Total somatic symptom score as a predictor of health outcome in somatic symptom disorders

Effectiveness of a symptom-clinic intervention delivered by general practitioners with an extended role for people with multiple and persistent physical symptoms in England: the Multiple Symptoms Study 3 pragmatic, multicentre, parallel-group, individually randomised controlled trial

BACKGROUND

People with multiple and persistent physical symptoms have impaired quality of life and poor experiences of health care. We aimed to evaluate the effectiveness of a community-based symptom-clinic intervention in people with multiple and persistent physical symptoms, hypothesising that this symptoms clinic plus usual care would be superior to usual care only.

METHODS

The Multiple Symptoms Study 3 was a pragmatic, multicentre, parallel-group, individually randomised controlled trial conducted in 108 general practices in the UK National Health Service in four regions of England between Dec 6, 2018, and June 30, 2023. Participants were individually randomised (1:1) to the symptom-clinic intervention plus usual care or to usual care only via a computer-generated, pseudo-random list stratified by trial centre. Allocation was done by the trial statistician and concealed with a centralised, web-based randomisation system; masking participants was not possible due to the nature of the intervention. The symptom-clinic intervention was a sequence of up to four medical consultations that aimed to elicit a detailed clinical history, fully hear and validate the participant, offer rational explanations for symptoms, and assist the participant to develop ways of managing their symptoms; it was delivered by general practitioners with an extended role. The primary outcome was Patient Health Questionnaire-15 (PHQ-15) score 52 weeks after randomisation, analysed by intention to treat. The trial is registered on the ISRCTN registry (ISRCTN57050216).

FINDINGS

354 participants were randomly assigned; 178 (50%) were assigned to receive the community-based symptoms clinic plus usual care and 176 (50%) were assigned to receive usual care only. At the primary-outcome point of 52 weeks, PHQ-15 scores were 14·1 (SD 3·7) in the group receiving usual care and 12·2 (4·5) in the group receiving the intervention. The adjusted between-group difference of -1·82 (95% CI -2·67 to -0·97) was statistically significantly in favour of the intervention group (p<0·0001). There were 39 adverse events in the group receiving usual care and 36 adverse events in the group receiving the intervention. There were no statistically significant between-group differences in the proportion of participants who had non-serious adverse events (-0·03, 95% CI -0·11 to 0·05) or serious adverse events (0·02, -0·02 to 0·07). No serious adverse event was deemed to be related to the trial intervention.

INTERPRETATION

Our symptom-clinic intervention, which focused on explaining persistent symptoms to participants in order to support self-management, led to sustained improvement in multiple and persistent physical symptoms.

FUNDING

UK National Institute for Health and Care Research.

Prevalence of functional disorders across Europe: a systematic review and meta-analysis

Functional Disorders (FD) refer to persistent somatic symptoms caused by changes in the functioning of bodily processes. Previous findings suggest that FD are highly prevalent, but overall prevalence rates for FD in European countries are scarce. Therefore, the aim of the present work was to estimate the point prevalence of FD in adult general populations. PubMed and Web of Science were searched from inception to June 2022. A generalized linear mixed-effects model for statistical aggregation was used for statistical analyses. A standardized quality assessment was performed, and PRISMA guidelines were followed. A total of 136 studies were included and systematically synthesized resulting in 8 FD diagnoses. The large majority of studies was conducted in the Northern Europe, Spain, and Italy. The overall point prevalence for FD was 8.78% (95% CI from 7.61 to 10.10%) across Europe, with the highest overall point prevalence in Norway (17.68%, 95% CI from 9.56 to 30.38%) and the lowest in Denmark (3.68%, 95% CI from 2.08 to 6.43%). Overall point prevalence rates for specific FD diagnoses resulted in 20.27% (95% CI from 16.51 to 24.63%) for chronic pain, 9.08% (95% CI from 7.31 to 11.22%) for irritable bowel syndrome, and 8.45% (95% CI from 5.40 to 12.97%) for chronic widespread pain. FD are highly prevalent across Europe, which is in line with data worldwide. Rates implicate the need to set priorities to ensure adequate diagnosis and care paths to FD patients by care givers and policy makers.

Determinants of adolescents' depression, anxiety, and somatic symptoms in Northwest Ethiopia: A non-recursive structural equation modeling

INTRODUCTION

In low and middle-income countries, adolescent mental health is not only a major public health challenge but also a development concern. Depression and anxiety are the most common mental health disorders and somatic symptoms often co-exist with them. Adolescents with common mental health problems are associated with an increased risk of suicide, future unemployment, and poor quality of life. However, little is known about the mental health of adolescents in Ethiopia. Thus, this study aimed to assess the determinants of depression, anxiety, and somatic symptoms among adolescents in Northwest Ethiopia, in 2022.

METHODS

An institution-based cross-sectional study was conducted from June 8 to 24, 2022. Two-stage stratified random sampling was used to select 1407 adolescents in Northwest Ethiopia. Structured and standardized self-administered questionnaires were used to collect the data. Non-recursive structural equation modeling was employed to assess the direct, indirect, and total effects of predictors. Adjusted regression coefficients and corresponding 95% confidence intervals were used to interpret the strength of the association.

RESULTS

The prevalence of depression, anxiety, and somatic symptoms were 28.21% (95% CI: 25.8, 31%), 25.05% (95%CI: 22.8, 27.5), and 25.24(95% CI: 23, 27.6%) respectively. Alcohol use had a significant positive effect on depression [β = 0.14, 95% CI: 0.073, 0.201], anxiety [β = 0.11, 95% CI: 0.041, 0.188], and somatic symptoms [β = 0.12, 95% CI: 0.062, 0.211]. Stress had a significant positive effect on depression [β = 0.76, 95% CI: 0.642, 0.900], anxiety [β = 1.10, 95% CI: 0.955, 1.264], and somatic symptoms [β = 086, 95% C: 0.700, 1.025]. Depression had a direct positive effect on anxiety [β = 0.74, 95% CI: 0.508, 1.010].

CONCLUSION

In this study, the prevalence of depression, anxiety, and somatic symptoms was moderate. Alcohol use and stress were significantly related to depression, anxiety, and somatic symptoms. The bidirectional relationship between anxiety and depression was significant. Therefore, public health interventions should focus on the bidirectional relationship between depression and anxiety, as well as on identified factors to reduce the burden of mental illness in adolescents.

Hair cortisol and self-perceived stress in adolescents with multi-system functional somatic disorders

BACKGROUND

Long-term stress causing altered hypothalamic-pituitary-adrenal (HPA) axis dynamics with cortisol dysfunction may be involved in the pathophysiology of functional somatic disorders (FSD), but studies on adolescents with multi-system FSD are lacking. Therefore, we investigated: 1) whether hair cortisol concentration (HCC) differentiates adolescents with multi-system FSD from a) a population-based sample and b) a subgroup derived from the sample reporting a high physical symptom load, and 2) whether FSD population HCC is associated with primary symptom presentations and self-perceived stress.

METHODS

We used data from a clinical sample with multi-system FSD (N = 91, age 15-19 years) and a population-based sample (N = 1,450, age 16-17 years) including a subgroup with top 10% total scores on physical symptoms (N = 147). Density plots and multiple linear regression were applied to compare HCC between groups. In the clinical sample, multiple linear regression was employed to assess the association between HCC and primary symptom clusters and self-perceived stress.

RESULTS

Median HCC was lower in the clinical sample than in the population-based sample (β = 0.80 (95%CI: 0.66, 0.97)), but not significantly different from median HCC in the derived subgroup (β = 0.84 (95%CI: 0.66, 1.07)). In the clinical sample, HCC was not significantly associated with primary symptom clusters (F(2, 82) = 0.13, p = 0.88) or self-perceived stress (F(4, 83) = 1.18, p = 0.33).

CONCLUSION

Our findings indicate that HCC is lowered in adolescents with multi-system FSD but not significantly associated with primary symptom presentations or self-perceived stress. Future studies including multiple measures of HPA axis dynamics alongside psychological measures may further elucidate the role of long-term stress in FSD.

TRIAL REGISTRATION

The AHEAD study was pre-registered at ClinicalTrials.gov (NCT02346071), 26/01/2015.

Subjective and physiological reactivity to emotional stressors in somatic symptom disorder

OBJECTIVE

We examined whether autonomic flexibility to experimentally presented stressors is reduced in somatic symptom disorder (SSD) as this would point to reduced vagal control as a proposed indicator of emotion regulation deficits.

METHOD

In this experimental study, the influence of health-related and social stressors on subjective and physiological reactivity was investigated in 29 subjects with SSD without any medical condition SSD(mc-), 33 subjects with SSD with medical condition SSD(mc+) and 32 healthy controls at the age from 18 to 70 years. Self-report and physiological variables were measured before and after/during stressor exposure, using state ratings of symptom intensity, disability, tension and mood, heart rate (HR), and heart rate variability (HRV).

RESULTS

Overall, the tension increased and the mood worsened after exposure to stressors compared to pre-exposure. Compared to HC, the two SSD groups showed higher symptom intensity, disability, tension and worse mood. The SSD(mc-) group revealed higher HR than HC (p = .012, d = -0.77). Compared to pre-exposure, symptom impairment increased after social stressor exposure in SSD(mc-) (p < .001, d = 1.36). HRV-root mean square of successive differences (RMSSD) only decreased in HC during exposure (p = .003, d = -1.09), not in the SSD groups. The two SSD groups did not differ in their reactivity to stressors.

CONCLUSION

HRV in SSD, seems to respond less flexibly to stressors, potentially reflecting overall physiological disturbance through reduced parasympathetic influence on HR. Stress reactivity in SSD(mc-) and SSD(mc+) do not seem to differ.

Predictors of somatic symptom burden in healthcare professionals during the COVID-19 pandemic: an 8-week follow-up study

BACKGROUND

Literature investigating the impact of COVID-19 on healthcare professionals barely addresses predictors of somatic symptom burden during the COVID-19 pandemic.

AIMS

As biopsychosocial models propose that not only the disease but also sociodemographic and psychosocial factors contribute to the development and maintenance of symptoms, this study investigates the predictive value of these factors for bothersome somatic symptoms in SARS-CoV-2 negative healthcare professionals.

METHODS

German healthcare professionals were assessed with self-rating questionnaires and underwent SARS-CoV-2 IgG antibody tests at baseline and 8 weeks later between April and August 2020. Differences in psychosocial variables between the time points were analyzed and regression analyses were performed to predict somatic symptoms at follow-up.

RESULTS

1185 seronegative healthcare professionals completed both assessments. Previous somatic symptom burden, higher levels of anxiety, being a nurse, younger age, higher psychological symptom burden, lower efficiency, and higher fatigability at baseline predicted somatic symptom burden at follow-up. Comparisons between baseline and follow-up showed a significant improvement in psychological impairment and deterioration of physical exhaustion.

CONCLUSIONS

Our study applies a biopsychosocial perspective to bothersome somatic symptoms during the COVID-19 pandemic and contributes to the identification of potential risk factors as a starting point for future interventions that could support the handling of symptoms.

Functional somatic symptoms in preschool attention-deficit/hyperactivity disorder: a secondary analysis of data from a randomized controlled trial of parent training

Children with attention-deficit/hyperactivity disorder (ADHD) can be more stress-vulnerable, and thereby, it has been suggested, prone to develop functional somatic symptoms (FSS) compared to their peers. In this paper, using data from 160 children aged 3-7 years with ADHD from the D'SNAPP study, a randomized controlled trial testing a parent training intervention, we addressed a number of questions about the role of FSS in ADHD. First, are FSS levels higher in an ADHD sample than in the children of the general population. Second, do FSS levels predict psychopathology and health-related quality of life (HRQoL) in ADHD samples. Third, does FSS levels moderate the effect of parent training on ADHD symptoms. We found that preschoolers with ADHD experienced more severe FSS than a general population-based sample (18.80% vs. 2.11%). Severe FSS were associated with increased psychopathology and impaired daily function and lower HRQoL. Level of baseline FSS did not moderate the effect of parent training on ADHD. FSS in preschool children with ADHD is associated with impaired daily functioning, but further research is warranted to determine the clinical impact of FSS in children with ADHD.

Novel intervention of high-frequency repetitive transcranial magnetic stimulation in patients with somatic symptom disorder and its safety and outcome

Somatic Symptom disorders (SSDs) are characterised by the presence of persistent somatic symptoms associated with excessive thoughts, feelings and behaviours related to the symptoms. However, current treatment modalities are non-specific with modest effects. We aim to explore the safety and outcome of high-frequency transcranial magnetic stimulation at medial Prefrontal Cortex in ten such patients. Patient Health Questionnaire-15, Hamilton Rating Scale for Depression and Hamilton Anxiety Rating Scale were applied to ten patients with Somatic Symptom Disorder. 15 sessions of 15Hz TMS using a double cone coil with 2500 pulses/session were administered. All patients completed their sessions except one. Eight of the nine patients reported significant improvement with a reduction of 33%-80% from their baseline PHQ-15 scores. One patient reported significant adverse effects. Double cone coil TMS at medial Prefrontal Cortex appears to be a safe therapeutic intervention with potentially good outcomes in SSDs.

Clinical Impact of Systematic Assessment and Psychoeducation in Specialized Treatment of Adolescents with Severe Functional Somatic Disorders: Results from the AHEAD Study

Functional somatic disorders (FSD), characterized by persistent and disabling physical symptoms, are common in adolescents. Diagnostic uncertainty and insufficient illness explanations are proposed perpetuating factors that may constitute barriers for treatment engagement. This study describes the impact of manualized assessment and psychoeducation on diagnostic certainty and various clinical outcomes in adolescents with multi-system FSD. Ninety-one adolescents (15-19 years) received systematic assessment (4 h) and a subsequent psychiatric consultation (1.5 h). Clinical characteristics included self-reported physical health, symptom severity, illness perception, illness-related behavior, and psychological flexibility assessed before and approximately two months after assessment, prior to specialized treatment. Data were analyzed using t-tests. Immediately following assessment, 71 (80.7%) adolescents out of 88 reported a higher diagnostic certainty and 74 (84.1%) reported that attending assessment gave them positive expectations for future treatment. A clinically relevant improvement of physical health was not observed at two months but considerable reductions were seen in symptom severity, illness worry, negative illness perceptions, illness-related limiting behavior, and psychological inflexibility. The results emphasize that systematic assessment and psychoeducation are important in their own right in the specialized treatment of adolescents with severe FSD.

The mediating effect of somatic symptom disorder between psychological factors and quality of life among Chinese breast cancer patients

Objective

We conducted this cross-sectional study to explore the mediating and predicting role of somatic symptom disorder (SSD) between psychological measures and quality of life (QOL) among Chinese breast cancer patients.

Methods

Breast cancer patients were recruited from three clinics in Beijing. Screening tools included the Patient Health Questionnaire-15 (PHQ-15), the Patient Health Questionnaire-9 (PHQ-9), the General Anxiety Disorder-7 scale (GAD-7), the Health Anxiety Scale (Whiteley Index-8, WI-8), the Somatic Symptom Disorder B-Criteria Scale (SSD-12), the Fear of Cancer Recurrence scale (FCR-4), the Brief Illness Perception Questionnaire (BIPQ-8), and the Functional Assessment of Cancer Therapy-Breast (FACT-B). Chi-square tests, nonparametric tests, mediating effect analysis, and linear regression analysis were used for the data analysis.

Results

Among the 264 participants, 25.0% were screened positive for SSD. The patients with screened positive SSD had a lower performance status, and a greater number of patients with screened positive SSD received traditional Chinese medicine (TCM) (p < 0.05). Strong mediating effects of SSD were found between psychological measures and QOL among patients with breast cancer after adjusting for sociodemographic variables as covariates (p < 0.001). The range of the percentage mediating effects was 25.67% (independent variable = PHQ-9) to 34.68% (independent variable = WI-8). Screened positive SSD predicted low QOL in physical (B = -0.476, p < 0.001), social (B = -0.163, p < 0.001), emotional (B = -0.304, p < 0.001), and functional (B = -0.283, p < 0.001) well-being, as well as substantial concerns caused by breast cancer (B = -0.354, p < 0.001).

Conclusion

Screened positive SSD had strong mediating effects between psychological factors and quality of life among breast cancer patients. Additionally, screened positive SSD was a significant predictor of lower QOL among breast cancer patients. Effective psychosocial interventions for improving QOL should consider the prevention and treatment of SSD or integrated SSD caring dimensions for breast cancer patients.

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.

How symptoms of simple acute infections affect the SSS-8 and SSD-12 as screening instruments for somatic symptom disorder in the primary care setting

Objective

Somatic symptom disorder (SSD) is one of the most common reasons for consultations in primary care, in addition to simple acute infections. Questionnaire-based screening instruments to identify patients at high risk of SSD are thus of great clinical relevance. Although screening instruments are frequently used, it is currently unclear to what extent they are influenced by the concurrent presence of simple acute infections. Therefore, this study aimed to investigate how symptoms of simple acute infections affect the two established questionnaires as screening instruments for somatic symptom disorder in the primary care setting.

Methods

In our cross-sectional, multicenter design, a total of 1,000 patients in primary care practices were screened using the two most established SSD screening questionnaires, the 8-item Somatic Symptom Scale (SSS-8) and the 12-item Somatic Symptom Disorder-B Criteria Scale (SSD-12), followed by clinical assessment by the primary care physician.

Results

A total of 140 patients with a simple acute infection (acute infection group, AIG) and 219 patients with chronic somatic symptoms (somatic symptom group, SSG) were included. The patients in the SSG showed higher total SSS-8 and SSD-12 scores than the patients in the AIG; however, the SSS-8 was more susceptible to changes triggered by symptoms of a simple acute infection than the SSD-12.

Conclusion

These results suggest that the SSD-12 is less susceptible to symptoms of a simple acute infection. Its total score and corresponding cutoff value provide a more specific and thus less susceptible screening tool for identifying SSD in primary care.

Stability and predictors of somatic symptoms in men and women over 10 years: A real-world perspective from the prospective MONICA/KORA study

OBJECTIVE

To assess the stability of somatic symptoms in community-dwelling participants.

METHODS

The study included 2472 participants (1190 men, 1282 women; mean age 44.3 ± 10.9) from the prospective population-based MONICA-S3 cohort (1994/95) and the 10-year follow-up KORA-F3 cohort. Somatic symptoms were assessed by an adapted version of the Somatic Symptom Scale-8 (SSS-8a) with scores ranging from 0 to 24. Somatic symptom stability was assessed by weighted kappa values (κ). Generalized Estimating Equation models assessing symptom stability were adjusted for sociodemographic, lifestyle, clinical and psychosocial risk factors, as well as pre-existing medical conditions.

RESULTS

The mean (±SD) SSS-8a was lower in men (S3: 6.88 ± 3.87, F3: 6.60 ± 3.86) than women (S3: 8.43 ± 4.0, F3: 8.31 ± 4.2) at both time points. However, somatic symptoms remained moderately stable in both genders over 10 years (κ =0.42 in men and κ = 0.48 in women), with the largest stability observed in trouble sleeping for men (κ =0.41) and pain in the joints for women (κ =0.41). Pre-existing somatic symptoms were significantly associated with increasing symptoms at follow-up [men: β = 0.82 (SE 0.12), women: β = 0.85 (SE 0.12)], followed by age and psychosocial factors, whereas higher education and recent health care utilization were inversely associated with increasing symptoms. Although hypertension and obesity were associated with increasing somatic symptoms in men, pre-existing medical conditions were not associated with increasing somatic symptoms in men nor women.

CONCLUSIONS

The current findings indicate that somatic symptoms remain moderately stable in the general population during 10 years of follow-up, mainly driven by sociodemographic and psychosocial factors.

Migraine in the context of chronic primary pain, chronic overlapping pain disorders, and functional somatic disorders: A narrative review

OBJECTIVE

To contextualize migraine as the most common primary headache disorder in relation to other chronic primary pain and non-pain functional somatic and mental conditions.

BACKGROUND

Migraine is increasingly understood as a sensory processing disorder within a broader spectrum of symptom disorders. This has implications for diagnosis and treatment.

METHOD

Narrative review based on a search of the literature of the last 15 years on the overlap of migraine with other symptom disorders.

RESULTS

Migraine as the prototypical primary headache disorder not only comprises many non-headache symptoms in itself, it also shows high comorbidity with other chronic pain and non-pain conditions (e.g., fibromyalgia syndrome, irritable bowel syndrome, functional non-epileptic seizures, depression, anxiety, and posttraumatic stress disorder). Such "symptom disorders" share several etiological factors (e.g., female preponderance, psychological vulnerability) and psychophysiological mechanisms (e.g., altered sensory processing, pain expectancy). These facts are acknowledged by several recent integrative conceptualizations such as chronic primary pain, chronic overlapping pain conditions, or functional somatic disorders. Accordingly, migraine management increasingly addresses the total symptom burden and individual contributors to symptom experience, and thus incorporates centrally acting pharmacological and non-pharmacological, that is, psychological and behavioral, treatment approaches.

CONCLUSIONS

Migraine and also other primary headache disorders should be seen as particular phenotypes within a broader spectrum of symptom perception and processing disorders that require integrative diagnostics and treatment. A harmonization of classifications and better interdisciplinary collaboration are desirable.

Gender specific somatic symptom burden and mortality risk in the general population

Gender specific all-cause mortality risk associated with a high somatic symptom burden (SSB) in a population-based cohort was investigated. The study population included 5679 women and 5861 men aged 25-74 years from the population-based MONICA/KORA Cohort. SSB was assessed following the Somatic Symptom Scale-8 and categorized as very high (≥ 95th percentile), high (60-95th percentile), moderate (30-60th percentile), and low (≤ 30th percentile). The impact of SSB on all-cause mortality risk within a mean follow-up period of 22.6 years (SD 7.1; 267,278 person years) was estimated by gender-specific Cox regression models adjusted for sociodemographic, lifestyle, somatic and psychosocial risk factors, as well as pre-existing medical conditions. Approximately 5.7% of men and 7.3% of women had very high SSB. During follow-up, 3638 (30.6%) mortality cases were observed. Men with a very-high SSB had 48% increased relative risk of mortality in comparison to men with a low SSB after adjustment for concurrent risk factors (1.48, 95% CI 1.20-1.81, p < .0001), corresponding to 2% increased risk of mortality for each 1-point increment in SSB (1.02; 95% CI 1.01-1.03; p = 0.03). In contrast, women with a very high SSB had a 22% lower risk of mortality (0.78, 95% CI 0.61-1.00, p = 0.05) and women with high SSB had an 18% lower risk of mortality (0.82; 95% CI 0.68-0.98, p = 0.03) following adjustment for concurrent risk factors. The current findings indicate that an increasing SSB is an independent risk factor for mortality in men but not in women, pointing in the direction of critical gender differences in the management of SSB, including women's earlier health care utilization than men.

Female sex and femininity independently associate with common somatic symptom trajectories

BACKGROUND

Multiple predictors have been associated with persistent somatic symptoms. However, previous studies problematically defined the persistence of symptoms, conflated participants' sex and gender, and focused on patient populations. Therefore, we studied associations between predictors, especially sex and gender, and longitudinal patterns of somatic symptoms in the general adult population. We also assessed whether predictors for persisting symptoms differ between sexes.

METHOD

To identify developmental trajectories of somatic symptoms, assessed by the SCL-90 SOM, we used latent class trajectory modeling in the Dutch Lifelines Cohort Study [N = 150 494; 58.6% female; median time to follow-up: 46.0 (min-max: 22.0-123.0) months]. To identify predictors of trajectories, we applied multiple logistic regression analyses. Predictors were measured by surveys at baseline and a composite gender index was previously developed.

RESULTS

A five-class linear LCGA model fitted the data best: 93.7% of the population had a stable symptom trajectory, whereas 1.5% and 4.8% of the population had a consistently increasing or decreasing symptom trajectory, respectively. Female sex predicted severe, stable symptom severity (OR 1.74, 95% CI 1.36-2.22), but not increasing symptom severity (OR 1.15, 95% CI 0.99-1.40). Femininity was protective hereof (OR 0.60, 95% CI 0.44-0.82 and OR 0.66, 95% CI 0.51-0.85, respectively). Merely a few predictors of symptom severity, for instance hours of paid employment and physical functioning, differed in strength between sexes. Yet, effect sizes were small.

CONCLUSION

Female sex and femininity predict symptom trajectories. No large sex differences in the strength of additional predictors were found, thus it may not be clinically useful to distinguish between predictors specific to male or female patients of persistent somatic symptoms.

Multiple health complaints in preadolescence and hospital contacts during adolescence: a prospective cohort study

Multiple health complaints (MHC) is increasing among preadolescents in many countries, but their prognostic effect for individual thriving or societal resource use is scarcely studied. This makes interpreting the significance of this increase challenging. We contribute by examining whether MHC in preadolescence predicts hospital contacts in adolescence by doing a nation-wide population-based cohort-study following preadolescents from the Danish National Birth-Cohort from 2010 to 2018. 96,382 children were invited at age 11. Responses to a modified version of the Health Behaviour in School Children Symptom Checklist (headache, dizziness, stomachache, irritability, feeling nervous, difficulty in getting to sleep and feeling low) was dichotomized into MHC (≥ 2 concurrent symptoms, each with a frequency of at least weekly, yes/no). Hospital contacts were derived from Danish registers from the date of answering the questionnaire to December 31st 2018. Negative binomial regression estimated incidence rate ratios (IRRs) comparing children with MHC to children without. Analyses were further broken down by hospital sector (psychiatric/somatic) and contact type (in-patient/out-patient/emergency room). 47,365 (49.1%) responded. Mean age was 11.2 years, 52% girls. 10.3% of responders reported MHC. For hospital contacts, the unadjusted IRR was 1.74 [95% CI 1.65, 1.83]. Results were robust to adjustment for sociodemographic variables and somatic/psychiatric morbidity diagnosed before baseline, IRR 1.62 [95% CI 1.54-1.71]. In conclusion, MHC in preadolescents are prognostic of hospital contacts. This shows that we cannot ignore MHC, and to prevent potentially unhelpful healthcare use, we must act. Future research should focus on the underlying causes of MHC to understand which changes will be most helpful and thus how to act.

The risk factors for self-reported fibromyalgia with and without multiple somatic symptoms: The Lifelines cohort study

OBJECTIVE

The numerous risk factors for fibromyalgia reflect its heterogeneous nature. This study assessed whether the predictors of fibromyalgia onset vary according to number of prior somatic symptoms.

METHODS

The prospective, population-based Lifelines cohort study included 138,617 adults without fibromyalgia or marked muscle pain. At baseline socio-demographic status, physical and psychiatric disorders, psycho-social and behavioural variables were assessed as potential predictors. At follow-up (mean 2.4 years later) new onsets of fibromyalgia were recorded by self-report. The predictors of new onsets of self-reported fibromyalgia were assessed using logistic regression with interaction terms between key variables and number of somatic symptoms.

RESULTS

At follow-up 679 (0.5%) participants reported new onset fibromyalgia. The strongest predictors were: female sex, rheumatoid and osteo-arthritis, IBS, impaired sleep, migraine, few years of education and impairment by bodily pain. Interaction terms with somatic symptoms were significant for years of education, low income, rheumatoid arthritis and no. of analgesics; these were predictors only for fibromyalgia with few somatic symptoms. Participants with multiple somatic symptoms had a higher number of predictors than those with few somatic symptoms.

CONCLUSION

This study suggests that people developing self-reported fibromyalgia with multiple pre-existing somatic symptoms have a high risk factor load reflecting risk factors for both fibromyalgia and multiple somatic symptoms. Self-reported fibromyalgia with few somatic symptoms has fewer predictors which may be specific to fibromyalgia. Future research could usefully study whether different pathophysiological mechanisms occur when fibromyalgia is preceded by high or low number of somatic symptoms.

Differences of medically unexplained symptoms among patients of different ages and sexes in the psychological clinic of a general hospital and the influencing factors of MUS: A cross-sectional study

OBJECTIVE

To analyse differences in sex, age, depression, insomnia, psychological stress, resilience, and perceived social support among patients with medically unexplained symptoms (MUS) in a psychological clinic of a general hospital, and to explore the influencing factors of MUS.

METHODS

This is a cross-sectional study. Seven hundred forty-six first-time patients were assessed with the integrated psychosomatic comprehensive evaluation system (IPS) to evaluate their MUS, depression, insomnia, psychological stress, resilience, and perceived social support. The psychological characteristics were compared with regard to sex and age group (<25 years, low age group; 26-44 years, middle age group; >45 years, high age group). The relationships between age and MUS were explored, and how psychological stress affects MUS was analyzed using the mediator effect model.

RESULTS

Different age groups had significant differences in sex, MUS, depression, psychological stress, resilience, and perceived social support. In further pairwise comparison, no significant difference existed in depression, psychological stress, resilience and perceived social support in the middle and low age groups, depression and psychological stress were higher than those in the high age group, resilience and perceived social support were lower than those of the high age group. MUS were higher in the middle age group than in the low age group. No significant difference existed between the two groups and the high age group. Age, severity of MUS, and perceived social support were significantly different between the sexes. Differences in MUS between men and women in different age groups were analyzed using two-factor analysis of variance. It revealed no interaction between sex and different age groups on MUS. The main effect analysis showed that the effects of different age groups on MUS were statistically significant. Based on pairwise comparative analysis, the MUS score in the low age group was lower than that in the middle age group. To clarify a nonlinear relationship between age and MUS, threshold effect analysis was conducted. The results indicated that the piecewise linear regression model could better depict the relationship between age and MUS. The inflection point was at the age of 60 years. Before the age of 60 years, MUS increased with age. No significant correlation existed between age and MUS after the age of 60 years. To understand the influencing factors of MUS, the intermediary effect model was analyzed using MUS as the dependent variable, psychological stress as the independent variable, resilience as mediator variable M1, perceived social support as mediator variable M2, and depression as mediator variable M3. Resilience, perceived social support, and depression had significant mediator effects on the effects of psychological stress on MUS with a total indirect effect of 69.81%.

CONCLUSION

The middle age group had greater MUS than the low age group. Before the age of 60 years, MUS increased with increasing age. Women had more severe MUS than men. Resilience, perceived social support, and depression had significant mediating effects on the effects of perceived stress on MUS. These findings suggest that clinicians should make more comprehensive and detailed evaluations and timely intervention for middle-aged and female patients. Improving psychological resilience and social support can reduce the impact of psychological stress on MUS. Therefore, psychotherapy and multidisciplinary comprehensive treatment are very important for patients is very important for patients.

[Mental and Somatic Health Care Use in Persistent Somatic Symptoms: 4-Year Follow Up of the Network for Somatoform and Functional Disorders (Sofu-Net)]

BACKGROUND

The stepped, coordinated, interdisciplinary Health Network for Somatoform and Functional Disorders (Sofu-Net) was developed to provide guideline-based care for patients with somatoform and functional disorders. This controlled cluster cohort study evaluated patients' mental and somatic health care use, clinical outcomes, and their predictors at 4-years follow-up.

METHOD

219 patients at risk for somatoform disorders from Sofu-Net practices (n=119) and control practices (n=100) were resurveyed after 4 years using structured interviews. Outcomes were mental and somatic health care use, somatic symptom burden and depressive symptoms.

RESULTS

127 patients (n=74 Sofu-Net, n=53 controls) were followed up. Compared with the control group, Sofu-Net patients were significantly more likely to be referred to psychotherapy (55.4 vs. 35.8%). Younger age and more frequent GP consultations on the occasion of psychosocial problems predicted mental health care use. No difference was found between the two groups in the severity of clinical symptoms or in the extent of somatic health care use. Significant predictors were the number of somatic diseases, increased fear of illness, female gender, increased depressive symptomatology, low physical and mental quality of life.

DISCUSSION

In the long term, the coordinated and interdisciplinary network structure succeeded in more successfully referring high-risk patients to psychotherapy. The role of the primary care physician proved to be important. However, this was not accompanied by an improvement in the patients' clinical condition or a decrease in outpatient physician utilization.

Persistence rate of DSM-5 somatic symptom disorder: 4-year follow-up in patients from a psychosomatic outpatient clinic

BACKGROUND

Somatic Symptom and Related Disorders (SSD) were introduced by DSM-5 in order to improve the classification of somatoform disorders. There is a lack of longitudinal studies on course and predictors of SSD. The present study investigates the natural course of SSD in a four-year follow-up study in patients from a psychosomatic outpatient clinic.

MATERIAL AND METHODS

At baseline, n = 360 outpatients completed a semi-structured clinical interview to assess SSD, and additional self-report questionnaires (SSS-8, SSD-12, PHQ-8, GAD-7, SF-12). 112 patients were re-assessed after four years. Persistence rate and predictors for persisting SSD were evaluated.

RESULTS

The prevalence rate of SSD at baseline was 51.8%, and 47.3% at follow-up. We found a persisting SSD in 30.4% (n = 34) of the patients, a remission rate of 21.4% (n = 24) and an incidence rate of 16.9% (n = 19). 31.3% (n = 35) of the sample never received a SSD diagnosis. Significant predictors for persistence were a high psychological burden through somatic symptoms (OR: 1.13, 95% CI: 1.01-1.26) and general anxiety (OR: 1.38, 95% CI: 1.01-1.88) at baseline.

CONCLUSION

This study indicates that SSD is highly prevalent and persistent in patients from a psychosomatic setting. Our findings indicate that psychological and behavioral factors contribute to the maintenance of SSD and present potential targets for interventions. Future interventions for SSD could potentially be optimized by addressing psychological processes such as catastrophic thinking styles and symptom focusing.

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.

The association of sex, age and FKBP5 genotype with common somatic symptoms: A replication study in the lifelines cohort study

OBJECTIVE

Our aim was to replicate a recent study that reported an association between the rs9470080 CC-genotype and common somatic symptoms in women, but not in men. Additionally, we quantified the genetic contribution to phenotypic variation in common somatic symptom levels.

METHODS

We used data from the Lifelines Cohort Study, including 28,299 participants (60.0% female; 44.2% CC-genotype; mean age 42.9 (14.2) years). Common somatic symptoms were measured with the SCL-90 SOM subscale. To assess the association between the rs9470080 genotype and SCL-90 SOM scores we applied similar analyses as the original study, including independent t-tests, two-way ANOVAs and a mixed ANOVA. To estimate the proportion of phenotypic variance in SCL-90 SOM scores explained by single nucleotide polymorphisms (SNPs), we used a genomic-relatedness-based restricted maximum-likelihood method.

RESULTS

We could not replicate the original study's findings. We found no association between the rs9470080 genotype and common somatic symptom levels in either female or male participants (F(1, 8775) = 1.07, p = 0.30 and F(1,13,903) = 0.01, p = 0.93, respectively). Genome-wide heritability analyses show that 12.1% (p = 2.1e-08) of the phenotypic variance in common somatic symptom levels in Lifelines can be explained by SNPs. The genetic contribution to common somatic symptom levels was higher in male participants (SNP-h² = 20.5%; p = 9.1e-08) than in female participants (SNP-h² = 12.0%, p = 2.8e-05).

CONCLUSION

Our findings of significant SNP-h² and the sex-specific differences herein, does warrant further sex-stratified research of individual genetic variants associated with common somatic symptoms. Preferably, further research should be performed within the analytic framework of a genome-wide association study.

Multiple Physical Symptoms of Community-Dwelling Older People in Western China: Prevalence and Its Association with Frailty

INTRODUCTION

Physical symptoms and frailty are common in older adults. A previous study has reported that multiple somatic symptoms are associated with frailty. In this study, we aimed to describe the picture of physical symptoms in older adults in western China and examine the relationship of multiple physical symptoms and frailty, as well as the sex difference of this relationship.

METHODS

Cross-sectional analyses were based on the West China Health and Aging Trend (WCHAT) study comprising 4,106 community-dwelling older adults (60-95 years). Frailty was assessed using the physical frailty phenotype (PFP). Participants' experience of 28 different physical symptoms in the past 4 weeks was assessed. Physical symptoms were divided into several categories according to organ systems. Multinomial logistic regression analyses were performed to examine the association between frailty and multiple physical symptoms.

RESULTS

Nearly half of the subjects reported experiencing at least 1 physical symptom during the past 4 weeks. Musculoskeletal symptoms were the most prevalent symptoms. More than 5 physical symptoms were more likely to be frailty, even when all covariates were controlled. A significant association between multiple musculoskeletal symptoms and frailty also was found after adjusted for all covariates and multiple symptoms of other organ systems. Similar results were obtained for multiple cardiopulmonary symptoms. Furthermore, there were sex differences in these relationships.

CONCLUSION

Multiple physical symptoms appear to have a detrimental impact on frailty in older adults. Compared with counting total symptoms, multiple symptoms of the same organ system may have a greater impact on frailty. Effective interventions and management of multiple physical symptoms are warranted to prevent frailty.

The BDS checklist as measure of illness severity: a cross-sectional cohort study in the Danish general population, primary care and specialised setting

OBJECTIVE

The bodily distress syndrome (BDS) checklist has proven to be useful in the diagnostic categorisation and as screening tool for functional somatic disorders (FSD). This study aims to investigate whether the BDS checklist total sum score (0-100) can be used as a measure of physical symptom burden and FSD illness severity.

DESIGN

Cross-sectional.

SETTING

Danish general population, primary care and specialised clinical setting.

PARTICIPANTS

A general population cohort (n=9656), a primary care cohort (n=2480) and a cohort of patients with multiorgan BDS from specialised clinical setting (n=492).

OUTCOME MEASURES

All data were self-reported. Physical symptoms were measured with the 25-item BDS checklist. Overall self-perceived health was measured with one item from the 36-item Short-Form Health Survey (SF-36). Physical functioning was measured with an aggregate score of four items from the SF-36/SF-12 scales 'physical functioning', 'bodily pain' and 'vitality'. Emotional distress was measured with the mental distress subscale (SCL-8) from the Danish version of the Hopkins Symptom Checklist-90. Illness worry was measured with the six-item Whiteley Index.

RESULTS

For all cohorts, bifactor models established that despite some multidimensionality the total sum score of the BDS checklist adequately reflected physical symptom burden and illness severity. The BDS checklist had acceptable convergent validity with measures of overall health (r=0.25-0.58), physical functioning (r=0.22-0.58), emotional distress (r=0.47-0.62) and illness worry (r=0.36-0.55). Acceptability was good with a low number of missing responses to items (<3%). Internal consistency was high (α ≥0.879). BDS score means varied and reflected symptom burden across cohorts (13.03-46.15). We provide normative data for the Danish general population.

CONCLUSIONS

The BDS checklist total sum score can be used as a measure of symptom burden and FSD illness severity across settings. These findings establish the usefulness of the BDS checklist in clinics and in research, both as a diagnostic screening tool and as an instrument to assess illness severity.

Somatic presentation of mental health concerns, stigma, and mental health treatment engagement among college students

Objective: To identify mental health and treatment utilization correlates of somatic symptoms.Participants: Undergraduate students (N = 184) were recruited through an online research portal from November 2017 to May 2018. Methods: Cross-sectional survey. Results: Somatic symptoms were significantly correlated with public stigma, depression, and anxiety. Controlling for demographics, somatic symptoms, depression scores, and belief in the effectiveness of therapy emerged as concurrent predictors of mental health treatment use in logistic regression analyses. Conclusions: Given the detrimental effects of somatic symptoms on health outcomes and academic performance, universal screening of somatic and psychiatric symptoms in primary care and mental health settings serving college students is warranted. Future research should differentiate between patients who experience somatic versus affective symptoms of depression. In addition, researchers should examine the degree to which addressing the relationship between somatic and psychological symptoms can help lessen the added burden of somatic symptoms on individuals' functioning.

Psychometric Testing of the Premenstrual Symptoms Questionnaire and the Association Between Perceived Injustice and Premenstrual Symptoms: A Cross-Sectional Study Among Japanese High School Students

Purpose

Premenstrual symptoms comprise a wide range of mood, behavioral, and physical symptoms occurring during the luteal phase. Perceived injustice is a belief linked to unfairness (ie, unnecessary suffering caused by illness). This study aimed to assess the validity and reliability of the Premenstrual Symptoms Questionnaire (PSQ), a patient-reported outcome measurement tool, and to examine the association between perceived injustice/perception of menstruation and premenstrual symptoms, as measured by the PSQ.

Materials and Methods

Of 1388 female students, we analyzed 879 students with regular menstrual cycles who completed the PSQ, the premenstrual dysphoric disorder (PMDD) scale, the Somatic Symptom Scale-8 (SSS-8), and the Injustice Experience Questionnaire-chronic (IEQ-chr). First, the PSQ was examined for evidence of reliability and validity. Next, we used multiple regression and multivariate logistic regression to investigate the association between perceived injustice and premenstrual symptoms, using PSQ score as both a continuous variable and a dichotomous variable (premenstrual disorders or not). Moreover, the association between PSQ score and perceived menstruation was tested using student's t-test and analysis of variance.

Results

In terms of reliability, Cronbach's α for PSQ score was 0.93. To assess structural validity, we used confirmatory factor analysis, which showed that the one-factor model and the two-factor model were a good fit. The PSQ showed good agreement with the PMDD scale. In terms of concurrent validity, PSQ total score correlated strongly with PMDD scale score, SSS-8 score, and IEQ-chr score (r = 0.88, 0.69, 0.57, respectively). IEQ-chr score predicted PSQ score (standardized regression coefficient = 0.53; P < 0.0001) and higher prevalence of premenstrual disorders (odds ratio: 1.15; 95% confidence interval: 1.12-1.19). Negative perception of menstruation was associated with premenstrual symptoms.

Conclusion

The PSQ showed sound psychometric properties among the adolescents in our sample. Perceived injustice and negative perception of menstruation were associated with premenstrual symptoms.

Empathy, social and emotional competencies, bullying perpetration and victimization as longitudinal predictors of somatic symptoms in adolescence

BACKGROUND

Somatic symptoms are an important adolescent health problem that affects individuals and the society as a whole. Although research focused on somatic symptoms has been very fruitful, studies about their longitudinal predictors are still in their early stages. The present study focuses on the relations between social and emotional competencies, empathy and bullying, and the presence of somatic symptoms concurrently and one year later.

METHOD

The sample consisted of 384 Spanish adolescents, who participated in a longitudinal study with a one-year follow-up. Validated questionnaires were used to assess social and emotional competencies, bullying, empathy and somatic complaints.

RESULTS

High scores in social and emotional competencies were related to low scores in somatic symptoms one year later. High affective empathy predicted more somatic symptoms concurrently and one year later. Bullying victimization was related to more somatic symptoms concurrently and one year later.

LIMITATIONS

Other-reports could be useful to further validate the results obtained with self-reports. Non-linear relations could be tested. Representative samples could be used in future studies.

CONCLUSIONS

These results suggest that it may be important to promote social and emotional competencies and reduce bullying to decrease somatic symptoms. More studies are needed to understand the impact of high affective empathy on somatic symptoms.

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.

Gender and sex independently associate with common somatic symptoms and lifetime prevalence of chronic disease

Sex and gender influence health differently. Associations between sex and health have been extensively studied, but gender (i.e. psychosocial sex) has been largely neglected, partly due to the absence of gender measures in cohort studies. Therefore, our objective was to test the unique associations of gender and sex with common somatic symptoms and chronic diseases, using a gender index created from existing cohort data. We applied LASSO logistic regression to identify, out of 153 unique variables, psychosocial variables that were predictive of sex (i.e. gender-related) in the Dutch LifeLines Cohort Study. These psychosocial variables covered gender roles and institutionalized gender. Using the estimated coefficients, gender indexes were calculated for each adult participant in the study (n = 152,728; 58.5% female; mean age 44.6 (13.1) years). We applied multiple ordinal and logistic regression to test the unique associations of the gender index and sex, and their interactions, with common somatic symptoms assessed by the SCL-90 SOM and self-reported lifetime prevalence of chronic diseases, respectively. We found that in 10.1% of the participants the gender index was not in line with participants' sex: 12.5% of men and 8.4% of women showed a discrepancy between gender index and sex. Feminine gender characteristics are associated with increased common somatic symptoms and chronic diseases, especially in men. Female sex is associated with a higher common somatic symptom burden, but not with a higher prevalence of chronic diseases. The study shows that gender and sex uniquely impact health, and should be considered in epidemiological studies. Our methodology shows that consideration of gender measures in studies is necessary and feasible, based on data generally present in cohort studies.

Making Sense of "Somatization": A Systematic Review of its Relationship to Pediatric Pain

OBJECTIVES

Pain and other physical symptoms commonly co-occur in childhood. There is debate about the relevance of somatization in understanding pain. The present review critically appraised and synthesized the extant literature on the relationship between pediatric pain and somatization.

METHODS

A systematic review (PROSPERO registration #95956) was conducted in Medline, PsycINFO, EMBASE, and CINAHL using search terms related to pain and somatization in children and adolescents. A total of 156 articles were eligible for inclusion in the review. For studies that measured somatization using a symptom questionnaire, descriptions of "somatization" were extracted. Data regarding the relationship between pain and somatization were extracted for studies measuring somatization using a diagnostic category (e.g., Somatic Symptom and Related Disorders [SSRDs]).

RESULTS

While many studies using somatic symptom questionnaires described somatization as having a psychological component, this was not always captured in measurement tools. Pain was reported as a common symptom in patients with an SSRD diagnosis, though rates varied depending on the specific diagnosis and pain location. Rates of SSRD diagnoses among pain patients were less frequent than rates of pain amongst SSRD patients.

CONCLUSIONS

SSRDs and pain commonly co-occur, though rates differ depending on diagnosis and pain location. Understanding the relationship between pain and somatization is complicated by the discrepancy between how somatization is defined and measured in questionnaire studies. A comprehensive and measurable definition of somatization is needed so researchers can better identify the shared and unique contributions of pain and somatization in pediatric populations.

Irritable bowel, chronic widespread pain, chronic fatigue and related syndromes are prevalent and highly overlapping in the general population: DanFunD

Prevalence of functional somatic syndromes (FSS) in the general population varies with observed overlap between syndromes. However, studies including a range of FSS are sparse. We investigated prevalence and characteristics of various FSS and the unifying diagnostic construct bodily distress syndrome (BDS), and identified mutual overlap of the FSS and their overlap with BDS. We included a stratified subsample of 1590 adults from a randomly selected Danish general population sample (n = 7493). Telephonic diagnostic interviews performed by three trained physicians were used to identify individuals with FSS and BDS. Prevalence of overall FSS was 9.3%; 3.8% for irritable bowel, 2.2% for chronic widespread pain, 6.1% for chronic fatigue, 1.5% for whiplash associated disorders, and 0.9% for multiple chemical sensitivity. Prevalence of BDS was 10.7% where 2.0% had the multi-organ type. FSS were highly overlapping with low likelihood of having a “pure” type. Diagnostic agreement of FSS and BDS was 92.0%. Multi-syndromatic FSS and multi-organ BDS were associated with female sex, poor health, physical limitations, and comorbidity. FSS are highly prevalent and overlapping, and multi-syndromatic cases are most affected. BDS captured the majority of FSS and may improve clinical management, making the distinction between multi- and mono-syndromatic patients easier.

Lifetime abuse and somatic symptoms among older women and men in Europe

BACKGROUND

Research suggests that survivors of interpersonal violence have an increasing experience of bodily symptoms. This study aims to scrutinise the association between lifetime abuse and somatic symptoms among older women and men, considering demographics/socio-economic, social support and health variables.

METHODS

A sample of 4,467 community-dwelling persons aged 60-84 years (57.3% women) living in seven European countries (Germany, Greece, Italy, Lithuania, Portugal, Spain, Sweden) was recruited for this cross-sectional study. Lifetime abuse (psychological, physical, sexual, financial and injury) was assessed on the basis of the UK study of elder abuse and the Conflict Tactics Scale-2, while somatic symptoms were assessed by the Giessen Complaint List short version.

RESULTS

Women reported somatic symptoms more frequently than men. Multiple regression analyses revealed that lifetime exposure to psychological abuse was associated with higher levels of somatic symptoms among both women and men, while experiencing lifetime sexual abuse was associated with somatic symptoms only among older women, after adjusting for other demographic and socio-economic variables. Country of residence, older age, and low socio-economic status were other independent factors contributing to a higher level of somatic symptoms.

CONCLUSIONS

The positive association between the experience of abuse during lifetime and the reporting of higher levels of somatic symptoms, in particular among older women, seems to suggest that such complaints in later life might also be related to the experience of mistreatment and not only to ageing and related diseases. Violence prevention throughout lifetime could help to prevent somatic symptoms in later life.

Explanation of somatic symptoms by mental health and personality traits: application of Bayesian regularized quantile regression in a large population study

BACKGROUND

Somatic syndrome is one of the remarkably prevalent issues in primary health care and subspecialty settings. We aimed to elucidate multidimensional associations between somatic symptoms with major mental problems and personality traits in the framework of the quantile regression model with a Bayesian approach.

METHODS

A total of 4763 employees at Isfahan University of Medical Sciences and Health Services in Isfahan province, Iran, filled out four validated questionnaires including Hospital Anxiety and Depression Scale (HADS), NEO Questionnaire, General Health Questionnaire (GHQ) and PHQ-15 for somatic symptom severity. In addition, Functional Gastrointestinal Disorders (FGIDs) were determined using Rome IV criteria. Exploratory Factor Analysis (EFA) and Bayesian regularized quantile regression with adaptive LASSO penalization were applied for reduced dimension of somatic symptoms and variable selection and parameter estimation, respectively.

RESULTS

The 25 major somatic symptoms were grouped into four factors including general, upper gastrointestinal, lower gastrointestinal and respiratory by EFA. Stress, depression, and anxiety had significant effects on all of the four extracted factors. The effect of anxiety in each four extracted factors was more than stress and depression. Neuroticism and agreeableness had significant effects on all of the four extracted factors, generally (p < 0.05).

CONCLUSIONS

Given the high prevalence of somatic symptoms and psychosomatic complaints in correlation with the diverse range of mental co-morbidities, developing more detailed diagnostic tools and methods is crucial; nonetheless, it seems that providing better interdisciplinary approaches in general medical practice is groundwork.

RIFD - A brief clinical research interview for functional somatic disorders and health anxiety

OBJECTIVE

Epidemiological research in functional somatic disorders such as irritable bowel syndrome, fibromyalgia, chronic fatigue syndrome, and bodily distress syndrome and related conditions such as health (illness) anxiety is often based on self-reported questionnaires or layman interviews. This study presents and describes the Research Interview for Functional somatic Disorders (RIFD) and provides first data regarding RIFD's ability to identify cases with functional somatic disorders and health anxiety in a two-phase design following self-reported symptom questionnaires.

METHODS

RIFD was performed by phone by trained family physicians on a stratified subsample of 1590 adults from a Danish general population cohort (n = 7493). Criterion validity was tested in a small preliminary test including 25 RIFD participants using Schedules of Clinical Assessment in Neuropsychiatry (SCAN), performed by a specialist in functional somatic disorders, as gold standard. Interrater reliability between interviewers was tested in 15 participants.

RESULTS

Compared with the comprehensive SCAN, preparation and conduction of RIFD were feasible and prompt. RIFD was well accepted by both interviewers and interviewees. RIFD identified cases with significantly more impairment than identified non-cases. Based on small preliminary tests, RIFD showed promising psychometric properties.

CONCLUSION

RIFD was a feasible, well-accepted and promising instrument for use in large epidemiological studies. However, larger studies investigating its psychometric properties are needed.

Why is the recognition rate of psychological distress under-estimated in general hospitals? A cross-sectional observational study in China

This study aimed to investigate the recognition rate of psychological distress in general hospitals in China and to examine the main associated factors.Using a cross-sectional study design, the questionnaires were administered to a total of 1329 inpatients from a tertiary hospital. The Patient Health Questionnaire-9 (PHQ-9), the Generalized Anxiety Disorder 7-item scale (GAD-7), the Patient Health Questionnaire (PHQ-15) and the Whiteley-7 (WI-7) were used to assess patients' mental health status. Two subjective questions were used to identify the awareness of psychological distress in patients and doctors.The frequency of psychological distress measured by the questionnaires was high in our sample (53.4%). However, the recognition rates of both patients (34.9%) and by doctors (39.1%) was low. The concordance rate between patients and doctors of whether the patient had psychological distress or not was extremely poor (Kappa = 0.089, P = .001). Factors associated with the poor concordance rate included patients' annual household income and clinically significant self-reported symptoms of anxiety and hypochondriasis.The recognition rate of psychological distress was underestimated and this may be related to a lack of awareness of mental disturbances and patients' low annual household income.

Potential effects of multimodal psychosomatic inpatient treatment for patients with functional vertigo and dizziness symptoms - A pilot trial

OBJECTIVES

Functional vertigo and dizziness (VD) are frequent and severely distressing complaints that are often described as hard to treat. Our aim was to provide preliminary data on potential effects of multimodal psychosomatic inpatient therapy for patients with functional VD symptoms in reducing vertigo-related handicap and related psychopathology, and to evaluate the role of symptom burden and body-related locus of control in predicting vertigo-related handicap at follow-up.

DESIGN

We conducted an uncontrolled clinical pilot trial.

METHODS

We included data of n = 72 inpatients with functional VD as a primary symptom and various psychopathological and/or physical comorbidities admitted for multimodal psychosomatic inpatient treatment. Patients completed self-report questionnaires assessing vertigo-related handicap (VHQ), somatization (PHQ-15), depression (BDI-II), anxiety (BAI), health-related quality of life (HRQOL; SF-36), and body-related locus of control (KLC) at admission (T0), discharge (T1), and 6 months after discharge (T2).

RESULTS

We observed medium effects for the change of vertigo-related handicap (T0-T1: g = -0.60, T0-T2: g = -0.67) and small effects for the change of somatization (T0-T1: g = -0.29, T0-T2: g = -0.24), mental HRQOL (T0-T1: g = 0.43, T0-T2: g = 0.49), and depression (T0-T1: g = -0.41, T0-T2: g = -0.28) from admission to discharge and admission to follow-up. Body-related locus of control did not predict vertigo-related handicap at follow-up.

CONCLUSIONS

Findings provide preliminary evidence for the beneficial role of psychosomatic inpatient treatment for patients with functional VD symptoms. Potentially relevant predictors of outcome at follow-up are discussed.

PRACTITIONER POINTS

The change of vertigo-related handicap and related variables through multimodal psychosomatic inpatient treatment was evaluated in a clinical pilot trial in patients with functional vertigo and dizziness. We observed medium effects for the change of vertigo-related handicap and small effects for the change of somatization, mental health-related quality of life, and depression. Internal body-related locus of control at admission did not predict vertigo-related handicap at follow-up.

Persistent unexplained physical symptoms: a prospective longitudinal cohort study in UK primary care

BACKGROUND

Unexplained physical symptoms (UPS) are extremely common among primary care attenders, but little is known about their longer-term outcome.

AIM

To investigate the persistence of somatic symptoms at 6 months among a cohort with multiple UPS, and identify prognostic factors associated with worsening symptom scores.

DESIGN AND SETTING

Prospective longitudinal cohort study involving adults attending UK general practice in North and Central London between January and December 2013.

METHOD

Consecutive adults attending nine general practices were screened to identify those with at least three UPS. Eligible participants completed measures of symptom severity (measured using the Patient Health Questionnaire Somatic Symptom Module [PHQ-15]), physical and mental wellbeing, and past health and social history, and were followed up after 6 months. Multivariable linear regression analysis was conducted to identify prognostic factors associated with the primary outcome: somatic symptom severity.

RESULTS

Overall, 245/294 (83%) provided 6-month outcome data. Of these, 135/245 (55%) reported still having UPS, 103/245 (42%) had symptoms still under investigation, and only 26/245 (11%) reported complete symptom resolution. Being female, higher baseline somatic symptom severity, poorer physical functioning, experience of childhood physical abuse, and perception of poor financial wellbeing were significantly associated with higher somatic symptom severity scores at 6 months.

CONCLUSION

This study has shown that at 6 months few participants had complete resolution of unexplained somatic symptoms. GPs should be made aware of the likelihood of UPS persisting, and the factors that make this more likely, to inform decision making and care planning. There is a need to develop prognostic tools that can predict the risk of poor outcomes.

The association of psychological factors and healthcare use with the discrepancy between subjective and objective respiratory-health complaints in the general population

BACKGROUND

We examined the prevalence of self-perceived respiratory symptoms (SRS) in the absence of any objective findings of respiratory pathology, and the association of such prevalence with psychological factors and healthcare use in the general population.

METHODS

The study was conducted among a nationally representative sample of Finnish adults (BRIF8901). Respiratory functioning was measured by a spirometry test. Structured questionnaires were used to measure SRS, physician visits and psychological factors of alexithymia, sense of coherence, illness worry and common mental disorders. Individuals with a diagnosed respiratory disease or a severe psychiatric disorder, determined in a diagnostic interview, were excluded, giving a sample comprising 4544 participants.

RESULTS

Twenty-six per cent of the general population and 36% of those with no diagnosed severe psychiatric disorder or respiratory disease experienced SRS despite a normal spirometry result. Psychological factors were associated with SRS (0.0001 &lt; p &lt; 0.032), and on the number of physician visit explaining 42.7% of the difference in visits between individuals with and without SRS, respectively. Illness worry was associated most strongly with SRS [odds ratio (OR) 1.29, 95% confidence interval (CI) 1.19-1.41, p &lt; 0.0001] and higher numbers of physician visits (OR 1.35, CI 1.32-1.38, p &lt; 0.00001), even after several adjustments.

CONCLUSIONS

Respiratory symptoms without objective findings are common in the general population. The study results underline the role of psychological factors in the reporting of respiratory symptoms and the associated medical burden, thereby indicating the functional nature of the symptomatology.

The association between neck and shoulder discomfort-Katakori-and high somatizing tendency

Objectives: 'Katakori', discomfort or dull pain around the neck and shoulder, is common in Japan. Somatizing tendency is important in the quality of daily living. This study aimed to examine the association between disability due to Katakori and high somatizing tendency.Methods: This internet study included 34,754 Japanese adults who reported Katakori in the past four weeks. Katakori was classified into four grades: 1) no Katakori, 2) Katakori without difficulty in activities for daily living (ADL), 3) Katakori with ADL difficulty but without absence from social activities, and 4) Katakori with absence from social activities. Somatizing tendency was assessed using the Somatic Symptom Scale-8 (SSS-8). The association between a very high (SSS-8 ≥ 16) somatizing tendency and Katakori grade was examined using logistic regression adjusting for age, sex, body mass index, marital status, smoking, regular exercise, low back pain, depression, and the number of chronic conditions.Results: Katakori grade was significantly associated with a very high somatizing tendency (Odds ratio (OR)= 5.36 [4.36-6.60] in grade 4 vs. 2, and OR= 2.57 [2.30-2.89] in grade 3 vs. 2).Conclusion: When treating severe Katakori with disability, somatizing tendency should be assessed to facilitate better management.

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.

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.

Building-Related Environmental Intolerance and Associated Health in the General Population

People frequently attribute adverse symptoms to particular buildings when exposure to pollutants is low, within nonhazardous levels. Our aim was to characterize building-related intolerance (BRI) in the general population. Data were derived from two population-based questionnaire surveys, the Västerbotten and Österbotten Environmental Health Study. We identified cases of BRI if respondents reported symptoms emerging from residing in certain buildings, when most other people had none. The questionnaires covered lifestyle factors, perceived general health, BRI duration and symptom frequency, the emotional and behavioral impact of BRI, coping strategies, and physician-diagnosed diseases. From the total of 4941 participants, we formed two case groups, 275 (5.6%) fulfilled criteria for self-reported BRI, and 123 (2.5%) for BRI with wide-ranging symptoms. Individuals in both case groups were significantly more often female, single, and perceived their general health as poorer than the referents, i.e., those reporting no BRI symptoms. The mean duration of BRI was 12 years. In both case groups, avoidance behavior was found in over 60%, and nearly half of the sample had sought medical care. BRI with wide-ranging symptoms was associated with elevated odds for all studied comorbidities (somatic and psychiatric diseases and functional somatic syndromes). The perceived health of individuals with BRI is poorer and comorbidities are more frequent than among referents. BRI seems to be similar to other environmental intolerances and shares features with functional somatic syndromes.

The associated features of multiple somatic symptom complexes

OBJECTIVE

To assess whether two or more functional somatic symptom complexes (SSCs) showed stronger association with psychosocial correlates than single or no SSC after adjustment for depression/anxiety and general medical disorders.

METHODS

In a population-based sample we identified, by standardised questionnaire, participants with chronic widespread pain, chronic fatigue and irritable bowel syndrome, excluding those with a medical cause for pain/fatigue. We compared psychosocial variables in three groups: multiple (>1), single or no FSS, adjusting for depression/anxiety and general medical disorders using ordinal logistic regression. We evaluated whether multiple SSCs predicted health status 1 year later using multiple regression to adjust for confounders.

RESULTS

Of 1443 participants (58.0% response) medical records were examined in 990: 4.4% (n = 44) had 2 or 3 symptom complexes, 16.2% a single symptom complex. Many psychosocial adversities were significantly associated with number of SSCs in the expected direction but, for many, statistical significance was lost after adjustment for depression/anxiety and medical illness. Somatic symptoms, health anxiety, impairment and number of prior doctor visits remained significantly associated. Impaired health status 1 year later was predicted by multiple somatic symptom complexes even after adjustment for depression, anxiety, medical disorders and number of symptoms.

CONCLUSIONS

Depression, anxiety, medical illness and health anxiety, demonstrated an exposure-response relationship with number of somatic symptom complexes. These may be core features of all Functional Somatic Syndromes and may explain why number of somatic symptom complexes predicted subsequent health status. These features merit inclusion in prospective studies to ascertain causal relationships.

Comorbid fibromyalgia: A qualitative review of prevalence and importance

Fibromyalgia (FM) may be an unrecognized cause of suffering for persons with an array of medical conditions. This is especially true for illness that is characterized by pain of any nature. Once believed to be a unique diagnosis, FM is recently reported to occur concomitantly with various rheumatic diseases, and importantly adversely impacts global health status. However, there is increasing report of FM associated with other diseases that are not defined by chronic pain. This qualitative review examines the evidence for comorbid FM in illness, and where available the effect of FM on the primary disease. Other than for musculoskeletal disorders, the published literature reporting an association of FM with illness is limited with scanty reports for some neurological, gastrointestinal, mental health and other overlapping pain conditions. Comorbid FM adversely affects both health status and outcome for rheumatic diseases, but with limited study in other diseases. When unrecognized, comorbid FM may be mistaken as poor control of the primary disease, leading to incorrect treatment decisions. FM may be a neglected condition that pervades many conditions and may contribute to the burden of illness. Physicians should be alert to the possibility of comorbid FM, and symptoms of FM should be specifically addressed.

SIGNIFICANCE

Comorbid fibromyalgia (FM) in other medical conditions is largely unrecognized. When reported as accompanying rheumatic diseases, FM adversely affects global health status. With limited reports of comorbid FM with other conditions, neglect to diagnose comorbid FM may misdirect treatments.

Longitudinal relationship between onset of physical symptoms and functional impairment

Patients with chronic physical symptoms (e.g., chronic pain) often have significant functional impairment (i.e., disability). The fear avoidance model is the dominant theoretical model of how the relationship between chronic physical symptoms and functional impairment develops and proposes a cyclical/bidirectional relationship. There has never been a definitive test of the proposed bi-directional relationship. The current study followed 767 Operation Enduring Freedom/Operation Iraqi Freedom soldiers from pre-deployment, when they were relatively healthy, to 1 year after deployment, when it was anticipated that symptoms would increase or develop. Over the four assessment time points, physical symptom severity consistently predicted worse functional impairment at the subsequent time point. Functional impairment did not show a consistent relationship with worsening of physical symptom severity. These findings suggest that changes to functional impairment do not have a short-term impact on physical symptom severity.

Persistent Physical Symptoms as Perceptual Dysregulation: A Neuropsychobehavioral Model and Its Clinical Implications

OBJECTIVE

The mechanisms underlying the perception and experience of persistent physical symptoms are not well understood, and in the models, the specific relevance of peripheral input versus central processing, or of neurobiological versus psychosocial factors in general, is not clear. In this article, we proposed a model for this clinical phenomenon that is designed to be coherent with an underlying, relatively new model of the normal brain functions involved in the experience of bodily signals.

METHODS

Based on a review of recent literature, we describe central elements of this model and its clinical implications.

RESULTS

In the model, the brain is seen as an active predictive processing or inferential device rather than one that is passively waiting for sensory input. A central aspect of the model is the attempt of the brain to minimize prediction errors that result from constant comparisons of predictions and sensory input. Two possibilities exist: adaptation of the generative model underlying the predictions or alteration of the sensory input via autonomic nervous activation (in the case of interoception). Following this model, persistent physical symptoms can be described as "failures of inference" and clinically well-known factors such as expectation are assigned a role, not only in the later amplification of bodily signals but also in the very basis of symptom perception.

CONCLUSIONS

We discuss therapeutic implications of such a model including new interpretations for established treatments as well as new options such as virtual reality techniques combining exteroceptive and interoceptive information.

Personality traits such as neuroticism and disability predict psychological distress in medically unexplained symptoms: A three-year experience from a single centre

BACKGROUND

People with medically unexplained symptoms (MUS) may have psychological co-morbidities.

AIMS

Our objectives were to assess the rates and identify correlates of psychological distress in MUS.

METHODS

A total of 171 subjects with MUS seeking treatment at a tertiary care facility were assessed over a 3-year period. Psychological distress was assessed using the Tamil version of General Health Questionnaire-12. Apart from socio-demographic factors, personality, coping, perceived social support and subjective disability were assessed using standard instruments.

RESULTS

Ninety subjects (52.6%) endorsed symptoms of psychological distress. MUS subjects with psychological distress reported higher levels of neuroticism (p < 0.001), lower extraversion (p < 0.001), lower perceived social support (p = 0.002), higher disability (p < 0.001), lower problem focused engagement (p = 0.378) and higher emotion focused engagement (p = 0.009). In multivariate analysis, high neuroticism scores (odds ratio 1.579, 95% CI 1.108 to 2.251) and high disability (odds ratio 1.302, 95% CI 1.147 to 1.478) emerged as independent predictors of psychological distress in MUS.

CONCLUSION

More than half of subjects with MUS have associated psychological distress. High levels of neuroticism and disability are potential markers of psychological distress in MUS. Copyright © 2017 John Wiley & Sons, Ltd.

Predicting the course of persistent physical symptoms: Development and internal validation of prediction models for symptom severity and functional status during 2 years of follow-up

OBJECTIVE

Increased knowledge about predictors of the course of persistent physical symptoms (PPS) is needed to identify patients at risk for long-term PPS in clinical settings. Therefore, we developed prediction models for the course of PPS in terms of symptom-severity and related functional status during a 2-year follow-up period.

METHODS

We used data of the PROSPECTS cohort study, consisting of 325 PPS patients from several health care settings. Symptom severity (PHQ-15), physical functioning (RAND 36 PCS) and mental functioning (RAND 36 MCS) were assessed at baseline and 6, 12 and 24 months afterwards. We applied mixed model analyses to develop prediction models for all outcomes, using all follow-up measurements. Potential predictors were based on empirical and theoretical literature and measured at baseline.

RESULTS

For symptom severity, physical functioning and mental functioning we identified predictors for the adverse course of PPS included physical comorbidity, higher severity and longer duration of PPS at baseline, anxiety, catastrophizing cognitions, embarrassment and fear avoidance cognitions, avoidance or resting behaviour and neuroticism. Predictors of a favourable course included limited alcohol use, higher education, higher levels of physical and mental functioning at baseline, symptom focusing, damage cognitions and extraversion. Explained interpersonal variance for all three models varied between 70.5 and 76.0%. Performance of the models was comparable in primary and secondary/tertiary care.

CONCLUSION

The presented prediction models identified several relevant demographic, medical, psychological and behavioural predictors for adverse and favourable courses of PPS. External validation of the presented models is needed prior to clinical implementation.