Exploration of DSM-IV Criteria in Primary Care Patients With Medically Unexplained Symptoms

Department of Medicine, Michigan State University, East Lansing, Michigan, USA.
Psychosomatic Medicine (Impact Factor: 3.47). 02/2005; 67(1):123-9. DOI: 10.1097/01.psy.0000149279.10978.3e
Source: PubMed


Investigators and clinicians almost always rely on Diagnostic and Statistical Manual of Mental Disorder, 4th edition's (DSM-IV) somatoform disorders (and its derivative diagnoses) to characterize and identify patients with medically unexplained symptoms (MUS). Our objective was to evaluate this use by determining the prevalence of DSM-IV somatoform and nonsomatoform disorders in patients with MUS proven by a gold standard chart review.
In a community-based staff model HMO, we identified subjects for a clinical trial using a systematic and reliable chart rating procedure among high-utilizing MUS patients. Only baseline data are reported here. The World Health Organization Composite International Diagnostic Interview provided full and abridged DSM-IV diagnoses. Patients with full or abridged DSM-IV somatoform diagnoses were labeled "DSM somatoform-positive," whereas those without them were labeled "DSM somatoform-negative."
Two hundred six MUS patients averaged 13.6 visits in the year preceding study, 79.1% were females, and the average age was 47.7 years. We found that 124 patients (60.2%) had a nonsomatoform ("psychiatric") DSM-IV diagnosis of any type; 36 (17.5%) had 2 full nonsomatoform diagnoses, and 41 (19.9%) had >2; 92 (44.7%) had some full anxiety diagnosis and 94 (45.6%) had either full depression or minor depression diagnoses. However, only 9 of 206 (4.4%) had any full DSM-IV somatoform diagnosis, and only 39 (18.9%) had abridged somatization disorder. Thus, 48 (23.3%) were "DSM somatoform-positive" and 158 (76.7%) were "DSM somatoform-negative." The latter exhibited less anxiety, depression, mental dysfunction, and psychosomatic symptoms (all p <.001) and less physical dysfunction (p = .011). Correlates of this DSM somatoform-negative status were female gender (p = .007), less severe mental (p = .007), and physical dysfunction (p = .004), a decreased proportion of MUS (p <.10), and less psychiatric comorbidity (p <.10); c-statistic = 0.77.
We concluded that depression and anxiety characterized MUS patients better than the somatoform disorders. Our data suggested radically revising the somatoform disorders for DSM-V by incorporating a new, very large group of now-overlooked DSM somatoform-negative patients who were typically women with less severe dysfunction.

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Available from: Joseph C Gardiner, Aug 15, 2014
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    • "While the eight medical specialist visits per year in our study were comparable with the seven visits found by Barsky et al. [10], the 15 primary care visits per year in our study were much higher than the four found by Barsky et al. [10]. Our findings on primary care visits were more comparable with studies of high-utilizing patients with UPS [8,32], in which the mean number of visits per year ranged from 13.6 [32] to 15.9 [8]. In contrast to the high number of primary care visits, the mean number of 0.24 hospital days PPPY in our study was extremely low. "
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    ABSTRACT: Background: To determine whether healthcare resources are allocated fairly, it is helpful to have information on the quality of life (QoL) of patients with Unexplained Physical Symptoms (UPS) and on the costs associated with them, and on how these relate to corresponding data in other patient groups. As studies to date have been limited to specific patient populations with UPS, the objective of this study was to assess QoL and costs in a general sample of patients with UPS using generic measures. Methods: In a cross-sectional study, 162 patients with UPS reported on their QoL, use of healthcare resources and lost productivity in paid and unpaid work. To assess QoL, the generic SF-36 questionnaire was used, from which multidimensional quality-of-life scores and a one-dimensional score (utility) using the SF-6D scorings algorithm were derived. To assess costs, the TiC-P questionnaire was used. Results: Patients with UPS reported a poor QoL. Their QoL was mostly decreased by limitations in functioning due to physical health, and the least by limitations in functioning due to emotional problems. The median of utilities was 0.57, and the mean was 0.58 (SD = .09).The cost for the use of healthcare services was estimated to be €3,123 (SD = €2,952) per patient per year. This cost was enlarged by work-related costs: absence from work (absenteeism), lower on-the-job productivity (presenteeism), and paid substitution of domestic tasks. The resulting mean total cost was estimated to be €6,815 per patient per year. Conclusions: These findings suggest that patients with UPS have a high burden of disease and use a considerable amount of healthcare resources. In comparison with other patient groups, the QoL values of patients with UPS were among the poorest and their costs were among the highest of all patient groups. The burden for both patients and society helps to justify the allocation of sufficient resources to effective treatment for patients with UPS.
    BMC Health Services Research 12/2013; 13(1):520. DOI:10.1186/1472-6963-13-520 · 1.71 Impact Factor
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    • "For a long time, revisions for somatoform disorders have been demanded since current diagnostic criteria are insufficient for therapeutic as well as scientific use [1] [2] [3] [4] [5]. Different changes have been proposed, such as less restrictive time criteria or the addition of psychosocial symptoms, such as health care utilization, catastrophizing, or a self-concept of being weak [6] [7] [8] [9]. "
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    ABSTRACT: Current diagnostic criteria for somatoform disorders demand revisions due to their insufficient clinical as well as scientific usability. Various psychological and behavioral characteristics have been considered for the proposed new category Somatic Symptom Disorder (SSD). With this study, we were able to jointly assess the validity of these variables in an inpatient sample. Using a cross-sectional design, we investigated N=456 patients suffering from somatoform disorder, anxiety, or depression. Within one week after admission to the hospital, informed consent was obtained and afterwards, a diagnostic interview and a battery of self-report questionnaires were administered. Logistic regression analyses were performed to determine which variables significantly add to construct and descriptive validity. Several features, such as somatic symptom severity, health worries, health habits, a self-concept of being weak, and symptom attribution, predicted physical health status in somatization. Overall, our model explained about 50% of the total variance. Furthermore, in comparison with anxious and depressed patients, health anxiety, body scanning, and a self-concept of bodily weakness were specific for DSM-IV somatoform disorders and the proposed SSD. The present study supports the inclusion of psychological and behavioral characteristics in the DSM-5 diagnostic criteria for somatoform disorders. Based on our results, we make suggestions for a slight modification of criterion B to enhance construct validity of the Somatic Symptom Disorder.
    Journal of psychosomatic research 01/2013; 74(1):18-24. DOI:10.1016/j.jpsychores.2012.09.015 · 2.74 Impact Factor
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    • "The nosological subtypes (e.g., Somatization, Pain, or Undifferentiated Somatoform Disorders in DSM-IV or Complex Somatic Symptom Disorder in the DSM-5 proposal) are all characterized by experience of medically unexplained somatic symptoms, with psychosocial factors playing an important role in symptom formation. Prevalence rates of SS reach up to 16% of the general population (depending on the number of somatic medically unexplained symptoms used as a criterion), and SS account for nearly 25% of all visits to primary care clinics (Escobar et al., 1998; Kellner, 1990; Kirmayer and Robbins, 1991; Kroenke, 2003; Kroenke et al., 1997; Rief et al., 2001; Smith et al., 2005; Toft et al., 2005). SS have been described by both mental health and medical professionals as one of the most challenging disorders to treat: pharmacological treatments have not yet been successful, and there is still a debate as to what kind of psychosocial interventions are most helpful. "
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    ABSTRACT: Somatization syndromes are highly prevalent disorders with unknown etiology and are challenging to treat. Integrating previous findings on alexithymia, attachment, and trauma, we hypothesized that somatization syndromes are associated with a specific internal representation of relationships-the unmet need for closeness with others (desire for interpersonal closeness combined with the fear of being rejected, hurt, or abandoned). Twenty patients with DSM-IV somatization syndromes and 20 well-matched healthy controls completed the Relationship Anecdotes Paradigm/Core Conflictual Relationship Themes interview and measures of interpersonal relatedness, alexithymia, and history of trauma. The results showed that the unmet need for closeness with others was the main internal representation of relationships in 90% of the patients and in only 10% of controls; it was also the strongest predictor of somatization syndrome diagnosis. This suggests that somatization syndromes are strongly associated with the interpersonal representation of the unmet need for closeness with others, which has direct implications for their treatment and future research on their etiology.
    The Journal of nervous and mental disease 05/2012; 200(5):413-22. · 1.69 Impact Factor
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