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Authors' reply

Published online by Cambridge University Press:  02 January 2018

Francis Creed
Affiliation:
Institute of Brain, Behaviour and Mental Health, University of Manchester, UK
Judith Rosmalen
Affiliation:
University of Groningen, University Medical Center Groningen, Interdisciplinary Center Psychopathology and Emotion Regulation, Groningen, The Netherlands
Barbara Tomenson
Affiliation:
Biostatistics Unit, Institute of Population Health, University of Manchester, Jean McFarlane Building (3rd Floor), Oxford Road, Manchester M13 9PL, UK. Email: barbara.tomenson@manchester.ac.uk
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Abstract

Type
Columns
Copyright
Copyright © Royal College of Psychiatrists, 2014 

We thank Desai & Chaturvedi for their interest in our paper. We agree that additional dimensions could be included as possible predictors of health status and healthcare use and that the latter would be influenced by the nature of local healthcare facilities. It was impossible to include such additional measures in our study because we were restricted to those measures that had been used in the original studies.

Desai & Chaturvedi mention duration and severity of symptoms as possible predictors of outcome. Duration is important but may not predict number of subsequent doctor visits. Reference Fiddler, Jackson, Kapur, Wells and Creed1 Severity is important and five of our studies used questionnaires (including the Patient Health Questionnaire-15) which assessed the degree of bothersomeness of each somatic symptom, a subjective measure of severity. The distinction between intensity and severity is complex, but one study noted that severity of pain did not explain the association between number of somatic symptoms and subsequent health status. Reference Creed, Tomenson, Chew-Graham, Macfarlane, Davies and Jackson2

The point raised by Desai & Chaturvedi regarding the co-occurrence of medically explained and unexplained symptoms is very important and forms one of the main points of the paper. Such co-occurrence of symptoms is common and constitutes one of the main difficulties of trying to make a diagnosis purely on the presence of medically unexplained symptoms. In the four sites where data were available, we found that the association of somatic symptoms with health status, after adjustment for confounders, was stronger for total somatic symptom score than for number of medically unexplained symptoms. We could not test this in relation to healthcare use but the association between number of somatic symptoms with healthcare use appears similar for medically explained and unexplained symptoms. Reference Jackson, Fiddler, Kapur, Wells, Tomenson and Creed3

Assessing abnormal illness behaviour is difficult in population-based studies using self-administered questionnaires, as most measures include items about how often the respondent visits doctors, which would overlap with our outcome measure of healthcare use. A better dimension might be a person’s general tendency to visit doctors even for minor reasons; this is a predictor of healthcare use independent of number of bothersome somatic symptoms. Reference Mewes, Rief, Brähler, Martin and Glaesmer4

The other dimension mentioned by Desai & Chaturvedi, health anxiety, is very important. In two studies a high number of somatic symptoms and pronounced health anxiety were both independent predictors of primary healthcare contacts (see Tomenson et al Reference Tomenson, McBeth, Chew-Graham, MacFarlane, Davies and Jackson5 ). Two other studies have shown a complex interaction between these dimensions, with health anxiety being a predictor of subsequent healthcare use only in respondents without a high number of somatic symptoms or who also have serious medical illnesses. Reference Jackson, Fiddler, Kapur, Wells, Tomenson and Creed3,Reference Tomenson, McBeth, Chew-Graham, MacFarlane, Davies and Jackson5

This field of research suffers from lack of prospective studies. The correlates, or predictors, of healthcare use are somewhat different for past use and future use. Reference Tomenson, McBeth, Chew-Graham, MacFarlane, Davies and Jackson5,Reference Barsky, Ettner, Horsky and Bates6 One paper made the intriguing, but plausible, suggestion that frequent visits to the physician could increase health anxiety and precipitate more somatic symptoms rather than the other way round. Reference Barsky, Ettner, Horsky and Bates6 Further prospective studies using well-validated questionnaires are needed. Reference Zijlema, Stolk, Löwe, Rief, White and Rosmalen7

Funding

The American Psychiatric Association funded this study. The original studies, whose data have been used in this paper, were funded by: German Federal Ministry of Research, Education and Science, BMBF, Deutsche Forschungsgemeinschaft (DFG), Netherlands Organisation for Scientific Research (NOW), Norwegian Research Council, UK Medical Research Council.

Footnotes

Declaration of interest

F.C. has been a member of the American Psychiatric Association DSM-5 work group on somatic distress disorders and is a member of the World Health Organization ICD-11 working group on the classification of somatic distress and dissociative disorders.

References

1 Fiddler, M Jackson, J Kapur, N Wells, A, Creed, F Childhood adversity and frequent medical consultations. Gen Hosp Psychiatry 2004; 26: 367–77.CrossRefGoogle ScholarPubMed
2 Creed, FH Tomenson, B Chew-Graham, C Macfarlane, GJ Davies, I Jackson, J, et al. Multiple somatic symptoms predict impaired health status in functional somatic syndromes. Int J Behav Med 2013; 20: 194205.CrossRefGoogle ScholarPubMed
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5 Tomenson, B McBeth, J Chew-Graham, CA MacFarlane, G Davies, I Jackson, J et al. Somatization and health anxiety as predictors of healthcare use. Psychosom Med 2012; 74: 656–64.Google Scholar
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7 Zijlema, WL Stolk, RP Löwe, B Rief, W White, PD Rosmalen, JGM How to assess common somatic symptoms in large-scale studies: a systematic review of questionnaires. J Psychosom Res 2013; 74: 459–68.Google Scholar
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