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Author's Accepted Manuscript: Psychiatry Research
Author's Accepted Manuscript: Psychiatry Research
PII: S0165-1781(16)31442-1
DOI: http://dx.doi.org/10.1016/j.psychres.2017.04.064
Reference: PSY10490
To appear in: Psychiatry Research
Received date: 26 August 2016
Revised date: 10 March 2017
Accepted date: 27 April 2017
Cite this article as: Zahra Heidari, Awat Feizi, Hamidreza Roohafza, Ammar
Hassanzadeh Keshteli and Payman Adibi, Somatoform Symptoms Profiles in
Relation to Psychological Disorders - A Population Classification Analysis in a
Large Sample of General Adults, Psychiatry Research,
http://dx.doi.org/10.1016/j.psychres.2017.04.064
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Somatoform Symptoms Profiles in Relation to Psychological Disorders - A Population
Zahra Heidaria,b, Awat Feizia,c*, Hamidreza Roohafzad, Ammar Hassanzadeh Keshtelie,f, Payman
Adibif,g
a
Department of Biostatistics and Epidemiology, School of Health, Isfahan University of Medical Sciences,
Isfahan, Iran
b
Student Research Center, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran
c
Psychosomatic Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
d
Cardiac Rehabilitation Research Center, Cardiovascular Research Institute, Isfahan University of
Medical Sciences, Isfahan, Iran
e
Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
f
Integrative Functional Gastroenterology Research Center, Isfahan University of Medical Sciences,
Isfahan, Iran
g
Department of Internal Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan,
Iran
*
Corresponding Author: Dr. Awat Feizi. Address: Department of Epidemiology and Biostatistics,
School of Public Health and Psychosomatic Research Center, Isfahan University of Medical
Abstract
on 4762 Iranian adults. Somatoform symptoms were assessed using a comprehensive 30-items
1
questionnaire and psychological disorders were evaluated by 12-item General Health
Questionnaire (GHQ-12) and Hospital Anxiety and Depression Scale (HADS) questionnaires.
Factor analysis and factor mixture modeling (FMM) were used for data analysis. Four
factor structure, based somatoform symptoms, was identified in our study population. Two
identified classes were labeled as “low psycho-fatigue complaints” and “high psycho-fatigue
complaints”. The scores of psychological disorders profile was significantly associated with four
somatoform symptoms profiles in both classes; however the stronger relationship was observed
in high psycho-fatigue complaints class. The prevalence of all the somatoform symptoms among
participants assigned to the "high psycho-fatigue complaints" class was significantly higher than
within our study population. Our study also provided informative pathways on the association of
psychological disorders with somatoform symptoms. These findings could be useful for dealing
1. Introduction
Somatoform symptoms such as headache, fatigue, dizziness or shortness of breath, are causing
significant functional impairments. They are defined as the presence of bodily symptoms as a
result of interrelations of mind and body and without physical explanation even after medical
evaluation, for that (Manshaee and Hamidi, 2013; Xiong et al., 2015). These symptoms are
prevalent not only in patients attending to primary care, secondary care and clinics but also in
2
general populations (Escobar et al., 2010; Novy et al., 2005; Steinbrecher et al., 2011). The
higher prevalence of these symptoms puts significant burden on the healthcare delivery system
and has considerable impact on quality of life (Gonzalez et al., 2009; Wong et al., 2015).
Persons with somatoform symptoms firstly seek help from a physician because of their physical
signs. However, after many physical examinations with lacking of results for determining the
etiology of them, individuals suffering from these symptoms are referred to a psychiatrist. There
are evidences that psychological disorders are risk factors for somatoform symptoms (Sugahara
et al., 2004; Wong et al., 2015; Zhu et al., 2012), in which patients with psychological disorders
are more likely to have somatoform symptoms than general population (Bener et al., 2013;
Gonzalez et al., 2009; Haftgoli et al., 2010; Han et al., 2014; Shidhaye et al., 2013). For instance,
high prevalence (73-92%) of somatoform symptoms has been reported in depressed patients
(Caballero et al., 2008; Simon et al., 1999; Sugahara et al., 2004). Wong et al. demonstrated that
anxiety is a modifiable risk factor for somatoform symptoms in which reducing anxiety could be
considered as an effective approach for reducing somatoform symptoms (Wong et al., 2015).
Some evidences showed that there is notable heterogeneity in the somatoform symptoms and few
studies are available on their classification (Fink et al., 2007; Gara et al., 1998; Kato et al., 2010;
Lacourt et al., 2013; Nimnuan et al., 2001). In previous researches, different statistical
techniques such as factor analysis, clustering, and latent class analysis (LCA) have been used to
address the heterogeneity (Fink et al., 2007; Kato et al., 2010; Lacourt et al., 2013). FMM is a
hybrid model that unifies factor analysis and latent class analysis in a single framework and
allows the underlying structure to be simultaneously dimensional and categorical (Lubke and
Muthén, 2005). This structure is considered categorical because FMM classifies the individuals
into sub-groups and it is also considered dimensional because this modeling approach takes into
3
account the heterogeneity within groups using continuous latent variables (Lubke and Muthén,
2005). Therefore, FMM may be superior to other methods both in terms of class detection and
class assignment. Some extensions of FMM allow including a set of explanatory variables in the
main structure of model. FMM with explanatory variables has been investigated under this
assumption that explanatory variables are allowed to affect both latent variables and group
Given the relations between somatoform symptoms and psychological disorders, the objectives
of the present study were identifying profiles of somatoform symptoms (latent factors) and
classifying studied population (latent classes) into more homogeneous subgroups based on
This cross-sectional population-based study was conducted in the framework of “Study of the
Epidemiology of Psychological, Alimentary Health and Nutrition” (SEPAHAN) project that was
performed in 2 phases in a large sample of Iranian adults population in the Isfahan province
(Adibi et al., 2012). In the first phase of SEPAHAN project, different questionnaires on
demographic information, lifestyle and nutritional factors, were distributed among 10087 invited
persons, and 8691 subjects took part (response rate: 86.16%). At the second phase, others
and somatoform symptoms, were distributed and 6239 questionnaires were completed (response
rate: 64.64%). Then, national identification numbers of the participants used to link the
questionnaires from both phases. Finally, after considering missing data, data on 4762 subjects
4
with completed information used in the current analysis. Written informed consent was obtained
from all participants. The study was approved by the Bioethics committee of Isfahan University
of Medical Sciences, Isfahan, Iran (Project numbers: #189069, #189082, and #189086). More
details about SEPAHAN project are presented elsewhere (Adibi et al., 2012).
SEPAHAN’s questionnaires common with “the patient health questionnaire (PHQ)” (Spitzer et
al., 1999) and “the 47-items questionnaire used in the Lacourt et al.’s study” (Lacourt et al.,
2013), as valid and standard tools for the assessment of somatoform symptoms. We used 31-
indicate how much they had experienced each symptom in the past three months on a four points
Likert scale (never, sometimes, often, and always). For one item (i.e. Dry mouth), the rating
scale was as: never, low and high. In order to assess the reliability of this instrument, we
conducted a separate mini survey of 100 participants selected randomly. There was strong
internal reliability, with a Cronbach's alpha score of 0.903 (Heidari et al., 2017b). In the current
study, in order to use all study participants in the analysis, we removed women specific
“menstrual disorder” item from 31 items; so 30 somatoform symptoms were used in the analysis.
Questionnaire (GHQ-12) was used to detect psychological distress. The internal consistency was
5
assessed by Cronbach's alpha coefficient and it was found to be 0.87 (Montazeri et al., 2005).
The each item of the instrument asks whether the participant has experienced a particular
symptom or behavior recently. Each item has a four-point Likert scale (less than usual, no more
than usual, rather more than usual, or much more than usual). A respondent’s score could be
between 0 and 12 points, and a threshold score of 4 or more was used to identify a respondent
Self-report screening instrument of Hospital Anxiety and Depression Scale (HADS) was used to
validated by Montazeri et al. for Iranian populations (Montazeri et al., 2003). It consists of 14
items which 7 of them are allocated to depression. It has a 4-point Likert scale ranging from 0
between 0 and 21 points (0-7: normal, 8-21: mild, moderate or severe disorder). Internal
consistency which is assessed by Cronbach’s alpha has been found to be 0.78 (Montazeri et al.,
2003).
marital status (single/married), educational level (under diploma, diploma (12 year formal
education) and university graduate) etc.) and life styles characteristics (weight (kg), height (m),
physical activity (inactive and moderately inactive/moderately active and active) based on
6
For following up our main study objective i.e. if participants could be clustered into meaningful
subgroups based on their somatoform symptoms using FMM, firstly, we performed factor
analysis on the 30 individual somatoform symptoms and resulted four interpretable factors based
symptoms were labeled based on the loaded items in each factor. Then, LCA was used to
determine the appropriate number of latent classes in studied population, models with 2 or 3
latent classes was found based on goodness of fit criteria. After that, we conducted different
FMMs with 4 factors and 2 or 3 latent classes. Determination of goodness of fit of models was
guided through comparing the Bayesian Information Criterion (BIC) (Schwarz, 1978) and
entropy indices across models. Lower BIC and higher entropy values indicate better model
fitting and class separation, respectively (Lubke and Muthén, 2007). Finally, we extracted a
latent factor from psychological problems (i.e. anxiety, depression and psychological distress) in
order to evaluate its association with somatoform symptoms profiles, in identified classes by
using FMM.
3. Results
Overall, 4762 adults contributed in the study. The mean age was 36.58±0.13 years. They
consisted of 2657 (55.8%) females and 3776 (81.2%) married. 2650 (57.2%) of participants had
college education. Psychological distress, anxiety, and depression were identified in 23.1%,
5.8% and 10.4% of participants, respectively. About 3.5% of individuals were underweight,
37.1% were overweight and 9.4% were obese. 34.8% of participants had regular physical activity
7
Four extracted profiles based on 30 individual somatoform symptoms were labeled as ‘psycho-
12.4%, 12.3%, 11.4% and 9.3% of total variance, respectively (Table 1) (Heidari et al., 2017b;
Table 2 shows the correlations between scores of somatoform symptoms profiles and the scores
distress, anxiety and depression) are significantly correlated with all somatoform symptoms
profiles. Among them, anxiety had stronger associations with somatoform symptoms profiles
(Table 2).
‘pharyngeal-respiratory’) was recognized using FMM. During model fitting, we observed that a
two-classes/four-factors model allowing for free intercepts, covariances and means across latent
classes had lowest BIC (346926.053) and entropy 0.995. These values indicating that individuals
are correctly classified by our fitted model. The two identified classes were labeled as “high
first class experienced higher scores of psychological-fatigue somatic symptoms (mean: 0.249 in
first class vs. 0 in second class) while experienced lower scores of somatoform symptoms in
8
individuals (89%) in the low psycho-fatigue complaints class and 519 participants (11%) in the
high psycho-fatigue complaints class. According to the two-class four-factor FMM solution,
approximately, all items are significantly loaded on their respective factor (Heidari et al., 2017a).
with somatoform symptoms profiles in the two extracted classes. In both classes, the profile of
psychological disorders is significantly related to the four somatoform symptoms profiles. The
regression coefficient of psychological disorders profile was near 0.3 in both classes. There was
gastrointestinal profile in both classes and its regression coefficient was greater in high psycho-
fatigue complaints class (0.152 and 0.147 in high and low psycho-fatigue complaints classes,
respectively; p<0.0001). Furthermore, the regression coefficients for neuro-skeletal profile were
0.219 and 0.210 in high and low psycho-fatigue complaints classes, respectively; (p<0.0001). It
can be seen that there is significant positive relationship between psychological disorders profile
and pharyngeal –respiratory profile in both classes; however, its regression coefficient on
pharyngeal –respiratory profile was greater in high psycho-fatigue complaints class (0.134 and
0.08 in high and low psycho-fatigue complaints classes, respectively; p< 0.0001). (Table 3)
The prevalence of the somatoform symptoms in two extracted latent classes is presented in Table
3, too. Although, majority of symptoms had a four-point Likert scale; we only reported the
response of participants to ‘often and always’ categories. The prevalence of all 30 somatoform
symptoms for participants assigned to the "high psycho-fatigue complaints" class was
significantly higher than other class (P<0.0001). In the "often" category, the most common
class were “dry mouth” (45%), “severe fatigue” (39%), followed by “headache”, back pain”,
9
“sleep disorder”, and “feeling low on energy” (all about 24%). In the "always" category, the
most frequent somatoform symptoms reported by participants assigned to the "high psycho-
fatigue complaints" class were “severe fatigue” (15%), followed by “feeling low on energy”
(13.6%), “pain in joints” (13%), “disturbing thoughts” (12.8%), “back pain” (12.1%) and “dry
4. Discussion
and low (89%) levels of psychological-fatigue complaints, and four-factors profiles (i.e.,
underlying structure of the somatoform symptoms were identified from a large sample of Iranian
adults using factor mixture modeling (FMM). We observed that the prevalence of all somatoform
symptoms for participants assigned to "high psycho-fatigue complaints" class was significantly
higher than" low psycho-fatigue complaints" class. Although, fitted FMM led to two classes with
mentioned characteristics, however, it should be noted that participants in both classes suffered
We did not find any study such as current study, which stratified a general large
population into homogeneous subgroups based on somatoform symptoms using FMM. However,
other statistical approaches i.e. clustering, factor analysis and LCA in some studies were used to
classify psychosomatic symptoms (Fink et al., 2007; Gara et al., 1998; Kato et al., 2010; Lacourt
et al., 2013; Nimnuan et al., 2001). For instance, in the Fink et al.’s study on 978 internal
medical, neurological, and primary care patients, a distinct pattern of cardiopulmonary (CP),
musculoskeletal/pain (MS), and gastrointestinal (GI) symptom factors as well as three classes of
10
patients including “non-bodily distress”, “modest bodily distress”, and “severe bodily distress”
were identified (Fink et al., 2007). The aforesaid study had similarities with our study in terms of
gastrointestinal and skeletal profiles. In the Gara et al.’s study 11 clusters of patients with
different patterns of medically unexplained symptoms, were identified using hierarchical cluster
analysis (Gara et al., 1998). The observed disparities in results of conducted studies in this area
of subject can be attributed to geographic, socio-economic status, culture and racial dependency
of somatoform symptoms.
in the form of physical symptoms (Wong et al., 2015) and there are evidences that psychological
disorders are risk factors for somatoform symptoms (Zhu et al., 2012). Majority of previous
studies were restricted to the association of psychological disorders with a few somatoform
symptoms or with an overall score of somatization (Kinnunen et al., 2010; Wong et al., 2015;
Zhu et al., 2012). In current study, three psychological disorders i.e. anxiety, depression and
psychological distress were combined (as a latent factor) and its collective association with
somatoform symptoms profiles was examined. We observed that the profile of psychological
disorders is positively associated with the four somatoform symptoms profiles with greater
coefficient in the high psycho-fatigue complaints class, except for psycho-fatigue profile.
Previous studies have emphasized on the strong association of psychological disorders with
somatoform symptoms. Wong et al. demonstrated that anxiety is a modifiable risk factor for
psychosomatic symptoms in general Chinese populations (Wong et al., 2015). Kinnunen et al.’s
study showed that nearly all psychosomatic symptoms are associated with mental health
symptoms (Kinnunen et al., 2010). The results of Zhu et al.’s study on 2408 clinical patients,
revealed that “depression and anxiety” are main risk factors for high somatic symptoms (Zhu et
11
al., 2012). Koh et al.’s study found that both anxiety and depression have direct effects on
somatic symptoms in patients suffering from these disorders (Koh et al., 2008). Dales et al.
indicated that psychological problems are important determinants of respiratory symptoms (such
as cough, wheeze and dyspnea) (Dales et al., 1989). The influence of psychological disorders,
such as anxiety and depression, on somatoform symptoms can be explained from biological
perspectives (Wong et al., 2015). Psychological disorders have major role in initiation and
modulation and alteration brain processing of incoming sensory signals (Wouters and
Boeckxstaens, 2016). Also, regarding to the association of psychological disorders profile with
neuro-skeletal profile of somatic symptoms, the possible role of neurotransmitters and cytokine
receptors (Trivedi, 2004; Vargas-Prada and Coggon, 2015; Walker et al., 2014) could be
mentioned.
It is important to recognize some strengths and limitations of the present study. A major
strength of our large population based study is the application of factor mixture model for
instead of dealing with them, separately. Furthermore, psychological disorders profile was
evaluated in identified classes through FMM. However, due to the cross-sectional nature of
SEPAHAN design, we could not infer cause–effect relationships from our findings. All used
information in the present analysis was collected by self-administered questionnaires that might
lead to misclassifying the participants. Finally, because SEPAHAN study’s participants were
health centers staffs, thus, generalization of the present findings to the Iranian general population
12
In summary, our study’s findings, in the context of an observational study, suggested that
somatoform symptoms had a dimensional-categorical structure within our population that could
be useful for dealing with treatment’s approaches. In addition, we showed that the profile of
Conflicts of interest
None
Acknowledgements
The present article was extracted from a Biostatistics PhD thesis at the School of Health, Isfahan
University of Medical Sciences, with project number 394832. SEPAHAN was financially
supported by a grant from the Vice Chancellery for Research and Technology, Isfahan
University of Medical Sciences (IUMS). We are grateful to thank all staff of Isfahan University
of Medical Sciences (MUI) who kindly participated in our study and staff of Public Relations
13
References
Adibi, P., Keshteli, A.H., Esmaillzadeh, A., Afshar, H., Roohafza, H., Bagherian-Sararoudi, R.,
Daghaghzadeh, H., Soltanian, N., Feinle-Bisset, C., Boyce, P., 2012. The study on the
Bener, A., Dafeeah, E.E., Chaturvedi, S.K., Bhugra, D., 2013. Somatic symptoms in primary
care and psychological comorbidities in Qatar: neglected burden of disease. Int. Rev.
Caballero, L., Aragonès, E., García-Campayo, J., Rodríguez-Artalejo, F., Ayuso-Mateos, J.L.,
Polavieja, P., Gómez-Utrero, E., Romera, I., Gilaberte, I., 2008. Prevalence, characteristics,
and attribution of somatic symptoms in Spanish patients with major depressive disorder
Dales, R.E., Spitzer, W.O., Schechter, M.T., Suissa, S., 1989. The influence of psychological
status on respiratory symptom reporting. Am. Rev. Respir. Dis. 139, 1459–1463.
doi:10.1164/ajrccm/139.6.1459
Escobar, J.I., Cook, B., Chen, C.-N., Gara, M.A., Alegría, M., Interian, A., Diaz, E., 2010.
Whether medically unexplained or not, three or more concurrent somatic symptoms predict
psychopathology and service use in community populations. J. Psychosom. Res. 69, 1–8.
Fink, P., Toft, T., Hansen, M.S., Ørnbøl, E., Olesen, F., 2007. Symptoms and syndromes of
bodily distress: an exploratory study of 978 internal medical, neurological, and primary care
Gara, M.A., Silver, R.C., Escobar, J.I., Holman, A., Waitzkin, H., 1998. A hierarchical classes
analysis (HICLAS) of primary care patients with medically unexplained somatic symptoms.
14
Psychiatry Res. 81, 77–86.
Gonzalez, D.S., Rodríguez, M., García, C., Prieto, R., Saiz-Ruiz, J., 2009. Gender differences in
major depressive disorder: somatic symptoms and quality of life. Rev. Psiquiatr. y salud
Haftgoli, N., Favrat, B., Verdon, F., Vaucher, P., Bischoff, T., Burnand, B., Herzig, L., 2010.
Patients presenting with somatic complaints in general practice: depression, anxiety and
somatoform disorders are frequent and associated with psychosocial stressors. BMC Fam.
Han, H., Wang, S.-M., Han, C., Lee, S.-J., Pae, C.-U., 2014. The relationship between somatic
Heidari, Z., Feizi, A., Roohafza, H., Hassanzadeh Keshteli, A., Shiravi, F.Z., Adibi, P., 2017a.
sectional study on a large sample of Iranian adults using factor mixture model. Int. J. Prev.
Heidari, Z., Keshteli, A.H., Feizi, A., Afshar, H., Adibi, P., 2017b. Somatic complaints are
significantly associated with chronic uninvestigated dyspepsia and its symptoms: a large
doi:10.5056/jnm16020
Kato, K., Sullivan, P.F., Pedersen, N.L., 2010. Latent class analysis of functional somatic
Kinnunen, P., Laukkanen, E., Kylmä, J., 2010. Associations between psychosomatic symptoms
in adolescence and mental health symptoms in early adulthood. Int. J. Nurs. Pract. 16, 43–
50.
15
Koh, K.B., Kim, D.K., Kim, S.Y., Park, J.K., Han, M., 2008. The relation between anger
management style, mood and somatic symptoms in anxiety disorders and somatoform
Lacourt, T., Houtveen, J., van Doornen, L., 2013. “Functional somatic syndromes, one or
Lubke, G., Muthén, B.O., 2007. Performance of factor mixture models as a function of model
size, covariate effects, and class-specific parameters. Struct. Equ. Model. A Multidiscip. J.
Lubke, G.H., Muthén, B., 2005. Investigating population heterogeneity with factor mixture
Manshaee, G.R., Hamidi, E., 2013. Prevalence of psychosomatic symptoms among adolescent’s
Montazeri, A., Harirchi, A.M., Shariati, M., Garmaroudi, G., Ebadi, M., Fateh, A., Toscani, F.,
Borreani, C., Boeri, P., Miccinesi, G., 2005. The 12-item General Health Questionnaire
(GHQ-12): translation and validation study of the Iranian version. Health Qual. Life
Outcomes 1, 66.
Montazeri, A., Vahdaninia, M., Ebrahimi, M., Jarvandi, S., 2003. The Hospital Anxiety and
Depression Scale (HADS): translation and validation study of the Iranian version. Health
National Collaborating Centre (N.C.C.) for Nursing and Supportive Care (UK), 2008. Irritable
Primary Care [Internet]. London: Royal College of Nursing (UK); 2008 Feb. Appendix J,
16
https://www.ncbi.nlm.nih.gov/ books/NBK51962/. [Last accessed on 2006 Oct].
Nimnuan, C., Rabe-Hesketh, S., Wessely, S., Hotopf, M., 2001. How many functional somatic
Novy, D., Berry, M.P., Palmer, J.L., Mensing, C., Willey, J., Bruera, E., 2005. Somatic
Schwarz, G., 1978. Estimating the dimension of a model. Ann. Stat. 6, 461–464.
doi:10.1214/aos/1176344136
Shabbeh, Z., Feizi, A., Afshar, H., Hassanzade Kashtali, A., Adibi, P., 2016. Identifying the
psychological problems. J. Maz. Univ. Med. Sci. 26, 82–94 [In Persian].
Shidhaye, R., Mendenhall, E., Sumathipala, K., Sumathipala, A., Patel, V., 2013. Association of
somatoform disorders with anxiety and depression in women in low and middle income
Simon, G.E., VonKorff, M., Piccinelli, M., Fullerton, C., Ormel, J., 1999. An international study
of the relation between somatic symptoms and depression. N. Engl. J. Med. 341, 1329–
1335.
Spitzer, R.L., Kroenke, K., Williams, J.B.W., Group, P.H.Q.P.C.S., 1999. Validation and utility
of a self-report version of PRIME-MD: the PHQ primary care study. Jama 282, 1737–1744.
Steinbrecher, N., Koerber, S., Frieser, D., Hiller, W., 2011. The prevalence of medically
Sugahara, H., Akamine, M., Kondo, T., Fujisawa, K., Yoshimasu, K., Tokunaga, S., Kubo, C.,
2004. Somatic symptoms most often associated with depression in an urban hospital
17
medical setting in Japan. Psychiatry Res. 126, 151–158.
Trivedi, M.H., 2004. The link between depression and physical symptoms. Prim Care
musculoskeletal pain and associated disability. Best Pract. Res. Clin. Rheumatol. 29, 374–
390.
Walker, A.K., Kavelaars, A., Heijnen, C.J., Dantzer, R., 2014. Neuroinflammation and
Wong, J.Y.-H., Fong, D.Y.-T., Chan, K.K.-W., 2015. Anxiety and insomnia as modifiable risk
factors for somatic symptoms in Chinese: a general population-based study. Qual. Life Res.
24, 2493–2498.
Wouters, M.M., Boeckxstaens, G.E., 2016. Is there a causal link between psychological
disorders and functional gastrointestinal disorders? Expert Rev. Gastroenterol. Hepatol. 10,
5–8.
Xiong, N., Fritzsche, K., Wei, J., Hong, X., Leonhart, R., Zhao, X., Zhang, L., Zhu, L., Tian, G.,
Nolte, S., 2015. Validation of patient health questionnaire (PHQ) for major depression in
Zhu, C., Ou, L., Geng, Q., Zhang, M., Ye, R., Chen, J., Jiang, W., 2012. Association of somatic
doi:10.1016/j.genhosppsych.2011.09.005
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Table 1. Factor loadings for the four extracted somatoform symptoms profiles from 30 somatoform
symptoms
Factor Loadings a
Somatoform Symptoms
Neuro- Pharyngeal -
Psycho-Fatigue Gastrointestinal
Skeletal Respiratory
Nausea 0.50
Constipation 0.49
Diarrhea 0.36
Headache 0.57
Back pain 0.66
Pain in joints 0.64
Eyesore 0.50
Severe fatigue 0.61
Dizziness and confusion 0.51
Chills and extreme cold 0.42
Hot flashes 0.38
Dry mouth 0.31
19
Neck pain 0.56
Globus sensation 0.55
Having trouble swallowing 0.61
Shortness of breath 0.46
Hoarseness 0.61
Wheezing (asthma) 0.52
Variance explained (%) 12.4 12.3 11.4 9.3
a
Factor loadings<0.3 are not shown for simplicity.
20
Table 2. Correlation between the scores of somatoform symptoms profiles and the scores of psychological disorders
21
Table 3. Comparison of psychological disorders profile and the prevalence of individual somatoform symptoms in
two extracted classes.
22
a
Regression coefficients for the association of psychological disorders profile with somatoform symptoms profiles; *P-
Value< 0.0001
b
The prevalence of all somatoform symptoms was significantly different between two classes (P <0.001).
23
Highlights
The aims of the current study were to classify studied population based on
psychosomatic complaints profiles and evaluate the profile of psychological disorders
in extracted classes.
Factor mixture modeling was used with data from a sample of 4762 Iranian adults.
A two-class, four-factor structure was identified for the psychosomatic complaints.
The profile of psychological disorders was significantly related to the psychosomatic
complaints profiles.
24