Article

The International Journal of

Psychiatry in Medicine
The association of 2017, Vol. 52(2) 147–159
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disorder and Somatic DOI: 10.1177/0091217417720894

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Symptoms with
frequent attendance
to health care services:
A cross-sectional study
from the Northern
Finland Birth
Cohort 1966
Tero S Kujanpää1, Jari Jokelainen1,2,
Juha P Auvinen1,2, and
Markku J Timonen1,2

Abstract
Objective: Generalized anxiety disorder is associated with higher rate of physical
comorbities, unexplained symptoms, and health care utilization. However, the role of
somatic symptoms in determining health care utilization is unclear. The present study
aims to assess the association of frequent attendance of health care services between
generalized anxiety disorder symptoms and somatic symptoms.
Method: This study was conducted cross-sectionally using the material of the
46-year follow-up survey of the Northern Finland Birth Cohort 1966. Altogether,
5585 cohort members responded to the questionnaires concerning health care
utilization, illness history, physical symptoms, and generalized anxiety disorder-7
screening tool. Odds ratios belonging to the highest decile in health care utilization

1
Faculty of Medicine, Center for Life Course Health Research, University of Oulu, Oulu, Finland
2
Unit of Primary Care, Oulu University Hospital, Oulu, Finland
Corresponding Author:
Tero S Kujanpää, Center for Life Course Health Research, Faculty of Medicine, University of Oulu, PO Box
5000, Oulu FI-90014, Finland.
Email: [email protected]
148 The International Journal of Psychiatry in Medicine 52(2)

were calculated for generalized anxiety disorder symptoms and all (n ¼ 4) somatic
symptoms of Hopkins Symptom Checklist-25 controlled for confounding factors.
Results: Adjusted Odds ratios for being frequent attender of health care services
were 2.29 (95% CI 1.58–3.31) for generalized anxiety disorder symptoms and
1.28 (95% CI 0.99–1.64), 1.94 (95% CI 1.46–2.58), 2.33 (95% CI 1.65–3.28), and
3.64 (95% CI 2.15–6.18) for 1, 2, 3, and 4 somatic symptoms, respectively. People
with generalized anxiety disorder symptoms had on average a higher number of
somatic symptoms (1.8) than other cohort members (0.9). Moreover, 1.6%
of people without somatic symptoms tested positive for generalized anxiety disorder,
meanwhile 22.6% of people with four somatic symptoms tested positive for general-
ized anxiety disorder.
Conclusions: Both generalized anxiety disorder symptoms and somatic symptoms
are associated with a higher risk for being a health care frequent attender.

Keywords
anxiety disorders, health services, epidemiology

Introduction
The top 10% of people utilizing most health care services account for 69–81% of
the total health care costs.1–4 Similarly, the top 10% of the primary care atten-
ders account for 30–50% of all primary care contacts.5 Therefore, the treatment
of frequent attenders of health care services has an essential societal and eco-
nomic impact.
Frequent attenders of health care services are not a uniform group, but
different profiles can be identified.6 Karlsson et al.6 found five different cate-
gories of primary care frequent attenders: patients with physical illness, patients
with psychiatric illness, crisis patients, somatizing patients, and patients
with multiple problems. Furthermore, earlier studies have shown psychiatric
disorders such as depressive and anxiety disorders to be common among
health care frequent attenders.7–10 Still, the reason for consulting in primary
care is most often a physical symptom regardless of the main problem of the
frequent attender.6
Generalized anxiety disorder (GAD) is an anxiety disorder characterized by
long-lasting and excessive anxiety and worry, which is difficult to be con-
trolled.11,12 It is common in society with a current prevalence of 2–3% and a
lifetime prevalence of 5%.13 Earlier studies have shown that GAD is associated
with high health care utilization.7,14–24 However, patients with GAD usually
presented in primary care with varying physical symptoms and only rarely com-
plained anxiety directly.23 Actually, patients with GAD have had anxiety as a
primary complaint only in 13.3% of the cases and they have had significantly
more somatic complaints, sleep disturbance, and depression than other patients
Kujanpää et al. 149

in primary care.23 In addition, patients with GAD have often consulted primary
care physicians several times for the same problem.14
Patients with GAD have had often a high number of both explained and
unexplained physical symptoms.25 Moreover, GAD has been associated with
high rate of physical comorbidities, such as hypertension, cardiac disorders,
gastrointestinal problems, genitourinary disorders, and migraine.26
Both GAD and anxiety symptoms have been associated with a high rate of
headaches.27,28 Moreover, patients referred to a specialist because of headaches
have had a higher level of anxiety symptoms than patients managed in primary
care.29 However, the presence of psychiatric disorder in a patient having head-
ache referred to a neurologist has been associated with a decreased likelihood of
an underlying neurological process.30 Similarly, many people reporting dizziness
have had high levels of anxiety and anxious patients with dizziness also have
utilized health care services more frequently than nonanxious patients.31
However, not all the people with GAD are frequent attenders of health care
services. It is still unclear what determines the health care utilization of the
sufferers of GAD. An earlier study has suggested that higher utilization of
health care services of patients with anxiety disorders is explained by comorbid
illnesses and not by anxiety symptoms.32 Moreover, results from another study
have indicated that both medical comorbidities and anxiety symptom severity
have an influence on health care utilization in patients with GAD.33 However,
the role of somatic symptoms in determining the health care utilization is
unclear. Somatic preoccupation due to the GAD-related worry34 may also
lead to high health care utilization. Therefore, we investigated the association
of frequent attendance of health care services between GAD and somatic
symptoms at population level taking into account also physical diseases as con-
founding factors.

Method
Northern Finland Birth Cohort 1966 (NFBC-1966) is a longitudinal birth cohort
study from an unselected population (http://www.oulu.fi/nfbc). The study popu-
lation was initially determined in Finland’s two northernmost provinces Oulu
and Lapland from all the mothers who had a calculated term between 1 January
1966 and 31 December 1966. Altogether 12,068 deliveries and 12,231 born chil-
dren (96.3% of all births in that area) comprised the initial study population.
These children have been subsequently followed. At the age of 46, a large
health examination was performed. It consisted of clinical examinations and
self-questionnaires. All the cohort members who were alive and whose postal
addresses were known at the age of 46 were asked to participate. Of these 10,282
cohort members, 5585 (54%) subjects responded to the questionnaires. These
questionnaires included questions about anxiety symptoms, physical symptoms,
illnesses, smoking habits, alcohol consumption, occupational class, and health
150 The International Journal of Psychiatry in Medicine 52(2)

care utilization. In addition, body weight and height were measured during the
clinical examination.
The subjects suffering from GAD symptoms were assessed using the Finnish
translation of GAD-7 scale. This is a short self-questionnaire based on
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition
(DSM-IV) symptom criteria for GAD.35 It consists of seven questions on how
often the subjects have been affected by different anxiety symptoms during the
past two weeks with these response options: ‘‘not at all,’’ ‘‘several days,’’ ‘‘more
than half the days,’’ and ‘‘nearly every day’’ scored 0 to 3, respectively.35 It has
shown to be a valid tool for detecting GAD with a sensitivity of 89% and
specificity of 82% on cut-off point 10 or more.35 The Finnish translation of
GAD-7 has also been validated among a small sample of health care frequent
attenders.15 We defined people with 10 or more points on GAD-7 as test positive
for GAD.
The somatic symptoms were assessed using the questions of physical sensa-
tions on Hopkins Symptom Checklist-25 (HSCL-25). This is a symptom inven-
tory for depressive and anxiety symptoms consisting of 25 items on how much
those problems have bothered individuals during the past week.36 The response
options are ‘‘not at all,’’ ‘‘a little,’’ ‘‘quite a bit,’’ and ‘‘extremely’’ scored 1 to 4,
respectively. From these 25 items, we selected all (n ¼ 4) the items concerning
somatic symptoms: headache, dizziness, palpitations, and tremor. We defined
the answers ‘‘a little,’’ ‘‘quite a bit,’’ and ‘‘extremely’’ as positive for each
symptom.
Health care utilization was assessed by asking in self-questionnaires about the
number of visits separately in different health care services, i.e., health centers,
ambulatory secondary care, mental health clinics, occupational health care, pri-
vate health care, and dental health care. Furthermore, the information on the
professional visited in these services was obtained. The total use of health care
services was calculated by a sum of the visits in all these services. Those people
who ranked to the top 10% in the total use of health care services were defined as
frequent attenders of health care services as this is the most used definition in
earlier research.5 As frequent attendance of health care services has earlier
reported to be associated to sex,5 the cut-off points in total health care utilization
for frequent attendance were defined separately for men and women so that the
highest decile of both men and women came to the frequent attender group. All
the people with the cut-off number or more visits were taken into the frequent
attender group.
Health care utilization,37,38 GAD,39,40 and somatic symptoms41–47 have ear-
lier reported to be associated with smoking status, alcohol consumption, body
mass index (BMI), occupational class, and somatic diseases. Therefore, these
variables were taken into account as confounding variables.
The smoking status was enquired in self-questionnaires at the age of 46.
Smoking habits were divided into three categories: nonsmoker, occasional
Kujanpää et al. 151

smoker, and current smoker. Weight and height were measured in the clinical
examination at the age of 46; self-reported values from the questionnaires were
used if the measurements were not performed. BMI was calculated by dividing
the weight (kg) with the square of height (m) and categorized in four classes
according to the definition by World Health Organization (BMI: under-
weight ¼ <18.5, normal weight ¼ 18.5–25, overweight ¼ 25–30, and obese ¼
>30). Alcohol consumption was enquired by asking the frequency and
amount of use of wine, cider, beer, and spirits. Then, mean alcohol consumption
per day (g/day) was calculated and categorized into four classes: (1) nonusers,
(2) light users (men < 230 g/week, women < 150 g/week), (3) moderate users (men
230–350 g/week, women 150–210 g/week), and (4) heavy users (men > 350 g/week,
women > 210 g/week).48 Occupational class was enquired in self-questionnaires
and categorized into four classes: (1) higher/lower professionals and entrepre-
neurs, (2) manual workers, (3) students, pensioners, others, and (4) farmers.
Somatic diseases were also enquired in self-questionnaires at the age of 46.
The study complied with the principles of the Declaration of Helsinki. The
participants took part on a voluntary basis and signed their informed consent.
The data were handled only on a group level and the personal information were
replaced by identification codes. The research was approved by the Ethics
Committee of the Northern Ostrobothnia Hospital District.

Statistical methods
Continuous variables are presented as means and standard deviations (SDs) and
categorical variables are presented as the number and percentage of subjects in
each category. For categorical variables, Pearson’s chi-square test was used to
identify any differences in proportions between frequent attenders of health care
services categories. Wilcoxon rank-sum tests were used to compare continuous
variables between frequent attenders of health care services groups.
Association of GAD symptoms and different numbers of somatic symptoms
to the frequent attenders of health care services was assessed in binary logistic
regression models. The potential confounding variables (occupational class,
BMI, smoking status, alcohol consumptions, and number of somatic diseases)
were used as adjusting variables in multivariate logistic regression models. The
possible two-way interaction between GAD-7 and numbers of somatic symp-
toms, as well as potential confounding variables were tested, and no statistically
significant interactions were found. The results were presented as crude and
adjusted odds ratios (OR) and their 95% confidence intervals (95% CI).

Results
Demographic characteristics of the study population are presented in Table 1.
The study population consisted of 5585 people, of whom 43% were men and
152 The International Journal of Psychiatry in Medicine 52(2)

Table 1. Demographic characteristics of the study population.

Frequent Other
attendersa peopleb
Characteristic N (%) N (%) P

Gender 0.0729
Men 241 (39.5%) 2155 (43.3%)
Women 369 (60.5%) 2820 (56.7%)
Occupational class <0.0001
Professionals, entrepreneurs 209 (37.1%) 2313 (49.5%)
Manual workers 266 (47.2%) 2031 (43.5%)
Farmers 74 (13.1%) 240 (5.1%)
Students, pensioners, others 15 (2.7%) 89 (1.9%)
Body mass index <0.0001
Underweight (<18.5 kg/m2) 1 (0.2%) 37 (0.8%)
Normal (18.5–25 kg/m2) 198 (32.5%) 1991 (40.1%)
Overweight (25–30 kg/m2) 224 (36.8%) 1961 (39.5%)
Obese (>30 kg/m2) 186 (30.5%) 971 (19.6%)
Alcohol consumptionc 0.0008
No use 84 (14.4%) 461 (9.6%)
Light use 438 (74.9%) 3924 (81.4%)
Moderate use 28 (4.8%) 216 (4.5%)
Heavy use 35 (6.0%) 222 (4.6%)
Current smoking <0.0001
No 400 (68.0%) 3779 (78.2%)
Occasional 49 (8.3%) 259 (5.4%)
Yes 139 (23.6%) 795 (16.5%)
Number of somatic diseases, mean (SD) 4.3 (3.1) 2.8 (2.4) <0.0001
SD: standard deviation.
a
People belonging to the highest decile in the total health care utilization.
b
People not belonging to the highest decile in the total health care utilization.
c
Light use: men < 230 g/week, women < 150 g/week, Moderate use: men 230–350 g/week, women
150–210 g/week, Heavy use: men > 350 g/week, women > 210 g/week.

57% women. Men and women belonging to the highest decile in the total health
care utilization had during the past year 11 or more and 14 or more total health
care visits, respectively. Frequent attenders of health care services differed stat-
istically significantly from the other people in the cohort regarding occupational
class, BMI, current smoking, alcohol consumption, and number of somatic
diseases.
Kujanpää et al. 153

Table 2. Odds ratios of GAD symptoms and somatic symptoms for frequent attendance
of health care services.

Crude OR Adjustedc OR
a b
Characteristic n /N (%) (95% CI) (95% CI)

GAD-7
<10 436/4798 (9.1%) 1.0 (Reference) 1.0 (Reference)
10 52/186 (28%) 3.88 (2.78–5.43) 2.29 (1.58–3.31)
Number of somatic symptoms
0 127/1992 (6.4%) 1.0 (Reference) 1.0 (Reference)
1 159/1797 (8.8%) 1.43 (1.12–1.82) 1.28 (0.99–1.64)
2 109/755 (14.4%) 2.48 (1.89–3.25) 1.94 (1.46–2.58)
3 67/354 (18.9%) 3.43 (2.49–4.73) 2.33 (1.65–3.28)
4 26/86 (30.2%) 6.37 (3.88–10.4) 3.64 (2.15–6.18)
GAD-7: 7-item generalized anxiety disorder scale; OR: odds ratio; CI: confidence interval.
a
Number of people belonging to the highest decile in the utilization of health services in each category.
b
Total number of people in each category.
c
Adjusted for alcohol consumption, BMI, number of somatic diseases, occupational class and smoking.

Table 2 shows both crude and adjusted ORs for frequent attendance of health
care services of GAD symptoms and somatic symptoms. People who tested
positive for GAD had statistically significantly higher risk for being frequent
attender of health care services than those who tested negative with adjusted OR
of 2.29 (95% CI 1.58–3.31). The number of somatic symptoms was also
statistically significantly associated with the risk of being health care frequent
attender. When compared to people without somatic symptoms, those people
with 1, 2, 3, and 4 somatic symptoms had adjusted OR for frequent attendance
of health care services 1.28 (95% CI 0.99–1.64), 1.94 (95% CI 1.46–2.58), 2.33
(95% CI 1.65–3.28), and 3.64 (95% CI 2.15–6.18), respectively. There was a
statistically significant gradient effect of 1.34 (95 % CI 1.23–1.46) in the rise
of adjusted OR in relation to the number of somatic symptoms.
Figure 1 illustrates the frequent attenders of health care services according to
the number of somatic symptoms and result in GAD-7. The higher the number
of somatic symptoms in relation to GAD is, the higher will be the share of
frequent attenders in the population.
People who tested positive for GAD had statistically significantly (p < 0.0001)
higher mean number of somatic symptoms (1.8) compared to those who tested
negative (0.9). Furthermore, the higher the number of somatic symptoms is, the
higher is the rate of positive test results for GAD. The prevalence of tests posi-
tive for GAD according to the number of somatic symptoms is presented in
Table 3. Meanwhile, only 1.6% of people without somatic symptoms tested
positive for GAD, even 22.6% of people with four somatic symptoms tested
154 The International Journal of Psychiatry in Medicine 52(2)

Figure 1. Frequent attenders of total health care services according to the number of
somatic symptoms and result in GAD-7.
GAD: generalized anxiety disorder.

Table 3. The prevalence of test positive GAD according to the number of

somatic symptoms obtained from the Hopkins Symptom Checklist 25.

Number of somatic Number of Number of people

symptoms people (N) with GAD-7  10 (n) n/N (%)

0 2095 33 1.6
1 1910 52 2.7
2 799 51 6.4
3 375 38 10.1
4 93 21 22.6
Chi-square test: p < 0.001.
GAD: generalized anxiety disorder.

positive for GAD. However, no interaction between GAD-7 and the number of
somatic symptoms for frequent attendance of health care services was found.

Discussion
Both GAD symptoms and the number of somatic symptoms were associated
with the risk of being frequent attender of health care services. People with GAD
symptoms also had on average a higher number of somatic symptoms.
Kujanpää et al. 155

A major strength of the present study is that it is based on a large cohort

sample of an unselected population and is not restricted to people who had
sought themselves to some service channel. In addition, frequent attenders of
health care services were defined by taking into account a large scale of different
health care services, which were separately asked. This is important, as not all
people attend the same service channels, and by not restricting the scope of
health services, the risk for selection bias is lower. Moreover, age could signifi-
cantly affect the results, and in this study setting, the age is efficiently standar-
dized so that all the people in the cohort were at the same age.
However, there were also some limitations in the present study. GAD-7 is a
self-report questionnaire that gives only symptoms and, therefore, a limited
approximation of the presence of GAD instead of definite diagnosis. Still,
GAD-7 is a validated tool to screen GAD.15,35,49 The data of health care util-
ization were self-reported and, therefore, prone to recall bias. Also, there is a
possibility for response bias, because 46% of the cohort members did not
respond to the questionnaires. The study population was also restricted to
46-year-old people and, therefore, the results cannot be directly generalized to
the whole population. Furthermore, the numbers of people tested positive for
GAD were small in some of the groups divided based on number of somatic
symptoms, which makes testing interaction between GAD and somatic symp-
toms for frequent attendance of health care services prone to bias because of a
lack of power.
To the best of our knowledge, there are no earlier studies investigating the
association between frequent attendance of health care services and GAD at the
population level. However, the finding in the present study that GAD symptoms
are associated with higher OR for being a frequent attender of health care ser-
vices is in line with the earlier findings in primary care setting.23 Still, a com-
parison between these studies is difficult due to major methodological
differences. In Germany, primary care patients with pure GAD and comorbid
GAD and major depressive disorder had OR for having at least four primary
care visits during the past year compared to patients without these disorders of
1.6 and 2.1, respectively.23 In the same study, the ORs for having at least two
visits for specialized doctors were 1.5 for both of these groups.23 In comparison,
results in this study suggest somewhat higher ORs. However, assessment of both
GAD and health care utilization was different in these studies. Large-scale con-
founding factors have been taken into account in the present study, which are
controversial to this earlier report. Moreover, earlier reports of high prevalence
rates of GAD yielding up to 21.8–35.2%7,14 support the association between
GAD and the frequent attendance of health care services observed in this study.
Earlier studies have been inconsistent on what determines the health care
utilization of the sufferers of anxiety disorders. Meanwhile, one study indicated
that medical comorbidities but not anxiety severity determines health care util-
ization,32 and another study showed that both medical comorbidities and
156 The International Journal of Psychiatry in Medicine 52(2)

severity of anxiety influence the health care utilization.33 However, earlier studies
have not focused on the impact of somatic symptoms in determining health care
utilization of sufferers of GAD. The present study showed that both GAD
symptoms and somatic symptoms are associated with frequent attendance of
health care services, and people who tested positive for GAD had on average
a significantly higher number of physical symptoms.
Despite the high health care utilization, the health behavior of sufferers of
GAD is not necessarily better than others. Among patients with coronary heart
disease, for example, patients with GAD have reported greater smoking, lower
physical activity, and lower adherence to prescribed medications.50 Therefore,
the treatment of people with GAD is challenging in order to obtain better health
outcomes with the use of these services.
The results in this study suggest that people with many different somatic symp-
toms and especially those frequently attending health care services have a high
rate of GAD. Therefore, the possibility of underlying GAD should be bore in
mind, especially when treating these patients. A comprehensive approach is
needed when treating people with GAD and/or multiple somatic symptoms to
meet their needs. Future studies with larger GAD samples are needed to investi-
gate the interaction for health care frequent attendance between GAD and som-
atic symptoms. Also, future studies are needed to understand the health outcomes
of the use of health services among patients with GAD and multiple somatic
symptoms and to further develop the management of these patient groups.

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the
research, authorship, and/or publication of this article: All authors have completed the
Unified Competing Interest form at http://www.icmje.org/coi_disclosure.pdf and declare
that authors did not receive support from any company for the submitted work. MT was
reimbursed by Oy Bristol-Myers Squibb (Finland) Ab, H. Lundbeck A/S, Pfizer Oy and
Servier Finland Oy for attending four conferences, was paid by Astra Zeneca, Oy Bristol-
Myers Squibb (Finland) Ab, Eli Lilly, Pfizer Oy and Servier Finland Oy for speaking on
different educational occasions, has received advisory panel payments from H. Lundbeck
A/S and Pfizer Oy for four meetings, and is a minor shareholder in Valkee Ltd. No other
relationships or activities that could appear to have influenced the submitted work.

Funding
The author(s) received no financial support for the research, authorship, and/or publica-
tion of this article.

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