The Conundrum of Medically Unexplained Symptoms: Questions to Consider

Recent developments on psychological factors in medically unexplained symptoms and somatoform disorders

Somatic symptoms which are not fully explained by a medical condition (medically unexplained symptoms) have a high relevance for the public health. They are very common both in the general population and in patients in health care, and may develop into chronic impairing conditions such as somatoform disorders. In recent years, the relevance of specific negative psychological factors for the diagnosis and the stability of somatoform disorders and for the impairment by medically unexplained symptoms gained more and more attention. This resulted-among others- in core changes in the diagnostic classification criteria of somatoform disorders. Against this background, the present "Perspective" will outline recent developments and findings in the area of medically unexplained somatic symptoms and somatoform disorders. Moreover, it will lay a special focus on evidence on specific negative psychological factors that may influence the course of unexplained somatic symptoms and disorders and the impairment caused by these symptoms.

Associations between self-reported respiratory symptoms and non-specific psychological distress following exposure to a prolonged landscape fire

We investigated the association between respiratory symptoms and psychological distress in the context of a prolonged smoke event, and evaluated whether smoke exposure, or pre-existing respiratory and mental health conditions, influenced the association. Three thousand ninety-six residents of a rural town heavily exposed to smoke from the 6-week Hazelwood coal mine fire, and 960 residents of a nearby unexposed town, completed Kessler's psychological distress questionnaire (K10) and a modified European Community Respiratory Health Survey. Logistic regression models evaluated associations between distress and respiratory symptoms, with interactions fitted to evaluate effect modification. Smoke exposed participants reported higher levels of distress than those unexposed, and participants reporting respiratory symptoms recorded higher levels of distress than participants without respiratory symptoms, irrespective of exposure. 5-unit increments in K10 scores were associated with 21%-48% increases in the odds of reporting respiratory symptoms. There were significant interactions with pre-existing asthma, chronic obstructive pulmonary disease and mental health conditions, but not with smoke exposure. Although participants with pre-existing conditions were more likely to report respiratory symptoms, increasing distress was most strongly associated with respiratory symptoms among those without pre-existing conditions. Communities exposed to landscape fire smoke could benefit from interventions to reduce both psychological and respiratory distress.

The ambivalence about accepting the prevalence somatic symptoms in PTSD: Is PTSD a somatic disorder?

This study examined the prevalence of somatic symptoms in post-traumatic stress disorder (PTSD) in a population-based military sample (N = 14,445). Descriptive statistics explored somatic symptom endorsement in the entire sample. A latent class analyses was conducted on participants with a posttraumatic stress checklist (PCL) score ≥29 (n = 2433), with class differentiated by somatic symptom endorsement.Multinomial logistic regression explored correlates of latent class. Somatic disorder was more prevalent in probable-PTSD (59.6%) and subsyndromal-PTSD (26.5%) than no-PTSD (5.0%) groups, supporting an intersection of pathophysiological processes between somatic and PTSD symptoms. A 3-class solution of Syndromal (26.7%),Psychological (17.7%), and Somatic (55.5%) classes provided the optimal representation of latent somatic symptom typologies in probable PTSD and subsyndromal PTSD. Differences between classes on key characteristics supported potentially meaningful class distinctions. Class was not predicted by number of deployments nor whether a member had ever deployed. However, class was predicted by life-time trauma, indicating that the PTSD somatic symptom relationship is not confined to combat related PTSD or the effect of toxic exposures on deployment, but that pre-existing pathophysiology related to life-time trauma may drive the relationship.The high degree of coincidence between PTSD and somatic symptoms and the high prevalence of somatic distress in the Syndromal and Somatic classes support somatic symptoms are a ubiquitous aspect of the clinical presentation and should be considered a central characteristic of PTSD and therefore included in the diagnostic criteria, as suggested by the original formulations of PTSD.

The Associations Between Physical and Psychological Symptoms and Traumatic Military Deployment Exposures

Current paradigms regarding the effects of traumatic exposures on military personnel do not consider physical symptoms unrelated to injury or illness as independent outcomes of trauma exposure, characteristically dealing with these symptoms as comorbidities of psychological disorders. Our objective was to ascertain the proportions of deployed military personnel who experienced predominantly physical symptoms, predominantly psychological symptoms, and comorbidity of the two and to examine the association between traumatic deployment exposures (TDEs) and these symptomatic profiles. Data were taken from a cross-sectional study of Australian Defence Force personnel who were deployed to the Middle East during 2001-2009 (N = 14,032). Four groups were created based on distributional splits of physical and psychological symptom scales: low-symptom, psychological, physical, and comorbid. Multinomial logistic regression models assessed the probability of symptom group membership, compared with low-symptom, as predicted by self-reported TDEs. Group proportions were: low-symptom, 78.3%; physical, 5.0%; psychological, 9.3%; and comorbid, 7.5%. TDEs were significant predictors of all symptom profiles. For subjective, objective, and human death and degradation exposures, respectively, the largest relative risk ratios (RRRs) were for the comorbid profile, RRRs = 1.47, 1.19, 1.48; followed by the physical profile, RRRs = 1.27, 1.15, 1.40; and the psychological profile, RRRs = 1.22, 1.07, 1.22. Almost half of participants with physical symptoms did not have comorbid psychological symptoms, suggesting that physical symptoms can occur as a discrete outcome trauma exposure. The similar dose-response association between TDEs and the physical and psychological profiles suggests trauma is similarly associated with both outcomes.

Symptom attribution and treatment seeking in Australian veterans

To understand the role of symptom attribution in treatment-seeking behaviours, survey results of 1356 veterans (age = 38-72 years) were analysed. Controlling for symptom frequency, significant relationships were found for specialist and psychological-related consultations. Those who favoured psychological explanations for symptoms were more likely to attend specialist and psychology-related consultations and filled significantly more prescriptions than people who predominantly explained symptoms by situational factors (normalisers). Veterans who favoured somatic explanations attended more general practitioner consultations than normalisers. Attributional style should be considered part of the constellation of factors influencing healthcare usage. Normalisers, the predominant group, used fewest health services and filled fewest prescriptions; this may have important implications for healthcare considering their tendency to minimise or downplay symptoms.

Medium- and long-term prognostic validity of competing classification proposals for the former somatoform disorders

BACKGROUND

DSM-5 introduced a fundamental revision of the category of somatoform disorders, which resulted in the new somatic symptom disorder (SSD) and related disorders. However, prognostic validity of SSD remains unclear, while other classification proposals, such as bodily distress disorder (BDD) or polysymptomatic distress disorder (PSDD), might be promising alternatives for the new ICD-11. Therefore, the comparison of the different approaches concerning long-term prognosis of disorder-relevant factors is of special interest.

METHOD

In a longitudinal design (baseline, 1-year, and 4-year follow-up), the three proposals (SSD, BDD, PSDD) were compared in an age-representative sample of the German general population (N = 321). To this end, the baseline sample was divided into three independent pairs of groups (with/without SSD, with/without BDD, with/without PSDD). It was tested how well each approach differentiated with regard to medium- and long-term healthcare utilization, number of symptoms, and impairment.

RESULTS

Criteria for BDD distinguished best with regard to future healthcare utilization resulting in a large-sized effect (f = 0.44) for the difference between persons with and without BDD, while SSD and PSDD revealed only medium-sized effects (f = 0.28 and f = 0.32) between subjects with and without diagnosis. The three proposals distinguished equally well with regard to future subjective impairment (between f = 0.39 and f = 0.41) and the number of reported symptoms (between f = 0.77 and f = 0.83).

CONCLUSION

In accordance with our data regarding prognostic validity, the current draft of the WHO group is based on the BDD proposal. However, existing limitations and weaknesses of the present proposal for the ICD-11 are further discussed.

Symptom attribution and symptom reporting in Australian Gulf War veterans

OBJECTIVE

To better understand the consistent elevated symptom reporting by Gulf War veterans; we compared Australian Gulf War veterans and military-comparison group on symptom attributional styles and the relationship with total number and grouping of somatic and psychological symptoms.

METHOD

Postal questionnaires were completed by Australian Gulf War veterans (n=697) and military-comparison group (n=659) in 2000-2002 and 2011-2012. Data were collected on deployments, military-psychological stressors, symptom reporting, symptom factors and attributional style (normalising, psychologising, somatising, mixed-attribution).

RESULTS

Gulf War veterans did not differ in attributional style from comparison group (p>0.05); normalising was the predominant style. Groups were combined for analyses. Psychologisers reported the highest overall symptoms (mean(M)=10.95, standard deviation(SD)=9.15), the most psychophysiological (M=1.71, SD=2.82), cognitive (M=5.79, SD=5.09) and arthro-neuromuscular symptoms (M=1.53, SD=1.73). Psychologisers and somatisers reported significantly more symptoms across overall symptoms, all three symptom factors and psychological distress than normalisers. Normalisers consistently reported fewest overall symptoms (M=2.85, SD=4.49), psychophysiological (M=0.40, SD=0.98), cognitive (M=1.14, SD=2.22), and arthro-neuromuscular symptoms (M=0.72, SD=1.31). Persistent symptoms, rather than remitted, between baseline and follow-up were associated with increased rates of psychologising and mixed-attribution compared with normalising. For incident symptoms a similar pattern was observed, some symptoms also showed increased rates of somatising.

CONCLUSIONS

In veterans, psychologising was associated with higher symptom reporting, whilst somatisers and mixed-attribution also demonstrated higher reporting than normalisers. Symptom persistence and incidence were associated with symptom attribution. The findings indicate that attributional style is associated with patterns of symptom reporting and highlights both past and present symptoms may influence attributional style.

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.

Managing the consultation with patients with medically unexplained symptoms: a grounded theory study of supervisors and registrars in general practice

BACKGROUND

Patients with medically unexplained symptoms (MUS) commonly present in general practice. They often experience significant disability and have difficulty accessing appropriate care. Many feel frustrated and helpless. Doctors also describe feeling frustrated and helpless when managing these patients. These shared negative feelings can have a detrimental effect on the therapeutic relationship and on clinical outcomes. The aim of this study was to explore how novice and experienced GPs manage patients with MUS and how these skills are taught and learned in GP training.

METHODS

A constructivist grounded theory study with 24 general practice registrars and supervisors in GP training practices across Australia.

RESULTS

Registrars lacked a framework for managing patients with MUS. Some described negative feelings towards patients that were uncomfortable and confronting. Registrars also were uncertain about their clinical role: where their professional responsibilities began and ended. Supervisors utilised a range of strategies to address the practical, interpersonal and therapeutic challenges associated with the care of these patients.

CONCLUSIONS

Negative feelings and a lack of diagnostic language and frameworks may prevent registrars from managing these patients effectively. Some of these negative feelings, such as frustration, shame and helplessness, are shared between doctors and patients. Registrars need assistance to identify and manage these difficult feelings so that consultations are more effective. The care of these patients also raises issues of professional identity, roles and responsibilities. Supervisors can assist their registrars by proactively sharing models of the consultation, strategies for managing their own feelings and frustrations, and ways of understanding and managing the therapeutic relationship in this difficult area of practice.

Inpatient hospital costs and length of stay for the treatment of affective and somatoform disorders - evidence from Germany

INTRODUCTION

Diagnosis related costs analyses are the subject of science and research and are of great relevance and importance for decision makers in the hospital and for funding bodies, but also for international health policy. Up to now, standardized costs analyses with valid costs data have not been available for inpatient care of patients with affective and somatoform disorders.

BACKGROUND

This clinical picture presents a major challenge for the provision of outpatient and inpatient care. An interdisciplinary approach in an inpatient setting can be beneficial for already "chronified" patients with severe forms of progression. Because of its structural and procedural demands, this type of care is associated with a greater expenditure of resources.

METHODS

Costs data from the years 2008 to 2012 were analyzed for a total of 17,424 hospitalized patients in more than 200 different hospitals in Germany. The study compared the costs of treating patients with the main diagnosis affective and somatoform disorders using standardized interdisciplinary therapy, with the costs of conventional therapy.

RESULTS

Interdisciplinary patient care is characterized by a high proportion of the costs derived from the structural and procedural implementation and the medical and nursing care. For interdisciplinary therapy with a mean period of hospitalization of 15.2 days, over 60% of the total costs were incurred by the personnel and material costs of the medical and non-medical infrastructure. The outlay is considerably greater than would be incurred by a conventional therapeutic approach without interdisciplinary therapy.

DISCUSSION AND CONCLUSION

For the first time, detailed diagnosis-related costs data are published which were generated by consistent, standardized cost unit accounting. An interdisciplinary, holistic approach to the clinical picture results in a significant increase in costs for the hospitals.

Medically unexplained symptoms: the need for effective communication and an integrated care strategy

Much is already known about medically unexplained symptoms (MUS) in terms of incidence, presentation and current treatment. What needs to be urgently addressed is a strategy for dealing with patients and their conditions, particularly when they do not fall neatly into medical frameworks or pathologies where the syndrome can be easily explained. This article will consider the provision of health and social care support for patients with MUS within an interprofessional education context. The author will contend that a sensitive and valued service for this large client group is dependent upon services without professional boundaries and practitioners with a clinical interest that can work together and agree an appropriate way forward in terms of care, support and strategic service provision. The article will support the idea that clear guidelines through the National Institute for Health and Care Excellence can offer clear clinical direction for practitioners working in primary and secondary care settings to work together interprofessionally to ensure a seamless and sensitive service for people with this condition.

Mixed emotional and physical symptoms in general practice: what diagnoses do GPs use to describe them?

AIMS

To determine what diagnostic terms are utilized by general practitioners (GPs) when seeing patients with mixed emotional and physical symptoms.

METHOD

Prototype cases of depression, anxiety, hypochondriasis, somatization and undifferentiated somatoform disorders were sourced from the psychiatric literature and the author's clinical practice. These were presented, in paper form, to a sample of GPs and GP registrars who were asked to provide a written diagnosis.

RESULTS

Fifty-two questionnaires were returned (30% response rate). The depression and anxiety cases were identified correctly by most participants. There was moderate identification of the hypochondriasis and somatization disorder cases, and poor identification of the undifferentiated somatoform case.

CONCLUSION

Somatization and undifferentiated somatoform disorders were infrequently recognized as diagnostic categories by the GPs in this study. Future research into the language and diagnostic reasoning utilized by GPs may help develop better diagnostic classification systems for use in primary care in this important area of practice.

A randomized controlled trial of cognitive-behavioral therapy for the treatment of PTSD in the context of chronic whiplash

OBJECTIVES

Whiplash-associated disorders (WAD) are common and involve both physical and psychological impairments. Research has shown that persistent posttraumatic stress symptoms are associated with poorer functional recovery and physical therapy outcomes. Trauma-focused cognitive-behavioral therapy (TF-CBT) has shown moderate effectiveness in chronic pain samples. However, to date, there have been no clinical trials within WAD. Thus, this study will report on the effectiveness of TF-CBT in individuals meeting the criteria for current chronic WAD and posttraumatic stress disorder (PTSD).

METHOD

Twenty-six participants were randomly assigned to either TF-CBT or a waitlist control, and treatment effects were evaluated at posttreatment and 6-month follow-up using a structured clinical interview, self-report questionnaires, and measures of physiological arousal and sensory pain thresholds.

RESULTS

Clinically significant reductions in PTSD symptoms were found in the TF-CBT group compared with the waitlist at postassessment, with further gains noted at the follow-up. The treatment of PTSD was also associated with clinically significant improvements in neck disability, physical, emotional, and social functioning and physiological reactivity to trauma cues, whereas limited changes were found in sensory pain thresholds.

DISCUSSION

This study provides support for the effectiveness of TF-CBT to target PTSD symptoms within chronic WAD. The finding that treatment of PTSD resulted in improvements in neck disability and quality of life and changes in cold pain thresholds highlights the complex and interrelating mechanisms that underlie both WAD and PTSD. Clinical implications of the findings and future research directions are discussed.

The symptom cluster experience profile framework

PURPOSE/OBJECTIVES

To present the novel Symptom Cluster Experience Profile (SCEP) framework for guiding symptom research in adult survivors of childhood cancers and other subgroups at risk for high symptom burden.

DATA SOURCES

Empirically derived model of symptom cluster experience profiles, existing theoretical frameworks, and data-based literature on symptoms and quality of life in adult survivors of childhood cancers.

DATA SYNTHESIS

In a previous study, the authors generated a preliminary model to characterize subgroups of adult survivors of childhood cancers with high-risk symptom cluster profiles. The authors developed the SCEP framework, which depicts symptom cluster experiences as subgroup-specific profiles that are driven by multiple sets of risk and protective factors. The risk and protective factors may directly and indirectly contribute to or alleviate symptoms through their effects on systemic stress. Systemic stress instigates and sustains the symptom experience that, in turn, is expressed through negative diffusion into other components of quality of life, such as functional status, general health perceptions, and overall quality of life.

CONCLUSIONS

The SCEP framework is an initial approach to unbundle the complex heterogeneity that underlies the clustering of symptoms. By measuring a wide range of risk and protective factors in future studies of adult survivors of childhood cancers and other subgroups at risk for high symptom burden, further development and validation of the SCEP framework will occur.

IMPLICATIONS FOR NURSING

The SCEP framework can be used to specify mechanisms underlying symptom cluster profiles and derive interventions targeted to high-risk symptom profiles. Findings from future studies can be translated to risk-based surveillance and symptom management clinical practice guidelines.

Psychiatric diagnoses in patients with burning mouth syndrome and atypical odontalgia referred from psychiatric to dental facilities

BACKGROUND

Burning mouth syndrome (BMS) and atypical odontalgia (AO) are two conditions involving chronic oral pain in the absence of any organic cause. Psychiatrically they can both be considered as "somatoform disorder". From the dental point of view, however, the two disorders are quite distinct. BMS is a burning or stinging sensation in the mouth in association with a normal mucosa whereas AO is most frequently associated with a continuous pain in the teeth or in a tooth socket after extraction in the absence of any identifiable cause. Because of the absence of organic causes, BMS and AO are often regarded as psychogenic conditions, although the relationship between oral pain and psychologic factors is still unclear. Some studies have analyzed the psychiatric diagnoses of patients with chronic oral pain who have been referred from dental facilities to psychiatric facilities. No study to date has investigated patients referred from psychiatric facilities to dental facilities.

OBJECTIVE

To analyze the psychiatric diagnoses of chronic oral pain patients, diagnosed with BMS and AO, and referred from psychiatric facilities to dental facilities.

STUDY DESIGN

Psychiatric diagnoses and disease conditions of BMS or AO were investigated in 162 patients by reviewing patients' medical records and referral forms. Psychiatric diagnoses were categorized according to the International Statistical Classification of Disease and Related Health Problems, Tenth Revision.

RESULTS

The proportion of F4 classification (neurotic, stress-related, and somatoform disorders) in AO patients was significantly higher than in BMS patients. BMS patients were more frequently given a F3 classification (mood/affective disorders). However, 50.8% of BMS patients and 33.3% of AO patients had no specific psychiatric diagnoses.

CONCLUSION

Although BMS and AO are both chronic pain disorders occurring in the absence of any organic cause, the psychiatric diagnoses of patients with BMS and AO differ substantially.

Diagnosing somatisation disorder (P75) in routine general practice using the International Classification of Primary Care

OBJECTIVE

(i) To analyze general practitioners' diagnosis of somatisation disorder (P75) using the International Classification of Primary Care (ICPC)-2-E in routine general practice. (ii) To validate the distinctiveness of the ICD-10 to ICPC-2 conversion rule which maps ICD-10 dissociative/conversion disorder (F44) as well as half of the somatoform categories (F45.0-2) to P75 and codes the other half of these disorders (F45.3-9), including autonomic organ dysfunctions and pain syndromes, as symptom diagnoses plus a psychosocial code in a multiaxial manner.

METHODS

Cross-sectional analysis of routine data from a German research database comprising the electronic patient records of 32 general practitioners from 22 practices. For each P75 patient, control subjects matched for age, gender, and practice were selected from the 2007 yearly contact group (YCG) without a P75 diagnosis using a propensity-score algorithm that resulted in eight controls per P75 patient.

RESULTS

Of the 49,423 patients in the YCG, P75 was diagnosed in 0.6% (302) and F45.3-9 in 1.8% (883) of cases; overall, somatisation syndromes were diagnosed in 2.4% of patients. The P75 coding pattern coincided with typical characteristics of severe, persistent medically unexplained symptoms (MUS). F45.3-9 was found to indicate moderate MUS that otherwise showed little clinical difference from P75. Pain syndromes exhibited an unspecific coding pattern. Mild and moderate MUS were predominantly recorded as symptom diagnoses. Psychosocial codes were rarely documented.

CONCLUSIONS

ICPC-2 P75 was mainly diagnosed in cases of severe MUS. Multiaxial coding appears to be too complicated for routine primary care. Instead of splitting P75 and F45.3-9 diagnoses, it is proposed that the whole MUS spectrum should be conceptualized as a continuum model comprising categorizations of uncomplicated (mild) and complicated (moderate and severe) courses. Psychosocial factors require more attention.

Support for the mutual maintenance of pain and post-traumatic stress disorder symptoms

BACKGROUND

Pain and post-traumatic stress disorder (PTSD) are frequently co-morbid in the aftermath of a traumatic event. Although several models attempt to explain the relationship between these two disorders, the mechanisms underlying the relationship remain unclear. The aim of this study was to investigate the relationship between each PTSD symptom cluster and pain over the course of post-traumatic adjustment.

METHOD

In a longitudinal study, injury patients (n=824) were assessed within 1 week post-injury, and then at 3 and 12 months. Pain was measured using a 100-mm Visual Analogue Scale (VAS). PTSD symptoms were assessed using the Clinician-Administered PTSD Scale (CAPS). Structural equation modelling (SEM) was used to identify causal relationships between pain and PTSD.

RESULTS

In a saturated model we found that the relationship between acute pain and 12-month pain was mediated by arousal symptoms at 3 months. We also found that the relationship between baseline arousal and re-experiencing symptoms, and later 12-month arousal and re-experiencing symptoms, was mediated by 3-month pain levels. The final model showed a good fit [chi2=16.97, df=12, p>0.05, Comparative Fit Index (CFI)=0.999, root mean square error of approximation (RMSEA)=0.022].

CONCLUSIONS

These findings provide evidence of mutual maintenance between pain and PTSD.

The unbearable lightness of somatisation: a systematic review of the concept of somatisation in empirical studies of pain

Somatisation is often invoked to explain pain and suffering in patients. Lipowski [34] defined somatisation as "a tendency to experience and communicate somatic distress and symptoms unaccounted for by pathological findings, to attribute them to physical illness, and to seek medical help for them" (p. 1359). His concept is widely accepted. This study investigated to what extent this conceptualisation is used in the empirical studies of pain. Studies were identified through searches from Web of Science, Pubmed and Psychinfo databases for the period from 1989 until 2007. Screening an initial set of 1020 articles resulted in 120 articles fulfilling inclusion criteria. One hundred and sixteen articles were retrieved and coded in terms of the conceptualisation of Lipowski [34]. All studies had a measure of somatic symptoms, most often questionnaires. Whether the symptoms were unaccounted for by pathological findings was rarely investigated. No study assessed whether the participants attributed the somatic complaints to physical illness. Most studies included patients seeking help in a clinical setting, but only one study investigated whether patients were seeking help for the somatisation complaints. In conclusion, no study fulfilled the construct criteria as defined by Lipowski [34]. Most studies focus upon the extent and diversity of somatic complaints. We recommend that researchers who use self-report instruments do not use the term "somatisation" (even if the instrument is labeled as a "somatisation" scale), but use the term "multiple physical symptoms" instead. The current operational use may unduly lead to a "psychologisation" of physical complaints.