Arthur J. Barsky

Performance of a five-item mental health screening test

We compared the screening accuracy of a short, five-item version of the Mental Health Inventory (MHI-5) with that of the 18-item MHI, the 30-item version of the General Health Questionnaire (GHQ-30), and a 28-item Somatic Symptom Inventory (SSI-28). Subjects were newly enrolled members of a health maintenance organization (HMO), and the criterion diagnoses were those found through use of the Diagnostic Interview Schedule (DIS) in a stratified sample of respondents to an initial, mailed GHQ. To compare questionnaires, we used receiver operating characteristic analysis, comparing areas under curves through the method of Hanley and McNeil. The MHI-5 was as good as the MHI-18 and the GHQ-30, and better than the SSI-28, for detecting most significant DIS disorders, including major depression, affective disorders generally, and anxiety disorders. Areas under curve for the MHI-5 ranged from 0.739 (for anxiety disorders) to 0.892 (for major depression). Single items from the MHI also performed well. In this population, short screening questionnaires, and even single items, may detect the majority of people with DIS disorders while incurring acceptably low false-positive rates. Perhaps such extremely short questionnaires could more commonly reach use in actual practice than the longer versions have so far, permitting earlier assessment and more appropriate treatment of psychiatrically troubled patients in primary care settings.

Functional Somatic Syndromes

The term functional somatic syndrome has been applied to several related syndromes characterized more by symptoms, suffering, and disability than by consistently demonstrable tissue abnormality. These syndromes include multiple chemical sensitivity, the sick building syndrome, repetition stress injury, the side effects of silicone breast implants, the Gulf War syndrome, chronic whiplash, the chronic fatigue syndrome, the irritable bowel syndrome, and fibromyalgia. Patients with functional somatic syndromes have explicit and highly elaborated self-diagnoses, and their symptoms are often refractory to reassurance, explanation, and standard treatment of symptoms. They share similar phenomenologies, high rates of co-occurrence, similar epidemiologic characteristics, and higherthan-expected prevalences of psychiatric comorbidity. Although discrete pathophysiologic causes may ultimately be found in some patients with functional somatic syndromes, the suffering of these patients is exacerbated by a self-perpetuating, self-validating cycle in which common, endemic, somatic symptoms are incorrectly attributed to serious abnormality, reinforcing the patient’s belief that he or she has a serious disease. Four psychosocial factors propel this cycle of symptom amplification: the belief that one has a serious disease; the expectation that one’s condition is likely to worsen; the “sick role,” including the effects of litigation and compensation; and the alarming portrayal of the condition as catastrophic and disabling. The climate surrounding functional somatic syndromes includes sensationalized media coverage, profound suspicion of medical expertise and physicians, the mobilization of parties with a vested self-interest in the status of functional somatic syndromes, litigation, and a clinical approach that overemphasizes the biomedical and ignores psychosocial factors. All of these influences exacerbate and perpetuate the somatic distress of patients with functional somatic syndromes, heighten their fears and pessimistic expectations, prolong their disability, and reinforce their sick role. A six-step strategy for helping patients with functional somatic syndromes is presented here. This paper is also available at http://www.acponline.org.TO THE EDITOR: Shah and Tsang (1) report on a man who presented with dysphagia after drinking a soda that had been unattended outside for 2 hours. Endoscopic evaluation revealed an erythematous and edematous posterior pharynx with two lesions consistent with stings. The authors ascribed these stings to two bees that the patient regurgitated just before the procedure. The circumstance and clinical findings are more consistent with a yellowjacket sting. Yellowjackets are often misidentified as bees, as shown in a recent report (2, 3). Wasps, particularly yellowjackets, are commonly mistaken for bees but differ in structure and behavior. Wasps feed on other insects and sweet substances, such as sap and nectar. Bees feed on nectar and pollen. The feeding cue for a yellowjacket is the smell of sugars, whereas the cues for foraging bees emanate from flowers. Yellowjackets are frequently found near open cans of soft drinks; bees rarely are. Bees usually sting people when they accidentally step on one that is foraging on a flower. Honeybees sting only once and often leave their stinger in the victim, whereas wasps can sting multiple times and do not leave their stinger behind. Misidentification of wasps for bees can have important clinical implications. When anaphylaxis develops to either type of sting, proper identification is important for desensitization because the venoms are immunologically distinct. If samples of the insect are available, the differences in body types allow easy identification. Wasps have smooth bodies, whereas bees are fuzzy. If a specimen is not available, knowing the circumstances of the stinging incident, looking for a stinger in the patient, and knowing the differences in behavior between wasps and bees could be helpful in correctly identifying the insect.

The Somatosensory Amplification Scale and its relationship to hypochondriasis

Forty-one DSM-III-R hypochondriacs and seventy-five randomly chosen patients were obtained from a medical outpatient clinic, and completed a psychiatric diagnostic interview and a ten-item self-report questionnaire, the Somatosensory Amplification Scale (SSAS); The SSAS asks the respondent how much s/he is bothered by various uncomfortable visceral and somatic sensations, most of which are not the pathological symptoms of serious diseases. SSAS scores were normally distributed, and had acceptable test-retest reliability and internal consistency. They were not related to sociodemographic characteristics, or to aggregate medical morbidity. Amplification was significantly higher in the DSM-III-R hypochondriacs than in the comparison sample, and was significantly correlated with the degree of hypochondriacal symptomatology within each sample. In the comparison sample, it was also significantly associated with depressive and anxiety disorders, but not with antisocial personality or substance abuse. The association between the amplification scale and DSM-III-R hypochondriasis remained highly significant after controlling for these concurrent psychiatric disorders.

Somatic symptom reporting in women and men

Women report more intense, more numerous, and more frequent bodily symptoms than men. This difference appears in samples of medical patients and in community samples, whether or not gynecologic and reproductive symptoms are excluded, and whether all bodily symptoms or only those which are medically unexplained are examined. More limited, but suggestive, literature on experimental pain, symptom reporting in childhood, and pain thresholds in animals are compatible with these findings in adults. A number of contributory factors have been implicated, supported by varying degrees of evidence. These include innate differences in somatic and visceral perception; differences in symptom labeling, description, and reporting; the socialization process, which leads to differences in the readiness to acknowledge and disclose discomfort; a sex differential in the incidence of abuse and violence; sex differences in the prevalence of anxiety and depressive disorders; and gender bias in research and in clinical practice. General internists need to keep these factors in mind in obtaining the clinical history, understanding the meaning and significance that symptoms hold for each patient, and providing symptom relief.

A systematic review of the epidemiology of somatisation disorder and hypochondriasis

BACKGROUND This paper reviews current knowledge regarding the prevalence and associated features of somatisation disorder and hypochondriasis in population-based and primary care samples. METHOD A systematic review of the literature, which used a standardised definition of somatisation disorder or hypochondriasis and which examined the characteristics and associated features of these disorders in population-based samples or primary care settings. RESULTS In population-based studies the prevalence of somatisation disorder and hypochondriasis was too low to examine associated features reliably. In studies using abridged criteria, a clear female predominance was not found in either disorder; there was a consistent relationship with few years of education. There was a close relationship with anxiety and depressive disorders, with a linear relationship between numbers of somatic and other symptoms of distress in several studies, including longitudinal studies. No studies showed that these symptom clusters fulfil the criteria of characteristic onset, course and prognosis required to merit the status of discrete psychiatric disorders. CONCLUSIONS On existing evidence, somatisation disorder and hypochondriasis cannot be regarded as definite psychiatric disorders. There is some evidence that numerous somatic symptoms or illness worry may be associated with impairment and high health care utilisation in a way that cannot be solely explained by concurrent anxiety and depression, but further research using population-based samples is required.

The paradox of health.

Although the collective health of the nation has improved dramatically in the past 30 years, surveys reveal declining satisfaction with personal health during the same period. Increasingly, respondents report greater numbers of disturbing somatic symptoms, more disability, and more feelings of general illness. Four factors contribute to the discrepancy between the objective and subjective states of health. First, advances in medical care have lowered the mortality rate of acute infectious diseases, resulting in a comparatively increased prevalence of chronic and degenerative disorders. Second, societys heightened consciousness of health has led to greater self-scrutiny and an amplified awareness of bodily symptoms and feelings of illness. Third, the widespread commercialization of health and the increasing focus on health issues in the media have created a climate of apprehension, insecurity, and alarm about disease. Finally, the progressive medicalization of daily life has brought unrealistic expectations of cure that make untreatable infirmities and unavoidable ailments seem even worse. Physicians should become more aware of these paradoxical consequences of medical progress so that they do not inadvertently contribute to a rising public dissatisfaction with medicine and medical care.

Resource utilization of patients with hypochondriacal health anxiety and somatization

Objectives.To examine the resource utilization of patients with high levels of somatization and health-related anxiety. Design.Consecutive patients on randomly chosen days completed a self-report questionnaire assessing somatization and health-related, hypochondriacal anxiety. Their medical care utilization in the year preceding and following completion of the questionnaire was obtained from an automated patient record. The utilization of patients above and below a predetermined threshold on the questionnaire was then compared. Patients and Setting. Eight hundred seventy-six patients attending a primary care clinic in a large, urban, teaching hospital. Outcome Measures. Number of ambulatory physician visits (primary care and specialist), outpatient costs (total, physician services, and laboratory procedures), proportion of patients hospitalized, and proportion of patients receiving emergency care. Results.Patients in the uppermost 14% of the clinic population on somatization and hypochondriacal health anxiety had appreciably and significantly higher utilization in the year preceding and the year following completion of the somatization questionnaire than did the rest of the patients in the clinic. After adjusting for group differences in sociodemographic characteristics and medical comorbidity, significant differences in utilization remained. In the year preceding the assessment of somatization, their adjusted total outpatient costs were

Psychobiological perspectives on somatoform disorders

1,312 (95% CI

Hidden Reasons Some Patients Visit Doctors

1154,

Patients Who Amplify Bodily Sensations

1481) versus