Validation of the Chinese Version of the Somatic Symptom Disorder–B Criteria Scale for Detecting DSM-5 Somatic Symptom Disorders: A Multicenter Study

Abstract

Objective This study aimed to validate the Chinese version of the Somatic Symptom Disorder–B Criteria Scale (SSD-12) in an outpatient sample from Chinese general hospitals and to determine the diagnostic performance of the SSD-12 as a screening tool for somatic symptom disorder (SSD). Methods The Chinese version of the SSD-12 was completed by 699 outpatients from nine general hospitals during a 16-month period (2016–2018). The SSD section of the Structured Clinical Interview for DSM Disorders, Fifth Edition, Research Version, was used to determine diagnostic accuracy (criterion validity). The construct validity of the SSD-12 was evaluated by examining correlations with the Whiteley Index-7, Patient Health Questionnaire-15, Patient Health Questionnaire-9, General Anxiety Disorder-7, World Health Organization Disability Assessment Schedule, and Medical Outcome Study 12-item Short Form Health Survey (SF-12). Results The SSD-12 had excellent internal consistency in this sample (Cronbach α = .95). Confirmatory factor analyses replicated a three-factor structure that reflects the cognitive, affective, and behavioral aspects (Comparative Fit Index = 0.963, Tucker-Lewis Index = 0.952, root mean square error of approximation = 0.08, 90% confidence interval = 0.08–0.09), but was also consistent with a general one-factor model of the SSD-12 (Comparative Fit Index = 0.957, Tucker-Lewis Index = 0.948, root mean square error of approximation = 0.09, 90% confidence interval = 0.08–0.10). The optimal cutoff point for the Structured Clinical Interview for DSM Disorders–based diagnosis of SSD was 16 (sensitivity = 0.76, specificity = 0.80). The SSD-12 sum score was significantly associated with somatic symptom burden (Patient Health Questionnaire-15: r = 0.52, p < .001), health anxiety (Whiteley Index-7: r = 0.82, p < .001), depressive symptoms (Patient Health Questionnaire-9: r = 0.63, p < .001), general anxiety (General Anxiety Disorder-7: r = 0.64, p < .001), health-related quality of life (physical component score of SF-12: r = −0.49, p < .001; mental component score of SF-12: r = −0.61, p < .001), and health-related disabilities (World Health Organization Disability Assessment Schedule: r = 0.56, p < .001). Conclusions Initial assessment indicates that the Chinese version of the SSD-12 has sufficient reliability and validity to warrant further testing in both research and clinical settings.

Validation of the Chinese version of the Somatic Symptom Scale-8 in patients from tertiary hospitals in China

“…The sum score for the SSS-8 was moderately to highly correlated with the PHQ-15, PHQ-9, GAD-7, SF-12, and WHO-DAS 2.0. This is consistent with previous studies and expectations (17,(25)(26)(27). The optimal cutoff score for SSD is 9 with sensitivity 0.674 and specificity 0.681.…”

“…The total score is between 0 and 48 points and a higher score indicates greater psychological distress associated with somatic symptoms. The SSD-12 Chinese version has demonstrated satisfactory validity ( 17 ).…”

Psychometric Evaluation of the Whiteley Index-8 in Chinese Outpatients in General Hospitals

“…Each of the items is rated on a 5-point Likert scale ranging from 0 to 5. The reliability and validity of this instrument have been verified in another study (Hüsing et al, 2018;Li et al, 2020).…”

“…The Chinese versions of the PHQ-9, PHQ-15, GAD-7, and SSD-12 have been validated in Chinese samples and published in research papers (He et al, 2010 ; Zhang et al, 2016 ; Ran et al, 2017 ; Li et al, 2020 ). The questionnaire in Chinese language can be requested from the corresponding author.…”

A review of psycho-physiological pathological mechanisms and clinical treatments of functional somatic symptoms

“…。中国六省市多家综合医院的流行病学调查研究 发现，在综合医院门诊就诊的患者群体中，符合躯体症状障碍者高达 33% [6] 。慢性功能性躯体不适的患者中有很多存在相关的明显的困扰 和苦恼， 心理行为社会功能受到显著影响， 治疗困难、 医患关系困难、 社会功能受损、生活质量下降、花费多、对医疗不满意，给患者和医 疗体系都构成重大负担。 [6] 自有国际疾病分类系统以来这一组疾病或障碍的名称、 描述性定 [7] 或称预测编码模型(predictive coding model) [10] 。 在这个模型中， 大脑不再是被动接受外周传来的躯体感受信号，而是根据先前的信 息对躯体感知进行主动概率推测，然后与外周的感觉传入信号进行 比对。当外周传入信号具有较高的精确度时，形成的知觉体验则更 倾向于外周传入信号 [11] 。当先验推测(预期)精确度较高时，会形 成更趋向于先验推测的知觉体验和经验；注意(attention)会加强 预期机制，而在注意转移时则会弱化预期机制 [12] 。上述过程持续不 断发生，促进预测信号与外周信号的最佳匹配。 MUS 多与内感受有关，而内感受多模糊不清，精确性较低， 因此，内感受知觉在很大程度上是一种信念(belief)的构建 [13] (此 时的信念不全是意识层面的) ，更趋近于先验推测/预测的结果。 而将内感受概念化为推理过程也在一定程度上模糊了躯体感 受和信念、期望等认知过程的界限。在疼痛研究中，研究者发现物 理疼痛(热刺激)与心理伤害(不情愿的分手)激活了相同的脑区： 前岛叶、前扣带回、次级躯体感受皮层等 [14] 。尽管二者在相应区域 的激活强度上有显著差异，但证实了躯体感知处理和情绪处理的神 经结构中高度同源性和重叠性 [15] 。有研究发现仅仅通过观看图片诱 导出现负面情绪状态就可以导致躯体症状报告增加 的功能性疾病与焦虑抑郁有相当高的共病率 [26][27][28][29] ,比如在功能性消化 不良的患者中 MDD 的共病率达到了 39.1% [28] ,多躯体症状患者焦虑 抑郁的检出率高达 50% [30] 。将 SSD 患者与躯体疾病患者相比，前者 心理痛苦程度(焦虑、抑郁情绪)显著高于后者，与 MDD 患者相当 [31] 。 SSD 患者中有相当部分对症状进行多重归因，包含躯体归因，心 理归因和社会环境归因等等 [32] ，但在就医中却常常只关注躯体部分。 因其对治疗的过度期待导致容易出现对就医的失望， "逛医生" ，医患关 系困难 [33] [46] 。 与传统的精神动力学治疗聚焦于内心冲突稍有不同，目前对功能 性躯体不适障碍的精神动力学治疗文献中，较为核心的一个假设是， 患者无法对自己的人际关系感受不良等内心苦恼进行"心智化" ，躯体 问题转而成为苦恼的表达方式 [47] 。 A c c e p t e d 另外，或病前即存在而病后强化、或病后继发出现的依恋问题以 及知识信任(epistemic trust)问题也可能是功能性躯体不适中的密 切相关问题，是治疗中需要聚焦解决的 [47] 。 情绪觉察和表达治疗： 心理创伤经历导致功能性躯体不适风险显著升高 [48] 。Lumley 和 Schubiner 开发了情绪觉察和表达治疗(Emotional Awareness and Expression Therapy，EAET)来针对功能性躯体不适患者中可能起到 重要影响的创伤和情绪回避问题 [49] 更为有效 [52] 。 身体取向心理治疗(Body-oriented Psychotherapy，BoPT)通 过激活资源(能力、身体力量和创造性)和强化(身体、自主神经) 自我调节能力，逐渐引入对不愉快的心理状况/事件/冲突的替代性反 应模式，解决既往不良的躯体强化模式。有助于减轻功能性躯体不适 [53,54] 。 总的来说， 当前证据显示上述几种个别式心理治疗对严重的功能 性躯体不适患者有效，是临床上非常重要的治疗方法 [55] 。 另外，虽然当前英文文献的荟萃分析资料不多，但在临床经验和 中，尤其在中国文化背景下，重要和有意义的治疗还包括团体心理治 疗和家庭治疗 [56] [58][59][60]…”