Author’s Accepted Manuscript

Somatoform Symptoms Profiles in Relation to

Psychological Disorders - A Population
Classification Analysis in a Large Sample of
General Adults

Zahra Heidari, Awat Feizi, Hamidreza Roohafza,

Ammar Hassanzadeh Keshteli, Payman Adibi
www.elsevier.com/locate/psychres

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

Classification Analysis in a Large Sample of General Adults

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

Sciences, Hezarjarib St, Isfahan, Iran. Tel.: +983137923250. awat_feiz@hlth.mui.ac.ir

Abstract

In order to identifying somatoform symptoms profiles, classifying study population and

evaluating of psychological disorders in extracted classes, we carried out a cross-sectional study

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

somatoform symptoms profiles were extracted, including ‘psycho-fatigue’, ‘gastrointestinal’,

‘neuro- skeletal’ and ‘pharyngeal-respiratory’. According to FMM results, a two-class 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

other class. We concluded that somatoform symptoms have a dimensional-categorical structure

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

with treatment’s approaches.

Keywords: Somatoform symptoms; psychological disorders; depression; anxiety; psychological

distress; factor mixture modeling

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

membership (Lubke and Muthén, 2005).

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

constructed profiles of somatoform symptoms and evaluating psychological disorders profile in

identified classes using FMM.

2. Materials and Methods

2.1 Study Design and Participants

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

questionnaires, which were designed to collect information on gastrointestinal, psychological,

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).

2.2 Procedures and Assessment of Variables

2.2.1 Assessment of somatoform symptoms

No separate specific questionnaire was available to assess somatoform symptoms in the

SEPAHAN project; however, we established a validated questionnaire based on 31 items in

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-

items questionnaire to evaluate the frequency of somatoform symptoms. Participants could

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.

2.2.2 Assessment of Psychological Variables

2.2.2.1 Psychological Distress

Iranian validated version of self-report screening instrument of 12-item General Health

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

with high-distress level (Montazeri et al., 2005).

2.2.2.2 Hospital Anxiety and Depression Scale

Self-report screening instrument of Hospital Anxiety and Depression Scale (HADS) was used to

assess depression and anxiety of participants. HADS is a self-administered questionnaire that is

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

(not present) to 3 (considerable). The anxiety or depression score of respondent could be

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).

2.2.3 Assessment of Other Variables

Self-administered standard questionnaires were distributed to gather demographic (age, gender,

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

General Practice Physical Activity Questionnaire (GPPAQ) (N.C.C., 2008) etc.).

2.3 Statistical Analysis

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

on orthogonal Varimax rotation procedure. Next, four extracted profiles of somatoform

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

(moderately active and active).

3.1 Extraction of somatoform symptoms profiles using exploratory factor analysis

7
Four extracted profiles based on 30 individual somatoform symptoms were labeled as ‘psycho-

fatigue’, ‘gastrointestinal’, ‘neuro-skeletal’ and ‘pharyngeal-respiratory’; they accounted for

12.4%, 12.3%, 11.4% and 9.3% of total variance, respectively (Table 1) (Heidari et al., 2017b;

Shabbeh et al., 2016).

3.2 Correlation between somatoform symptoms profiles and psychological disorders

Table 2 shows the correlations between scores of somatoform symptoms profiles and the scores

of psychological disorders of studied population. Psychological disorders (i.e. psychological

distress, anxiety and depression) are significantly correlated with all somatoform symptoms

profiles. Among them, anxiety had stronger associations with somatoform symptoms profiles

(Table 2).

3.3 Factor mixture modeling’ results

The latent structure or unobserved heterogeneity of studied population in terms of four

somatoform symptoms profiles (i.e., ‘psycho-fatigue’, ‘gastrointestinal’, ‘neuro-skeletal’ and

‘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

psycho-fatigue complaints” and “low psycho-fatigue complaints”; because participants in the

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

physical domains (gastrointestinal, neuro-skeletal and pharyngeal-respiratory). There were 4243

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).

Table 3 contains regression coefficients on the association of psychological disorders profile

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

a significant positive relationship between the profile of psychological disorders and

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

somatoform symptoms reported by participants assigned to "high psycho-fatigue complaints"

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

mouth” (10.5%). (Table 3)

4. Discussion

In this cross-sectional population-based study, two classes characterized by high (11%)

and low (89%) levels of psychological-fatigue complaints, and four-factors profiles (i.e.,

‘psycho-fatigue’, ‘gastrointestinal’, ‘neuro- skeletal’ and ‘pharyngeal-respiratory’) representing

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

from other somatoform symptoms profiles with different degrees.

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.

It is believed that somatoform symptoms are the manifestations of psychological illnesses

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

development of gastrointestinal symptoms potentially via mechanisms involving immune

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

identifying profiles of somatoform symptoms, and classifying study population, simultaneously,

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

must be done with caution.

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

psychological disorders is significantly associated with different somatoform symptoms profiles.

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

Unit, and other authorities of IUMS for their excellent cooperation.

13
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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

Sleep Disorder 0.46

Pounding heart 0.41 0.41

Feeling low on energy 0.69

Feeling like ‘butterflies’ 0.78

Difficulty concentrating 0.64

Disturbing thoughts 0.80

Chest pain 0.52

Feeling of fullness 0.69

Nausea 0.50

Gastroesophageal reflux 0.54

Pain or discomfort in the

0.71
abdomen

Constipation 0.49

Diarrhea 0.36

Bloating or swelling of the

0.67
abdomen

Anal pain 0.48

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

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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

Cumulative variance 12.4 24.7 36.1 45.4

a
Factor loadings<0.3 are not shown for simplicity.

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Table 2. Correlation between the scores of somatoform symptoms profiles and the scores of psychological disorders

Somatoform Symptoms Profiles

Pharyngeal -
Psycho-Fatigue Gastrointestinal Neuro-Skeletal
Respiratory
Depression 0.799 0.415 0.541 0.385
Anxiety 0.907 0.504 0.612 0.461
Psychological
Distress 0.650 0.373 0.472 0.344

- All presented correlations are significant at the 0.01 level

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Table 3. Comparison of psychological disorders profile and the prevalence of individual somatoform symptoms in
two extracted classes.

High Psycho-Fatigue Complaints class Low Psycho-Fatigue Complaints class

(n=519) (n=4243)
Estimate Estimate
Often b Always b Often Always
(SE)a (SE)a
Number Number Number Number
Psycho-Fatigue Profile 0.282 0.300
* (%) (%) (%) (%)
(0.011) (0.011)*
Sleep Disorder 120 33 (6.7) 411 99 (2.4)
(24.3) (10.1)
Pounding heart 74 (14.7) 22 (4.4) 210 (5.0) 45 (1.1)
Feeling low on energy 121 68 (13.6) 574 230 (5.6)
(24.2) (13.9)
Feeling like ‘butterflies’ 36 (7.2) 28 (5.6) 148 (3.6) 58 (1.4)
Difficulty concentrating 68 (13.5) 40 (8.0) 200 (4.8) 78 (1.9)
Disturbing thoughts 95 (19.0) 64 (12.8) 421 202 (4.9)
(10.2)
Gastrointestinal Profile 0.152 0.147
(0.014)* (0.008)*
Chest pain 77 (15.2) 13 (2.6) 146 (3.5) 16 (0.4)
Feeling of fullness 90 (17.7) 24 (4.7) 230 (5.5) 40 (1.0)
Nausea 40 (8.1) 16 (3.2) 78 (1.9) 22 (0.5)
Gastroesophageal reflux 30 (6.1) 11 (2.3) 50 (1.2) 16 (0.4)
Pain or discomfort in the 82 (16.2) 22 (4.4) 276 (6.7) 44 (1.1)
abdomen
Constipation 74 (14.7) 33 (6.6) 341 (8.2) 73 (1.8)
Diarrhea 13 (2.6) 4 (0.8) 56 (1.3) 6 (0.1)
Bloating or swelling of the 91 (18.4) 44 (8.9) 398 (9.9) 123 (3.1)
abdomen
Anal pain 35 (7.3) 11 (2.3) 76 (1.9) 9 (0.2)
Neuro-Skeletal Profile 0.219 0.210
(0.016)* (0.011)*
Pounding heart 74 (14.7) 22 (4.4) 210 (5.0) 45 (1.1)
Headache 124 45 (9.0) 602 106 (2.6)
(24.8) (14.5)
Back pain 124 61 (12.1) 524 179 (4.3)
(24.7) (12.7)
Pain in joints 104 66 (13.0) 407 (9.8) 173 (4.2)
(20.5)
Eyesore 76 (15.0) 23 (4.6) 233 (5.6) 54 (1.3)
Severe fatigue 197 76 (15.0) 933 206 (5.0)
(39.0) (22.6)
Dizziness and confusion 79 (15.7) 29 (5.8) 215 (5.2) 34 (0.8)
Chills and extreme cold 41 (8.1) 9 (1.8) 80 (1.9) 13 (0.3)
Hot flashes 59 (11.7) 15 (3.0) 168 (4.0) 35 (0.8)
Pharyngeal –Respiratory 0.134 0.081
Profile (0.015)* (0.011)*
Dry mouth 227 53 (10.5) 1170 116 (2.8)
(45.0) (28.2)
Neck pain 65 (12.9) 13 (2.6) 98 (2.4) 17 (0.4)
Globus sensation 61 (12.2) 18 (3.6) 52 (1.2) 10 (0.2)
Having trouble swallowing 51 (10.1) 5 (1.0) 0 0
Shortness of breath 68 (13.5) 31 (6.1) 139 (3.3) 40 (1.0)
Hoarseness 26 (5.2) 5 (1.0) 47 (1.1) 11 (0.3)
Wheezing (asthma) 26 (4.9) 6 (1.2) 53 (1.3) 17 (0.4)

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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).

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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.

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