Original article
Whether medically unexplained or not, three or more concurrent somatic symptoms predict psychopathology and service use in community populations

https://doi.org/10.1016/j.jpsychores.2010.01.001Get rights and content

Abstract

Objectives

To examine the frequency of somatic symptoms in a community population of various ethnic backgrounds and to identify correlates of these symptoms such as psychopathology, use of services, and personal distress.

Methods

Using a 14-symptom inventory with interviewer probes for somatic symptoms, we determined the presence of general physical symptoms (GPS) in a sample of 4864 white, Latino, and Asian US community respondents. Medically “edited” verbatim interview responses were used to decide whether or not physical symptoms would qualify as medically unexplained physical symptoms (MUPS). We then assessed the association between GPS and MUPS and psychiatric disorders, psychological distress, and use of services, in both unadjusted and multivariate regression analyses.

Results

One-third (33.6%) of the respondents reported at least one GPS and 11.1% reported at least one MUPS within the last year. 10.7% of respondents had three or more GPS and 1.5% had three or more MUPS. Three or more GPS and MUPS were positively associated with depressive, anxiety, and substance use disorders; service use; and psychological distress in unadjusted comparisons. In multivariate regressions, GPS persisted as a significant predictor, but there was no significant independent effect of MUPS, after controlling for GPS and other covariates.

Conclusions

Regardless of the presence or absence of medical explanations, physical symptoms are an important component of common mental disorders such as depression and anxiety and predict service use in community populations. These results suggest that three or more current GPS can be used to designate a “case” and that detailed probes and procedures aimed at determining whether or not physical symptoms are medically unexplained may not be necessary for classification purposes.

Introduction

Physical symptoms and complaints are a common manifestation of psychological distress worldwide, and mental disorders such as depression and anxiety often present with physical symptoms [1], [2], [3], [4], [5], [6], [7], [8]. The somatic presentations of mental disorders may vary from country to country and take new forms and shapes as cultures evolve and medical paradigms shift [9]. Typically, these somatic presentations have a tendency to remain medically unexplained, become chronic and disabling, and lead to seeking medical attention particularly in primary care settings [3], [10], [11], [12], [13].

Previous research on somatic symptoms highlighted the value of a dimensional approach. The ECA study results had shown that the DSM-III category of somatization disorder was very restrictive and this led to suggestions for using lower somatic symptom thresholds to facilitate the study of somatic presentations of mental disorders in clinical and community populations [14]. This dimensional (in contrast to a categorical) approach allowed the examination of different severity thresholds, such as “full” and “abridged somatization” disorder [15]. The presence of high levels of symptoms (e.g., five or more) was suggested as a reasonable threshold to designate “cases” in clinical and epidemiological studies [15], [16].

The issue of whether somatic symptoms have or do not have a medical explanation is complex and has constrained additional research on these symptoms. Traditionally, a system of probing to rule out “medical explanations” for the somatic symptoms had been required by measuring instruments and diagnostic systems. Previous studies such as the ECA [14] did labor through the assessment and probing of long lists of somatic symptoms in search of medical explanations. This increased interviewing time, assessment complexity, and costs, and may have been the reason that led other large-scale epidemiological studies (e.g., NCS, NSRAD) to omit the assessment of somatoform symptoms. As a result, opportunities for understanding somatic symptoms in community samples were missed.

The requirement of a medical explanation for presenting somatic symptoms has been less relevant in studies utilizing clinical samples. Both the World Health Organization (WHO) study [2], [8] and a US study in primary care [17] showed that regardless of medical explanations, as number of presenting somatic symptoms increased, so did the odds that the person would also meet criteria for common psychiatric disorders such as depression and anxiety. However, these observations have not been replicated in epidemiological studies using nonclinical samples. In addition, research on somatic symptoms has been complicated by reliability concerns regarding the report of lifetime somatic symptoms. For example, only a fraction of “lifetime” somatic symptoms reported at Time 1 were also reported at Time 2 in a longitudinal study [2], [18]. This supports the reliance on current (within the previous year) rather than on lifetime somatic symptoms. Moreover, there has long been an active debate concerning somatic symptoms and their relationship to gender, ethnicity, or socioeconomic background. Clinical and epidemiological studies in the US have shown a tendency for Latino or non-Caucasian groups to present with more somatic symptoms [19], [20], but international studies have produced mixed results [21], [22]. Debate has also focused on the role of gender, income, and education, with a higher frequency of somatoform syndromes being generally reported among women and those from low educational and socioeconomic backgrounds [1].

The current study sought to build on previous research by examining somatic symptoms as part of the National Latino and Asian American Study (NLAAS), a study that examined an ethnically diverse, nationally representative sample of the general population. The NLAAS incorporated a list of key somatic symptoms and focused on the assessment of current symptoms (present during the last year) rather than of lifetime somatic symptoms. It included probes to explore whether symptoms were severe, led to seeking medical care, and, if so, respondent was asked about the physician's diagnosis/explanation for the symptoms. In this article, we will examine somatic symptoms with and without medical explanations and assess their correlates and predictive value.

Section snippets

Sample and data

Data comes from the NLAAS, a nationally representative survey of Latino and Asian English- and Spanish-speaking adults (age 18 or older) in the noninstitutionalized population of the coterminous United States (described in more detail elsewhere) [23], [24]. Survey data included rates of mental disorders and substance abuse, service use, and sociodemographic characteristics. The University of Michigan Survey Research Center collected data for the NLAAS via in-person household interviews or

Results

Of a total of 4864 respondents, 1649 (33.6%) reported the presence of at least one frequent and severe GPS and 507 (11.8%) reported the presence of at least one frequent and severe MUPS leading to a medical visit during the previous year. A total of 526 (10.7%) respondents reported three or more frequent/severe GPS, and 66 (1.5%) respondents reported three or more frequent/severe MUPS during the same period. An analysis of individual symptoms (not shown) showed that the most frequent GPS were

Discussion

To our knowledge, this study is the first large-scale epidemiological survey in the US in over a decade to systematically assess somatic symptoms, elicit only current physical symptoms that cause disruption in daily life, and examine their association with common psychopathological entities and use of services. The data in this article confirm that physical symptoms are commonly reported by a racially and ethnically diverse sample of community respondents. Thus, despite the fact that we

Acknowledgments

This work was partially supported by grant P20MH074634 from the National Institute of Mental Health.

References (36)

  • ParkerG et al.

    Depression in the Chinese: the impact of acculturation

    Psychol Med

    (2005)
  • SabogalF et al.

    Hispanic familism and acculturation: What changes and what doesn't?

    Hisp J Behav Sci

    (1987)
  • RyderAG et al.

    The cultural shaping of depression: somatic symptoms in China, psychological symptoms in North America?

    J Abnorm Psychol

    (2008)
  • GurejeO et al.

    Somatization in cross-cultural perspective: a World Health Organization study in primary care

    Am J Psychiatry

    (1997)
  • ShorterE

    From paralysis to fatigue

    (1992)
  • HaugTT et al.

    The association between anxiety, depression, and somatic symptoms in a large population: the HUNT-II study

    Psychosom Med

    (2004)
  • EscobarJI et al.

    Somatization in the community

    Arch Gen Psychiatry

    (1987)
  • EscobarJI et al.

    Somatic Symptom Index (SSI): a new and abridged somatization construct: prevalence and epidemiological correlates in two large community samples

    J Nerv Ment Dis

    (1989)
  • Cited by (0)

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