تعداد علائم جسمی نتیجه دقیق تر اضطراب سلامت در بیماران مراجعه کننده کلینیک های مغز و اعصاب، قلب و عروق، گوارش را پیش بینی می کند

Background In consecutive new outpatients, we aimed to assess whether somatization and health anxiety predicted health care use and quality of life 6 months later in all patients or in those without demonstrable abnormalities. Method On the first clinic visit, participants completed the Illness Perception Questionnaire (IPQ), the Health Anxiety Questionnaire (HAQ), and the Hospital Anxiety and Depression Scale (HADS). Outcome was assessed as: (a) the number of medical consultations over the subsequent 6 months, extracted from medical records, and (b) Short-Form Health Survey 36 (SF36) physical component score 6 months after index clinic visit. Results A total of 295 patients were recruited (77% response rate), and medical consultation data were available for 275. The number of bodily symptoms was associated with both outcomes in linear fashion (P<.001), and this was independent of anxiety and depression. Similar associations were found in people with or without symptoms due to demonstrable structural abnormalities. Health anxiety was associated only with health-related quality of life in patients with symptoms explained by demonstrable abnormalities. Conclusion The number of bodily symptoms and degree of health anxiety have different patterns of association with outcome, and these need to be considered in revising the diagnoses of somatization and hypochondriasis.

One of the criticisms of DSM-IV somatoform disorders is the lack of evidence to support their existence as independent diagnoses [1]. Researchers outside of specialist clinics appear to have abandoned the DSM-IV diagnosis of somatization disorder in favor of more practical definitions, such as abridged somatization or multisomatoform disorder [2], [3] and [4]. Both are based on the number of bothersome unexplained somatic symptoms. Similarly, the DSM criteria for a diagnosis of hypochondriasis are too restrictive for use in primary care or population-based samples, so researchers have evolved several ways of measuring hypochondriasis [5], [6], [7], [8] and [9]. This has led to widely differing estimates of the prevalence of hypochondriasis [3]. Previous research has aimed to define the threshold above which the number of bodily symptoms is closely associated with increased disability and health care costs. Most early studies included only somatoform symptoms, defined as bodily symptoms that are medically unexplained, are disabling, and/or lead to medical help seeking [4] and [10]. It is not surprising, therefore, that numerous such symptoms are associated with disability and health care use. Two studies suggested that the relationship between the number of bodily symptoms, health care use, and disability holds for all bodily symptoms whether or not they are explained by demonstrable abnormalities [11] and [12]. Other researchers have combined the number of bodily symptoms with dimensions of hypochondriasis (disease fear, disease conviction, and bodily preoccupation) and found that primary care patients scoring in the top 14% of this combined measure had increased health care use [7]. An alternative view regards the number of bodily symptoms and health anxiety as continua without any clear “cutoff” point indicating a specific psychiatric diagnosis. If this is the case, there may be a linear association between the number of somatic symptoms and degree of health anxiety, and external validating measures such as health care use and degree of impaired function [12]. Similarly, the association between the number of bodily symptoms or health anxiety and postulated associated features (such as female sex predominance, adverse childhood experiences, and depression) can be tested appropriately. These relationships can be tested in patients who have symptoms explained by demonstrable pathological abnormalities and medically unexplained symptoms. We have previously analyzed data from 129 of the patients included in the present study, showing a significant association between adverse childhood experiences and the number of bodily symptoms [13]. The number of bodily symptoms mediated the association between adverse childhood experiences and frequent health care use; this relationship was strongest in patients with medically unexplained symptoms [13]. The aim of this study was to test the following hypotheses in new patients at medical clinics: Hypothesis 1. Both the number of bodily symptoms and the degree of health anxiety are associated, in linear fashion, with subsequent health care use and degree of impaired function. Hypothesis 2. These relationships will be true only for patients with medically unexplained symptoms. Hypothesis 3. Any association between the number of body symptoms and outcome is mediated by depression and anxiety.

Of the 383 patients approached on their first clinic visit, 295 (77%) joined the study. Of the 295, 114 (38.6%) participants had medically unexplained symptoms: 33 of 112 (29.5%) in neurology, 24 of 60 (40%) in cardiology, and 57 of 123 (46.3%) in gastroenterology (χ2=7.10, P=.029). The most common medically unexplained symptoms were: noncardiac chest pain, palpitations, headaches, limb pains, paresthesia, and irritable bowel syndrome. There were no significant differences among participants attending the three clinics in terms of demographic features, anxiety scores, or depression scores, but health anxiety was higher in those attending cardiology clinics; thus, we adjusted for clinic in subsequent analyses. We also adjusted for age because patients with symptoms not unexplained by demonstrable abnormalities were significantly younger than those with symptoms explained by demonstrable abnormality [43.2 (S.D.=12.8) vs. 50.0 (S.D.=13.5), P<.005]. Neither IPQ identity scale nor health anxiety scale was associated with age, sex, marital status, ethnic group, or type of symptom (demonstrable abnormalities or not), but compared to those of high socioeconomic status, those of low socioeconomic status had increased health anxiety scores [median (IQR)=16 (8–22) vs. 11 (7–19); P=.005.] and increased IPQ identity scores [number of bodily symptoms; median (IQR)=9 (5–10) vs. 8 (5–9); P=.006].