Elsevier

Journal of Psychosomatic Research

Volume 91, December 2016, Pages 48-54
Journal of Psychosomatic Research

Multiple somatic symptoms in primary care: A field study for ICD-11 PHC, WHO's revised classification of mental disorders in primary care settings

https://doi.org/10.1016/j.jpsychores.2016.10.002Get rights and content

Highlights

  • A field study of WHO’s new classification of mental disorders for primary care, the ICD-11 PHC

  • Bodily stress disorder, health anxiety replace unexplained somatic complaints, hypochondriasis

  • There is substantial overlap between BSS and HA

  • Both BSS and HA are strongly associated with mood and anxiety disorders

  • Anxious depression is the commonest psychological disorder with the greatest disability

Abstract

Objective

A World Health Organization (WHO) field study conducted in five countries assessed proposals for Bodily Stress Syndrome (BSS) and Health Anxiety (HA) for the Primary Health Care Version of ICD-11. BSS requires multiple somatic symptoms not caused by known physical pathology and associated with distress or dysfunction. HA involves persistent, intrusive fears of having an illness or intense preoccupation with and misinterpretation of bodily sensations. This study examined how the proposed descriptions for BSS and HA corresponded to what was observed by working primary care physicians (PCPs) in participating countries, and the relationship of BSS and HA to depressive and anxiety disorders and to disability.

Method

PCPs referred patients judged to have BSS or HA, who were then interviewed using a standardized psychiatric interview and a standardized measure of disability.

Results

Of 587 patients with BSS or HA, 70.4% were identified as having both conditions. Participants had an average of 10.9 somatic symptoms. Patients who presented somatic symptoms across multiple body systems were more disabled than patients with symptoms in a single system. Most referred patients (78.9%) had co-occurring diagnoses of depression, anxiety, or both. Anxious depression was the most common co-occurring psychological disorder, associated with the greatest disability.

Conclusion

Study results indicate the importance of assessing for mood and anxiety disorders among patients who present multiple somatic symptoms without identifiable physical pathology. Although highly co-occurring with each other and with mood and anxiety disorders, BSS and HA represent distinct constructs that correspond to important presentations in primary care.

Introduction

The World Health Organization (WHO) is currently developing the Eleventh Revision of the International Classification of Diseases (ICD-11). For the previous version of the classification, the ICD-10, WHO produced separate guidelines for the identification and management of mental disorders encountered in primary care settings, the ICD-10 PHC [1]. A WHO Working Group consisting of primary care physicians (PCPs) with a special interest in mental illness and mental health professionals with experience in teaching mental health skills to PCPs has proposed a revised classification of mental disorders for primary health care for ICD-11 (ICD-11 PHC) [2]. The ICD-11 PHC has been amended from the corresponding manual for ICD-10 in light of criticisms from experts in both primary care and mental health [2], [3], [4], [5], and after considering feedback from focus groups of PCPs in eight countries [6]. This article reports on a cross-sectional descriptive field study conducted in five countries of the Working Group's proposals for disorder categories characterized by: 1) three or more somatic symptoms not considered by the treating PCP to have a medical basis; and 2) excessive and unjustified anxiety about health.

The ICD-10 PHC [1] contained a category called ‘medically unexplained somatic complaints’, defined by negative physical investigations and frequent visits to the PCP despite these negative findings. The development of the ICD-11 PHC provided an opportunity to re-think this description, drawing in part on research conducted in Denmark by Fink and colleagues [7], [8], including a recommendation that three or more symptoms was a useful threshold for primary care populations [9]. Fink and his colleagues proposed a conceptualization of Bodily Distress Syndrome that emphasized the co-occurrence of symptoms falling into cardiopulmonary, musculoskeletal, and gastrointestinal clusters and explicitly linking these symptom clusters to ‘functional’ syndromes of non-cardiac chest pain, fibromyalgia, and irritable bowel syndrome. This conceptualization was subsequently expanded to include an additional cluster of ‘general’ symptoms (e.g., concentration difficulties, memory impairment, fatigue) theorized as corresponding to chronic fatigue syndrome [7], [9]. Support for the notion that apparently distinct collections of somatic symptoms are united by underlying common features has been provided by a number of empirical studies [10], [11], [12], [13], [14], [15], [16], [17], [18], [19].

The Working Group proposed that Bodily Stress Syndrome (BSS) replace the ICD-10 PHC concept of medically unexplained symptoms in the ICD-11 PHC, in part because it was seen as opening a more useful therapeutic dialogue with the patient. For the purpose of the present study, BSS was defined as being characterized by three or more somatic symptoms associated with distress and/or interference with daily functioning and not explained by a known physical pathology. The Working Group also proposed the inclusion of Health Anxiety (HA) in the ICD11-PHC, to replace the ICD-10 PHC category of hypochondriasis. As with BSS, this change was in part based on the greater usefulness of HA than hypochondriasis as a framework for intervention [20]. HA is characterized by either or both of: 1) persistent, intrusive ideas or fears of having illness that cannot be stopped, or can only be stopped with great difficulty; or 2) intense preoccupation with minor bodily sensations or problems that are misinterpreted as signs of serious disease. PCPs have indicated they consider this to be an important clinical presentation [6], but the extent to which HA is a separate phenomenon from BSS in primary care settings is unclear.

The objective of the present study was to examine how the proposed descriptions for BSS and HA corresponded to what was observed by working PCPs in a range of countries, and the relationship of BSS and HA to depressive and anxiety disorders and to disability. An important question addressed by the study was whether the overlap between BSS and HA and depressive and anxiety symptoms suggested that the presentation of multiple somatic complaints in primary care might reflect undetected psychological disorders [2].

Among patients identified as having BSS, the study also examined the occurrence of the symptom clusters emphasized in the Danish studies in order to evaluate whether these would be a useful basis for sub-classification of BSS in the ICD-11 PHC.

The study was conducted in primary care centres in Brazil, China, Mexico, Pakistan, and Spain. Although not representative of the entire world, these countries include four large middle-income countries and encompass considerable diversity in language, culture, and resources. Approximately 70% of the world's population live in middle-income countries [21], so it was considered that results in these countries might provide more information about the global applicability of the ICD-11 PHC proposals than previous studies conducted in the U.S. or in single countries in Western Europe.

Section snippets

Method

The study sample included 587 patients from five countries being seen in routine primary care practice and identified by their PCPs as meeting the proposed ICD-11 PHC diagnostic requirements for BSS, HA, or both. Because the assignment of both diagnoses involves the consideration of other relevant medical information (e.g., physical pathology that may be contributing to symptoms) and sometimes requires knowledge of patients over time, it was considered that PCPs were in the best position to

Results

As shown in Fig. 1, participating PCPs approached 722 patients to participate in the study. Of these, 33 declined to participate for a variety of reasons shown in the figure. Of the remaining 689 patients, 48 did not meet the diagnostic requirements for BSS or HA according to the information provided on the Encounter Form, 50 did not complete the CIS-R (e.g., because they did not return for a separate appointment to do so), and there were data recording problems for 4 patients, leaving a total

Discussion

As we reported earlier (2), PCPs indicate that BSS is a common phenomenon in their practices and represents an important component of their workload. As a concept, BSS brings together under a common rubric allegedly different patterns of symptoms variously described as constituting different ‘functional’ syndromes (e.g., fibromyalgia, irritable bowel syndrome) [7], [9]. HA is also an important clinical phenomenon in primary care, but in this study we found that it is largely, though not

Competing interest statement

All authors have completed the ICMJE Form for Disclosure of Potential Conflicts of Interest, available at http://icmje.org/coi_disclosure.pdf, and declare that the authors have no competing interests to report.

Acknowledgements

The research described in this article was funded by: the World Health Organization; the Psychiatry Research Trust of Institute of Psychiatry, London; the National Research Council CNPQ, Brazil (Grant number 476905/2012-5), the Committee on Research and Conference Grants, University of Hong Kong, and the National Council of Science and Technology, Mexico (CONACYT) (Grant number SALUD-2013-01-202283). Apart from the individuals affiliated with these institutions who are authors of this article,

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