Estimated frequency of somatic symptom disorder in general practice: cross-sectional survey with general practitioners

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Estimated frequency of somatic symptom disorder in general practice: cross-sectional survey with general practitioners
BMC Psychiatry volume 22, Article number: 632 (2022)

Abstract
Background
Somatic symptom disorder (SSD) is the successor diagnosis of somatoform disorder in the 5th Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Relevance and frequency of SSD and its clinical symptoms in general practice are still unknown. We estimate frequencies of patients fulfilling the diagnostic criteria of SSD in general practice.

Methods
Mailed and online survey with general practitioners (GP) in Germany using a cross-sectional representative sample from registries of statutory health insurance physicians. GPs estimated percentages of their patients who show the clinical symptoms of SSD according to DSM-5; that is, one or more burdensome somatic symptoms (A criterion), excessive symptom- or illness-related concern, anxiety, or behaviour (B criterion), and persistence of the symptoms over at least 6 months (C criterion). Statistical analysis used means and confidence intervals of estimated patient proportions showing SSD symptoms. Frequency of full-blown SSD was based on the products of these proportions calculated for each GP.

Results
Responses from 1728 GPs were obtained. GPs saw the clinical symptoms of SSD fulfilled (A and B criteria) in 21.5% (95% CI: 20.6 to 22.3) of their patients. They further estimated that in 24.3% (95% CI: 23.3 to 25.2) of patients, symptoms would persist, yielding a total of 7.7% (95% CI: 7.1 to 8.4) of patients to have a full-blown SSD.

Conclusions
We estimate a frequency of 7.7% of patients in general practice to fulfil the diagnostic criteria of SSD. This number may figure as a reference for the yet to be uncovered prevalence of SSD and it indicates a high clinical relevance of the clinical symptoms of SSD in general practice.

Registration
German Clinical Trials Register (Deutschen Register Klinischer Studien, DRKS).

DRKS-ID: DRKS00012942.

The date the study was registered: October 2nd 2017.

The date the first participant was enrolled: February 9th 2018.

Background
With the introduction of the 5th Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013 [1], the diagnosis of somatoform disorder was replaced by somatic symptom disorder (SSD). The clinical symptoms of SSD combine both, physical and psychological symptom burden. That is, besides the A criterion of at least one life-disrupting physical symptom, SSD requires excessive symptom- or illness-related concern, anxiety, or behaviour as it’s B criterion – the so-called psychological positive criteria. Finally, SSD assumes symptom persistence of at least 6 months as its C criterion. SSD no longer requires the exclusion of a medical cause for physical complaints. The International Classification of Diseases 11th Revision (ICD-11) made a similar development from the group of somatoform disorders in ICD-10 to the diagnosis of bodily distress disorder, which is comparable with SSD [2].

Representative and unbiased prevalence studies for SSD are still rare as evidenced in a recent scoping review [3]. In a community health centre one rather small study, using a clinical interview to diagnose SSD with 202 participants, revealed 20.8% of patients diagnosed with SSD [4]. Prevalence estimation using a combination of Patient Health Questionnaire (module for somatic symptom severity, PHQ-15), Whiteley-Index, and Brief Illness Perception Questionnaire (BIPQ) as a proxy measure for SSD revealed a proportion of 45.5% of SSD in a selected sample of 325 patients with medically unexplained physical symptoms in general practice [5]. More gold standard prevalence data is still missing and there is no knowledge about what proportions of patients in clinical practice show symptoms of SSD.

(...)

Discussion
GPs in our study had estimated that about one fifth of their patients show clinical symptoms of SSD related to the main A and B criterion; namely life-disrupting physical symptoms and excessive symptom- or illness-related thoughts, concern, and behaviour. Moreover, symptom persistence of more than 6 months was reported for 24.3% of patients – C criterion. The assessments for all diagnostic criteria combined, indicated that a frequency of 7.7% patients in general practice were likely to possess full-blown SSD. Furthermore, GPs estimated that 34% of their patients would show one or more distressing symptoms for the diagnostic A criterion of SSD, and between 20 and 25% of their patients would fulfil any one of the B criteria. The estimated proportion of patients showing a somatoform disorder (according to DSM-IV-TR) best predicted the proportions of clinical symptoms of SSD.

Although, our data does not consist of the prevalence rates estimated based on standard clinical interviews, our frequency estimation of 7.7% can be compared with estimations from other research. A small sample study in general practice yielded a prevalence of 20.8% for SSD [4]. In the general population, the prevalence of SSD was estimated to be 4.5% [17]. About 20% of the general population were at least sometimes concerned about bodily symptoms, had higher levels of anxiety related to symptoms, or showed higher levels of symptom-related behaviour [18]. In conclusion, our estimation of SSD frequency is lower than earlier data from general practice, but corresponds with estimations for the general population of about one out of twenty persons to show SSD.

(...)

Conclusions
We estimate a frequency of 7.7% of patients in general practice to fulfil the diagnostic criteria of SSD. Even if this result is based on subjective frequency estimations by GPs and is not a prevalence, it may figure as a reference for the yet to be determined prevalence of SSD. Furthermore, we found the strongest association between the estimated patient proportions of those showing the clinical symptoms of SSD and those with somatoform disorder. This suggests that, presently, GPs may treat the diagnostic criteria of SSD as a continuation of somatoform disorder as it applies to patients showing persistent somatic symptoms and symptom-related concern. So, the results may be due to the actual overlap of both diagnoses in patients in general practice.

With passing time the diagnosis of SSD as a mental disorder may become more and more familiar not only for psychological or psychiatric specialists but also for GPs. Its implementation in similar form in ICD-11 may further acquaint clinicians who do not use DSM-5 to diagnose...
 
"Methods
Mailed and online survey with general practitioners (GP) in Germany using a cross-sectional representative sample from registries of statutory health insurance physicians. GPs estimated percentages of their patients who show the clinical symptoms of SSD according to DSM-5; that is, one or more burdensome somatic symptoms (A criterion), excessive symptom- or illness-related concern, anxiety, or behaviour (B criterion), and persistence of the symptoms over at least 6 months (C criterion). Statistical analysis used means and confidence intervals of estimated patient proportions showing SSD symptoms. Frequency of full-blown SSD was based on the products of these proportions calculated for each GP."

1. I can't help remembering that as well as research being research it can also be used as a guise under which to market things. ie information more likely to go in if you put it in the text of a question someone has to answer, than read in a leaflet they've been sent. People go back and read it and think about the answer, look up the definition.

Great way of replacing prior different definition in their memory without them noticing it - and of course reading a leaflet that says 'we've taken away the need for them to actually not have another illness in order to diagnose hypochondria' might make a few focus on the 'is that a good idea' part of it.

2. Which diseases/ailments couldn't fit these criterion - on the basis of a patient walking in with it not having been looked at and them just presenting their symptoms. Because it seems to be 'all chronic illness' but also 'all acute illness that has been left for 6months'. Most people not yet diagnosed who've had something/anything for that long basically?

I mean it is literally easier to list those not covered by it? Maybe Bell's Palsy type things, but as skin I suspect is somehow in there but you'd have to surely pick up moles etc.. Is it basically most things that there isn't a 'higher obligation for' re: some sort of red flag list
 
hmm this is worse than I thought now I have finally managed to find the additional material which has the translation of the actual letter sent: https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-022-04100-0#additional-information

The first question after the quite assertive that this was a good change description was:

"I think that the change in the diagnostic criteria from somatoform disorder to somatic stress disorder described above makes sense."

Now I can't think of a more leading, and deliberately ambiguous question - re: it is asking 'do you understand what you just read' or meaning 'should they have changed it' but really naughty to be in such terms as to almost literally be the 'Yes Prime Minster' video clip that I now can't find but I think it was @SNT Gatchaman that posted it (?) on how surveys can make you say any answer they want.

So they answer that however (does it matter?) then - well I've just pasted it - I hope that is allowed,but the order is as relevant in building people up to nudging them to 'be convinced' as anything

I think that the change in the diagnostic criteria from somatoform disorder to somatic stress disorder described above makes sense.

What proportion of your patients have one or more somatic symptoms that are distressing and lead to significant limitations in their daily living?

What proportion of your patients have inappropriate and persistent thoughts about the seriousness of their symptoms?

What proportion of your patients have persistent and severe anxiety about their health or symptoms?

What proportion of your patients spend excessive time and energy on symptoms or health concerns?

In what proportion of your patients is the symptom burden persistent (> 6 months, individual symptoms need not be continuous)?

What proportion of your patients experience persistent, distressing and limiting somatic symptoms together with persistent thoughts, anxieties and time spent on these symptoms?
Click to expand...

I was half-checking to make sure they hadn't put any prevalence suggestions in their description (which they haven't)


It's worse than I thought because they are 'building up' and doing it without the 6mnths bit at all. Which is actually about the only criteria in the whole illness. And sort of suggesting that people pre-diagnose those who walk in and just what filibuster them up to 6months when at that point they 'meet' the criteria by virtue of not having been investigated and being pretty annoyed?
 
The paper said:
Furthermore, we found the strongest association between the estimated patient proportions of those showing the clinical symptoms of SSD and those with somatoform disorder
Click to expand...
Oh, wow, they found an association between Humpty and Dumpty stop the damn presses.

This reminds of Vanilla Ice explaining how the intro to Ice, ice Baby is different than Under pressure by Queen.
 
Results of an early DSM-5 field trial study on what was at that point projected to be called "CSSD", as reported by Joel E Dimsdale, MD, chair of the Somatic symptom disorder Work Group, at the 2012 annual meeting of the American Psychiatric Association.

The field trial study comprised:

a control group of 488 "healthy patients";
a "diagnosed illness" group of 205 patients with cancer and malignancy (some in this group were said to have severe coronary disease);
a "functional somatic" group comprising 94 people with "irritable bowel" and "chronic widespread pain" (a term used synonymously with fibromyalgia).


15% of the "diagnosed illness" study group, comprising patients with cancer or severe coronary disease, were caught by [C]SSD and would meet the criteria for application of an additional mental disorder diagnosis.

26% of the "functional somatic" study group, comprising patients with irritable bowel or chronic widespread pain, met the [C]SSD criteria.

7% of the 488 "healthy patient" control group were also caught by the [C]SSD criteria.
 
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