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Specific Somatoform Disorder in the General Population

Received April 30, 2002; revised Aug. 4, 2002; accepted Oct. 4, 2002. From the Department of Psychiatry, Ernst-Moritz-Arndt-University of Greifswald, the Department of Epidemiology and Social Medicine, the University of Greifswald, Greifswald, Germany, and the Department of Psychiatry, University of Lübeck, Lübeck, Germany. Address reprint requests to Dr. Grabe, Department of Psychiatry, Ernst-Moritz-Arndt-Universität Greifswald, im Klinikum der Hansestadt Stralsund, Rostocker Chaussee 70, 18437 Stralsund, Germany; grabeh{at}mail.uni-greifswald.de (e-mail).

ABSTRACT

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The authors assessed the validity of the recently proposed diagnosis for specific somatoform disorder in the general population. German versions of the DSM-IV adapted Composite International Diagnostic Interview were administered to a representative sample of 4,075 individuals. Multivariate analyses were used to compare impairment, life satisfaction, and use of health care. A total of 803 of 4,075 subjects (19.7%) with undifferentiated somatization disorder were identified, which included 51 subjects (1.3%) who met criteria for specific somatoform disorder. Subjects with specific somatoform disorder were more impaired, had lower life satisfaction, and had higher use of health care than subjects with undifferentiated somatization disorder only. The proposed diagnosis of specific somatoform disorder demonstrated a high validity independent of comorbid depressive and anxiety disorders.

INTRODUCTION

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Somatoform symptoms are among the most common reasons for seeking medical help. Escobar et al.¹ and Schwartz et al.² reported a lifetime prevalence of somatoform disorders of 4%–5% in the general population. Despite the clinical and economic importance of somatoform disorders, there is still a major need for an empirical evaluation of current classification criteria. Because of the rather restrictive diagnostic criteria of somatization disorder, according to DSM-III-R³ and DSM-IV,⁴ most patients with somatoform symptoms fall into the category of undifferentiated somatoform disorder, which is defined as residual. To overcome this unsatisfactory situation, Escobar and colleagues^1,5 proposed an abridged diagnosis of somatization disorder that requires four symptoms in men and six symptoms from the list of 35 DSM-III-R somatization symptoms. Main critical points of this concept are that the Somatic Severity Index 4/6 criteria are based on the DSM-III symptom list, which was not empirically validated, that it has been used mainly in epidemiological research, and that the Somatic Severity Index 4/6 criteria may be overinclusive in clinical groups. Other approaches investigating the Somatic Symptom Index have found good discrimination between mild and severe forms of somatization with a cutoff point of eight symptoms of 35.⁶ Rief and Hiller⁷ presented an empirical analysis, selecting 32 symptoms with satisfying psychometric performance from DSM-IV and ICD-10 criteria; 21 somatic symptoms were omitted. A cutoff point of seven or more symptoms yielded the best discrimination between low and high disability. Moreover, the need for a new classification of somatization disorder was emphasized—not mainly based on number of symptoms but to include cognitive factors, illness behavior, and psychosocial impairment.^7–9 One promising approach to this problem was introduced by Kroenke et al.^10,11 with the concept of multisomatoform disorder, which focuses on current somatoform symptoms. On the basis of their clinical and empirical work, Rief and Hiller^7,8 proposed and defined three new diagnoses for the classification of somatoform disorders:

1. A polysymptomatic somatoform disorder with a duration of at least 2 years, the presence of at least seven unexplained physical symptoms, characteristic psychological features, and significant distress or impairment.
   
2. A specific somatoform disorder, requiring at least one unexplained physical symptom and a substantial impairment in more than one life area.
   
3. A health anxiety disorder, corresponding to the DSM-IV criterion of hypochondriasis.
   

In the present study, we aimed to do the following:

1. To assess the prevalence of undifferentiated somatization disorder according to DSM-IV and of specific somatoform disorder in the general population.
   
2. To investigate whether the proposed diagnosis of specific somatoform disorder, which requires at least one unexplained physical symptom and significant impairment, identifies a subgroup of subjects with a lower quality of life, more days of impairment in activities of daily living, more use of health care, and a higher number of hospitalizations.
   
3. To investigate the relationship between the diagnosis of specific somatoform disorder and the Somatic Severity Index 4/6 criteria standard.
   

METHOD

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Sample
The data came from a baseline cross-section of a longitudinal study that was part of the project Transitions in Alcohol Consumption and Smoking. The survey was based on individuals living in the northern German city of Lübeck or in one of 46 surrounding communities that constituted the catchment area of Lübeck. The aim of the community selection was precise representation with regard to settlement structure. The total population living in this area consisted of 325,107 individuals. Consideration of the inclusion criteria by age (range=18–64) and nationality (to avoid problems with language, only Germans were included), 193,452 citizens were the target population. A random sample of 6,447 addresses was drawn from all registration office files. A total of 619 (9.6%) of these turned out to not fulfill the inclusion criteria (the subject had moved out of the sampling area, the subject was not known under the registered address, the subject was of non-German nationality, the subject was deceased, lived in prison, or resided in other institutions). Of the remaining 5,829 individuals, a total of 4,093 completed the interview, which corresponded to a response rate of 70.2%. Reasons for nonresponse were refusal (N=979), no contact with the sampled individual (N=668), nonparticipation because of illness (N=80), or incomplete interview or interview obtained by phone (N=9). An analysis of the reasons for nonresponse revealed that older subjects refused more often, and younger ones more frequently moved out of the sampling area or could not be reached. Because of these compensatory effects, a small amount of deviation from the target population and the final sample resulted, which would not justify the methodological problems inherent in weighting. Eighteen of the 4,093 interviews could not be analyzed because of nonsystematic reasons.

Diagnostic Assessment
The diagnostic interview was performed in face-to-face interviews with the fully structured and standardized Munich Composite International Diagnostic Interview,^12,13 the most recent German version of the World Health Organization (WHO) Composite International Diagnostic Interview¹⁴ adapted for DSM-IV. The responses of the participants were directly entered into a laptop computer. The interviews were performed by trained freelancers, interviewing both as a chief occupation and as a sideline; however, all were experienced in conducting health surveys. To control for a possible interviewer bias, a heterogeneous interviewer crew was selected that consisted of 56 individuals of all age groups (mean=36.1, SD=11.2, range=21–69) and both sexes (46.3% women). After 5 days of initial interviewer training, continuous individual brush-up sessions were administered by WHO Composite International Diagnostic Interview trainers. A complete hard copy of all interviews was edited by a WHO Composite International Diagnostic Interview trainer with regard to consistency and clinical relevance of the symptoms. In regular meetings attended by experts, uncertain cases were clarified by consensus, and homogeneous work was guaranteed. Weekly contact and feedback made it possible to add missing information by immediate inquiry and continuous monitoring of interviewer activities. In the applied diagnostic algorithm for undifferentiated somatization disorder, we specifically asked the subjects about the findings, statements, and diagnosis given by his or her physician regarding the cause of his or her physical symptoms.¹⁵ The reported physical symptoms were labeled as minor, induced by drugs, medication, or alcohol, caused by a somatic illness or injury, and, finally, having excluded all prior categories, as symptoms possibly representing a relevant somatoform symptom. Only symptoms meeting the last criterion were reported in the results section and accepted by the data editor as contributing to the diagnosis of undifferentiated somatoform disorder. An additional question assessed the associated impairment in more than one life area as contributing to the diagnosis of specific somatoform disorder (Figure 1).

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FIGURE 1.  Structured Diagnostic Algorithma for the Diagnosis of Undifferentiated Somatoform Disorder and Specific Somatoform Disorder aFrom the Munich Composite International Diagnostic Interview.12,13

Quality of life was measured with the Satisfaction With Life Scale, which consists of five items.¹⁶ Additionally, satisfaction with life was assessed with a 5-point rating scale that differentiates eight life domains (work, partnership, family, friends, financial situation, living conditions, health, and leisure time) that was adapted from the Questionnaire on Health Behavior.¹⁷ These ratings were summarized in an unweighted manner to yield a domain satisfaction composite score. The Social Support Appraisal Scale¹⁸ was used to assess the perceived availability of social support with 28 items (on a 4-point rating scale), which may represent an important factor for coping with life stressors.

All diagnoses were made according to DSM-IV by Munich Composite International Diagnostic Interview diagnostic software (version 1.0).

Analysis Procedures
Group comparisons between subjects with undifferentiated somatization disorder only (not fulfilling the criteria for specific somatoform disorder) and subjects with specific somatoform disorder were calculated with multivariate analysis of variance (MANOVA) with age as a covariate in regard to three different set of variables:

1. The number of consultations of family doctors, specialists, psychiatrists, and psychologists and the number and duration of hospitalizations and days unable to work during the past 12 months.
   
2. The self-rated score for satisfaction with life (Satisfaction With Life Scale) and within eight different life domains and for self-rated social support (Social Support Appraisal Scale) within the past 6 months.
   
3. The number of days during the past month of being unable or too mildly impaired to perform activities of daily living because of psychological or physical problems.
   

It is noteworthy that the subjects who fulfilled the diagnoses of somatization disorder (N=1), hypochondriasis (N=5), and somatoform pain disorder (N=499),¹⁵ according to the Munich Composite International Diagnostic Interview for DSM-IV were not included in our analyses. Subjects possibly fulfilling the criteria for multisomatoform disorder (N=10) were not specifically identified or excluded.

All described computations were performed with SPSS software package, version 7.5.1 (SPSS, Chicago).

RESULTS

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In our general population sample (N=4,075), 803 subjects (19.7%) with undifferentiated somatization disorder were identified (Table 1). Within this group, 51 subjects (1.3% of the total sample) also met the criteria for specific somatoform disorder. The age at onset of somatic symptoms was earlier in the women than in the men (t=4.0, df=803, p<0.001), and the duration of symptoms was longer in the women than in the men (t=–3.7, df=803, p<0.001).

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TABLE 1. Prevalence and Duration of Undifferentiated Somatoform Disorder Only and Specific Somatoform Disorder in a Representative Sample of 4,075 Subjects

Sociodemographic characteristics for subjects with specific somatoform disorder and with undifferentiated somatization disorder only are depicted in Table 2. The men (t=2.2, df=339, p=0.03) and the women (t=3.3, df=460, p=0.001) with specific somatoform disorder were significantly younger, and the men tended to be better educated (²=16.6, df=6, p=0.01) and unmarried (²=13.4, df=4, p=0.001) compared to the men with undifferentiated somatization disorder only.

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TABLE 2. Sociodemographic Characteristics of Subjects With Undifferentiated Somatization Disorder Only and Specific Somatoform Disorder in a Representative Sample of 4,075 Subjects

The two diagnostic groups were compared in regard to the three sets of variables (Table 3, Table 4, and Table 5). By assessing the comorbid lifetime prevalence of any depressive disorder and any anxiety disorder according to DSM-IV, we found significantly more lifetime diagnoses of depressive disorders in the subjects with specific somatoform disorder (11 out of 51) than in those with undifferentiated somatization disorder only (81 out of 671) (²=5.5, df=1, p=0.02). For the lifetime prevalence of anxiety disorders, no significant group differences were found (²=0.6, df=1, p=0.45). To exclude the putative influence of depressive disorders on the analyses shown in Table 3, Table 4, and Table 5, the same MANOVAs were performed, with the exclusion of all subjects with the lifetime diagnosis of depressive disorders from the analyses. Still, significant differences could be confirmed for treatment-seeking behavior (MANOVA: Wilks's lambda=0.95; F=2.2, df=9, 359, p=0.02), for self-rated satisfaction with life and social support (MANOVA: Wilks's lambda=0.97; F=3.2, df=3, 332, p<0.03), and for impairment in activities of daily living (MANOVA: Wilks's lambda=0.95; F=4.0, df=3, 221, p=0.009).

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TABLE 3. Comparison of Subjects With Undifferentiated Somatoform Disorder Only and Specific Somatoform Disorder by Health Behaviors in the Past 12 Months, Corrected for Differences in Agea

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TABLE 4. Comparison of Subjects With Undifferentiated Somatoform Disorder Only and Specific Somatoform Disorder by Satisfaction With Life and Self-Rated Social Support in the Past 6 Months, Corrected for Differences in Agea

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TABLE 5. Comparison of Subjects With Undifferentiated Somatoform Disorder Only and Specific Somatoform Disorder by Impairments in Activities of Daily Living in the Past Month, Corrected for Differences in Agea

We applied the Somatic Severity Index 4/6 criteria to our total sample and identified 15 men and 13 women who met these criteria. However, none of these subjects fulfilled the criteria for specific somatoform disorder.

DISCUSSION

TOP ABSTRACT INTRODUCTION METHOD RESULTS DISCUSSION REFERENCES

 
The present study underlined the difficulties in classifying somatoform symptoms in the general population. Severe, polysymptomatic cases fulfilling the criteria for a somatization disorder are rare, as indicated by one single subject in our sample who met these criteria. Even when we excluded all patients with somatization disorder and somatoform pain disorder (N=499, 12.2%¹⁵), 803 (19.7%) of our general population sample reported severe and distressing somatic symptoms that could not be related to an organic process, corresponding to a lifetime diagnosis of undifferentiated somatization disorder, according to the fully structured Munich Composite International Diagnostic Interview. In order to differentiate these subjects, we applied the diagnostic criteria for specific somatoform disorder that constituted the assessment of psychosocial impairment in more than one life area.

Although somatic symptoms tend to emerge in the early 20s (in women) or the mid-20s (in men) and have a chronic duration in most cases of undifferentiated somatization disorder, we found only 51 subjects to be severely impaired by their symptoms within different life areas, fulfilling the diagnosis of specific somatoform disorder. The validity of the diagnosis of specific somatoform disorder in regard to the psychosocial effects of the disorder was supported by a significantly higher number of consultations with the family doctor and psychologists and by a higher number of days spent in the hospital. Furthermore, the group of subjects with specific somatoform disorder showed significantly more days of mild impairment in activities of daily living because of psychological problems and an inability to perform activities of daily living because of physical problems. However, it seems that the professional status of the subjects with specific somatoform disorder was not severely altered. Furthermore, self-rated satisfaction with life was significantly lower in subjects with specific somatoform disorder, independently of social support. We could also demonstrate that these differences turned out to be independent of comorbid depressive and anxiety disorders.

It is impressive that none of the 28 subjects who met the Somatic Severity Index 4/6 criteria also fulfilled the specific somatoform disorder criteria of a significant impairment in different life areas. This demonstrates that number of symptoms is not necessarily associated with psychosocial impairment due to somatization.

At least within general population samples, the DSM-IV diagnosis of undifferentiated somatoform disorder may be overinclusive, and the Somatic Severity Index 4/6 criteria diagnosis does not capture severe cases. However, in investigations of clinical study groups with somatoform disorders, it is obvious that these patients already suffer to a considerable degree from their symptoms and seek treatment. In clinical settings, the Somatic Severity Index 4/6 criteria were expected to be overinclusive in not differentiating somatizing patients from those with other diagnoses.⁸

Possible limitations to our results may come from our sampling, the interview process, and the application and interpretation of the standardized criteria of the Munich Composite International Diagnostic Interview. Sampling procedures were aimed at defining a representative community sample. A total of 70.2% of the selected individuals completed the interview, which is considered satisfactory. Institutionalized subjects were excluded from sampling. In regard to somatoform disorders, this might not lead to a serious underestimation of affected subjects in the community because they do not tend to be institutionalized because of their disorders. From a methodological point of view, lay interviews always present a source of concern; however, the Munich Composite International Diagnostic Interview was specially validated for lay interviewers.¹⁹ Especially regarding somatoform disorders, the interviewers were instructed to include only somatic symptoms that were unexplained or insufficiently explained by the presence of a somatic illness. Moreover, our interviewers had experience in conducting health surveys and were specifically trained to perform the Composite International Diagnostic Interview. However, over- or underestimation of somatoform diagnoses might have occurred to some degree because of the following:

1. We did not consult the subject's physician or evaluate the medical record but strictly asked the subject about the findings, statements, and the diagnoses given by his or her physician regarding the cause of his or her physical symptoms. Thereby, we aimed to minimize the influence of personal organic explanations given by the subject that could lead to an underestimation of somatoform disorders, especially by lay interviewers.
   
2. Minimal organic findings may be overinterpreted by a physician as being the cause for somatic complaints in cases of somatization. However, the high prevalence rates for undifferentiated somatization disorder and pain disorder¹⁵ do not suggest a significant underestimation of somatized physical symptoms.
   
3. The Munich Composite International Diagnostic Interview diagnostic algorithm for the DSM-IV diagnosis of undifferentiated somatization disorder may overestimate the prevalence of this disorder because the strict distress and impairment criterion (criterion C) that has been introduced into DSM-IV has not been fully integrated into the Munich Composite International Diagnostic Interview for DSM-IV.
   

Our data show that many subjects from the general population experience unexplained somatic symptoms, but only a minority of these are severely distressed or impaired. This result gives empirical support for diagnostic approaches that do not only rely on the number of physical symptoms but include strict criteria on the assessment of associated impairment and distress. By applying the proposed diagnosis of specific somatoform disorder, we found that only 1.3% of the subjects in our sample met this lifetime diagnosis. These subjects showed marked impairments in psychosocial function, reductions in life satisfaction, and increased consultations of family doctors and psychologists as well as more days spent in the hospital compared to the subjects with undifferentiated somatization disorder only, pointing to the validity of the proposed diagnosis of specific somatoform disorder. The other proposed diagnosis of polysymptomatic somatoform disorder (subjects with more than seven unexplained somatic symptoms and characteristic psychological features and significant impairment) may represent a rare but distinct disorder in the general population. Further steps toward empirically derived diagnostic categories of somatoform disorders should include additional validation of the DSM-IV list of somatic symptoms and the proposed diagnoses by Rief and Hiller^7,8 as well as the concept of multisomatoform disorder by Kroenke et al.^10,11

ACKNOWLEDGMENTS

 
This study is part of the German Research Network Analytical Epidemiology of Substance Abuse. Factors related to the use and abuse of psychoactive substances are analyzed by different research groups in the context of several longitudinal studies. Contact persons are Dr. Büringer and Dr. Küfner (IFT Institute for Therapy Research, Munich), Dr. Wittchen (Max-Planck-Institute, Munich), Dr. John (University of Greifswald, Greifswald, Germany), and Dr. Dilling (Medical University of Lübeck, Lübeck, Germany). The German Research Network is funded in the context of the Biological and Psychosocial Factors of Drug Abuse and Dependence by the Federal Ministry of Education, Science, Research, and Technology. Data described in this article are part of Transitions in Alcohol Consumption and Smoking, Part 1: Drug Use in the Adult General Population in a Northern German City and Surrounding Communities, grant 01EB9406; principal investigators are Dr. John and Dr. Dilling.

REFERENCES

TOP ABSTRACT INTRODUCTION METHOD RESULTS DISCUSSION REFERENCES

 

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