Somatic symptoms and psychological concerns in a general adolescent population: Exploring the relevance of DSM-5 somatic symptom disorder

https://doi.org/10.1016/j.jpsychores.2015.07.012Get rights and content

Highlights

  • We explore the relevance of DSM-5 somatic symptom disorder (SSD) among adolescents.

  • Combining somatic symptoms with psychological concerns decreases prevalence rates.

  • Girls report more symptoms, but are less functionally impaired by these than boys.

  • SSD-research requires combined measures based on symptoms, concerns and impairment.

  • Medical and mental problems substantially overlap with adolescent somatic symptoms.

Abstract

Objective

DSM-5 somatic symptom disorder (SSD) constitutes a major change for psychosomatic medicine and psychiatry, as well as for epidemiological research in these fields. This study investigates somatic symptoms and psychological concerns among adolescents in order to systematically explore the relevance of SSD for general adolescent populations.

Methods

A cross-sectional population-based design, with a symptoms-based strategy and a symptom-and-psychological-concern-based strategy, was used to estimate the prevalence of somatic symptoms and psychological concerns in a general adolescent population (n = 2476, mean age = 16 years, 49% boys, 51% girls). Somatic symptoms and psychological concerns in relation to gender, and self-reported medical and psychiatric conditions were investigated. The association between somatic symptoms, psychological concerns, and functional impairment in school-, family-, peer- and physical activities was studied.

Results

Reporting 3 + persistent distressing somatic symptoms was significantly more common than reporting one or more persistent distressing somatic symptom(s) combined with serious psychological concern. The prevalence of such complaints was significantly higher in girls. The proportion of medical and psychiatric conditions was highest in the group reporting 3 + persistent distressing somatic symptoms combined with serious psychological concern. Belonging to this group most significantly increased odds ratios for functional impairment.

Conclusion

For large-scale studies on SSD, results suggest the use of measures based on multiple somatic items in combination with psychological concerns, and a methodologically sound standardized measure of functional impairment. To further enhance clinical decision-making, the relation of symptoms to functional impairment, and the substantial overlap of SSD with medical and psychiatric conditions during adolescence should be addressed.

Introduction

Bodily complaints during adolescence have historically always been common among diverse youth populations [1], [2], in pediatric settings [2], [3], as well as in psychosomatic medicine [3], [4], and child and adolescent psychiatry [4], [5]. At present, there is increasing evidence that the presence of somatic symptoms, in combination with disproportionate concerns and feelings regarding these symptoms, are an important component of mental disorder [6]. Moreover, in epidemiology, multiple somatic symptoms reliably predict psychopathology and healthcare use in population-based studies [6], [7], [8]. Consequently, the introduction of the new DSM-5 category ‘somatic symptom disorder’ (SSD) [9] is generally seen as a major change in the fields of public mental health and psychiatry [10].

An overarching philosophical motivation for this introduction of SSD was to overcome mind–body dualism [9] and a felt previous overemphasis on the centrality of multiple medically unexplained symptoms in the DSM-IV somatoform disorders [11]. Hence, the DSM-5 diagnosis requires the presence of only a single persistent distressing somatic symptom, and the distinction between ‘medically explained’ and ‘medically unexplained’ symptoms was set aside. Consequently, SSD is solely based on ‘positive’ criteria, i.e.; one or more somatic symptoms that are distressing or result in significant disruption of daily life (Criterion A), excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns (Criterion B), and the state of being symptomatic is persistent and typically more than 6 months (Criterion C) [9].

However, considerable concerns regarding the creation of SSD have also been expressed [12]. As the diagnosis no longer excludes patients with a somatic disease, it is argued that many people with medical conditions will now be mislabeled as mentally ill [13]. Due also to depending on the presence of only a single somatic symptom [14], [15], it is further contended that the new criteria will lead to unrealistic estimates of psychiatric prevalence rates [16]. At present, the prevalence of adult SSD is not known, but is thought to be around 5%–7% [9]. Data on adolescent populations are not available. Based on the abovementioned criticisms, recommendations with regard to the relevant DSM-5 chapter have ranged from calls for a more critical rethinking [17], to the urgent appeal to rewrite the text [18], and even to the suggestion of completely ignoring its use [19].

Obviously, these widely voiced apprehensions are serious, and the relevance of the diagnosis of SSD among adolescents needs to be addressed. As a preliminary step towards more clarity on these topics, this explorative study first uses a symptoms-based strategy and a symptom-and-psychological-concern-based strategy to investigate somatic symptoms and psychological concerns in a general adolescent population. Subsequently, it investigates group-differences with regard to gender, somatic symptoms, and psychological concerns. It then relates somatic symptoms and psychological concerns to self-reported medical and psychiatric conditions. Finally, associations in somatic symptoms, psychological concerns, gender and functional impairment are examined.

The article's main aims are 1) to investigate differences in prevalence rates when using a symptoms-based strategy and a symptom-and-psychological-concerns-based strategy, 2) to study somatic symptoms and psychological concerns in relation to self-reported medical and psychiatric conditions, and 3) to identify the most functionally impaired group with regard to somatic symptoms and psychological concerns in a general adolescent population.

Section snippets

Sample

Data from a general questionnaire distributed in a cross-sectional population-based study (Young in Värmland), targeting all 15- to 16-year olds in grade 9 within the Swedish county of Värmland (n = 3104) in 2011, were used. The data-collection was conducted by the Centre for Research on Child and Adolescent Mental Health, Karlstad University, Sweden. The questionnaire was completed anonymously in school-classrooms and participation was voluntary. The questionnaire covered a wide range of

Results

Questionnaires were returned for 2620 adolescents (response rate 84.4%). Complete data were available for 2476 adolescents. The genders were equally represented (49% boys, 51% girls), and the majority of adolescents was born in Sweden (92.7%), lived together with both parents (62.6%), and was 16 years old in the year of investigation (95.0%).

Discussion

To our knowledge, this is the first epidemiological study on somatic symptoms and psychological concerns using a standardized questionnaire, including questions on self-reported health conditions, to try to systematically assess and explore the relevance of DSM-5 SSD in a general adolescent population. The studied sample was relatively large, targeted all adolescents in grade 9 (15 to 16 years old) in a Swedish county, attained a high response rate, and had an equal gender-distribution.

The

Conflict of interest

The authors have no conflicting interests to declare.

Source of funding

The study was funded by a program grant from The Swedish Research Council for Health, Working Life and Welfare (Forte) [2012-1736].

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