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

  • Barbara Tomenson (a1), Cecilia Essau (a2), Frank Jacobi (a3), Karl Heinz Ladwig (a4), Kari Ann Leiknes (a5), Roselind Lieb (a6), Gunther Meinlschmidt (a7), John McBeth (a8), Judith Rosmalen (a9), Winfried Rief (a10) and Athula Sumathipala (a11)...
Abstract
Background

The diagnosis of somatisation disorder in DSM-IV was based on ‘medically unexplained’ symptoms, which is unsatisfactory.

Aims

To determine the value of a total somatic symptom score as a predictor of health status and healthcare use after adjustment for anxiety, depression and general medical illness.

Method

Data from nine population-based studies (total n = 28377) were analysed.

Results

In all cross-sectional analyses total somatic symptom score was associated with health status and healthcare use after adjustment for confounders. In two prospective studies total somatic symptom score predicted subsequent health status. This association appeared stronger than that for medically unexplained symptoms.

Conclusions

Total somatic symptom score provides a predictor of health status and healthcare use over and above the effects of anxiety, depression and general medical illnesses.

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Copyright
Corresponding author
Barbara Tomenson, Biostatistics Unit, Institute of Population Health, University of Manchester, Jean McFarlane Building (3rd Floor), Oxford Road, Manchester M13 9PL, UK. Email: barbara.tomenson@manchester.ac.uk
Footnotes
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See editorial, pp. 320–321, this issue.

Declaration of interest

F.C. has been a member of the American Psychiatric Association DSM-5 work group on somatic distress disorders and he and A.S. are members of the World Health Organization ICD-11 working group on the classification of somatic distress and dissociative disorders.

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

  • Barbara Tomenson (a1), Cecilia Essau (a2), Frank Jacobi (a3), Karl Heinz Ladwig (a4), Kari Ann Leiknes (a5), Roselind Lieb (a6), Gunther Meinlschmidt (a7), John McBeth (a8), Judith Rosmalen (a9), Winfried Rief (a10) and Athula Sumathipala (a11)...
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eLetters

Do "numbers" count?!

Geetha Desai, Psychiatrist
15 December 2013

The article by Tomenson et al. (2013) on total somatic symptoms scoreand health outcome has raised few interesting questions. The study had concluded that total somatic symptoms score predicted health status and health care use. We would like to highlight that another important parameter that could have been included is the duration of the symptoms. The measures that have been used in the studies include different instruments and they assess current or lifetime symptoms and not duration or severity of symptoms. This could have an impact on the health care usage. Other drawbacks are related to care pathways and age of subjects. In developing countries, where there are many coexisting health care systems, relying only on allopathic setups may be difficult. Hence, it would be an important aspect that could have been taken into consideration. The age range has been highly variable (18-75) could resultin both medically explained and unexplained symptoms and both existing in the same individual.Measuring the severity of the symptoms which again varied in different instruments, being bothersome to interference in functioning may alone notindicate the severity. The intensity of symptoms can have a bearing on theseverity and has been demonstrated in a study done by Kroneke et al (2002). Another important component on health status and health care usagewould be the concept of abnormal illness behaviour (AIB, Pilowsky 1969). AIB could also determine significant health care usage. The authors have made efforts to consider health anxiety as variable which could again influence health status. Thus, it is not only the number of somatic symptoms count for health outcome but other variables mentioned above. Future research should focus on both current and life time symptoms, number of symptoms, duration, severity and AIB for better understanding of health status and health careusage.

References

Tomenson B, Essau C, Jacobi F, Ladwig KH, Leiknes KA, Lieb R, Meinlschmidt G, McBeth J, Rosmalen J, Rief W, Sumathipala A, Creed F; EURASMUS Population Based Study Group. Total somatic symptom score as a predictor of health outcome in somatic symptom disorders.Br J Psychiatry. 2013 Nov;203:373-80. doi: 10.1192/bjp.bp.112.114405.

Kroenke K, Spitzer RL, Williams JB. The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med. 2002 Mar-Apr;64(2):258-66.

Pilowsky I. Abnormal Illness behaviour.Br J Med Psychol. 1969 Dec;42(4):347-51.

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Conflict of interest: None declared

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Reflection of a GP trainee on somatisation

Dr Ian Humble, GP registrar
02 December 2013

We read with interest "Total somatic symptom score as a predictor of health outcome in somatic symptom disorders"(1). As a gp trainee currentlybased in psychiatry along with my past experience on a medical ward, I have often encountered patients with so called "Medically unexplained Physical Symptoms". One article suggests that 10% of the NHS budget is used to tackle such symptoms(2). I often find myself taking a rather cynical approach with such patients, and prior to my psychiatry rotation, I had not really considered the notion of primary and secondary gains.

There is clearly a complex relationship between physical and mental health and my psychiatry attachment has allowed me to appreciate this first hand. At times, they are two completely separate entities, and at others they are implicitly linked. Mental illness has been shown to have an increased prevalence in those with chronic illness(3). It is important to weigh up the impact of a persons psychological profile and past experiences in order to truly appreciate the impact of one on the other I now ask myself whether they are motivated by primary or secondary gains. One study showed that "somatisers" had at least one event which had the potential for secondary gain(4).

This article also suggests that those with a higher score went on to develop more health problems. This raises the question, are we missing something? While one study highlighted that those with "medically unexplained symptoms" were not misdiagnosed, it did show that in around 4%of cases their co-morbidities were not as well managed(5).

This shows the importance of not simply assuming a functional cause, and that each new symptom should be approached individually. At the same time we need to minimise over investigation in such patients in order to reduce impact and manage budgets better which would be a part of my job inthe future. This further highlights the role of a medic in psychiatric teams.

I wonder if "Medically Yet to be explained Symptoms" may be a better phrase. We must remember that conditions such as schizophrenia and HIV were at one stage "medically unexplained"(6). I have no doubt that there are many more conditions that we are yet to explain. Despite this however,more joined up working with mental health and physical health should be encouraged.

It is clear that "medically unexplained symptoms" still remain a challenge in medicine today, and that a balance needs to be found between when to investigate and when to reassure. This will have a major impact ofdwindling NHS budgets. It is clearly important to consider the benefits ofsuch symptoms or diagnoses to patients, but also not to be too cynical as this could lead to mis-diagnosis. I for one still find such cases particularly challenging but with my psychiatry experience, I now feel empowered to take a more objective view.

References

1.Barbara Tomenson, Cecilia Essau, Frank Jacobi, Karl Heinz Ladwig, Kari Ann Leiknes, Roselind Lieb et al. Total somatic symptom score as a predictor of health outcome in somatic symptom disorder. BJP 2013, 203:373-380.

2.Bermingham, Sarah L; Cohen, Alan; Hague, John; Parsonage, Michael.The cost of somatisation among the working-age population in England for the year 2008-2009. Mental Health in Family Medicine, Volume 7, Number 2, June 2010, pp. 71-84(14).

3.Chapman DP, Perry GS, Strine TW. The vital link between chronic disease and depressive disorders. Prev Chronic Dis. 2005 Jan;2(1):A14. Epub 2004 Dec 15.

4.T K Craig, H Drake, K Mills, and A P Boardman. The South London Somatisation Study. II. Influence of stressful life events, and secondary gain. BJP August 1994 165:248-58.

5.Skovenborg EL, Schr?der A. Is physical disease missed in patients with medically unexplained symptoms? A long-term follow-up of 120 patientsdiagnosed with bodily distress syndrome. General hospital psychiatry (2013).

6.Creed F, Fink P. Is there a better term than "Medically unexplained symptoms"? Journal of Psychosomatic Research 68 (2010) 5-8.

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Conflict of interest: GP trainee currently working with Crisis and Access Teams

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