structural vestibular disorders. Neurologists and otologists are more likely to encounter patients with vestibular symptoms due to persistent postural-perceptual dizziness or panic disorder than Ménière's disease or bilateral vestibular loss. Successful approaches to identifying functional and psychiatric causes of vestibular symptoms can be incorporated into existing practices without much difficulty. The greatest challenge is to set aside dichotomous thinking that strongly emphasizes investigations of structural diseases in favor of a three-pronged approach that assesses structural, functional, and psychiatric disorders simultaneously. The pathophysiologic mechanisms underlying functional and psychiatric causes of vestibular symptoms are better understood than many clinicians realize. Research methods such as advanced posturographic analysis and functional brain imaging will push this knowledge further in the next few years. Treatment plans that include patient education, vestibular rehabilitation, cognitive and behavioral therapies, and medications substantially reduce morbidity and offer the potential for sustained remission when applied systematically. Diagnostic and therapeutic approaches are necessarily multidisciplinary in nature, but they are well within the purview of collaborative care teams or networks of clinicians coordinated with the neurologists and otologists whom patients consult first.

Health Anxiety and Its Relationship to Disability and Service Use: Findings From a Large Epidemiological Survey

OBJECTIVE

To explore the contribution of health anxiety to disability and use of mental health and medical services, independently of co-occurring mental and physical conditions.

METHODS

Data from the Australian National Survey of Mental Health and Wellbeing 2007 were analyzed (n = 8841). Participants were aged 16 to 85 years (mean [standard deviation] = 46.3 [19.0] years) and 54% were women.

RESULTS

Health anxiety accounted independently for high disability and service use. People with health anxiety were more likely to use both mental health (for psychiatrists: odds ratio [OR] = 2.1, 95% confidence interval [CI] = 1.2-3.5; for psychologists: OR = 1.9, 95% CI = 1.2-3.3) and specialist medical services (OR = 1.7, 95% CI = 1.2-2.3) than people without health anxiety. However, they were not high-frequency attenders to specialist mental health services (OR = 1.6 [95% CI = 0.9-3.0] and OR = 1.3 [95% CI = 0.6-2.9]) compared with people with other mental disorders (OR = 11.7 [95% CI = 4.3-31.8] and OR = 29.5 [95% CI = 13.5-64.6] for psychiatrists and psychologists, respectively). People with health anxiety were likely to be high-frequency attenders to general practice (OR = 2.0, 95% CI = 1.4-2.8) and specialist medical services (OR = 2.4, 95% CI = 1.7-3.6).

CONCLUSIONS

It is important to recognize and treat health anxiety, even when coexisting with other conditions, to prevent high disability burden and excessive service use. The cross-sectional design and self-reported outcomes may have resulted in overestimation of the associations. Future work is needed on actual service use using reviews of medical records.

[Depression, anxiety, stress, and mortality]

The analytical paper summarizes the main results of recent investigations of the relationships of depression, anxiety, and stress with overall and cardiovascular mortality. It shows that depression and stress are associated with an increased risk of death mainly from cardiovascular diseases, and depression treatment and stress control can increase life expectancy.

Clinical characteristics of persistent frequent attenders in primary care: case-control study

BACKGROUND

Most frequent attendance in primary care is temporary, but persistent frequent attendance is expensive and may be suitable for psychological intervention. To plan appropriate intervention and service delivery, there is a need for research involving standardized psychiatric interviews with assessment of physical health and health status.

OBJECTIVE

To compare the mental and physical health characteristics and health status of persistent frequent attenders (FAs) in primary care, currently and over the preceding 2 years, with normal attenders (NAs) matched by age, gender and general practice.

METHODS

Case-control study of 71 FAs (30 or more GP or practice nurse consultations in 2 years) and 71 NAs, drawn from five primary care practices, employing standardized psychiatric interview, quality of life, health anxiety and primary care electronic record review over the preceding 2 years.

RESULTS

Compared to NAs, FAs were more likely to report a lower quality of life (P < 0.001), be unmarried (P = 0.03) and have no educational qualifications (P = 0.009) but did not differ in employment status. FAs experienced greater health anxiety (P < 0.001), morbid obesity (P = 0.02), pain (P < 0.001) and long-term pathological and ill-defined physical conditions (P < 0.001). FAs had more depression including dysthymia, anxiety and somatoform disorders (all P < 0.001).

CONCLUSIONS

Persistent frequent attendance in primary care was associated with poor quality of life and high clinical complexity characterized by diverse and often persistent physical and mental multimorbidity. A brokerage model with GPs working in close liaison with skilled psychological therapists is required to manage such persistent complexity.

Medically unexplained symptoms and the risk of loss of labor market participation--a prospective study in the Danish population

BACKGROUND

Medically Unexplained Symptoms (MUS) are frequently encountered in general practice. However, little is known whether MUS affects labor market participation. We investigated the prospective association between MUS at baseline and risk of long-term sickness absence (LTSA), unemployment, and disability pensioning in a 5-year-follow-up study.

METHODS

In the Danish Work Environment Cohort Study 2005, 8187 randomly selected employees from the Danish general population answered a questionnaire on work and health. Responses were linked with national registers on prescribed medication and hospital treatment. Participants were classified with MUS if they: a) had reported three or more symptoms during the last month, and b) did not have a chronic condition, neither in the self-reported nor the register data. We assessed LTSA, unemployment, and disability pensioning by linking our data with National registers of social transfer payments.

RESULTS

Of the 8187 participants, 272 (3.3%) were categorized with MUS. Compared to healthy participants, participants with MUS had an increased risk of LTSA (Rate ratio (RR) = 1.76, 95% CI = 1.28-2.42), and of unemployment (RR = 1.48, 95% CI = 1.02-2.15) during follow-up. MUS participants also showed an elevated RR with regard to risk of disability pensioning, however this association was not statistically significant (RR = 2.06, 95% CI = 0.77-5.52).

CONCLUSION

MUS seem to have a negative effect on labor market participation defined by LTSA and unemployment, whereas it is more uncertain whether MUS affects risk of disability pensioning.

Why do they keep coming back? Psychosocial etiology of persistence of frequent attendance in primary care: a prospective cohort study

BACKGROUND

Patients who visit their General Practitioner (GP) very frequently over extended periods of time often have multimorbidity and are costly in primary and specialist healthcare. We investigated the impact of patient-level psychosocial and GP-level factors on the persistence of frequent attendance (FA) in primary care.

METHODS

Two-year prospective cohort study in 623 incident adult frequent attenders (>90th attendance centile; age and sex-adjusted) in 2009. Information was collected through questionnaires (patients, GPs) and GPs' patient data. We used multilevel, ordinal logistic regression analysis, controlling for somatic illness and demographic factors with FA in 2010 and/or 2011 as the outcome.

RESULTS

Other anxiety (odds ratio (OR) 2.00; 95% confidence interval from 1.29 to 3.10) over 3years and the number of life events in 3years (OR 1.06; 1.01-1.10 per event; range of 0 to 12) and, at baseline, panic disorder (OR 5.40; 1.67-17.48), other anxiety (OR 2.78; 1.04-7.46), illness behavior (OR 1.13; 1.05-1.20 per point; 28-point scale) and lack of mastery (OR 1.08; 1.01-1.15 per point; 28-point scale) were associated with persistence of FA. We found no evidence of synergistic effects of somatic, psychological and social problems. We found no strong evidence of effects of GP characteristics.

CONCLUSION

Panic disorder, other anxiety, negative life events, illness behavior and lack of mastery are independently associated with persistence of frequent attendance. Effective intervention at these factors, apart from their intrinsic benefits to these patients, may reduce attendance rates, and healthcare expenditures in primary and specialist care.

Anxiety in Parkinson's disease: identification and management

Anxiety disturbances are recognized as common psychiatric comorbidities in Parkinson's disease (PD) and contribute to significant impairments in areas of cognitive, functional, motor and social performance. Anxiety in PD results in reduced quality of life, higher levels of care dependency and increased caregiver burden. Surprisingly, there is a paucity of treatment data. In one randomized, controlled study, bromazepam was found to be effective for anxiety in PD. However, usage of benzodiazepines in the PD population is limited by potential risk of confusion and falls. There are no controlled studies of selective serotonin reuptake inhibitors (SSRIs) for anxiety in PD. However, results from uncontrolled studies suggest that SSRIs are effective for anxiety in PD, although in these studies anxiety outcomes were secondary. This review underscores that, given the high prevalence of anxiety disturbances in PD, there is a significant paucity of treatment data for this population. Additional studies are warranted. In the meantime, clinicians should rely on empiric assessments of known risks and putative benefits to guide treatment decisions. Cognitive and behavioral therapies (with or without pharmacotherapy) have demonstrated efficacy and warrant consideration. When feasible, a targeted and individualized multimodal approach utilizing psychotherapeutic interventions along with pharmacologic therapies should be considered.

Functional somatic symptoms and consultation patterns in 5- to 7-year-olds

OBJECTIVE

To investigate the frequency of and factors linked to medical consultation for functional somatic symptoms (FSS) among 5- to 7-year-old children.

METHODS

We assessed 1327 children from the Copenhagen Child Cohort 2000 for FSS at ages 5 to 7 years. Register data on past health care use in general practice were compared between children with and those without parent-reported medical consultation for FSS at the age of 5 to 7 years: respective consulters (n = 96) and nonconsulters (n = 211) and children without FSS (n = 1019). Degree of parental worries about the child's symptoms and parent-reported symptom characteristics and associated impacts were compared between consulters and nonconsulters.

RESULTS

Among 308 children with FSS, 31.1% were consulters. Being a consulter was significantly associated with multisymptomatic presentation, parental worries about the symptoms, symptom impact, and a higher past health care use in general practice. Multiple logistic regression analysis controlled for gender, comorbid physical disease, and symptom severity revealed that the number of face-to-face contacts in general practice during the child's first 4 years of life predicted being an consulter for FSS at 5 to 7 years (odds ratio 1.03, 95% confidence interval 1.00-1.06; odds ratio interpreted per unit change in number of contacts).

CONCLUSIONS

This study adds to our understanding of health care use for FSS in childhood by highlighting the influence of parents' early consultation patterns with their child and the influence of parental perceptions of their child's health and FSS-related impact on pediatric health care use for FSS. Management of health care use in children with FSS should address these aspects.

How to assess common somatic symptoms in large-scale studies: a systematic review of questionnaires

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.

Emerging themes in the revision of the classification of somatoform disorders

The somatoform disorders, as currently defined in DSM-IV and ICD-10, have been criticized for their complexity and poor clinical utility. In this paper we consider these criticisms as well as the conceptual question of whether there is sufficient evidence for classifying them as mental and behavioural disorders. The review suggests that, as currently defined, somatoform disorders do not fulfil a recently articulated set of criteria for mental and behavioural disorders. In particular, the disorders are not defined according to positive psychological and behavioural disorders and evidence is sparse to support their classification as different and distinct diagnoses. Any revision of the disorders should not be based on 'medically unexplained' symptoms. Rather, the relevant diagnoses should include a combination of bothersome somatic symptoms with several other psychological features including beliefs about somatic symptoms and evidence of marked concerns about health and illness. Finally, the review presents a set of proposals for the revision of these disorders, by the Somatic Disorders and Dissociative Disorders Working Group of the WHO International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders, which attempt to take account of the criticisms and current understanding of somatic experiences.