Study of Rates and Factors Associated to Psychosomatic Syndromes Assessed Using the Diagnostic Criteria for Psychosomatic Research across Different Clinical Settings.

INTRODUCTION: Diagnostic Criteria for Psychosomatic Research (DCPR) serve as an instrument for identifying and classifying specific psychosomatic syndromes that are not adequately encompassed in standard nosography. The present study aimed at measuring the prevalence of DCPR syndromes in different clinical settings and exploring factors associated to such diagnoses. METHODS: A cross-sectional and nationwide study recruited 6,647 patients in different clinical settings: 306 were diagnosed with fibromyalgia (FM), 333 with irritable bowel syndrome, 1,109 with migraine, 2,550 with coronary heart disease (CHD), and 2,349 with type 2 diabetes (T2D). Participants underwent DCPR diagnostic interview and were assessed for depression (Patient Health Questionnaire-9), anxiety (Generalized Anxiety Disorder 7-Item Scale), and subjective well-being (World Health Organization-5 Well-Being Index). The PsychoSocial Index was used to evaluate global well-being, stress, and abnormal illness behavior. The prevalence of DCPR diagnoses was calculated, and factors associated to such diagnoses were analyzed by logistic regression. RESULTS: Alexithymia (64.47%), irritable mood (20.55%), and demoralization (15.60%) were the most prevalent psychosomatic syndromes, with demoralization being most common in FM (49.02%). The factors associated to DCPR diagnoses encompassed high anxiety or abnormal illness behavior, and poor well-being. Notably, stress was found to be associated specifically to FM and T2D, with OR of 1.24 (95% CI: 1.06-1.46) and 1.26 (95% CI: 1.18-1.36), respectively. CONCLUSION: DCPR is a clinically helpful complementary assessment tool in need of being widely implemented in clinical settings in order to have a comprehensive picture of the patients.

Illness Denial in Medical Disorders: A Systematic Review.

INTRODUCTION: Illness denial pertains to medical patients who do not acknowledge the presence or severity of their disease or the need of treatment. OBJECTIVE: This systematic review was performed to clarify the clinical role and manifestations of illness denial, its impact on health attitudes and behavior, as well as on short- and long-term outcomes in patients with medical disorders. METHODS: The systematic search according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines was conducted on PubMed, Scopus, and Web of Science. RESULTS: The initial search yielded a total of 14,098 articles; 176 studies met the criteria for inclusion. Illness denial appeared to be a relatively common condition affecting a wide spectrum of health attitudes and behavior. In some cases, it may help a person cope with various stages of illness and treatment. In other situations, it may determine delay in seeking treatment, impaired adherence, and reduced self-management, leading to adverse outcomes. The Diagnostic Criteria for Psychosomatic Research (DCPR) were found to set a useful severity threshold for the condition. An important clinical distinction can also be made based on the DCPR for illness denial, which require the assessment of whether the patient has been provided with an adequate appraisal of the medical situation. CONCLUSIONS: This systematic review indicates that patients with medical disorders experience and express illness denial in many forms and with varying degrees of severity. The findings suggest the need for a multidimensional assessment and provide challenging insights into the management of medical disorders.

A snapshot of patient experience of illness control after a hospital readmission in adults with chronic heart failure.

BACKGROUND: Approximately 6.5 million adults have chronic heart failure (HF), the number one cause of 30-day hospital readmission. Managing HF and its symptoms is critical for patients. Hospitalization may impact patients' perceptions of illness control, which can affect illness management. However, how hospital readmissions are perceived as related to one's ability to control their HF and its symptoms has not been examined. OBJECTIVE: The purpose was to explore the experiences of people with HF in managing their illness (i.e., illness control), understand their perceptions of illness control after recent hospital readmission, and clarify the concept of illness control in people with chronic HF. METHODS: A qualitative approach, applied thematic analysis was employed. Purposive sampling was used to identify participants. Semi-structured interviews were conducted in 10 participants' homes. Ongoing, concurrent, and comparative data analysis was used with ATLASti© data management software. RESULTS: Two themes were identified, strategies to control HF and barriers to controlling HF. Strategies to control HF included four subthemes: managing dietary intake and medications; self- advocacy; monitoring symptoms; and support. Barriers to control also had four subthemes: healthcare systems issues; health care professional relationships and interactions; personal characteristics; and knowledge deficits. CONCLUSION: People use many different strategies to control HF. Control comes from both within and outside of the individual. The desire to control HF and its symptoms was evident, but implementing strategies is challenging and takes time, experience, and trial and error. Individuals did not view readmission negatively but as necessary to help them control their symptoms.

"One time I fell, but I didn't have to cry." A qualitative study on everyday physical complaints in children.

OBJECTIVE: Young children experience physical complaints, like abdominal pain or minor injuries from playing, almost every day. These experiences may shape how they deal with health issues later in life. While models exist to explain illness perception in adults, information is lacking on the perspective of young children. This qualitative study aimed to explore important themes in the experience of everyday physical complaints in four- and five-year-old children, using children as informants. STUDY DESIGN: 30 semi-structured interviews were performed in which four- and five-year-old children were questioned about their experiences with everyday physical complaints. The interviews were double coded using Atlas.ti and subsequently qualitative content analysis was used to define themes. RESULTS: All participating children were able to elaborate on their experiences with physical complaints. Three themes emerged from the interviews: causes of complaints, appraisal of complaints, and implications of complaints. In their appraisal of complaints, four- and five-year-old children made a distinction between visible and invisible complaints and real or pretended complaints. CONCLUSION: Four- and five-year-old children can already give details about their experiences with everyday physical complaints. They have developed ideas about the causes and implications of complaints and try to make an appraisal.

A cross-sectional hospital-based study of correlates of disability in patients with chronic low back pain in KwaZulu-Natal, South Africa.

BACKGROUND: Chronic low back pain (CLBP) is the leading cause of disability globally and is a major concern in public health. However, there is limited evidence on the prevalence and correlates of disability among adults in Sub-Saharan Africa. Thus, this study aimed at determining factors influencing disability among adult patients with CLBP in KwaZulu-Natal. METHODS: This analytical cross-sectional hospital-based study was conducted among adult CLBP patients in KwaZulu-Natal, South Africa. Data on disability, fear avoidance beliefs and illness behavior were gathered from 554 adult participants using self-administered questionnaires. Multiple linear regression analysis was conducted to determine factors associated with disability. Statistical significance was set at p < 0.05. RESULTS: Based on the multivariable linear regression, being a female (ß = 0.343, p < 0.001) and fear avoidance beliefs about work (ß = 0.221, p = 0.044) were significantly associated with greater disability, while, smoking 1 to 10 cigarettes per day (ß = -0.106, p = 0.011) and higher illness behaviour scores (ß = -0.165, p = 0.024) were significantly associated with less disability The model accounted for 20% of the total variance in Oswestry disability scores. CONCLUSION: This study has concluded that disability in CLBP is predicted by multiple of factors, with psychosocial factors (fear avoidance beliefs and heavy cigarette smoking) playing a significant role. Manual work was also identified as a significant predictor of CLBP disability. Therefore, guidelines should emphasize on early identification of these yellow flags in primary care.

A Biopsychosocial Approach to HIV Fatigue: A Cross-Sectional and Prospective Analysis to Identify Key Modifiable Factors.

This study aimed to identify the prevalence and predictors of current fatigue and fatigue at 1-year follow-up, in people with HIV. Participants were recruited from HIV outpatient clinics in London, England. We explored a range of bio-psychosocial factors associated with current fatigue severity, identifying the most salient factors in a multifactorial model. A prospective study explored the predictive value of specific psychological and behavioral factors in predicting fatigue severity at one year. Sixty-four of 131 (49%) participants met the criteria for clinically significant fatigue at baseline. Psychological and behavioral variables, but not immune-virologic markers or antiretroviral treatment, were associated with current fatigue severity. In the multifactorial model, catastrophizing and distress independently predicted current fatigue severity. Higher levels of fatigue at 1 year was predicted by baseline catastrophizing, symptom focusing, distress and sleep quality, when controlling for baseline fatigue, clinical and demographic variables. These findings suggest psychological and behavioral factors are important in the maintenance of fatigue in people with HIV and identify potential opportunities for treatment. Future interventions for fatigue in HIV should not only address anxiety, depression and distress but could be optimized by targeting psychological processes such as catastrophic thinking styles and symptom focusing.

Qualitative Analysis of Illness Representations and Coping Perceptions Among Older Adults With Chronic Spinal Disability: "A Thought in the Back of My Mind".

OBJECTIVE: The purpose of this study was to explore older adults' illness representations, their beliefs about health, and their coping perceptions of chronic spinal disability. METHODS: This qualitative descriptive study used structured interviews that were completed during a randomized trial of non-pharmacological management of spine-related disability with chiropractic spinal manipulative therapy and exercise. Dual coders conducted a descriptive thematic analysis of 50 randomly selected transcripts supported by qualitative data management software. The Common-Sense Model provided an organizing framework for coding and interpretation. RESULTS: Fifty participants (34 women, median age: 68 years) described 4 illness representations, 4 coping styles, and 6 coping strategies for their management of spinal disability. Illness representations formed a continuum of little-to-no health impact to bothersome symptoms to heightened symptom intensity to unmanaged pain and/or disability. Most participants adopted either self-care or self-management coping styles, but some used healthcare-seeking or fear avoidance with worsening symptoms or interference with employment or preferred activities. Participants mentioned 6 coping strategies for spinal disability. Distraction included position changes, hobbies, and supportive relationships. Limitation focused on rest and/or relaxation, restricted movements, and activity modifications. Prevention enhanced self-care knowledge, posture and/or ergonomics, nutrition, and stress management. Movement emphasized stretching, home exercise and/or walking, and exercise therapy. Palliation augmented patient comfort through the use of heat and/or ice, over-the-counter medicine, and spinal manipulation. Avoidance strategies included missing employment, stopping house and/or yard work, and prescription medication. CONCLUSION: The community-dwelling older adults in this study offered varied illness representations of their chronic spinal disability. Most participants combined and personalized coping strategies to minimize pain and symptom impact; thus, representations may influence the coping styles adopted by older persons to manage their spinal conditions. A quote from a participant that pain was "a thought in the back of my mind" suggests the presence of cognitive and emotional processes that may influence individual perceptions and feelings about their spinal symptoms or conditions. These findings suggest that there may be a broader role for spine care clinicians to include teaching older people about self-management strategies to better cope with spinal disabilities.

Perceptions of illness severity in adults with drug-resistant temporal lobe epilepsy.

OBJECTIVE: The purpose of this study was to explore how subjective perceptions of illness severity were described by a sample of participants with drug-resistant epilepsy (DRE) who were considering surgery. METHODS: A qualitative methodology, constructivist grounded theory, guided all aspects of the study. Data were collected via 51 semi-structured interviews with 35 adults in our multiethnic sample. At interview, the 20 women (57%) and 15 men (43%) ranged in age from 18 to 68 years (mean = 35.6 years) and had lived with epilepsy for an average of 15.4 y (range = 2-44 years). RESULTS: A grounded theory with four interrelated categories was developed to reflect the process by which participants arrived at an explanation of illness severity. Illness severity for participants evolved as participants reflected upon the burdensome impact of uncontrolled seizures on self and others. Epilepsy, when compared with other chronic conditions, was described as less serious, and participants imagined that other peoples' seizures were comparatively worse than their own. Illness severity was not uppermost in participants' minds but emerged as a concept that was both relative and linked to social burden. Perceptions of overall disease severity expanded upon determinants of seizure severity to offer a more complete explanation of what patients themselves did about longstanding, uncontrolled epilepsy. CONCLUSIONS: Perceptions of illness severity played a vital role in treatment decision-making with the potential to impact the illness trajectory. How to measure components of illness severity represents a new challenge for outcomes research in DRE.

Patients' pre- and postoperative expectations as predictors of clinical outcomes six months after cardiac surgery.

The aim of this study was to investigate not only preoperative expectations (as shown previously), but also postoperative expectations of patients predict clinical outcomes six months after cardiac surgery. Furthermore, the study sought to examine illness behavior as a possible pathway through which expectations may affect postoperative well-being. Seventy patients scheduled for cardiac surgery were examined one day before surgery, ~7-10 days after surgery, and six months after surgery. Regression analyses indicated that disability at follow-up (primary outcome) was significantly predicted by postoperative (ß = -.342, p = .008), but not by preoperative expectations (ß = -.213, p = .069). Similar results were found for the secondary outcomes, i.e. quality of life and depressive symptoms. A bootstrapped mediation analysis showed that although both postoperative expectations and illness behavior had significant unique effects on disability, there was no significant mediation effect. While previous studies have mainly focused on patients' preoperative expectations, the present is the first to emphasize the predictive value of patients' expectations a few days after surgery, pointing to the potential of interventions targeting postoperative expectations. However, given the non-significant results of the mediation analysis, it remains unclear how exactly patients' expectations affect clinical outcomes in cardiac surgery.

A Trial Integrating Different Methods to Assess Psychosocial Problems in Primary Care.

BACKGROUND: A number of studies have documented psychosocial problems, psychiatric morbidity and impaired quality of life in primary care patients. OBJECTIVE: The aim of this trial was to test the usefulness of the joint use of different diagnostic interviews and self-rated questionnaires. METHODS: Two hundred consecutive patients in a primary care practice in Italy underwent the Structured Clinical Interview for DSM-5 and the Semi-Structured Interview for the Diagnostic Criteria for Psychosomatic Research (DCPR) in its recently revised form. As self-rated evaluations, the PsychoSocial Index, the Short-Form Health Survey and the Illness Attitude Scales were administered. RESULTS: There were 46 patients (23%) with at least 1 DSM-5 diagnosis. Eighty-eight patients (44%) had at least 1 DCPR diagnosis, mainly maladaptive illness behavior (26.5%), allostatic overload (15.5%) and demoralization (15%). There were 47 (23.5%) patients who had a DCPR diagnosis only; 5 subjects (2.5%) had a DSM diagnosis only. Patients with DCPR syndromes displayed significantly higher self-rated levels of stress, psychological distress and maladaptive illness behavior and significantly lower levels of quality of life and well-being than patients with no diagnoses. CONCLUSIONS: In a busy clinical setting, a simple self-rated questionnaire such as the PsychoSocial Index may afford a useful tool to unveil patient current distress. The DCPR can provide clinical information for a substantial number of patients who do not satisfy DSM-5 classification criteria and yet present with psychosocial problems, as measured by self-rated scales. The DCPR may improve the assessment and treatment plan of primary care psychologists or consulting psychiatrists.

The mediating effect of health anxiety in the relationship between functional somatic symptoms and illness behavior in Chinese inpatients with depression.

BACKGROUND: Functional somatic symptoms in depression disorder may cause inappropriate illness behavior hindering the treatment process. Health anxiety may play a role in this relationship, but few studies have examined it. The current study aimed to investigate the role of health anxiety in the relationship between functional somatic symptoms and illness behavior in patients with depression. METHODS: The present study recruited 323 hospitalized patients with depression to complete the Patient Health Questionnaire-15, Whiteley-Index-7, and Scale for the Assessment of Illness Behavior, then constructed a structural equation model to examine whether health anxiety mediated the relationship between functional somatic symptoms and illness behavior. RESULTS: The results showed significant correlations between any two of the three variables of interest. More importantly, health anxiety played a partially mediating role (42.86%) in the relationship between functional somatic symptoms and illness behavior. Further analysis suggested that elderly patients reached higher health anxiety than younger patients when their functional somatic symptoms were mild. CONCLUSIONS: These results highlight that health anxiety may mediate the influence of functional somatic symptoms on illness behavior. The implications of assessing and intervening in health anxiety in patients with depression were discussed.

Association Between Symptoms of Central Sensitization and Cognitive Behavioral Factors in People With Chronic Nonspecific Low Back Pain: A Cross-sectional Study.

OBJECTIVE: The objective of this cross-sectional study was to analyze the relationship between symptoms of central sensitization (CS) and important cognitive behavioral and psychosocial factors in a sample of patients with chronic nonspecific low back pain. METHODS: Participants with chronic nonspecific low back pain for at least 3 months were included in the study. They completed several questionnaires and a functional test. Pearson's correlation was used to analyze associations between symptoms of CS and pain behavior, functioning, pain, pain catastrophizing, kinesiophobia, and illness perceptions. Additionally, a between-group analysis was performed to compare patients with and without clinically relevant symptoms of CS. RESULTS: Data from 38 participants were analyzed. Significant associations were found between symptoms of CS and all other outcomes, especially current pain (r = 0.510, P = .001), mean pain during the past 7 days (r = 0.505, P = .001), and pain catastrophizing (r = 0.518, P = .001). Patients with clinically relevant symptoms of CS scored significantly worse on all outcomes compared with persons without relevant symptoms of CS, except on functioning (P = .128). CONCLUSIONS: Symptoms of CS were significantly associated with psychosocial and cognitive behavioral factors. Patients exhibiting a clinically relevant degree of symptoms of CS scored significantly worse on most outcomes, compared with the subgroup of the sample with fewer symptoms of CS.

The Clinical Inadequacy of the Placebo Model and the Development of an Alternative Conceptual Framework.

Placebo effects are often attributed to clinical interactions and contextual factors that affect expectations of the patient about the treatment and result in symptom changes. The prevailing conceptualization consists of an undifferentiated placebo response that needs to be minimized in controlled investigations and maximized in clinical practice. However, treatment outcome is the cumulative result of the interaction of several classes of variables with a selected treatment: living conditions (housing, nutrition, work environment, social support), patient characteristics (age, sex, genetics, general health conditions, personality, well-being), illness features and previous therapeutic experience, self-management, and treatment setting (physician's attitude and attention, illness behavior). Such variables may be therapeutic or countertherapeutic, and are unlikely to be simply additive. In certain patients their interactive combination may lead to clinical improvement, whereas in other cases it may produce no effect, and, in a third group, it may lead to worsening of the condition. Maximizing patients' expectations does not necessarily result in sustained effects and, in due course, may actually lead to worsening of the condition (violation of expectations). In this paper, we outline a multifactorial conceptual model that may have implications for the design of clinical trials as well as for clinical practice, with special reference to psychopharmacology and psychotherapy. The effects of drug treatment may be potentiated by specific nonpharmacological treatment strategies, and this synergism may disclose significant differences against placebo. Medical outcomes may be unsatisfactory not because technical interventions are missing, but because our conceptual models and thinking are inadequate.

Predicting wellbeing among people with epilepsy using illness cognitions.

OBJECTIVE: This study sought to examine the synergistic contribution of illness-related perceptions (stigma, severity, and threat) and illness behavior to wellbeing among people with epilepsy. Poorer wellbeing was expected among those who perceived greater stigma, illness severity, and threat and had more extreme illness behavior. METHODS: Individuals with a diagnosis of epilepsy (N=210), recruited through local and online support groups, completed a questionnaire comprising demographic and epilepsy-specific information, and validated measures of illness perceptions and behavior, epilepsy-related quality of life, and general psychological health. RESULTS: Bivariate associations among illness cognition, illness behavior, and wellbeing were all as expected. Structural equation modeling highlighted the strong, direct effect of illness threat on quality of life, with other contributions from perceived stigma and an abnormal illness behavior syndrome (i.e., maladaptive illness responses). Significant variance was accounted for in both quality of life (64%) and psychological health (34%). CONCLUSION: Preliminary evidence of the contributions of illness threat and maladaptive illness responses to wellbeing highlights the need for longitudinal research to examine the dynamic nature of such findings. Clinicians are encouraged to consider the potential value of screening for both illness threat and abnormal illness behavior to facilitate interventions.

Effectiveness of an Educational Physiotherapy and Therapeutic Exercise Program in Adult Patients With Hemophilia: A Randomized Controlled Trial.

OBJECTIVE: To assess the efficacy of an educational physiotherapy home exercise intervention for physical improvement, pain perception, quality of life, and illness behavior in patients with hemophilic arthropathy. DESIGN: Single-blind randomized controlled trial. SETTING: Home. PARTICIPANTS: Patients with hemophilia (N=20) were randomly allocated to an educational intervention group or to a control group. INTERVENTIONS: The educational intervention was performed every 2 weeks over a 15-week period, and home exercises were carried out once a day, 6 days a week, over the same period. MAIN OUTCOME MEASURES: Joint status was evaluated using the Gilbert scale; pain was assessed using the visual analog scale; illness behavior was evaluated using the Illness Behavior Questionnaire; and the perception of the quality of life was evaluated using the A36 Hemophilia-QoL questionnaire. RESULTS: We observed significant differences in the intervention group and the control group for both quality of life and illness behavior. There was no significant improvement in joint status; however, an improvement was noted in terms of perception of pain in the ankle. CONCLUSIONS: A physiotherapy program based on educational sessions and home exercises can improve the perception of pain in patients with hemophilic arthropathy of the ankle. It improves some variables in the perception of the quality of life and illness behavior.

The role of perceived sleep norms in subjective sleep appraisals and sleep-related illness behavior.

The present investigation sought to extend extant research on subjective sleep complaints by examining their relation to perceived sleep norms. Results from two studies showed that individuals' distress and illness behavior in response to symptoms of fatigue and non-restorative sleep was influenced by their perceptions of peer norms for those symptoms. Individuals who believed they experienced a greater degree of fatigue and non-restorative sleep than their peers reported more distress arising from those symptoms, and were also more likely to seek social support and medical treatment for them. Furthermore, participants who scored higher in neuroticism were more likely to believe they experienced worse fatigue and non-restorative sleep than their peers, and thus reported higher symptom-related distress, and higher likelihood of engaging in illness behaviors. These results provide preliminary evidence of the clinical relevance of perceived norms in the way individuals respond to and manage sleep related problems.

Validated Measures of Illness Perception and Behavior in People with Knee Pain and Knee Osteoarthritis: A Scoping Review.

OBJECTIVE: To identify validated measures that capture illness perception and behavior and have been used to assess people who have knee pain/osteoarthritis. METHODS: A scoping review was performed. Nine electronic databases were searched for records from inception through April 19, 2015. Search terms included illness perception, illness behavior, knee, pain, osteoarthritis, and their related terms. This review included English language publications of primary data on people with knee pain/osteoarthritis who were assessed with validated measures capturing any of 4 components of illness perception and behavior: monitor body, define and interpret symptoms, take remedial action, and utilize sources of help. Seventy-one publications included relevant measures. Two reviewers independently coded and analyzed each relevant measure within the 4 components. RESULTS: Sixteen measures were identified that capture components of illness perception and behavior in the target population. These measures were originally developed to capture constructs that include coping strategies/skills/styles, illness belief, illness perception, self-efficacy, and pain behavior. Coding results indicated that 5, 11, 12, and 5 of these measures included the monitor body, define and interpret symptoms, take remedial action, and utilize sources of help components, respectively. CONCLUSIONS: Several validated measures were interpreted as capturing some components, and only 1 measure was interpreted as capturing all of the components of illness perception and behavior in the target population. A measure that comprehensively captures illness perception and behavior could be valuable for informing and evaluating therapy for patients along a continuum of symptomatic knee osteoarthritis.

Help seeking behavior and onset-to-alarm time in patients with acute stroke: sub-study of the preventive antibiotics in stroke study.

BACKGROUND: Patients with acute stroke often do not seek immediate medical help, which is assumed to be driven by lack of knowledge of stroke symptoms. We explored the process of help seeking behavior in patients with acute stroke, evaluating knowledge about stroke symptoms, socio-demographic and clinical characteristics, and onset-to-alarm time (OAT). METHODS: In a sub-study of the Preventive Antibiotics in Stroke Study (PASS), 161 acute stroke patients were prospectively included in 3 Dutch hospitals. A semi-structured questionnaire was used to assess knowledge, recognition and interpretation of stroke symptoms. With in-depth interviews, response actions and reasons were explored. OAT was recorded and associations with socio-demographic, clinical parameters were assessed. RESULTS: Knowledge about stroke symptoms does not always result in correct recognition of own stroke symptoms, neither into correct interpretation of the situation and subsequent action. In our study population of 161 patients with acute stroke, median OAT was 30 min (interquartile range [IQR] 10-150 min). Recognition of one-sided weakness and/or sensory loss (p = 0.046) and adequate interpretation of the stroke situation (p = 0.003), stroke at daytime (p = 0.002), severe stroke (p = 0.003), calling the emergency telephone number (p = 0.004), and transport by ambulance (p = 0.040) were associated with shorter OAT. CONCLUSION: Help seeking behavior after acute stroke is a complex process. A shorter OAT after stroke is associated with correct recognition of one-sided weakness and/or sensory loss, adequate interpretation of the stroke situation by the patient and stroke characteristics and logistics of stroke care, but not by knowledge of stroke symptoms.

The clinical inadequacy of the DSM-5 classification of somatic symptom and related disorders: an alternative trans-diagnostic model.

The Diagnostic and Statistical of Mental Disorders, Fifth Edition (DSM-5) somatic symptom and related disorders chapter has a limited clinical utility. In addition to the problems that the single diagnostic rubrics and the deletion of the diagnosis of hypochondriasis entail, there are 2 major ambiguities: (1) the use of the term "somatic symptoms" reflects an ill-defined concept of somatization and (2) abnormal illness behavior is included in all diagnostic rubrics, but it is never conceptually defined. In the present review of the literature, we will attempt to approach the clinical issue from a different angle, by introducing the trans-diagnostic viewpoint of illness behavior and propose an alternative clinimetric classification system, based on the Diagnostic Criteria for Psychosomatic Research.

The Heterogeneity of Illness Behaviors in Patients with Medically Unexplained Physical Symptoms.

PURPOSE: To investigate the heterogeneity of illness behavior in patients with medically unexplained physical symptoms (MUPS), we clustered patients in regard to their degree of engaging in different aspects of illness behavior and identified related variables with these behaviors. METHOD: A sample of N = 224 patients attending treatment in primary care with a history of MUPS (at least two symptoms) was investigated by analyzing different aspects of illness behavior with the self-reported number of doctor visits during the last 6 months and the Scale for the Assessment of Illness Behavior (SAIB; e.g., expression of symptoms). RESULTS: Two distinct clusters were identified by cluster analysis: a low (n = 106) and a high (n = 118) illness behavior clusters. The high illness behavior cluster exhibited a significantly higher rate of health anxiety than the low illness behavior cluster. Regression analysis revealed a particular effect of sex in the high illness behavior cluster: whereas being male was associated with increased illness behavior as measured by the SAIB, being female was linked to a higher number of doctor visits. Increased health anxiety was associated with the SAIB illness behavior in both clusters. Depression and anxiety did not show incremental associations with all aspects of illness behavior. CONCLUSION: Knowledge of the pattern of illness behavior in patients with MUPS enables us to improve psychological treatments that directly address specific aspects of illness behavior or health anxiety. Differences between sexes in illness behaviors require more differentiated consideration in future research.