Original articleNumber of bodily symptoms predicts outcome more accurately than health anxiety in patients attending neurology, cardiology, and gastroenterology clinics
Introduction
One of the criticisms of DSM-IV somatoform disorders is the lack of evidence to support their existence as independent diagnoses [1]. Researchers outside of specialist clinics appear to have abandoned the DSM-IV diagnosis of somatization disorder in favor of more practical definitions, such as abridged somatization or multisomatoform disorder [2], [3], [4]. Both are based on the number of bothersome unexplained somatic symptoms. Similarly, the DSM criteria for a diagnosis of hypochondriasis are too restrictive for use in primary care or population-based samples, so researchers have evolved several ways of measuring hypochondriasis [5], [6], [7], [8], [9]. This has led to widely differing estimates of the prevalence of hypochondriasis [3].
Previous research has aimed to define the threshold above which the number of bodily symptoms is closely associated with increased disability and health care costs. Most early studies included only somatoform symptoms, defined as bodily symptoms that are medically unexplained, are disabling, and/or lead to medical help seeking [4], [10]. It is not surprising, therefore, that numerous such symptoms are associated with disability and health care use. Two studies suggested that the relationship between the number of bodily symptoms, health care use, and disability holds for all bodily symptoms whether or not they are explained by demonstrable abnormalities [11], [12]. Other researchers have combined the number of bodily symptoms with dimensions of hypochondriasis (disease fear, disease conviction, and bodily preoccupation) and found that primary care patients scoring in the top 14% of this combined measure had increased health care use [7].
An alternative view regards the number of bodily symptoms and health anxiety as continua without any clear “cutoff” point indicating a specific psychiatric diagnosis. If this is the case, there may be a linear association between the number of somatic symptoms and degree of health anxiety, and external validating measures such as health care use and degree of impaired function [12]. Similarly, the association between the number of bodily symptoms or health anxiety and postulated associated features (such as female sex predominance, adverse childhood experiences, and depression) can be tested appropriately. These relationships can be tested in patients who have symptoms explained by demonstrable pathological abnormalities and medically unexplained symptoms. We have previously analyzed data from 129 of the patients included in the present study, showing a significant association between adverse childhood experiences and the number of bodily symptoms [13]. The number of bodily symptoms mediated the association between adverse childhood experiences and frequent health care use; this relationship was strongest in patients with medically unexplained symptoms [13].
The aim of this study was to test the following hypotheses in new patients at medical clinics: Hypothesis 1 Both the number of bodily symptoms and the degree of health anxiety are associated, in linear fashion, with subsequent health care use and degree of impaired function. Hypothesis 2 These relationships will be true only for patients with medically unexplained symptoms. Hypothesis 3 Any association between the number of body symptoms and outcome is mediated by depression and anxiety.
Section snippets
Method
We performed this study in the neurology, gastroenterology, and cardiology outpatient departments of two large hospitals in the UK. These clinics receive referrals from primary care and from other hospital outpatient clinics (i.e., secondary and tertiary referrals). We approached new patients at these clinics if they were aged 18–75 years, physically and mentally able to complete questionnaires, and clearly symptomatic; we excluded asymptomatic patients (e.g., those with hypertension or heart
Results
Of the 383 patients approached on their first clinic visit, 295 (77%) joined the study. Of the 295, 114 (38.6%) participants had medically unexplained symptoms: 33 of 112 (29.5%) in neurology, 24 of 60 (40%) in cardiology, and 57 of 123 (46.3%) in gastroenterology (χ2=7.10, P=.029). The most common medically unexplained symptoms were: noncardiac chest pain, palpitations, headaches, limb pains, paresthesia, and irritable bowel syndrome.
There were no significant differences among participants
Discussion
This prospective study of patients in specialist clinics receiving secondary and tertiary referrals has three main findings. Firstly, we found that the number of bodily symptoms and health anxiety relate to outcome in different ways. The former relates, in a linear fashion, to subsequent health care use and health-related quality of life, and there is no cutoff score above which outcome is worse. This is similar to previous cross-sectional findings [10], [12]. Secondly, we showed that this
Acknowledgments
This work was supported by the Central Manchester NHS Trust R&D Directorate and the Functional Gastrointestinal Disorders Working Group.
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