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BackgroundFunctional somatic disorders (FSDs) with symptoms from multiple organs, i.e., multi-system type, are common in the general population and may lead to disability and reduced quality of life. Evidence for efficient treatment programs has been established, however, there is a need for making treatments accessible to a larger group of patients. Internet-delivered therapy has become prevalent and has proven as effective as face-to-face therapy, while providing a flexible and easily accessible treatment alternative. The aim of the current study is to compare the efficacy of the therapist-assisted internet-delivered treatment program One step at a time (OneStep) with the internet-delivered self-help program Get started (GetStarted).MethodsA total of 166 participants aged 18–60 years diagnosed with multi-system FSD will be assessed and randomized to either 1) OneStep: a 14-week program consisting of 11 treatment modules based on principles from cognitive behavioural therapy or 2) GetStarted consisting of 1 module on psychoeducation. The primary outcome is physical health, assessed by a Short Form Health Survey (SF-36) aggregate score of the subscales vitality, physical functioning, and bodily pain 3 months after end-of-treatment and self-reported improvement assessed by the Clinical Global Improvement Scale. Secondary outcomes include symptom load, depression, anxiety, and illness worry. Process measures include emotional distress, illness perception, illness behaviour, and symptom interference.ConclusionsThis study is the first study to test an internet-delivered treatment program for FSD, multi-system type and has the potential to show the importance of making evidence-based internet-delivered treatment for FSD more accessible.

OBJECTIVE: Epidemiological research in functional somatic disorders such as irritable bowel syndrome, fibromyalgia, chronic fatigue syndrome, and bodily distress syndrome and related conditions such as health (illness) anxiety is often based on self-reported questionnaires or layman interviews. This study presents and describes the Research Interview for Functional somatic Disorders (RIFD) and provides first data regarding RIFD's ability to identify cases with functional somatic disorders and health anxiety in a two-phase design following self-reported symptom questionnaires.METHODS: RIFD was performed by phone by trained family physicians on a stratified subsample of 1590 adults from a Danish general population cohort (n = 7493). Criterion validity was tested in a small preliminary test including 25 RIFD participants using Schedules of Clinical Assessment in Neuropsychiatry (SCAN), performed by a specialist in functional somatic disorders, as gold standard. Interrater reliability between interviewers was tested in 15 participants.RESULTS: Compared with the comprehensive SCAN, preparation and conduction of RIFD were feasible and prompt. RIFD was well accepted by both interviewers and interviewees. RIFD identified cases with significantly more impairment than identified non-cases. Based on small preliminary tests, RIFD showed promising psychometric properties.CONCLUSION: RIFD was a feasible, well-accepted and promising instrument for use in large epidemiological studies. However, larger studies investigating its psychometric properties are needed.

This study retrospectively compares two previous parallel running, randomized, controlled trials of pharmacotherapy (imipramine) and psychotherapy (acceptance and commitment therapy) for multi-organ functional somatic disorder (FSD). Differences in demographics, psychiatric comorbidity, illness severity, and illness duration associated with eligibility for the two trials and patients' willingness to participate are explored using linear or binary regression models. 418 patients with multi-organ FSD was included. We found that 377 (95%) were eligible for psychotherapy and 257 patients (61%) for pharmacotherapy. Patients eligible for pharmacotherapy were less severely impaired, less often received disability pension, reported shorter illness duration and experienced less psychological distress than patients eligible for psychotherapy. Whilst exclusion criteria for both trials differed markedly, it was not possible to clearly identify patient or illness characteristics associated with patients' willingness to participate. The study showed that trial-specific exclusion criteria led to the selection of less complex and less severely impaired patients in the pharmacological trial in this sample of multi-organ FSD. Our findings have important implications for the interpretation and comparability of RCT results of different treatments in multi-organ FSD and may point to some common flaws in study design and interpretation of pharmacological vs. psychotherapeutic intervention trials in psychiatry.

Objective Self-reported symptom questionnaires are often used for identifying individuals with functional somatic disorders (FSD) in epidemiological research. Studies on their validity in establishing clinically valid cases are, however, lacking. We aimed to compare and dissect the processes of identifying participants with FSD with symptom questionnaires and FSD diagnoses established by diagnostic interviews. Methods Individuals from the adult Danish population (n = 1590) filled in symptom questionnaires and participated in a diagnostic research interview, performed over telephone by trained family physicians. The two methods were described and compared in different steps: 1) Agreement on presence of symptoms, 2) agreement after FSD symptom pattern criteria had been applied, and 3) agreement on final FSD diagnoses. Results Agreement on symptom presence was high (>82%). Using FSD symptom pattern criteria, the two methods agreed in 30–62% of cases within each category. Discrepancies were mainly due to participants fulfilling symptom patterns in the interview but not in the questionnaires. Agreement between final FSD questionnaire cases and final FSD interview diagnoses was moderate (>68%) with lower FSD prevalence in the interview (26.2% vs 44.5%). Discrepancies were largely explained by the interviewers assessing the symptom patterns to be caused by an alternative physical or mental condition. Conclusion Prevalence of final FSD diagnoses were markedly lower in the diagnostic interview compared to self-reported questionnaires cases; mainly because of the clinical evaluation of symptom attribution and impairment. Symptom questionnaires may be valuable as screening tools and as trans-diagnostic comparison while diagnostic interviews are necessary in establishing clinically significant FSD diagnoses.

Mange patienter henvender sig i almen praksis med legemlige symptomer, som ikke passer med traditionelt definerede sygdomme (også kaldet medicinsk uforklarede eller funktionelle symptomer). På baggrund af forskning i almen praksis er der nu udviklet kriterier for en ny diagnose for patienter med funktionelle lidelser. Denne diagnose har fået betegnelsen bodily distress syndrome (BDS). Det er karakteristisk for patienter med BDS, at de har funktionspåvirkning pga. mange symptomer, og at symptomerne typisk lokaliserer sig til en eller flere symptomgrupper: en kardiopulmonal, en gastrointestinal, en muskuloskeletal og en gruppe af generelle symptomer (træthed, hovedpine, søvnforstyrrelser mv.). Der er nu udviklet et spørgeskema vedrørende de symptomer, der indgår i BDS-diagnosen (BDS-checklisten). I det aktuelle studie deltog 2.480 patienter i en spørgeskemaundersøgelse i almen praksis i Region Midtjylland i perioden 2008-2009. Statistiske analyser bekræftede kriterierne for BDS. Det vil sige, at patienternes symptomer ved brug af BDS-checklisten grupperede sig på samme måde som i de tidligere undersøgelser af BDS, selvom de tidligere undersøgelser byggede på kliniske interviews. Yderligere viste analyserne, at patienterne i undersøgelsen kunne deles i tre grupper: en gruppe af patienter uden BDS, en gruppe af patienter med symptomer fra få (en til to) af symptomgrupperne og en gruppe af patienter med symptomer fra flere (end to) symptomgrupper. Det vil sige, at BDS-checklisten kan være med til at skelne patienter med BDS fra patienter uden BDS og desuden kan skelne mellem patienter med moderat BDS og svær BDS. Symptomerne i BDS-checklisten er de samme, som optræder i skemaet for BDS i DSAM’s kliniske vejledning om funktionelle lidelser. Som for andre spørgeskemaer gælder det, at BDS-checklisten ikke kan stå alene. En læges vurdering er nødvendig for at afgøre, om en patient skal have stillet diagnosen BDS.

Health anxiety (HA) is prevalent and costly for health services. However, little is known about the full societal burden of HA. Based on complete register data, we (1) compared weeks on sickness-related benefits (SB) in untreated patients with severe HA (n=126) with a matched population sample (n=12,600); and (2) tested whether Acceptance & Commitment group Therapy (ACT-G) (n=63) reduced weeks on SB during the first year after randomisation compared to a waitlist (n=63). We found that (1) HA patients showed a six-monthly increment of 2 weeks on SB compared with the general population (p

Denne artikel undersøger karakteristika, sygefravær og førtidspension for patienter med multiple medicinsk uforklarede symptomer (MUS) og somatoforme lidelser og sammenligner disse med en gruppe af patienter med veldefineret fysisk sygdom. Resultaterne viser, at patienter med somatoforme lidelser havde en øget risiko for sygefravær. Derudover fandt forfatterne til artiklen, at både patienter med multiple medicinsk uforklarede symptomer og somatoforme lidelser havde en øget risiko for at få fleksjob og/eller førtidspension sammenlignet med referencegruppen i studiet. Resultaterne viser, at der er behov for en tidlig indsats på området i almen praksis. Undersøgelsen blev udført som et registerbaseret kohortestudie med ti års opfølgning, og den bygger på data fra studiet Functional Illness in Primary Care (FIP-studiet). OBJECTIVE: The objective was to explore patient characteristics and 10-year outcome of sick leave and work disability for patients with recent-onset multiple medically unexplained symptoms (MUS) and persistent somatoform disorders (SD).METHOD: Consecutive patients consulting their family physician (FP) completed a preconsultation questionnaire on symptoms and mental illness (n=1785). The main problem was categorized by the FP after the consultation, and a stratified subsample was examined using a standardized diagnostic interview (n=701). Patients were grouped into three cohorts: recent onset of multiple MUS (n=84); Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, persistent SD (n=183); and reference group with well-defined physical disease according to FP (n=833). Register data on sick leave and disability pension were obtained.RESULTS: At index consultation, disability pension was received by 8.3% (n=7) in the recent-onset multiple MUS group, 19.1% (n=35) in the SD group and 3.5% (n=29) in the reference group. Both the recent-onset multiple MUS group [hazard ratio (HR)=2.28, 95% confidence interval (CI): 1.14-4.55] and the SD group (HR=3.26, 95% CI:1.93-5.51) had increased risk of new disability pension awards. Furthermore, the SD group had increased risk of sick leave.CONCLUSIONS: Both recent-onset and persistent MUS have significant long-term impact on patient functioning in regard to working life; this calls for early recognition and adequate management of MUS in primary care.

Health anxiety (or hypochondriasis) is prevalent, may be persistent and disabling for the sufferers and associated with high societal costs. Acceptance and Commitment Therapy (ACT) is a new third-wave behavioral cognitive therapy that has not yet been tested in health anxiety. 34 consecutive Danish patients with severe health anxiety were referred from general practitioners or hospital departments and received a ten-session ACT group therapy. Patients were followed up by questionnaires for 6 months. There were significant reductions in health anxiety, somatic symptoms and emotional distress at 6 months compared to baseline: a 49% reduction in health anxiety (Whiteley-7 Index), a 47% decrease in emotional distress (SCL-8), and a 40% decrease in somatic symptoms (SCL-90R Somatization Subscale). The patients' emotional representations and perception of the consequences of their illness (IPQ) improved significantly, and 87% of the patients were very or extremely satisfied with the treatment.

Objective To investigate whether the general practitioners' (GP) diagnosis of medically unexplained symptoms (MUS) and/or the diagnosis functional disorders (FD) can predict the patients' 2-year outcome in relation to physical and mental health and health care utilisation. Furthermore, to identify relevant clinical factors which may help the GP predict the patient's outcome. Method The study included 38 GPs and 1785 consecutive patients who presented a new health problem. The GPs completed a questionnaire on diagnosis for each patient. Patients completed the Common Mental Disorder Questionnaire (CMDQ) and the SF-36 questionnaire at baseline and after 24 months. A stratified sample of 701 patients was diagnosed with a psychiatric research interview. Data on health cost was obtained from national registers. Results A FD diagnosis following the research interview was associated with a decline in physical health (OR 3.27(95%CI 1.84–5.81)), but this was not the case with MUS diagnosed by the GP. MUS was associated with a poor outcome on mental health (OR 2.16 (95%CI 1.07–4.31)). More than 4 symptoms were associated with a poor outcome on physical health (OR 5.35 (95%CI 2.28–12.56)) and on mental health (OR 2.17(95%CI 1.02–4.59)). Neither FD nor MUS were associated with higher total health care use. However, FD (OR 2.31(95%CI 1.24–4.31)) and MUS (OR 1.98(95%CI 1.04–3.75)) was associated with increased cost in primary care. Conclusion Our current diagnoses of MUS show limitations in their prediction of the patients' illness course. Although, the ICD-10 diagnoses of functional disorders was not developed for the primary care setting, our results indicate that some of its elements would be useful to bring in when rethinking the diagnosis for MUS in primary care, elements that are easily obtainable for the GP in a normal consultation. Our results may contribute to the construction of a more useful diagnostic for these patients in primary care.

Udgivelsesdato: 2007-Feb OBJECTIVE: Little is known about whether illness perceptions affect health outcomes in primary care patients. The aim of this study was to examine if patients' illness perceptions were associated with their self-rated health in a 2-year follow-up period. METHODS: One thousand seven hundred eighty-five primary care patients presenting a new or recurrent health problem completed an adapted version of the illness perception questionnaire and the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) at baseline and 3, 12, and 24 months' follow-up. Linear regressions were performed for (1) all patients, (2) patients without chronic disorders presenting physical disease, and (3) patients presenting medically unexplained symptoms (MUS). RESULTS: Negative illness perceptions were associated with poor physical and mental health at baseline. They most strongly predicted changes in health status at follow-up for the whole group of patients. Patients presenting with MUS had more negative illness perceptions and lower mental and physical components subscale of the SF-36 scores at all time points. CONCLUSIONS: Patients' perception of a new or recurrent health problem predicts self-reported physical and mental health up to 2 years after consulting the general practitioner and offers an obvious starting point for addressing nonbiomedical aspects of illness.

We investigated 198 new neurological patients to learn if mental illness had an impact on nonpsychiatric health care use. Mental illness was assessed in a two-phase design, including the Schedules for Clinical Assessment in Neuropsychiatry (SCAN), providing ICD-10 diagnoses and two brief rating scales: the Symptom Check List (SCL-8) for anxiety and depression and the Whiteley-7 for somatization. The patients' use of health care was studied 5-10 years before and 18 months after the psychiatric assessment, using data from national patient registers. Mental illness was linked to data on health care use through weighted logistic regression. ICD-10 psychiatric disorders increased the risk of subsequent high use of nonpsychiatric hospital admissions - somatoform disorders with more than five times (OR=5.6; 95% CI=1.6-20.1) and anxiety/depression with almost four times (OR=3.7; 95% CI=1.1-12.0). There was also a trend, though less marked, linking mental illness to previous hospital use. Use of primary care was also markedly increased by mental disorders, however, only in patients entering the study as inpatients. In conclusion, neurological patients are at risk of being high users of health care if they have a mental illness, somatoform disorders being the most powerful risk factor. The results are consistent with the findings among internal medical patients.

Objective To find the prevalence of somatoform disorders (SDs) among internal medical inpatients and to study the comorbidity with other psychiatric disorders. Methods Of 392 eligible consecutive medical inpatients, 294 (75%) accepted to participate and, using a two-phase design, were assessed for ICD and DSM-IV somatoform diagnoses and for ICD-10 psychiatric diagnoses. Results A total of 18.1% (95% CI: 12.8–24.9%) of the patients fulfilled the diagnostic criteria for an ICD-10 disorder, and 20.2% (95% CI:14.7–27.2% ) for a DSM-IV SD. The prevalence of specified disorders revealed marked differences between the two diagnostic systems, e.g., concerning somatisation disorder (SD), which was more prevalent in the ICD-10 (5%) than in the DSM-IV (1.5%) equivalent. Quite the contrary was found in undifferentiated SD (0.7% in ICD-10 and 10% in DSM-IV). According to ICD-10 criteria, 3.5% had hypochondriasis, 2.6% a dissociative disorder, 3.2% a somatoform autonomic dysfunction, 1.5% had neurasthenia or persistent somatoform pain disorder, and 5% had an SD, unspecified. SDs were more prevalent among younger females. Thirty-six percent of the patients with SDs also had another psychiatric disorder, 11% a depression, and 25% an anxiety disorder. The physicians detected about 1/3 of the cases. Conclusion Somatoform disorders were prevalent among internal medical inpatients especially among younger women.

Objective The objective of this study is to validate the eight-item dichotomised version of the Symptoms Check List (SCL-8d) as a screening tool for psychiatric disorders. Methods The study population included 198 consecutive new neurological inpatients and outpatients and 294 consecutive internal medical inpatients, aged 18 or older. All patients received the SCL-8d questionnaire, and a stratified subsample was interviewed using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) interview. We tested the external SCL-8d validity using the SCAN interview as gold standard. The test was performed based on weighted data to correct for the skewness introduced by stratification. Results The diagnostic performance of the SCL-8d was excellent in the internal medical setting but not quite as good in the neurological sample. It performed better among the older compared with the younger patients, whereas the scale was not affected by gender. In the combined sample at the cut point 0/1, the sensitivity (SE) of the SCL-8d was 0.73 (confidence interval [CI] 95% : 0.60–0.82), the specificity (SP) 0.61 (CI 95% : 0.53–0.68) and the positive predictive value (PPV) 0.42 (CI 95% : 0.34–0.50), using any International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) psychiatric disorder, excluding somatoform and substance abuse disorders, as gold standard. The risk of a patient having a mental disorder (except phobia, substance abuse or somatoform disorder) was less than 6% in case of a negative screening test. In patients with a current depressive disorder, 87.1% (27/31) were screening positive, and all except 1 (93.0%) of the 14 patients with a modest to severe depression scored 1 or higher on the SCL-8d. All 17 patients with an anxiety disorder, excluding phobias, were screening positive. Conclusion The study suggests that the SCL-8d is a valid, brief screening tool for use in nonpsychiatric medical settings, especially to detect emotional psychiatric disorders (EPDs).

There is increasing pressure to effectively treat patients with complex care needs from the moment of admission to the general hospital. In this study, the authors developed a measurement strategy for hospital-based care complexity. The authors' four-factor model describes the interrelations between complexity indicators, highlighting differences between length of stay (LOS), objective complexity (such as medications or consultations), complexity ratings by the nurse, and complexity ratings by the doctor. Their findings illustrate illustrate limitations in the use of LOS as a sole indicator for care complexity. The authors show how objective and subjective complexity indicators can be used for early and valid detection of patients needing interdisciplinary care.

Objective: To determine the prevalence of ICD-10 mental disorders among internal medical inpatients, the relation between mental disorder, age, and gender, and the recognition and referral of the disordered patients. Method: 294 consecutive medical inpatients were examined with a two-phase design using the SCAN (Schedules for Clinical Assessment in Neuropsychiatry) for ICD-10 psychiatric diagnoses. Information from questionnaires and interviews with patients, doctors, nurses, and from medical records. Results: The prevalence of current mental disorders was 38.7%, being heavily increased in young patients. Main diagnoses were somatoform disorders (17.6%), phobias (12.9%), substance use disorders (10.9%), and depression (8.3%). Psychiatric consultations were very few. About 38–56% of the cases were recognized by medical doctors and nurses, and only about 20% were in mental health treatment. Conclusion: The prevalence of mental disorders among internal medical inpatients is high and increased in young patients and women. Detection and referral are low, and few are treated.

In a study of 294 consecutive medical inpatients, the authors assessed a subsample of 157 patients for psychiatric diagnoses using an extensive semistructured interview, Schedules for Clinical Assessment in Neuropsychiatry (SCAN). Patients rated their health and physical functioning, and medical consultants assessed them for chronic and life-threatening diseases. A life-threatening condition increased odds for having a psychiatric diagnosis by 3.1 times (95% Confidence Interval (CI): 1.03-9.1), while a chronic medical disease had no such impact (OR=1.1; 95% CI: 0.5-2.3). In women, mental disorders were strongly associated with self-rated disability (OR=6.7; 95% CI: 1.6-27.8) and self-rated health (OR=9.4; 95% CI: 2.7-32.4). This association was absent in men (OR(disability)=0.7; 95% CI: 0.2-2.7; OR(health)=1.6; 95% CI: 0.6-4.7). Analyses included adjustment for age and gender.

The authors investigated the importance of psychological distress and somatization among patients with musculoskeletal illness in general practice. The authors used the Hopkins Symptom Check List (SCL-8) and the Whiteley Index to rate 1,720 patients with musculoskeletal illness referred to physiotherapy from general practice. General practitioners (GPs), patients, and physiotherapists often noted stress or psychological distress to be a possible cause of the patient's musculoskeletal illness, but agreement between them was low. If the GP included the patient's own view on psychological distress, the result of the SCL-8 did not add much to the detection of distress. The results emphasize the importance of discussing psychological distress when dealing with patients with musculoskeletal illness.

The aim of this study was to investigate the internal and external validity of the Whiteley Index as a screening instrument for somatization illness. A 14-item version of the Whiteley Index for hypochondriacal traits was given to 99 of 191 consecutive primary care patients, aged 18-65 years, and to 100 consecutive patients, aged 18-60 years, admitted for the first time to a neurological ward. The primary care sample was, in addition, interviewed by means of the SCAN (Schedules for Clinical Assessment in Neuropsychiatry) psychiatric interview. The GPs and the neurologists were asked to rate various characteristics of the patients that might indicate somatization. The internal validity of the Whiteley Index was tested by means of latent structure analysis. On this basis, a reduced seven-item scale (Whiteley-7 scale) and two subscales (i.e., an Illness Conviction and Illness Worrying scale, each with three items) were constructed. All three had a high internal validity fitting into the very restricted Rasch statistical model (p>0.05) and an acceptable transferability between most of the subpopulations investigated. In the primary care population, the Whiteley-7 and the Illness Conviction scales at cut-point 0/1 showed 1.00 and 0.87 sensitivity and 0.65 and 0.87 specificity, respectively, using as "gold standard" the fulfillment of criteria for at least one ICD-10 somatoform disorder, and 0.71 and 0.63 sensitivity and 0.62 and 0.87 specificity, respectively, as gold standard for the fulfillment of criteria for at least one DSM-IV somatoform disorder, excluding the NOS diagnostic group. The Illness Worrying subscale showed less impressive performance in this respect. The agreement between the Whiteley-7 scale including the two subscales and neurologists' rating and the GPs' rating and the somatization subscale on the SCL-90 was modest or worse. It may be concluded that the Whiteley-7 scale and the Illness Conviction subscale had acceptable psychometric profiles, and both seem to be promising screening tools for not only hypochondriasis but also for somatoform disorders in general.

The purpose of this paper is to describe the development and to test the reliability of a new method called INTERMED, for health service needs assessment. The INTERMED integrates the biopsychosocial aspects of disease and the relationship between patient and health care system in a comprehensive scheme and reflects an operationalized conceptual approach to case mix or case complexity. The method is developed to enhance interdisciplinary communication between (para-) medical specialists and to provide a method to describe case complexity for clinical, scientific, and educational purposes. First, a feasibility study (N = 21 patients) was conducted which included double scoring and discussion of the results. This led to a version of the instrument on which two interrater reliability studies were performed. In study 1, the INTERMED was double scored for 14 patients admitted to an internal ward by a psychiatrist and an internist on the basis of a joint interview conducted by both. In study 2, on the basis of medical charts, two clinicians separately double scored the INTERMED in 16 patients referred to the outpatient psychiatric consultation service. Averaged over both studies, in 94.2% of all ratings there was no important difference between the raters (more than 1 point difference). As a research interview, it takes about 20 minutes; as part of the whole process of history taking it takes about 15 minutes. In both studies, improvements were suggested by the results. Analyses of study 1 revealed that on most items there was considerable agreement; some items were improved. Also, the reference point for the prognoses was changed so that it reflected both short- and long-term prognoses. Analyses of study 2 showed that in this setting, less agreement between the raters was obtained due to the fact that the raters were less experienced and the scoring procedure was more susceptible to differences. Some improvements--mainly of the anchor points--were specified which may further enhance interrater reliability. The INTERMED proves to be a reliable method for classifying patients' care needs, especially when used by experienced raters scoring by patient interview. It can be a useful tool in assessing patients' care needs, as well as the level of needed adjustment between general and mental health service delivery. The INTERMED is easily applicable in the clinical setting at low time-costs.

This study describes the utilization of surgical operations, frequency and outcome of medical and surgical treatment in a group of persistent somatizers compared with a control group of nonsomatizers. The study was carried out using the Danish national medical register to identify persons in the general population (age range 17–49 yr) with at least 10 general admissions during an 8-yr period. Persistent somatizers were defined as persons with more than six medically unexplained general hospital admissions in their lifetimes before 1985. Conversely, non-somatizers were patients whose admissions could mainly be ascribed to well-defined somatic disorders. The findings show that persistent somatizers had been exposed to extensive surgery, outnumbering the non-somatizers. Surgical operations were of several categories, with gastrointestinal and gynaecological operations being the most frequent. The physicians used medical and surgical treatment nearly as often for treating persistent somatizers as in the treatment of the non-somatizers. Surgical or medical treatment was used in nearly half of the medically unexplained admissions. The outcome of the surgical treatment of the persistent somatizers was, however, generally unsuccessful in that the effect was unsatisfactory in three quarters of cases. Similarly, two thirds of the medical treatments were judged to be unsuccessful in persistent somatizers. The findings suggest that the costs of somatic diagnostic procedures and fruitless surgical and medical treatment attempts on persistent somatizers are enormous, and only exceeded by the risk of iatrogenic harm. This emphasizes the need for an early diagnosis of somatization and of treating it properly.