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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)...

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


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.


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


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.


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.

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:
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See editorial, pp. 320–321, this issue.

Declaration of interest


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1 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (4th edn) (DSM-IV). APA, 1994.
2 Creed, F., Guthrie, E., Fink, P., Henningsen, P., Rief, W., Sharpe, M., et al. Is there a better term than “medically unexplained symptoms”? J Psychosom Res 2010; 68: 58.
3 Dimsdale, J., Creed, FH. The proposed diagnosis of somatic symptom disorders in DSM-5 to replace somatoform disorders in DSM-IV-a preliminary report. J Psychosom Res 2009; 66: 473–6.
4 Creed, F. Should general psychiatry ignore somatization and hypochondriasis? World Psychiatry 2006; 5: 146–50.
5 Kroenke, K., Spitzer, RL, Williams, JB. The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med 2002; 64: 258–66.
6 Kisely, S., Goldberg, D., Simon, G. A comparison between somatic symptoms with and without clear organic cause: results of an international study. Psychol Med 1997; 27: 1011–9.
7 Barsky, AJ, Orav, EJ, Bates, DW. Somatization increases medical utilization and costs independent of psychiatric and medical comorbidity. Arch Gen Psychiatry 2005; 62: 903–10.
8 Lieb, R., Meinlschmidt, G., Araya, R. Epidemiology of the association between somatoform disorders and anxiety and depressive disorders: an update. Psychosom Med 2007; 69: 860–3.
9 Ladwig, KH, Marten-Mittag, B., Lacruz, ME, Henningsen, P., Creed, F. Screening for multiple somatic complaints in a population-based survey: does excessive symptom reporting capture the concept of somatic symptom disorders? Findings from the MONICA-KORA Cohort Study. J Psychosom Res 2010; 68: 427–37.
10 Creed, FH, Davies, I., Jackson, J., Littlewood, A., Chew-Graham, C., Tomenson, B., et al. The epidemiology of multiple somatic symptoms. J Psychosom Res 2012; 72: 311–7.
11 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (5th edn) (DSM-5). APA, 2013.
12 Essau, CA. Course and outcome of somatoform disorders in non-referred adolescents. Psychosomatics 2007; 48: 502–9.
13 Lieb, R., Zimmermann, P., Friis, RH, Hofler, M., Tholen, S., Wittchen, HU. The natural course of DSM-IV somatoform disorders and syndromes among adolescents and young adults: a prospective-longitudinal community study. Eur Psychiatry 2002; 17: 321–31.
14 Wittchen, H., Perkonigg, A., Lachner, G., Nelson, CB. Early Developmental Stages of Psychopathology Study (EDSP): objectives and design. Eur Addict Res 1998; 4: 1827.
15 Lieb, R., Isensee, B., von Sydow, K., Wittchen, HU. The Early Developmental Stages of Psychopathology Study (EDSP): a methodological update. Eur Addict Res 2000; 6: 170–82.
16 Rief, W., Mewes, R., Martin, A., Glaesmer, H., Brähler, E. Evaluating new proposals for the psychiatric classification of patients with multiple somatic symptoms. Psychosom Med 2011; 73: 760–8.
17 Mewes, R., Rief, W., Brahler, E., Martin, A., Glaesmer, H. Lower decision threshold for doctor visits as a predictor of health care use in somatoform disorders and in the general population. Gen Hsp Psychiatry 2008; 30: 349–55.
18 Leiknes, KA, Finset, A., Moum, T. Commonalities and differences between the diagnostic groups: current somatoform disorders, anxiety, depression and musculoskeletal disorders. J Psychosom Res 2010; 68: 439–46.
19 Jacobi, F., Wittchen, H-U, Muller, N., Holting, C., Sommer, S., Lieb, R., et al. Estimating the prevalence of mental and somatic disorders in the community: aims and methods of the German National Health Interview and Examination Survey. Int J Methods Psychiatr Res 2002; 11: 119.
20 Ladwig, KH, Marten-Mittag, B., Formanek, B., Dammann, G. Gender differences of symptom reporting and medical health care utilization in the German population. Eur J Epidemiol 2000; 16: 511–8.
21 Rosmalen, JGM, Tak, LM, de Jonge, P. Empirical foundations for the diagnosis of somatization: implications for DSM-5. Psychol Med 2011; 41: 1133–42.
22 Sumathipala, A. National Survey on Mental Health in Sri Lanka: Final Research Report. Institute of Research and Development, 2007.
23 Zerssen, D. Die Beschwerde-Liste Klinische Selbstbeurteilungsfragebogen aus dem Münchner Psychiatrischen Informationszentrum [List of Clinical Complaints: Self-Rating Questionnaires from the Munich Centre for Psychiatric Research]. Beltz, 1976.
24 Derogatis, LR. SCL-90-R: Administration, Scoring, and Procedures Manual for The Revised Version. Johns Hopkins University School of Medicine, 1997.
25 Derogatis, LR, Lipman, RS, Rickels, K., Uhlenhuth, EH, Covi, L. The Hopkins Symptom Checklist (HSCL): a self-report symptom inventory. Behav Sci 1974; 19: 115.
26 Wittchen, H-U. Reliability and validity studies of the WHO Composite International Diagnostic Interview (CIDI): a critical review. J Psychiatr Res 1994; 28: 5784.
27 Gandek, B., Ware, JE, Aaronson, NK, Apolone, G., Bjorner, JB, Brazier, JE, et al. Cross-validation of item selection and scoring for the SF-12 Health Survey in nine countries: results from the IQOLA Project. International Quality of Life Assessment. J Clin Epidemiol 1998; 51: 1171–8.
28 Williams, A. Euroqol – a new facility for the measurement of health-related quality-of-life. Health Policy 1990; 16: 199208.
29 Kroenke, K., Spitzer, RL, Williams, JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001; 16: 606–13.
30 Spitzer, RL, Kroenke, K., Williams, JBW, Lowe, B. A brief measure for assessing generalized anxiety disorder – the GAD-7. Arch Intern Med 2006; 166: 1092–7.
31 Zigmond, AS, Snaith, RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand 1983; 67: 361–70.
32 Wittchen, H-U, Jacobi, F. Size and burden of mental disorders in Europe – a critical review and appraisal of 27 studies. Eur Neuropsychopharmacol 2005; 15: 357–76.
33 Creed, FH, Barsky, A. A systematic review of somatisation and hypochondriasis. J Psychosom Res 2004; 56: 391408.
34 Üün, TB, Sartorius, N. Mental Illness in General Health Care. An International Study. Wiley, 1996.
35 Katon, W., Lin, EHB, Kroenke, K. The association of depression and anxiety with medical symptom burden in patients with chronic medical illness. Gen Hosp Psychiatry 2007; 29: 147–55.
36 Huijbregts, KML, van der Feltz-Cornelis, C., van Marwijk, HWJ, de Jong, FJ, van der Windt, DAWM, Beekman, ATF. Negative association of concomitant physical symptoms with the course of major depressive disorder: a systematic review. J Psychosom Res 2010; 68: 511–9.
37 Creed, F. The relationship between somatic symptoms, health anxiety, and outcome in medical out-patients. Psychiatr Clin North Am 2011; 34: 545–64.
38 Kisely, S., Goldberg, D., Simon, G. A comparison between somatic symptoms with and without clear organic cause: results of an international study. Psychol Med 1997; 27: 1011–9.
39 Jackson, J., Fiddler, M., Kapur, N., Wells, A., Tomenson, B., Creed, F. Number of bodily symptoms predicts outcome more accurately than health anxiety in patients attending neurology, cardiology, and gastroenterology clinics. J Psychosom Res 2006; 60: 357–63.
40 Kroenke, K., Zhong, X., Theobald, D., Wu, JW, Tu, WZ, Carpenter, JS. Somatic symptoms in patients with cancer experiencing pain or depression prevalence, disability, and health care use. Arch Intern Med 2010; 170: 1686–94.
41 Sogutlu, A., Levenson, JL, McClish, DK, Rosef, SD, Smith, WR. Somatic symptom burden in adults with sickle cell disease predicts pain, depression, anxiety, health care utilization, and quality of life: the PiSCES Project. Psychosomatics 2011; 52: 272–9.
42 Kendell, R., Jablensky, A. Distinguishing between the validity and utility of psychiatric diagnoses. Am J Psychiatry 2003; 160: 412.
43 Mayou, R., Kirmayer, LJ, Simon, G., Kroenke, K., Sharpe, M. Somatoform disorders: time for a new approach in DSM-V. Am J Psychiatry 2005; 162: 847–55.
44 Klengel, T., Heck, A., Pfister, H., Brückl, T., Hennings, JM, Menke, A., et al. Somatization in major depression – clinical features and genetic associations. Acta Psychiatr Scand 2011; 124: 317–28.
45 Nickel, R., Egle, UT, Rompe, J., Eysel, P., Hoffmann, SO. Somatisation predicts the outcome of treatment in patients with low back pain. J Bone Joint Surg Br 2002; 84B: 189–95.
46 Creed, F., Tomenson, B., Guthrie, E., Ratcliffe, J., Fernandes, L., Read, N., et al. The relationship between somatisation and outcome in patients with severe irritable bowel syndrome. J Psychosom Res 2008; 64: 613–20.
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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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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.


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.


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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