Psychosomatics 47:498-503, December 2006
doi: 10.1176/appi.psy.47.6.498
© 2006 Academy of Psychosomatic Medicine
Somatoform Disorder in Primary Care: Course and the Need for Cognitive-Behavioral Treatment
Ingrid A. Arnold, M.D., Ph.D.,
Margot W.M. de Waal, M.Sc., Ph.D.,
Just A.H. Eekhof, M.D., Ph.D., and
Albert M. van Hemert, M.D., Ph.D.
Received June 28, 2005; revised December 23, 2005; accepted January 13, 2006. From the Dept. of General Practice and Nursing Home Medicine, Leiden University Medical Center, The Netherlands, and Parnassia Psychomedical Centre, The Hague, the Netherlands (AMvH). Send correspondence and reprint requests to Ingrid A Arnold, M.D., Dept. of General Practice and Nursing Home Medicine, Leiden University Medical Center, P.O. Box 2088, 2301 CB, The Netherlands. e-mail: i.a.arnold{at}lumc.nl
|
ABSTRACT
|
Medically unexplained physical symptoms are prevalent in primary care. Of all patients attending the family physician, 16% have a somatoform disorder as described by DSM–IV. Cognitive-behavioral treatment has been demonstrated to be effective in secondary care. However, the course of somatoform disorders and their need for treatment have not yet been established in primary care. In this study, data from 1,046 attendees in family practice were analyzed for prevalence, course, and eligibility for treatment. Over a 6-month follow-up, the prevalence of somatoform disorder decreased from 16.1% to 12.3%. After assessment of eligibility, about 5% of patients demonstrated a need for treatment.
|
INTRODUCTION
|
Somatoform disorders are among the most prevalent psychiatric disorders in primary care. Recently, we reported a prevalence of 16.1% for DSM–IV somatoform disorders in a Dutch primary-care consulting population.1 Most common was the undifferentiated somatoform disorder, with a prevalence of 13.1%. These patients suffer from one or more medically unexplained physical symptoms, such as fatigue, headache, or gastrointestinal symptoms, causing clinically significant impairment for at least 6 months. Earlier, Fink et al.2 reported an even higher prevalence of somatoform disorders: 30%, in a Danish primary-care consulting population.
Over the last 10 years, it has become increasingly clear that cognitive-behavioral therapy is an effective treatment for patients with somatoform disorders. A number of systematic reviews have concluded that cognitive-behavioral therapy is an effective treatment for selected medically unexplained physical symptoms, such as fatigue, irritable bowel syndrome, and fibromyalgia.3–6 A randomized, controlled trial conducted at a general-medical outpatient clinic demonstrated that cognitive-behavioral treatment was also effective in patients with more heterogeneous medically unexplained physical symptoms.7 Many of the patients included in these studies would qualify for a diagnosis of undifferentiated somatoform disorder. If all patients with somatoform disorders in primary care were offered cognitive-behavioral therapy, this approach would result in a very substantial increase in treatment.
It remains to be seen, however, whether treatment is indicated for and acceptable to each and every patient who is diagnosed with a somatoform disorder in primary care. The natural course of somatoform disorders is often benign. Studies on the prognosis of medically unexplained physical symptoms mostly report improvement of symptoms or recovery in the majority of patients after 1 year.8–10 In treatment studies, recovery in the non-treatment arm is usually also considerable. It seems wise to start with a period of "wait and see" before formal treatment is initiated. Furthermore, we may doubt whether all patients with somatoform disorders are willing to accept psychological treatment. In one study in secondary care, we found that most patients accepted psychological treatment, but it is unclear whether the same applies to patients in primary care.4,11,12 Moreover, common clinical wisdom states that "somatizing patients do not like psychologizing."
In the SOmatization study of the University of Leiden (SOUL), we had the opportunity to estimate the proportion of patients in primary care who had persistent symptoms of somatoform disorder who would accept treatment if a program of brief cognitive-behavioral therapy were offered to them. After an initial diagnostic assessment of their somatoform disorder, patients were followed for 6 months to monitor spontaneous recovery. Patients reporting persistence of their symptoms were subsequently evaluated for a brief cognitive-behavioral treatment by their own general practitioner. Our findings may help to make a realistic estimate of the additional need for treatment of somatoform disorders.
|
METHOD
|
The SOUL Cohort
The SOmatization study of the University of Leiden (SOUL study) was designed as a prospective, cohort study in family practice. Screening questionnaires were used to identify high-risk patients. For a further diagnostic assessment by means of a psychiatric interview, we invited all high-risk patients and a sample of 15% of the low-risk patients. More details on the procedure have been published elsewhere.1
For the present study, the prevalence of persistent somatoform disorder was established after 6 months. All the patients with persistent symptoms underwent an assessment as to their eligibility for cognitive-behavioral treatment provided by their own family physician. The Medical Ethical Committee of the Leiden University Medical Center approved the study protocol.
Population
In a flow-chart (Figure 1), we illustrate patient recruitment and follow-up. The study took place in eight university-affiliated family practices in The Netherlands. The distribution of age and gender is similar to that of the Dutch population. The study was limited to natives of The Netherlands. The electronic medical records of all patients were available through the central database of the family-practice registration network, Leiden RNUH-LEO. Between April 2000 and December 2001, patients were selected from a random sample of 1,778 consecutive patients, age 25 to 80. They received screening questionnaires by mail. A total number of 1,046 patients (59%) returned the questionnaire and indicated that they were willing to participate. The main feature of the non-response analyses was a slight underrepresentation of young men in the examined sample.
Questionnaires
Participants completed the Short Form Health Survey (SF–36)13 as a measure of functional impairment, the Hospital Anxiety and Depression Scale (HADS)14 as a measure of anxiety and depression, the Illness Attitude Scales (IAS) as a measure of health anxiety and illness behavior,15 and a Physical Symptom Checklist (PSC)16 to quantify the number of reported physical symptoms. A total score of >15 on the HADS or a score of >5 on the PSC defined the high-risk sample. All patients with a high score and a sample of patients with a low score were invited for a diagnostic interview. Patients were excluded if they were unable to participate in an interview because of handicaps such as deafness, aphasia, or cognitive impairment.
Diagnostic Interview
WHO-certified clinical researchers used the Schedules for Clinical Assessment in Neuropsychiatry (SCAN, Version 2.1)17 as the diagnostic interview. The assessment included psychiatric diagnoses and concurrent physical illnesses. Also, patients with a somatoform disorder reported the frequency and the severity of the main unexplained symptoms. Frequency could be expressed as Never, Sometimes, Often, or Always. Patients indicated the severity on a visual-analog scale (VAS), on which 0 meant no symptoms and 10 meant unbearable symptoms. All chronic somatoform disorders with a duration of at least 6 months were recorded.
Follow-Up
All 119 patients with a diagnosis of somatoform disorder received follow-up questionnaires 6 months after baseline with the PSC, HADS, SF–36, and IAS. Also, they reported on the frequency and severity of their main physical symptoms. Somatoform symptoms were considered to be persistent if the patient reported on at least one unexplained symptom with a frequency of at least "Often" and a severity of at least 5 on the VAS.
Non-responding patients received a reminder, and patients who had moved were traced with information from the family physician. A total of 100 patients returned the questionnaires, of which 99 were suitable for analysis, an overall response rate of 83%.
Eligibility and Acceptability
All patients indicating persistent symptoms were evaluated by a family-physician-researcher (IAA) on their eligibility for cognitive-behavioral therapy by their family physician. Treatment was not offered to patients who were already receiving psychological treatment for their symptoms, nor to patients with a serious somatic disease or serious psychiatric diseases such as psychosis, substance abuse, posttraumatic stress disorder, or severe personality disorder. Patients with a concurrent anxiety or depressive disorder were not excluded because cognitive-behavioral therapy is an effective treatment for these disorders. All potentially eligible patients received a personal invitation letter for an interview, along with written information on cognitive-behavioral therapy. Subsequently, the family-physician-researcher (IAA) contacted them by telephone and visited them at home. During the interview, we determined whether significant clinical impairment, according to a DSM–IV diagnosis of somatoform disorder, was still present or whether new exclusion criteria had arisen. All eligible patients were offered cognitive-behavioral treatment for their symptoms.
Analyses
In order to obtain estimates for the consulting population, all prevalence estimates and their 95% confidence intervals (CI) were calculated by using weights that were inversely proportional to the sampling probabilities,18 Comparisons between groups of interested versus uninterested patients were performed by t-tests. Analyses were conducted with SPSS for Windows 11.0.
|
RESULTS
|
Follow-Up
Figure 2 presents the follow-up and eligibility of all 99 patients with a somatoform disorder; 30 were regarded as recovered after 6 months. These patients reported a frequency of "Never" or "Sometimes" or a severity of <5 on a VAS for their main symptom. The remaining 69 patients reported persistent symptoms on the VAS. This corresponds with a weighted prevalence of 12.3% for persisting symptoms (CI: 9.1%–15.5%) in the consulting population.
Eligibility and Acceptability
Of the 69 patients who reported persisting medically unexplained physical symptoms, 20 patients were not offered treatment; 10 of them had already received ongoing psychological treatment for their symptoms. In three patients, major psychiatric disorders were the cause of exclusion, and the remaining seven had a serious somatic disorder.
For 49 patients with persistent symptoms, cognitive-behavioral treatment was considered as suitable. Regarding psychiatric comorbidity, 15 of the 49 patients had a concurrent anxiety and/or depressive disorder diagnosed at baseline. All 49 potentially eligible patients received written information about cognitive-behavioral therapy and were contacted by the family-physician-researcher (IAA) to ask whether they were interested in treatment. A total of 23 patients indicated that they were not interested; 18 of these indicated that they were not motivated to undergo treatment because they had accepted their symptoms as a part of their life; 3 patients had objections against treatment because of negative experiences in the past; and 2 patients reported a lack of time.
A total of 26 patients were interested in treatment. This corresponds with a weighted prevalence of 4.8% (CI: 2.6%–7.0%) in the consulting population that was screened at baseline.
Table 1 presents patient characteristics at follow-up. When comparing recovered patients with patients reporting current symptoms, the mean severity of the main physical symptoms was significantly higher in patients with current symptoms. In particular, those who had already received treatment reported significantly more symptoms on all measures. Generally, patients with current symptoms also had higher scores on the HADS and more functional limitations, although this difference did not always reach significance.
View this table:
[in this window]
[in a new window]
|
TABLE 1. Patient Characteristics at Follow-Up (mean, with 95% confidence limits), Gender and Weighted Means of Age, Symptoms, and Functional Limitations
|
Among patients who would be eligible for treatment by the family physician and who were not already receiving treatment, most differences were minor. Interested patients were significantly younger (42 versus 50 years of age) and experienced less health anxiety, according to the IAS (6.3 versus 12.5) than those not interested in treatment.
|
DISCUSSION
|
In this follow-up study, we demonstrated that the course of somatoform disorders is not favorable, given that three-quarters of all patients diagnosed with a somatoform disorder reported persisting symptoms after 6 months. The estimated prevalence of a persisting somatoform disorder was 12.3% of consecutive consulting patients in primary care.
Of all the patients with an initial diagnosis of a somatoform disorder in primary care and 6-month follow-up (N=99), enrollment in a course of brief cognitive-behavioral therapy was a suitable treatment option for only 26%. During the 6-month follow-up period, the symptoms had diminished in 30% of the patients. Long-term psychological treatment for a psychiatric condition was already going on in 10%. In another 10% of the patients, cognitive-behavioral therapy for somatoform disorders was not the preferred treatment because of a psychiatric disorder or a serious comorbid somatic disease. Finally, 23% of the initial selection of patients did not consider cognitive-behavioral therapy an acceptable treatment for their problems. Taking the sampling scheme into account, these data for somatoform disorders suggest an additional need for cognitive-behavioral therapy in nearly 5% of the consulting population in primary care.
In our study, the natural course of recovery was less favorable than in previous studies.8–10 Most previous studies had focused on medically unexplained symptoms, rather than on the more strict diagnosis of somatoform disorders. In our study, we took meticulous care to limit the diagnoses to patients with clinically significant symptoms. Compared with previous studies, our total prevalence was estimated at 16.1%, which was rather low. These were the patients, however, with the more serious symptoms and functional limitations, and, in these patients, spontaneous recovery is less likely, and treatment could bring about a substantial improvement.
For a considerable number of patients, cognitive-behavioral treatment was not an acceptable option. Our approach of the patients was similar to the one in our previous studies.7,12 Patients received personal letters from their own family physician. They were contacted by telephone and visited at home by the family-physician/researcher (IAA), who offered information concerning the treatment in a sympathetic way, avoiding unnecessary "psychologizing." A systematic accounting of the reasons why cognitive-behavioral treatment was unacceptable suggests that most patients, often those with longstanding symptoms, simply did not feel like investing their time and effort in therapy. We assume that younger patients declined more often because they gave priority to their work or family. Also, the higher level of health anxiety in patients who did not accept treatment might have led to avoidance of explicit treatment of their symptoms. We cannot exclude the possibility that an intervention offered in a regular consultation with their family physician would have been more acceptable to some patients.
The non-response issue merits separate discussion. Our study may be biased in that it may well be possible that non-responding patients withdrew because they were less interested in treatment. This may have led to an overestimation of the need for treatment. In a scenario in which the non-responding patients were considered ineligible or not interested in treatment, 2.5% of the consulting population would have been suitable for treatment.
Our findings suggest that an additional 4.8% of the consulting population in primary care may need cognitive-behavioral therapy. These patients constitute a selection with more severe, persistent, and debilitating unexplained physical symptoms. The figure would be higher if more patients accepted therapy when it was offered. Consequently, somatoform disorders warrant a substantial extra effort from the healthcare system so as to provide appropriate treatment. In addition to the treatment options in secondary care, general-practitioners require time-limited, focused, and effective approaches to address these problems in primary care.
There is a high prevalence of persistent somatoform disorders in primary care. One in eight patients reports persisting somatoform symptoms after 6 months of follow-up. At least one in 22 patients would accept cognitive-behavioral therapy for somatoform disorders if it were offered; therefore, the development of suitable interventions for primary care is indicated to meet the needs of this group of patients.
|
ACKNOWLEDGMENTS
|
This study was funded by The Netherlands Organization for Health Research and Development (ZON-MW).
|
REFERENCES
|
- De Waal MW, Arnold IA, Eekhof JA, et al: Somatoform disorders in general practice: prevalence, functional impairment, and comorbidity with anxiety and depressive disorders. Br J Psychiatry 2004; 184:470–476[Abstract/Free Full Text]
- Fink P, Sorensen L, Engberg M, et al: Somatization in primary care: prevalence, healthcare utilization, and general-practitioner recognition. Psychosomatics 1999; 40:330–338[Abstract/Free Full Text]
- Kroenke K, Swindle R: Cognitive-behavioral therapy for somatization and symptom syndromes: a critical review of controlled clinical trials. Psychother Psychosom 2000; 69:205–215[CrossRef][Medline]
- Raine R, Haines A, Sensky T, et al: Systematic review of mental health interventions for common somatic symptoms: can research evidence from secondary care be extrapolated to primary care? BMJ 2002; 325:1082–1093[Abstract/Free Full Text]
- Nezu AM, Nezu CM, Lombardo ER: Cognitive-behaviour therapy for medically unexplained symptoms: a critical review of the treatment literature. Behaviour Therapy 2001; 32:537–583[CrossRef]
- Looper KJ, Kirmayer LJ: Behavioral-medicine approaches to somatoform disorders. J Consult Clin Psychol 2002; 70:810–827[CrossRef][Medline]
- Speckens AE, Van Hemert AM, Spinhoven P, et al: Cognitive-behavioral therapy for medically unexplained physical symptoms: a randomised, controlled trial. BMJ 1995; 311(7016):1328–1332[Abstract/Free Full Text]
- Speckens AE, van Hemert AM, Bolk JH, et al: Unexplained physical symptoms: outcome, utilization of medical care, and associated factors. Psychol Med 1996; 26:745–752[Medline]
- Gureje O, Simon GE, Von Korff M: A cross-national study of the course of persistent pain in primary care. Pain 2001; 92(1-2):195-200
- Khan AA, Khan A, Harezlak J, et al: Somatic symptoms in primary care: etiology and outcome. Psychosomatics 2003; 44:471–478[Abstract/Free Full Text]
- Speckens AE, van Hemert AM, Bolk JH, et al: The acceptability of psychological treatment in patients with medically unexplained physical symptoms. J Psychosom Res 1995; 39:855–863[CrossRef][Medline]
- Arnold IA, Speckens AEM, Van Hemert AM: Medically unexplained physical symptoms: the feasibility of group cognitive-behavioral therapy in primary care. J Psychosom Res 2004; 57:517–520[CrossRef][Medline]
- Aaronson NK, Muller M, Cohen PD, et al: Translation, validation, and norming of the Dutch-language version of the SF-36 Health Survey in community and chronic disease populations. J Clin Epidemiol 1998; 51:1055–1068[CrossRef][Medline]
- Zigmond AS, Snaith RP: The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand 1983; 67:361–370[Medline]
- Speckens AE, Spinhoven P, Sloekers PP, et al: A validation study of the Whitely Index, the Illness Attitude Scales, and the Somatosensory Amplification Scale in general-medical and family-practice patients. J Psychosom Res 1996; 40:95–104[Medline]
- van Hemert AM, Hengeveld MW, Bolk JH, et al: Psychiatric disorders in relation to medical illness among patients of a general-medical outpatient clinic. Psychol Med 1993; 23:167–173[Medline]
- Wing JK, Babor T, Brugha T, et al: SCAN. Schedules for Clinical Assessment in Neuropsychiatry. Arch Gen Psychiatry 1990; 47:589–593[Abstract]
- Cochran WG: Sampling Techniques, 3rd Edition. New York, Wiley, 1997
This article has been cited by other articles:
|
|
|
|
 
J. L. Jackson and K. Kroenke
Prevalence, Impact, and Prognosis of Multisomatoform Disorder in Primary Care: A 5-Year Follow-up Study
Psychosom Med,
May 1, 2008;
70(4):
430 - 434.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
W. Rief and G. Rojas
Stability of Somatoform Symptoms Implications for Classification
Psychosom Med,
November 1, 2007;
69(9):
864 - 869.
[Abstract]
[Full Text]
[PDF]
|
|
|
Get information about faster international access.
Privacy Policy
Copyright © 2006
Academy of Psychosomatic Medicine.
All rights reserved.
Home
| Search
| Current Issue
| Past Issues
| Subscribe
| All APPI Journals
| Help
| Contact Us
|
TOP
ABSTRACT
INTRODUCTION
