Psychological risk factors of somatic symptom disorder: A systematic review and meta-analysis of cross-sectional and longitudinal studies.

OBJECTIVE: Current diagnostic concepts of somatic symptom disorder (SSD) in DSM-5 and bodily distress disorder (BDD) in ICD-11 require certain psychological criteria, but researchers have called for further specification. Therefore, in a first step, this systematic review and meta-analysis aimed to summarize the current evidence on psychological factors associated with SSD/BDD and/or disorder-relevant clinical outcomes such as symptom severity and impairment. METHODS: Psychological factors were systematically searched using Pubmed, Cochrane Library and Psycinfo via EBSCO. Studies providing original data in English or German, after 2009 were included. Cross-sectional, cohort and case-control studies investigating at least one psychological factor in individuals with SSD/BDD in the context of disorder-relevant outcomes were included. RESULTS: Forty-three eligible studies (n = 3760 patients) in SSD (none in BDD) provided data on at least one psychological factor, 37 in case-control format, 10 cross-sectional and 5 longitudinal. Meta-analyses of the case-control studies found patients with SSD to be more impaired by depression (SMD = 1.80), anxiety (SMD = 1.55), health anxiety (SMD = 1.31) and alexithymia (SMD = 1.39), compared to healthy controls. Longitudinal results are scarce, mixed, and require refining, individual studies suggest self-concept of bodily weakness, anxiety and depression to be predictive for persistent SSD and physical functioning. CONCLUSION: This review provides a detailed overview of the current evidence of psychological factors in relation to SSD/BDD. Future studies on SSD and BDD should include under-studied psychological factors, such as negative affect, fear avoidance, or emotion regulation. More longitudinal studies are needed to assess the predictive value of these factors.

Helpful explanatory models for persistent somatic symptoms (HERMES): Results of a three-arm randomized-controlled pilot trial.

OBJECTIVE: This three-arm randomized controlled trial aimed to test the efficacy of an etiological model for persistent somatic symptoms (PSS) translated into video-animated explanatory models in comparison to a control group, and to examine additional value of personalization of the explanatory models (i.e. possibility to choose information based on mechanisms of symptom persistence). METHODS: Outpatients with PSS were shown one of three 15-min video animations: a) explanatory model without personalization, b) explanatory model with personalization, c) no explanatory model control group. Changes in somatic symptom severity (PHQ-15) and psychological burden related to somatic symptoms or associated health concerns (SSD-12) from baseline to one-month follow-up were the primary outcome. Health-related quality of life (SF-12) and perceived usefulness (USE) were also assessed. RESULTS: Seventy-five patients with PSS were allocated to the study arms (Mage = 44.2 ± 13.3 years, 56% female). The study arms did not differ significantly on the primary outcomes. However, no explanatory model participants reported significantly greater mental quality of life improvements than explanatory model without personalization participants (Mdiff = 7.50 [0.43; 14.56]). Further, explanatory model with personalization participants rated the individual fit of the intervention significantly higher than no explanatory model participants (Mdiff = 2.05 [0.17; 3.93]). All groups rated credibility of the intervention as very high. CONCLUSION: The HERMES materials seemed to have been too brief to improve symptom related outcomes. However, all three interventions were positively evaluated regarding their usefulness, particularly in case of additional personalization. Future studies should investigate potential effects of an increased intervention dose. TRIAL REGISTRATION: DRKS00018803.

Patients' acceptance of explanatory models for persistent somatic symptoms: A qualitative analysis within the HERMES study.

OBJECTIVE: The aim of this qualitative study was to provide an in-depth analysis of participants' experiences with video-animated explanatory models developed within the three-arm randomized controlled HERMES study ('Helpful explanatory models for somatic symptoms') and suggestions for further intervention improvement. METHODS: Semi-structured qualitative interviews were conducted with psychosomatic outpatients with persistent somatic symptoms (PSS) after they were randomized to view one of three psychoeducational videos on a tablet computer: a) an explanatory model without personalization or b) an explanatory model with personalization in the two experimental groups or c) PSS guidelines without an explanatory model in the control group. Qualitative interviews were audiotaped, transcribed and analyzed applying thematic analysis. RESULTS: Seventy-five patients with PSS were allocated to the study arms, mean duration of interviews was 8.19 min (SD = 3.19, range 4.02-19.49 min). Although all participants gave positive feedback regardless of their allocated study arm, those in the explanatory model without and with personalization groups were especially likely to rate the psychoeducational interventions as helpful. Results highlighted previous illness course, symptom perceptions and patient characteristics as key factors related to patients' response to the video interventions and optimal personalization of the explanatory model. CONCLUSION: The present study not only demonstrated the acceptance of all three psychoeducational interventions developed within the HERMES study, but also provided valuable insights into potential key factors that may increase their impact and potential starting points for tailored psychoeducation in patients with PSS.

The framework for systematic reviews on psychological risk factors for persistent somatic symptoms and related syndromes and disorders (PSY-PSS).

Introduction: Numerous psychological factors are believed to play a pivotal role in the development and maintenance of persistent somatic symptoms (PSS) in all fields of medicine. However, very few of these factors have been empirically investigated in relation to PSS. The aim of this study is firstly to propose a framework and define search terms for systematic reviews on the empirical evidence and diagnostic value of psychological risk factors for PSS and PSS-related outcomes (PSY-PSS). Secondly, the application of the framework is illustrated using the example of a systematic review on the relevance of psychological factors in somatic symptom disorders (SSD; DSM-5) and bodily distress disorders (BDD; ICD-11). Methods: Following a narrative review approach, two comprehensive lists of search terms to identify studies in (1) relevant patient groups with PSS and (2) relevant psychological factors were generated by reviewing the current literature and employing an iterative process of internal revision and external expert feedback. Results: We identified 83 relevant symptoms, syndromes and disorders for which we defined a total of 322 search terms (list 1). We further comprised 120 psychological factors into 42 subcategories and 7 main categories (list 2). The introduced lists can be combined to conduct systematic reviews on one or more specific psychological factors in combination with any symptom, syndrome or disorder of interest. A protocol of the application of this framework in a systematic review and meta-analysis on psychological etiological factors of SSD and BDD is presented following the PRISMA guidelines. Discussion: This framework will help to gather systematic evidence on psychological factors in order to improve the understanding of the etiology of PSS, to refine future diagnostic conceptualizations of PPS, and to develop optimized mechanism-based interventions for individuals with PPS and related syndromes and disorders.

From the identification of biopsychosocial risk factors to an increase in pain-related self-efficacy (IDRIS) - The online-based conveyance of an explanatory model for chronic back pain: Study protocol of a cohort multiple randomized controlled trial.

Background: Back pain has a high global prevalence and carries a substantial risk for chronification. Biopsychosocial factors are assumed to be critical in the transition from acute to chronic back pain. Digital interventions are a promising tool to educate patients about their complaints. Thus, providing patients with an explanatory model regarding their individual risk factors in the early stage of their complaints via the internet might thus be a valuable approach in treatment. Objectives: The objectives of the present online study are to investigate the influence of a personalized psychoeducational intervention on self-efficacy and functioning and to examine biopsychosocial risk factors for symptom chronification. The intervention is based on a current model summarizing the empirical knowledge on relevant factors for persistent somatic symptoms, which has not been studied in back pain patients yet. Methods: An observational cohort of patients with acute and subacute back pain (N = 564) will be asked about biopsychosocial risk factors via online survey at baseline, 4-week, and 12-week follow-up. Within this cohort, a randomly selected group of 132 participants (intervention group) with psychological burden (MCS-12 score of the SF-12 ≤ 50) and relevant somatic symptom intensity and interference (mean sum score of two numeric rating scales ≥5) and no prior psychotherapeutic treatment will be offered a personalized explanatory model in the form of an animated psychoeducational video. The video will be personalized in terms of participants' individual symptom profile and will be made accessible to watch online for 7 days. Participants will be compared to a control group receiving no treatment regarding change in pain-specific self-efficacy after 1 month as primary outcome, and change in functioning after 1 and 3 months, respectively, as secondary outcomes. Acceptance and usefulness of the intervention will be evaluated using the number of video views and a numeric rating scale. Discussion: This is the first investigation of a personalized, video-animated online psychoeducation based on patients' individual risk factors for the chronification of back pain and the first systematic evaluation of the risk factors included in a comprehensive aetiological model on persistent somatic symptoms in back pain patients. This way, this study contributes to the understanding of cross-disorder psychopathological factors and a stronger consideration of biopsychosocial factors in the treatment of persistent somatic symptoms. If proven effective, the internet-based intervention will make an important contribution to the early treatment of back pain. Ethical approval: The study was approved by the Local Psychological Ethics Committee (LPEK) at the Center for Psychosocial Medicine of the University Medical Center Hamburg-Eppendorf. Trial registration: The study was registered at the German Clinical Trials Register in December 2021 (registration trial number: DRKS00025445).

Somatic symptom disorder: a scoping review on the empirical evidence of a new diagnosis.

BACKGROUND: In 2013, the diagnosis of somatic symptom disorder (SSD) was introduced into the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This review aims to comprehensively synthesize contemporary evidence related to SSD. METHODS: A scoping review was conducted using PubMed, PsycINFO, and Cochrane Library. The main inclusion criteria were SSD and publication in the English language between 01/2009 and 05/2020. Systematic search terms also included subheadings for the DSM-5 text sections; i.e., diagnostic features, prevalence, development and course, risk and prognostic factors, culture, gender, suicide risk, functional consequences, differential diagnosis, and comorbidity. RESULTS: Eight hundred and eighty-two articles were identified, of which 59 full texts were included for analysis. Empirical evidence supports the reliability, validity, and clinical utility of SSD diagnostic criteria, but the further specification of the psychological SSD B-criteria criteria seems necessary. General population studies using self-report questionnaires reported mean frequencies for SSD of 12.9% [95% confidence interval (CI) 12.5-13.3%], while prevalence studies based on criterion standard interviews are lacking. SSD was associated with increased functional impairment, decreased quality of life, and high comorbidity with anxiety and depressive disorders. Relevant research gaps remain regarding developmental aspects, risk and prognostic factors, suicide risk as well as culture- and gender-associated issues. CONCLUSIONS: Strengths of the SSD diagnosis are its good reliability, validity, and clinical utility, which substantially improved on its predecessors. SSD characterizes a specific patient population that is significantly impaired both physically and psychologically. However, substantial research gaps exist, e.g., regarding SSD prevalence assessed with criterion standard diagnostic interviews.

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.

Helpful explanatory models for somatoform symptoms (HERMES): study protocol of a randomised mixed-methods pilot trial.

INTRODUCTION: Persistent somatic symptoms (PSS) are common both in the general population and primary care. They are bothersome in terms of psychological and somatic symptom burden. Health professionals often struggle with communication, as there is a lack of scientifically supported explanatory models for PSS or a focus merely on somatic aspects of the complaints, which both frustrate patients' needs. The objective of the present study is therefore to develop a psychoeducational intervention based on a current evidence-based explanatory model, to examine its feasibility and form the basis for a large-scale randomised controlled trial. METHODS AND ANALYSIS: In a randomised controlled mixed-methods pilot trial, 75 adult psychosomatic outpatients with PSS (duration of symptoms ≥6 months) and accompanying psychological (Somatic Symptom B-Criteria Scale total score ≥18) and somatic symptom burden (Patient Health Questionnaire-15 score >10) and no prior psychosomatic treatment will be eligible. Participants will be presented with either the explanatory model without (intervention group 1, n=25) or with elements of personalisation (intervention group 2, n=25). Participants in the control group (n=25) will receive information on current PSS guidelines. Participants will be blinded to group assignment and interventions will be shown on tablet computers at the outpatient clinic. After 1 month, qualitative follow-up telephone interviews will be conducted. As primary outcomes, mean changes in psychological and somatic symptom burden will quantitatively be compared between groups, respectively. Behavioural change mechanisms and feasibility of the three interventions will be evaluated using quantitative and qualitative measures. ETHICS AND DISSEMINATION: Ethics approval has been granted by the medical ethics board of the Hamburg Medical Chamber (PV5653). Results from this study will be published in peer-reviewed journals and presented at national and international conferences. TRIAL REGISTRATION NUMBER: DRKS00018803.

Application and validation of the bodily distress syndrome checklist in a psychosomatic outpatient sample.

OBJECTIVE: The BDS checklist is a self-report measure to assess the most common somatic symptoms in functional somatic syndromes, based on the diagnostic concept of Bodily Distress Syndrome. The aim of the study was to examine the psychometric properties and validity of the BDS checklist in a psychosomatic sample and to investigate whether it is suitable to detect DSM-5 somatic symptom disorders (SSD). METHOD: In a cross-sectional study, n = 368 patients from a psychosomatic outpatient clinic completed the BDS checklist and a semi-structured clinical interview on SSD. Item and scale characteristics and measures of reliability and validity were determined. RESULTS: The BDS checklist showed good item characteristics and reliability (Cronbach α = 0.89). Factor analysis confirmed four symptom clusters (CFI = 0.95, TLI = 0.95, RMSEA = 0.091, 90% CI = 0.085-0.097). The BDS total score showed significant correlations with other measures of somatic symptom burden (r = 0.79, p < .001), health anxiety (r = 0.46, p < .001), depression (r = 0.45, p < .001), and general anxiety (r = 0.41, p < .001). Higher BDS checklist scores were associated with higher physical and mental health impairment and higher health care use. Diagnostic accuracy regarding somatic symptom disorder was moderate (AUC = 0.72, 95% CI: 0.67-0.77). CONCLUSION: Findings of our study indicate that the BDS checklist is a reliable and valid measure to assess the most common somatic symptoms in a psychosomatic setting. It is however not sufficient to detect persons at risk for somatic symptom disorder. A combination with further questionnaires could probably improve diagnostic accuracy.

Excessiveness in Symptom-Related Thoughts, Feelings, and Behaviors: An Investigation of Somatic Symptom Disorders in the General Population.

OBJECTIVE: The diagnostic criteria of somatic symptom disorder (SSD) emphasize that somatic symptoms receive disease value once they are accompanied by excessive thoughts, feelings, or behaviors. The main objective of this study was to examine what constitutes excessiveness in psychological reactions to somatic complaints and how excessive symptom-related behavior influences self-reported health status and health care utilization. METHODS: A national, representative general population survey was performed between January and March 2016 in Germany, including 2395 individuals older than 13 years. Self-report questionnaires (Somatic Symptom Scale-8, Somatic Symptom Disorder-B Criteria Scale) were used to operationalize the SSD criteria. Group differences in the daily amount of time dedicated to physical complaints were analyzed between individuals with and without SSD. Stepwise linear regression analyses were performed to predict general mental and physical health status, and health care utilization. RESULTS: There was a significant effect of group (SSD yes/no) in daily time spent on symptoms, after controlling for age, sex, depression, and anxiety (F(1,2336) = 447.53, p < .001). The SSD group (n = 213) reported an average of 4 hours, whereas individuals without SSD reported 30 minutes. Results of the regression analyses showed that the combination of somatic symptoms and symptom-related psychological features is predictive of worsened self-reported physical and mental health status, and increased health care utilization. CONCLUSIONS: A range of 3 to 4 hours per day spent on dealing with physical complaints seems indicative of excessiveness. If, during a clinical consultation, a patient reports such a large amount of time, a more comprehensive clinical examination of SSD should follow.

Sensitivity to change and minimal clinically important difference of the 7-item Generalized Anxiety Disorder Questionnaire (GAD-7).

BACKGROUND: Effective treatment requires regular follow-up and monitoring of symptoms. We investigated sensitivity to change and minimal clinically important difference of the Generalized Anxiety Disorder Scale (GAD-7). METHODS: This study included all participants from a multisite trial of chronic depression. Baseline and follow-up (12 and 48 weeks) data were used to assess treatment response. Effect sizes (ES) and standardized response means (SRM) of pre- and post-GAD-7 mean changes were calculated for subgroups of patients, who did or did not improve according to ratings in the Hamilton Rating Scale for Depression (HRSD-24). RESULTS: N = 261 patients were included in the analyses. In the subgroup of patients who improved according to HRSD-24, GAD-7 scores were significantly lower after 12 weeks (t = -6.31, df = 120, p < .001; ES = -0.51, SRM = -0.57), and 48 weeks of treatment (t = -12.68, df = 141, p < .001; ES = -1.0, SRM = -1.7), when compared to admission. In the group who worsened, GAD-7 scores were significantly higher after 12 weeks (t = 2.96, df = 41, p = .005; ES = 0.30, SRM = 0.46), and increased after 48 weeks (t = 1.99, df = 21, p = .059; ES = 0.37, SRM = 0.43), when compared to baseline. The unchanged group showed no significant difference between baseline and follow-up. MCID was estimated 4 points on the GAD-7 total score. LIMITATIONS: Confirmation of these findings and further investigation of the GAD-7 in populations and trials focusing on anxiety-specific treatment is highly recommended. CONCLUSIONS: Results show that the GAD-7 is sensitive to detect change in psychopathology over the course of treatment.

Detecting DSM-5 somatic symptom disorder: criterion validity of the Patient Health Questionnaire-15 (PHQ-15) and the Somatic Symptom Scale-8 (SSS-8) in combination with the Somatic Symptom Disorder - B Criteria Scale (SSD-12).

BACKGROUND: The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) introduced somatic symptom and related disorders (SSD) to improve the diagnosis of somatoform disorders. It is unclear whether existing questionnaires are useful to identify patients with SSD. Our study investigates the diagnostic accuracy of the Patient Health Questionnaire-15 (PHQ-15) and the Somatic Symptom Scale-8 (SSS-8) in combination with the Somatic Symptom Disorder - B Criteria Scale (SSD-12). METHODS: For this cross-sectional study, participants were recruited from a psychosomatic outpatient clinic. PHQ-15, SSS-8, and SSD-12 were administered and compared with SSD criteria from a diagnostic interview. Sensitivity and specificity were calculated for optimal individual and combined cutpoints. Receiver operator curves were created and area under the curve (AUC) analyses assessed. RESULTS: Data of n = 372 patients [31.2% male, mean age: 39.3 years (s.d. = 13.6)] were analyzed. A total of 56.2% fulfilled the SSD criteria. Diagnostic accuracy was moderate for each questionnaire (PHQ-15: AUC = 0.70; 95% CI = 0.65-0.76; SSS-8: AUC = 0.71; 95% CI = 0.66-0.77; SSD-12: AUC = 0.74; 95% CI = 0.69-0.80). Combining questionnaires improved diagnostic accuracy (PHQ-15 + SSD-12: AUC = 0.77; 95% CI = 0.72-0.82; SSS-8 + SSD-12: AUC = 0.79; 95% CI = 0.74-0.84). Optimal combined cutpoints were ⩾9 for the PHQ-15 or SSS-8, and ⩾23 for the SSD-12 (sensitivity and specificity = 69% and 70%). CONCLUSIONS: The combination of the PHQ-15 or SSS-8 with the SSD-12 provides an easy-to-use and time- and cost-efficient opportunity to identify persons at risk for SSD. If systematically applied in routine care, effective screening and subsequent treatment might help to improve quality of life and reduce health care excess costs.

Substance Abuse-Related Self-Stigma in Women with Substance Use Disorder and Comorbid Posttraumatic Stress Disorder.

BACKGROUND: Self-stigma is a result of internalizing negative stereotypes by the affected person. Research on self-stigma in substance use disorders (SUD) is still scarce, especially regarding the role of childhood trauma and subsequent posttraumatic disorders. OBJECTIVES: The present study investigated the progressive model of self-stigma in women with SUD and posttraumatic stress disorder (PTSD), and the predictive value of PTSD severity and childhood trauma experiences on self-stigma. METHOD: In a cross-sectional study with 343 women with SUD and PTSD, we used the Self-Stigma in Alcohol Dependency Scale, the Childhood Trauma Questionnaire (CTQ), the PTSD Symptom Scale Interview (PSS-I), and to control for SUD severity and depression, the Addiction Severity Index Lite and the Beck Depression Inventory-II. Hierarchical regression analyses were conducted for each stage of self-stigma (aware-agree-apply-harm). RESULTS: The interrelated successive stages of self-stigma were largely confirmed. In the regression models, no significant effects of the PSS-I- and the CTQ-scores were observed at any stage of self-stigma. Agreeing with negative stereotypes was solely predicted by younger age, applying these stereotypes to oneself was higher in women with younger age, higher depression and SUD severity, and suffering from the application (harm) was only predicted by depression. CONCLUSIONS: The progressive model of self-stigma could be confirmed in women with SUD and PTSD, but PTSD severity and childhood trauma did not directly affect this process. Self-stigma appears to be related to depression in a stronger way than PTSD is related to women with SUD and PTSD.

Validity and sensitivity to change of the Somatic Symptom Disorder-B Criteria Scale (SSD-12) in a clinical population.

OBJECTIVE: The SSD-12 is a brief self-report questionnaire to measure the psychological criteria of DSM-5 Somatic Symptom Disorder. This study examines its psychometric properties in a German inpatient sample from a psychosomatic rehabilitation setting, and provides evidence to its sensitivity to change. METHOD: Patients completed the SSD-12 and the Health49-subscale on somatoform complaints before and after receiving inpatient treatment. Therapists evaluated the psychological improvement of their patients at the end of treatment. Effect sizes (ES) and standardized response means (SRM) of pre- and post-SSD-12 mean changes were calculated for subgroups of patients who did or did not improve. RESULTS: SSD-12 scores at discharge were significantly lower compared to scores at admission for subgroups of patients who improved according to clinicians (t=2976, df=103, p=.004), and for patients who improved according to self-report (t=5.059, df=159, p<.001). Effect sizes of change in SSD-12 scores in the improved subgroups were ES=-0.19 and ES=-0.30, and standardized response means were SRM=-0.29 and SRM=-0.40, respectively. CONCLUSION: The SSD-12 shows sound psychometric properties and is useful and time-efficient for monitoring psychological burden associated with bothersome somatic symptoms. Its sensitivity to change over time could be documented.

Comparing the diagnostic concepts of ICD-10 somatoform disorders and DSM-5 somatic symptom disorders in patients from a psychosomatic outpatient clinic.

OBJECTIVE: The reconceptualization of somatic symptom and related disorders in DSM-5 led to numerous consequences in terms of prevalence and affected patient populations. The present study aimed to investigate frequencies of ICD-10 somatoform disorders and DSM-5 somatic symptom disorders, and how the respective diagnostic groups differ in terms of sociodemographic and psychopathological characteristics. It discusses the usefulness and reliability of the new diagnostic criteria. METHOD: Patients from a German psychosomatic outpatient clinic (n = 438) completed self-report questionnaires on depression (PHQ-9), anxiety (GAD-7), symptom burden (PHQ-15), psychological distress (SSD-12), and quality of life (SF-12). ICD-10 diagnoses were provided by treating clinicians, DSM-5 diagnoses were assessed via semi-structured telephone interviews. The prevalence of somatic symptom disorders and their overlap with ICD-10 somatoform disorders was evaluated. Comparisons between patients with either diagnosis were drawn. RESULTS: More than half of the sample (n = 239, 54.6%) fulfilled the criteria for a somatic symptom disorder. Compared to patients fulfilling ICD-10 criteria only, patients with a somatic symptom disorder presented higher levels of symptom related distress (p = .045), health related anxiety (p = .004), general anxiety (p = .011), and lower mental health-related quality of life (p = .015), while patients with ICD-10 somatoform disorders reported a lower physical health-related quality of life (p = .031). CONCLUSION: DSM-5 criteria included more patients than ICD-10 somatoform disorders in our sample. Patients diagnosed with a somatic symptom disorder appear to be more severely impaired in terms of general and health-related anxiety and psychological distress associated to their somatic symptoms, especially when diagnosed with a severe form of somatic symptom disorder.

Somatoform disorder in primary care: The influence of co-morbidity with anxiety and depression on health care utilization.

RATIONALE, AIMS, AND OBJECTIVES: Patients with somatoform disorders are frequent attenders in primary and secondary care. While co-morbid mental disorders, especially depression and anxiety, are frequently present, there is controversy on whether mental co-morbidity leads to higher health care utilization (HCU). The present paper investigates the influence of co-morbid depressive and anxiety disorders on primary, specialized somatic and mental HCU in primary care patients with somatoform disorders. Additionally, we investigated the predictive value of self-rated health and illness perception on HCU. METHODS: Patients in 19 primary care practices were screened with the Patient Health Questionnaire, and patients at high risk for somatoform disorders were assessed using the Composite International Diagnostic Interview. N = 71 patients with somatoform disorders were analysed. We analysed whether having one vs two co-morbidities (depression and/or anxiety), self-rated health, and illness perception were predictors for primary, specialized somatic and mental HCU using binominal and hierarchical regression analyses. RESULTS: Having both co-morbid depressive and anxiety disorder predicted higher primary HCU (IRR = 1.96, 95% CI, 1.30-2.93), and increased the odds of being in mental health care (OR = 5.16, 95% CI, 1.10-24.20), while only one co-morbidity did not. No differences were found for specialized somatic HCU. Illness perception and self-rated health did not predict HCU. CONCLUSION: Not a single but only the presence of multiple co-morbidities predicts primary and mental HCU in patients with somatoform disorder. Health care utilization might be essentially influenced by the associated psychological distress, which should be considered in treatment.