Skip to main content Accessibility help

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

  • Sanna Selinheimo (a1) (a2) (a3), Tuula Vasankari (a4) (a5), Markus Jokela (a3), Merja Kanervisto (a6), Sami Pirkola (a7), Jaana Suvisaari (a2) and Tiina Paunio (a1) (a2) (a8)...



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.


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.


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 < p < 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 < 0.0001] and higher numbers of physician visits (OR 1.35, CI 1.32–1.38, p < 0.00001), even after several adjustments.


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.


Corresponding author

Author for correspondence: Sanna Selinheimo, E-mail: or Tiina Paunio, E-mail:


Hide All
Agardh, EE, Ahlbom, A, Andersson, T, Efendic, S, Grill, V, Hallqvist, J, Norman, A and Östenson, C-G (2003) Work stress and low sense of coherence is associated with type 2 diabetes in middle-aged Swedish women. Diabetes Care 26, 719724.
Antonovsky, A (1987) Unraveling the Mystery of Health: How People Manage Stress and Stay Well. San Francisco: Jossey-Bass.
Aromaa, A and Koskinen, S (eds.) (2004). Health and Functional Capacity in Finland. Baseline Results of the Health 2000 Health Examination Survey. Helsinki: Publications of the National Public Health Institute = Kansanterveyslaitos.
Bagby, RM, Parker, JD and Taylor, GJ (1994 a) The twenty-item Toronto Alexithymia Scale-I. Item selection and cross-validation of the factor structure. Journal of Psychosomatic Research 38, 2332.
Bagby, RM, Taylor, GJ and Parker, JD (1994 b) The twenty-item Toronto Alexithymia Scale-II. Convergent, discriminant, and concurrent validity. Journal of Psychosomatic Research 38, 3340.
Baiardini, I, Braido, F, Ferraioli, G, Menoni, S, Bruzzone, M, Conte, ME, Gani, F, Ridolo, E, Scordamaglia, A and Canonica, GW (2011) Pitfalls in respiratory allergy management: alexithymia and its impact on patient-reported outcomes. Journal of Asthma 48, 2532.
Bailey, PE and Henry, JD (2007) Alexithymia, somatization and negative affect in a community sample. Psychiatry Research 150, 1320.
Barsky, AJ and Borus, JF (1999) Functional somatic syndromes. Annals of Internal Medicine 130, 910921.
Barsky, AJ, Ettner, SL, Horsky, J and Bates, DW (2001 a) Resource utilization of patients with hypochondriacal health anxiety and somatization. Medical Care 39, 705715.
Barsky, AJ, Orav, EJ and Bates, DW (2005) Somatization increases medical utilization and costs independent of psychiatric and medical comorbidity. Archives General Psychiatry 62, 903910.
Barsky, AJ, Peekna, HM and Borus, JF (2001 b) Somatic symptom reporting in women and men. Journal of General Internal Medicine 16, 266275.
Bernabe, E, Tsakos, G, Watt, RG, Suominen-Taipale, AL, Uutela, A, Vahtera, J and Kivimaki, M (2009) Structure of the sense of coherence scale in a nationally representative sample: the Finnish Health 2000 survey. Quality of Life Research 18, 629636.
Bhandari, A and Wagner, T (2006) Self-reported utilization of health care services: improving measurement and accuracy. Medical Care Research and Review 63, 217235.
Bleichhardt, G and Hiller, W (2007) Hypochondriasis and health anxiety in the German population. British Journal of Health Psychology 12, 511523.
Bogaerts, K, Notebaert, K, Van Diest, I, Devriese, S, De Peuter, S and Van den Bergh, O (2005) Accuracy of respiratory symptom perception in different affective contexts. Journal of Psychosomatic Research 58, 537543.
Bogaerts, K, Van Eylen, L, Li, W, Bresseleers, J, Van Diest, I, De Peuter, S, Stans, L, Decramer, M and Van den Bergh, O (2010) Distorted symptom perception in patients with medically unexplained symptoms. Journal of Abnormal Psychology 119, 226.
Brunner, WM, Schreiner, PJ, Sood, A and Jacobs, DR Jr. (2014) Depression and risk of incident asthma in adults. The CARDIA study. American Journal of Respiratory and Critical Care Medicine 189, 10441051.
Burton, C (2003) Beyond somatisation: a review of the understanding and treatment of medically unexplained physical symptoms (MUPS). The British Journal of General Practice 53, 231239.
Clarke, DM, Piterman, L, Byrne, CJ and Austin, DW (2008) Somatic symptoms, hypochondriasis and psychological distress: a study of somatisation in Australian general practice. Medical Journal of Australia 189, 560.
Cohen, S, Doyle, WJ, Turner, RB, Alper, CM and Skoner, DP (2003) Emotional style and susceptibility to the common cold. Psychosomatic Medicine 65, 652657.
Creed, F and Barsky, A (2004) A systematic review of the epidemiology of somatisation disorder and hypochondriasis. Journal of Psychosomatic Research 56, 391408.
Deary, IJ, Scott, S and Wilson, JA (1997) Neuroticism, alexithymia and medically unexplained symptoms. Personality and Individual Differences 22, 551564.
De Gucht, V and Heiser, W (2003) Alexithymia and somatisation: a quantitative review of the literature. Journal of Psychosomatic Research 54, 425434.
Disler, R, Gallagher, R and Davidson, P (2012) Factors influencing self-management in chronic obstructive pulmonary disease: an integrative review. International Journal of Nursing Studies 49, 230242.
Eisner, MD, Katz, PP, Lactao, G and Iribarren, C (2005) Impact of depressive symptoms on adult asthma outcomes. Annals of Allergy, Asthma & Immunology 94, 566574.
Eliasen, M, Kreiner, S, Ebstrup, JF, Poulsen, CH, Lau, CJ, Skovbjerg, S, Fink, PK and Jørgensen, T (2016) Somatic symptoms: prevalence, co-occurrence and associations with self-perceived health and limitations due to physical health – a Danish population-based study. PLoS ONE 11, e0150664.
Eriksson, M and Lindström, B (2005) Validity of Antonovsky's sense of coherence scale: a systematic review. Journal of Epidemiology and Community Health 59, 460466.
Eriksson, M and Lindström, B (2006) Antonovsky's sense of coherence scale and the relation with health: a systematic review. Journal of Epidemiology and Community Health 60, 376381.
Feldman, JM, Lehrer, PM and Hochron, SM (2002) The predictive value of the Toronto Alexithymia Scale among patients with asthma. Journal of Psychosomatic Research 53, 10491052.
Fink, P, Ewald, H, Jensen, J, Sørensen, L, Engberg, M, Holm, M and Munk-Jørgensen, P (1999) Screening for somatization and hypochondriasis in primary care and neurological in-patients: a seven-item scale for hypochondriasis and somatization. Journal of Psychosomatic Research 46, 261273.
Fletcher, CM, Elmes, PC, Fairbairn, AS and Wood, CH (1959) The significance of respiratory symptoms and the diagnosis of chronic bronchitis in a working population. British Medical Journal 2, 257266.
Frostholm, L, Fink, P, Christensen, KS, Toft, T, Oernboel, E, Olesen, F and Weinman, J (2005) The patients’ illness perceptions and the use of primary health care. Psychosomatic Medicine 67, 9971005.
Frostholm, L, Oernboel, E, Christensen, KS, Toft, T, Olesen, F, Weinman, J and Fink, P (2007). Do illness perceptions predict health outcomes in primary care patients? A 2-year follow-up study. Journal of Psychosomatic Research 62, 129138.
Gallagher, R, Donoghue, J, Chenoweth, L and Stein-Parbury, J (2008) Self-management in older patients with chronic illness. International Journal of Nursing Practice 14, 373382.
Goodwin, R and Engstrom, G (2002) Personality and the perception of health in the general population. Psychological Medicine 32, 325332.
Haug, TT, Mykletun, A and Dahl, AA (2004) The association between anxiety, depression, and somatic symptoms in a large population: the HUNT-II study. Psychosomatic Medicine 66, 845851.
Henningsen, P, Zimmermann, T and Sattel, H (2003) Medically unexplained physical symptoms, anxiety, and depression: a meta-analytic review. Psychosomatic Medicine 65, 528533.
Henningsen, P, Zipfel, S and Herzog, W (2007) Management of functional somatic syndromes. The Lancet 369, 946955.
Hiirola, A, Pirkola, S, Karukivi, M, Markkula, N, Bagby, R, Joukamaa, M, Jula, A, Kronholm, E, Saarijärvi, S and Salminen, J (2017) An evaluation of the absolute and relative stability of alexithymia over 11years in a Finnish general population. Journal of Psychosomatic Research 95, 8187.
Hynninen, KMJ, Breitve, MH, Wiborg, AB, Pallesen, S and Nordhus, IH (2005) Psychological characteristics of patients with chronic obstructive pulmonary disease: a review. Journal of Psychosomatic Research 59, 429443.
Janssens, T, Verleden, G, De Peuter, S, Petersen, S and Van den Bergh, O (2011) The influence of fear of symptoms and perceived control on asthma symptom perception. Journal of Psychosomatic Research 71, 154159.
Joukamaa, M, Miettunen, J, Kokkonen, P, Koskinen, M, Julkunen, J, Kauhanen, J, Jokelainen, J, Veijola, J, Laksy, K and Jarvelin, MR (2001) Psychometric properties of the Finnish 20-item Toronto Alexithymia Scale. Nordic Journal of Psychiatry 55, 123127.
Jyväsjärvi, S, Joukamaa, M, Väisänen, E, Larivaara, P, Kivelä, S-L and Keinänen-Kiukaanniemi, S (2001) Somatizing frequent attenders in primary health care. Journal of Psychosomatic Research 50, 185192.
Katon, W, Lin, EH and Kroenke, K (2007) The association of depression and anxiety with medical symptom burden in patients with chronic medical illness. General Hospital Psychiatry 29, 147155.
Katon, WJ and Walker, EA (1998) Medically unexplained symptoms in primary care. The Journal of Clinical Psychiatry 59(Suppl 20), 1521.
Kirmayer, LJ, Groleau, D, Looper, KJ and Dao, MD (2004) Explaining medically unexplained symptoms. The Canadian Journal of Psychiatry 49, 663672.
Kivimäki, M, Feldt, T, Vahtera, J and Nurmi, J-E (2000) Sense of coherence and health: evidence from two cross-lagged longitudinal samples. Social Science & Medicine 50, 583597.
Kolk, A, Hanewald, G, Schagen, S and van Wijk, CG (2002) Predicting medically unexplained physical symptoms and health care utilization: a symptom-perception approach. Journal of Psychosomatic Research 52, 3544.
Kooiman, CG, Bolk, JH, Rooijmans, HG and Trijsburg, RW (2004) Alexithymia does not predict the persistence of medically unexplained physical symptoms. Psychosomatic Medicine 66, 224232.
Kroenke, K and Spitzer, RL (1998) Gender differences in the reporting of physical and somatoform symptoms. Psychosomatic Medicine 60, 150155.
Kroenke, K, Spitzer, RL and Williams, JB (2002) The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosomatic Medicine 64, 258266.
Lehrer, P, Feldman, J, Giardino, N, Song, H-S and Schmaling, K (2002) Psychological aspects of asthma. Journal of Consulting and Clinical Psychology 70, 691.
Loengaard, K, Bjorner, JB, Fink, PK, Burr, H and Rugulies, R (2015) Medically unexplained symptoms and the risk of loss of labor market participation – a prospective study in the Danish population. BioMedCentral Public Health 15, 844.
Löwe, B, Spitzer, RL, Williams, JB, Mussell, M, Schellberg, D and Kroenke, K (2008) Depression, anxiety and somatization in primary care: syndrome overlap and functional impairment. General Hospital Psychiatry 30, 191199.
Lundh, LG and Simonsson-Sarnecki, M (2001) Alexithymia, emotion, and somatic complaints. Journal of Personality 69, 483510.
Mattila, AK, Kronholm, E, Jula, A, Salminen, JK, Koivisto, A-M, Mielonen, R-L and Joukamaa, M (2008) Alexithymia and somatization in general population. Psychosomatic Medicine 70, 716722.
Michael, CS, Callahan, CM, Counsell, SR, Westmoreland, GR, Stump, TE and Kroenke, K (2005) Physical symptoms as a predictor of health care use and mortality among older adults. The American Journal of Medicine 118, 301306.
Nici, L, Donner, C, Wouters, E, Zuwallack, R, Ambrosino, N, Bourbeau, J, Carone, M, Celli, B, Engelen, M and Fahy, B (2006) American thoracic society/European respiratory society statement on pulmonary rehabilitation. American Journal of Respiratory and Critical Care Medicine 173, 13901413.
Nimnuan, C, Hotopf, M and Wessely, S (2001) Medically unexplained symptoms: an epidemiological study in seven specialities. Journal of Psychosomatic Research 51, 361367.
olde Hartman, TC, Borghuis, MS, Lucassen, PL, van de Laar, FA, Speckens, AE and van Weel, C (2009) Medically unexplained symptoms, somatisation disorder and hypochondriasis: course and prognosis. A systematic review. Journal of Psychosomatic Research 66, 363377.
Owens, KM, Asmundson, GJ, Hadjistavropoulos, T and Owens, TJ (2004) Attentional bias toward illness threat in individuals with elevated health anxiety. Cognitive Therapy and Research 28, 5766.
Pallant, JF and Lae, L (2002) Sense of coherence, well-being, coping and personality factors: further evaluation of the sense of coherence scale. Personality and Individual Differences 33, 3948.
Perala, J, Suvisaari, J, Saarni, SI, Kuoppasalmi, K, Isometsa, E, Pirkola, S and Partonen, T, Tuulio-Henriksson, A, Hintikka, J, Kieseppa, T, Harkanen, T, Koskinen, S and Lonnqvist, J (2007) Lifetime prevalence of psychotic and bipolar I disorders in a general population. Archives of General Psychiatry 64, 1928.
Petrie, KJ, Faasse, K, Crichton, F and Grey, A (2014) How common are symptoms? Evidence from a New Zealand national telephone survey. British Medical Journal Open 4, e005374.
Petrie, KJ and Weinman, J (2012) Patients’ perceptions of their illness: the dynamo of volition in health care. Current Directions in Psychological Science 21, 6065.
Pilowsky, I (1967) Dimensions of hypochondriasis. The British Journal of Psychiatry 113, 8993.
Pirkola, SP, Isometsä, E, Suvisaari, J, Aro, H, Joukamaa, M, Poikolainen, K, Koskinen, S, Aromaa, A and Lönnqvist, JK (2005) DSM-IV mood-, anxiety- and alcohol use disorders and their comorbidity in the Finnish general population. Social Psychiatry and Psychiatric Epidemiology 40, 110.
Poppius, E, Tenkanen, L, Kalimo, R and Heinsalmi, P (1999) The sense of coherence, occupation and the risk of coronary heart disease in the Helsinki Heart Study. Social Science & Medicine 49, 109120.
Quanjer, PH, Stanojevic, S, Cole, TJ, Baur, X, Hall, GL, Culver, BH, Enright, PL, Hankinson, JL, Ip, MS and Zheng, J (2012) Multi-ethnic reference values for spirometry for the 3–95-yr age range: the global lung function 2012 equations. European Respiratory Journal 40, 13241343.
Reid, S, Wessely, S, Crayford, T and Hotopf, M (2001) Medically unexplained symptoms in frequent attenders of secondary health care: retrospective cohort study. British Medical Journal 322, 767.
Rhee, H, Belyea, MJ and Halterman, JS (2011) Adolescents’ perception of asthma symptoms and health care utilization. Journal of Pediatric Health Care 25, 105113.
Rief, W, Hessel, A and Braehler, E (2001) Somatization symptoms and hypochondriacal features in the general population. Psychosomatic Medicine 63, 595602.
Robbins, JM and Kirmayer, LJ (1991) Attributions of common somatic symptoms. Psychological Medicine 21, 10291045.
Robbins, JM and Kirmayer, LJ (1996) Transient and persistent hypochondriacal worry in primary care. Psychological Medicine 26, 575589.
Rose, GA and Blackburn, H (1968) Cardiovascular Survey Methods. Geneva: World Health Organization.
Serrano, J, Plaza, V, Sureda, B, De Pablo, J, Picado, C, Bardagi, S, Lamela, J, Sanchis, J and Group SHRAR (2006) Alexithymia: a relevant psychological variable in near-fatal asthma. European Respiratory Journal 28, 296302.
Short, ME, Goetzel, RZ, Pei, X, Tabrizi, MJ, Ozminkowski, RJ, Gibson, TB, DeJoy, DM and Wilson, MG (2009) How accurate are self-reports? An analysis of self-reported healthcare utilization and absence when compared to administrative data. Journal of Occupational and Environmental Medicine/American College of Occupational and Environmental Medicine 51, 786.
Simon, G, Gater, R, Kisely, S and Piccinelli, M (1996) Somatic symptoms of distress: an international primary care study. Psychosomatic Medicine 58, 481488.
Simonsson, B, Nilsson, KW, Leppert, J and Diwan, VK (2008) Psychosomatic complaints and sense of coherence among adolescents in a county in Sweden: a cross-sectional school survey. BioPsychoSocial Medicine 2, 1.
Speckens, AE, Spinhoven, P, Sloekers, PP, Bolk, JH and van Hemert, AM (1996) A validation study of the Whitely Index, the Illness Attitude Scales, and the Somatosensory Amplification Scale in general medical and general practice patients. Journal of Psychosomatic Research 40, 95104.
Steinbrecher, N, Koerber, S, Frieser, D and Hiller, W (2011) The prevalence of medically unexplained symptoms in primary care. Psychosomatics 52, 263271.
Stewart, DE and Yuen, T (2011) A systematic review of resilience in the physically ill. Psychosomatics 52, 199209.
Sunderland, M, Newby, JM and Andrews, G (2013) Health anxiety in Australia: prevalence, comorbidity, disability and service use. The British Journal of Psychiatry 202, 5661.
Suominen, S, Helenius, H, Blomberg, H, Uutela, A and Koskenvuo, M (2001) Sense of coherence as a predictor of subjective state of health: results of 4 years of follow-up of adults. Journal of Psychosomatic Research 50, 7786.
Taylor, GJ, Bagby, RM and Parker, JD (1999) Disorders of Affect Regulation: Alexithymia in Medical and Psychiatric Illness. Cambridge: Cambridge University Press.
Tomenson, B, Essau, C, Jacobi, F, Ladwig, KH, Leiknes, KA, Lieb, R, Meinlschmidt, G, McBeth, J, Rosmalen, J and Rief, W (2013) Total somatic symptom score as a predictor of health outcome in somatic symptom disorders. The British Journal of Psychiatry 203, 373380.
Tyrer, P, Cooper, S, Crawford, M, Dupont, S, Green, J, Murphy, D, Salkovskis, P, Smith, G, Wang, D and Bhogal, S (2011) Prevalence of health anxiety problems in medical clinics. Journal of Psychosomatic Research 71, 392394.
van der Sluijs, J, Ten Have, M, Rijnders, C, van Marwijk, H, de Graaf, R and van der Feltz-Cornelis, C (2015) Medically unexplained and explained physical symptoms in the general population: association with prevalent and incident mental disorders. PLoS ONE 10, e0123274.
Vazquez, I, Sández, E, González-Freire, B, Romero-Frais, E, Blanco-Aparicio, M and Verea-Hernando, H (2010) The role of alexithymia in quality of life and health care use in asthma. Journal of Asthma 47, 797804.
Waller, E and Scheidt, CE (2006) Somatoform disorders as disorders of affect regulation: a development perspective. International Review of Psychiatry 18, 1324.
Watson, D and Pennebaker, JW (1989) Health complaints, stress, and distress: exploring the central role of negative affectivity. Psychological Review 96, 234.
World Health Organization (1993) Composite International Diagnostic Interview (CIDI), Version 1.1. Geneva: World Health Organization.
World Health Organization (1997) Composite International Diagnostic Interview (CIDI), Version 2.1. Geneva: World Health Organization.
Yorke, J, Fleming, SL and Shuldham, C (2007) Psychological interventions for adults with asthma: a systematic review. Respiratory Medicine 101, 114.


Type Description Title
Supplementary materials

Selinheimo et al. supplementary material 1
Selinheimo et al. supplementary material

 Word (20 KB)
20 KB
Supplementary materials

Selinheimo et al. supplementary material 2
Supplementary Figure

 Unknown (1.7 MB)
1.7 MB


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed