Sidney Benjamin

Features of somatization predict the onset of chronic widespread pain: Results of a large population-based study

OBJECTIVE Chronic widespread pain, the clinical hallmark of the fibromyalgia syndrome, is associated with other physical and psychological symptoms both in patients studied in a clinical setting and in those identified in the community. The present study was undertaken to examine the hypothesis that psychological and physical indicators of the process of somatization predict the development of new chronic widespread pain. METHODS In this population-based prospective study, 1,658 adults ages 18-65 years completed a detailed pain questionnaire, which included a pain drawing. They also completed the following psychosocial instruments: General Health Questionnaire, Somatic Symptom Checklist, Fatigue Questionnaire, and Illness Attitude Scales. Individuals were followed up at 12 months, at which time 1,480 (93% of subjects still living at their baseline address) provided data on pain status, using the same instruments. RESULTS At baseline, 825 subjects were classified as pain free and 833 as having pain not satisfying criteria for chronic widespread pain. Of those, 18 (2%) and 63 (8%), respectively, were classified as having chronic widespread pain at followup. After adjustment for age and sex, there were strong relationships between baseline test scores and subsequent risk of chronic widespread pain (odds ratio for the Somatic Symptom Checklist 3.3; odds ratio for the Illness Behavior subscale of the Illness Attitude Scales 9.0). All 95% confidence intervals excluded unity. These associations were independent of baseline pain status. CONCLUSION Subjects who are free of chronic widespread pain are at increased future risk of its development if they display other aspects of the process of somatization. Data from this population-based prospective study lend powerful support to the hypothesis that chronic widespread pain can be one manifestation of the somatization of distress.

The association between chronic widespread pain and mental disorder: a population-based study.

OBJECTIVE Patients with chronic widespread pain (CWP) have been reported to have a greater prevalence of mental disorders and somatization than that found in the general population, but the true association between CWP and mental disorders is unknown. In this study, we investigated whether there is an increased prevalence of mental disorder in people with CWP from the general population. We also describe the psychiatric diagnoses associated with CWP. METHODS In a population-based case-control study, 1,953 subjects (75% of a random sample of individuals age 18-65 years) completed a questionnaire that included a pain assessment and the 12-item General Health Questionnaire (GHQ-12). Of 710 subjects scoring >1 on the GHQ-12, 301 were assessed further using a structured psychiatric interview and detailed assessment of medical records to identify cases of mental disorder, in accordance with criteria of the 10th edition of the International Classification of Diseases. The association between CWP and mental disorder was modeled using logistic regression, adjusting for possible confounders including age, sex, and nonresponders. RESULTS We estimated the overall population prevalence of mental illness to be 11.9%. The odds of having a mental disorder for subjects with versus those without CWP were 3.18 (95% confidence interval 1.97-5.11). Most subjects with mental disorders were diagnosed as having mood and anxiety disorders. Only 3 cases of somatoform disorders were identified, and all were associated with pain. CONCLUSION This study, although unable to demonstrate a cause-and-effect relationship, showed that 16.9% of those with CWP were estimated to have a psychiatric diagnosis, suggesting that these disorders should be identified and treated.

The association between tender points, psychological distress, and adverse childhood experiences: A community-based study

OBJECTIVE To examine the hypothesis that characteristics of somatization and illness behavior, and their childhood antecedents, are associated with the presence of multiple tender points. METHODS Two hundred eighty-nine subjects who had demonstrated psychological distress (General Health Questionnaire score > or =2) had a tender point examination and in-depth psychological evaluation. In addition, subjects were interviewed about a number of adverse childhood experiences. The 99 subjects with 5 or more tender points were compared with the remaining 190 subjects. RESULTS A high tender point count (> or =5) was associated with low levels of self-care (odds ratio [OR] 2.4, 95% confidence interval [95% CI] 1.1-5.0), reports of a greater number of somatic symptoms (OR 2.2, 95% CI 1.0-4.9), high levels of fatigue (OR 3.3, 95% CI 1.7-6.3), and a pattern of illness behavior characterized by increased medical care usage (OR 4.2, 95% CI 2.1-8.4). Those with high tender point counts were substantially more likely to report adverse childhood experiences, including loss of parents (OR 2.1, 95% CI 1.1-3.9) and abuse (OR 6.9, 95% CI 2.0-24.6). These results were not explained by the presence of chronic pain. CONCLUSION These data add further weight to the hypothesis that tender points, as part of the fibromyalgia syndrome, are strongly associated with specific components of psychological distress as well as characteristics of somatization and its antecedents. It is possible that these features contribute to the development of the syndrome of fibromyalgia.

Transcultural patterns of somatization in primary care: a preliminary report.

The ethnic origins of patients consulting their general practitioners (GP) were determined using criteria of country of birth, religion and preferred language. Three samples with preferred languages of English, Gujarati or Urdu were compared on a standardized interview with regard to symptom complaint, perception and attribution and also completed the General Health Questionnaire and Illness Behaviour Questionnaire. Their GPs provided diagnoses and ratings of physical and mental disorders. Compared with the English group, the Gujaratis had fewer psychosocial complaints, perceived less anxiety and were more likely to attribute their complaints to physical causes. They had higher scores on the Hypochondriasis and Denial scales. Their GPs rated them as less likely to have relevant physical or mental disorders. The Urdu group was intermediate in most respects. Thus somatization was commoner in these two Asian groups with different ethnic origins. However, overall levels of somatization appear to be high even in the English group. No significant differences were found between groups for complaints or ratings of depression, and the differences found in the somatization process appear to be related only to anxiety.

The relationship of chronic pain, mental illness and organic disorders

&NA; One hundred and six consecutive new attenders at a regional pain relief clinic were assessed using ratings of pain, standardized psychiatric interviews and physical examination by independent assessors. Approximately half the subjects had diagnosed mental illness and two‐thirds had diagnosed organic disease. Pain ratings were higher in those with mental illness but were not related to the presence of organic pathology. The distribution of mental illnesses was not related to the organic status and those without physical disease had the lowest ratings on psychiatric assessments. All major findings were confirmed at a follow‐up assessment. There is no evidence that these subjects can be divided into a simple dichotomy of those with physical or mental illnesses, or that pain measures can discriminate between them. It is concluded that all chronic pain patients require both physical and mental state assessment.

Abnormal illness behaviour: childhood experiences and long-term consequences

Concepts of illness and related beliefs and behaviours are often inappropriate to health state. They develop in childhood and we review the processes that are often involved, which are influenced by ethnic, cultural, demographic, social, psychological and biological factors. Unusual patterns of care experienced by some children and the inappropriate illness behaviours of those with particular influence over them play a central part in the development of the most extreme disorders. Prospective studies are limited but indicate that patterns of illness behaviour in childhood are often persistent and continue or recur in adult life. Inappropriate patterns of invalidism are common in children and adults and the poor prognosis, considerable costs and personal distress indicate the need for primary prevention as well as more active intervention for those who are at particular risk.

The validity of the General Health Questionnaire for first-stage screening for mental illness in pain clinic patients

&NA; The validity of the 28‐item version of the General Health Questionnaire (GHQ‐28) was determined by comparison with the Clinical Interview Schedule (CIS) in 56 pain clinic patients. Despite some limitations, the GHQ can be used effectively and cheaply as the first stage of an assessment to identify potential “cases” of mental disorder which must then be verified using a second‐stage clinical interview such as the CIS. This process can result in a considerable reduction in the proportion of patients requiring a psychiatric interview and, therefore, in reduced service costs. Factors associated with lower validity coefficients include female sex, age above 60 years and pain with a duration of less than 2 years.

The self care assessment schedule (SCAS) — I. The purpose and construction of a new assessment of self care behaviours

The Self Care Assessment Schedule (SCAS) is a new questionnaire which measures the frequency of ten behaviours during a period of fourteen days. Data are presented for five patient samples and a group of non consulting controls and the distributions of scores between groups show expected differences. In some groups scores are significantly greater for male subjects and those with the most chronic disorders but scores are not related to age. It is tentatively suggested that the SCAS may be used to determine the severity of aspects of disability based on percentile scores.

The effect of illness behaviour on the apparent relationship between physical and mental disorders

Evidence for associations between organic disease and psychopathology is reviewed and it is concluded that some of this is determined by complaint and consultation behaviours. The concept of illness behaviour is described. The Self Care Assessment Schedule (SCAS) is a new measure of illness behaviour and has been used to provide an independent assessment of psychiatric day patients, gynaecology and surgical outpatients. Only weak positive correlations were found between SCAS scores and mental illness, measured using the General Health Questionnaire (GHQ). Subjects with organic pathology differed little from those without organic pathology, with regard to SCAS and GHQ scores. However SCAS and GHQ scores were more highly correlated in those without organic pathology. It is concluded that claimed associations between physical disease and psychopathology should be based on objective evidence rather than subjective complaints and that this should be found across the entire spectrum of illness behaviour.

Is asthma a psychosomatic illness?—I.: A retrospective study of mental illness and social adjustment☆

Abstract A group of 53 asthmatics and 50 matched controls together with their first-degree relatives has been followed up retrospectively after an interval of 15 years. There was no evidence that the mental illness experienced by the asthma group differed significantly from that of controls during the follow up period eithet in period prevalence or diagnosis. The presence of mental illness amongst asthmatics was not related to the prognosis for asthma, nor to the age of onset, family history of asthma or other atopic conditions. The asthma group showed only slightly greater impairment in social adjustment than controls. These findings are discussed in the light of traditional views of asthma as a psychosomatic illness.