Prevalence, characteristics and measurement of somatic symptoms related to mental health in medical students: a scoping review

Figures & data

Figure 1. PRISMA-ScR flow diagram for study selection and screening. From: Tricco et al. [39].

Table 1. Study characteristics and results on mental health-related somatic symptoms in medical students.

Article	Design	Objectives	Participant characteristics	Primary outcomes measures & results
Adhikari et al. [50]	Cross-sectional descriptive	Prevalence of depression, somatic symptoms, anxiety syndromes, eating disorders, suicidal ideation, thoughts of dropping out of medical school and marijuana use in medical students at KIST Medical College and Teaching Hospital, Nepal.	n = 343; Age: not reported; 49.0% female	PHQ-9, PHQ-15*; Psychological variable(s): depression, anxiety, panic syndrome, eating disorders, suicidality; Somatic symptoms: 22.4% (18–26.9) medium to high severity; Females reported more somatic symptoms (30.4 vs. 14.9%; Chi-sq 11.829, p = .001) with menstrual symptoms, then headaches; males reported headaches first then ‘pain in extremities’. Other reported symptoms: indigestion, altered bowel, SOB, palpitations, fainting, dizzy, chest pain, sex problems, back pain, and stomach pain.
Algarni et al. [32]	Cross-sectional descriptive	Prevalence of neck, shoulder, low-back musculoskeletal pain (MSP) and associated factors in medical students at College of Medicine at King Saud University and King Saud Bin Abdulaziz University for Health Sciences, Saudi Arabia.	n = 469; Mean age: 21.4 (1.3); 60.6% female	SNQ; Psychological variable(s): depression; Musculoskeletal pain (MSP) is associated with depression related to medical school (OR 2.93, CI 1.73–4.98, p < .001) and other mental health-related somatic symptoms (OR 2.93, CI 1.37–5.27, p = .004).
Alshagga et al. [33]	Cross-sectional descriptive	Prevalence, location, and factors associated with MSP among medical students in a private Malaysian medical college.	n = 232; Mean age: 20.6 (2.2); 72.9% female	SNQ; Psychological variable(s): stress via year in school; Higher MSP in past week in clinical students (OR 2.0, CI 1.15–3.67, p = .015) those with history of physical trauma (OR 2.6, CI 1.22–5.29, p = .011) family history of MSP (OR 2.6, CI 1.22–5.29, p = .011), and increased BMI (OR = 1.1, 95% CI 1.0–1.1, p = 0.03). Higher in past year for same populations.
Behera et al. [34]	Cross-sectional descriptive	Prevalence of neck pain and the associated factors among medical students of a premier medical college in India.	n = 331; Mean age: 20.5 (1.7); 33.2% female	Web-based questionnaire developed using the Kobo Toolbox (Harvard Humanitarian Initiative); Psychological variable(s): stress; 2.9× greater odds of neck pain in 3rd and 4th-year students than 1st-year students. Students who attributed neck pain to academic stress had 3.5× greater odds of having neck pain (p < .001).
Bolatov et al. [51]	Cross-sectional descriptive	Burnout and associated factors in a sample of medical students from Astana Medical University, Kazakhstan.	n = 736; Mean age: 20.3 (2.74); 75.0% female	OLBI-S, CBI, GAD-7, PHQ-9; Psychological variable(s): depression, anxiety, burnout, suicidality; Having academic burnout was associated with mental health-related somatic conditions including headache (p < .001), tiredness (p < .001), and sleep disturbance (p < .001). Burnout levels correlate with CBI-S and OLBI-S mental health-related somatic indicators (r = 0.313–0.624, p < 0.001).
Chinawa et al. [52]	Cross-sectional descriptive	Presence of somatization in medical students at two teaching hospitals in Nigeria.	n = 385; Mean age: 23.55 (3.33); % female not reported	ESS*; Psychological variable(s): general/any; Prevalence of mental health-related somatic disorder: 14.3% overall (males 14.2% and females 14.4%). 11.4% had head features while 7.8% had body features of mental health-related somatic disorder.
Clarvit [53]	Cross-sectional descriptive	Prevalence of oligomenorrhea. amenorrhea, dysmenorrhea, and other during menses in a group of medical students at Albert Einstein College of Medicine, USA.	n = 159; Mean age: 26.8; 100% female	Questionnaire, unspecified; Psychological variable(s): stress; Prevalence of oligomenorrhea 8.4% during and 10.9% prior to medical school; amenorrhea 1.9 and 2.6% respectively; dysmenorrhea 73.2 and 71.1% respectively. No sig. correlations with medical school stressors.
Diebig et al. [42]	Longitudinal	Mediating role of learning family conflicts in medical students in two cohorts at one university in Germany.	n = 128; Mean age: 20.7 (3.47); 70.0% female	COPSOQ, PHQ-15*; Psychological variable(s): familial conflict; Long-term commuting is associated with poor health and somatic symptoms. Commuting strain predicted somatic symptoms. Conflicts between learning and family responsibilities affected the relationship between commuting strain and somatic symptoms (indirect effect estimate between = 0.13, SE = 0.05, 95% CI [0.05; ∞), Evidence Ratio = 250.57).
Dighriri et al. [35]	Cross-sectional descriptive	Prevalence of neck, shoulder, and lowback MSP and associated factors associated among medical students at Jizan University, Saudi Arabia.	n = 440; Mean age: 22.4 (1.6); 50.0% female	Questionnaire, unspecified; Psychological variable(s): stress, depression; History of trauma (OR = 2.59; 95% CI: 1.54–5.64) and history of depression (OR = 2.95, 95% CI: 1.54–5.64) were significantly correlated with MSP. Participants with history of trauma had a 2.7x higher likelihood of reporting MSP (OR = 2.70; 95% CI: 1.36–5.36). Depressive symptoms associated with studying resulted in 2x higher chance of MSP (OR = 1.94; 95% CI: 1.03–3.66). Students with mental health-related somatic symptoms had 3x greater likelihood MSP (OR = 2.98; 95% CI: 1.71–5.18).
El-Gilany et al. [54]	Cross-sectional descriptive	Find the prevalence of mental disorders and associated factors among medical students at Mansoura University, Egypt.	n = 900; Age: n = 491 under age 20, n = 409 age 20 or above; 53.2% female	SCL-90-R*; Psychological variable(s): depression, OCD, interpersonal sensitivity; Prevalence of somatization 21.7%. Being younger than 20 years old, a man, preclinical, living outside the campus, belonging to families of rural residence, and very low or low social class were independent predictors of somatization with AORs of 1.8, 1.6, 1.5, 8.3, 1.8, and 2.5 respectively.
Feussner et al. [37]	Cross-sectional descriptive	Examine prevalence of somatization and associated resilience factors in a sample of medical and dental students at a university in Germany.	n = 142; Mean age: 23.21 (3.44); 70.4% female	BDI-II, SOMS-2*, NEOFFI; Psychological variable(s): depression, resilience; A critical somatization index of 7 points (minimum) was found in 50.7% (X2[df = 1] = 4.558; p = .033.) 1.4% of the students fulfilled the ICD-10 and DSM-IV criteria for somatization disorder.
Fino et al. [48]	Longitudinal	Examine if trait mindfulness mitigates effects of stress, mental health-related somatic symptom burden, and sleep-wake quality in medical students at the Medical School of University of Bologna, Italy.	n = 305; Mean age: 20.47 (1.9); 50.4% female	STAI-Y, FFMQ, PSS, PPS*, MSQ; Psychological variable(s): stress, trait mindfulness; Total prevalence of mental health-related somatic symptoms = 19.81%. Trait anxiety was strongly associated with stress, mental health-related somatic symptoms, and sleep quality at the beginning and end of the first trimester. Mental health-related somatic symptoms also significantly increased (Z = −3511, p < .0001).
Gallas et al. [29]	Cross-sectional descriptive	Evaluate prevalence of FGIDs and associated risk factors in medical students at the Faculty of Medicine of Monastir, Tunisia.	n = 343; Mean age: 30.2 (0.8); 68.5% female	Rome III, Mental health-related somatic symptoms checklist*, HAD; Psychological variable(s):depression, anxiety; Probable or definite anxiety was an risk factor for functional gastrointestinal disorders (FGIDs) (OR = 2.5, 95% CI= 1.1–5.8). Probable or definite anxiety correlated to somatic symptoms (OR = 2.5, 95% CI= 1.1–5.8). Anxiety resulted in 2x greater risk of having a FGID (OR= 2.5; 95% CI: 1.1–5.8).
Glaser et al. [38]	Longitudinal	Assess the effect of academic stress on the ability to generate an immune response, in medical students at Ohio State University, USA.	n = 48; Mean age: 23.31 (SEM 0.20); 47.9% female	SSS-8*, PSS, biomarkers; Psychological variable(s): stress, anxiety, social support; Seroconverts from the first vaccine were shown to be significantly less anxious than those who seroconverted later (F(l,44) = 6.28, p < .02). PSS: there were significant differences between antibody positive and antibody negative groups (F(l,43) = 4.22, p < .05). Social support was significantly correlated with antibodies to HBsAg and blastogenic response to SAg for the third injection (t = 2.21, p < .05).
Goweda et al. [55]	Cross-sectional descriptive	Screen for somatic symptom disorder (SSD) among medical students at Faculty of medicine, Umm Al-Qura University, Saudi Arabia.	n = 374; Mean age: not reported; 44.9% female	SSD diagnostic criteria; Psychological variable(s): stress; 20.3% had very high risk for somatic symptom disorder (SSD), 18.7% had high risk, 19.8% medium risk, 24.6% low risk, 16.6% had none to minimal risk. Prevalence of SSD estimated at 39%. Females had higher risk than males (p = .002). Most commonly reported symptoms were feeling tired/having low energy, poor sleep, and stomach/bowel issues.
Ivashchenko et al. [56]	Cross-sectional descriptive	Investigate changes of state anxiety and autonomic symptoms among medical students at I.M. Sechenov Moscow State Medical University, Russia.	n = 54; Mean age: not reported; 51.85% female	STAI, VASQ*; Psychological variable(s): state anxiety; Correlation between autonomic symptoms and gender was found one day before exams (r = 0.46; p = .003) and after exams (r = 0.901; p < .001), but not two weeks before exams.
Lloyd and Gartrell [57]	Cross-sectional descriptive	Examine presence of psychiatric symptomatology in a sample of medical students at the University of Texas Medical School at Houston, USA.	n = 285; Mean age: 25.8; 36.5% female	HSCL; Psychological variable(s): depression, anxiety, OCD; Medical students were two SDs > than general population on the Interpersonal Sensitivity and Obsessive-Compulsive Disorder (OCD) symptom subscales. Mean score on the Depression and Anxiety subscales was one standard deviation greater. Symptoms highest in 2nd year med students. Females had overall higher scores (t = 3.37, p < .001). From Somatization subscale, headaches (t = 4.82, p < .01) and loss of sexual interest/pleasure (3.30, p < .01), were sig different between genders and higher in females.
Mosley et al. [58]	Cross-sectional descriptive	Prevalence and correlations between stress, coping strategies, depression, and somatic symptoms in medical students at University of Mississippi School of Medicine, USA.	n = 69; Mean age: 26; 32.0% female	MEHS-R, CSI, CESD-R, WPSI*; Psychological variable(s): stress, depression, coping strategies; 57% had high levels of somatic distress (mean = 0.66 (.42)). 23% met levels for clinical depression (mean = 11.48 (7.13)). Stress frequency was correlated with depression (.54, p < .001) and somatic symptoms (0.71, p < .001). Stress intensity was also correlated with somatic symptoms (0.31, p < .01).
Oró et al. [43]	Quasi-experimental repeated measures	Evaluate and compare effects of a mindfulness-based program in medical students at a school in Spain.	n = 143; Mean age: 20.28 (1.54); 73.4% female	SLC-90-R*, PSS, MBI-SS; Psychological variable(s): stress, burnout, mindfulness; Somatization decreased after a mindfulness program in the intervention group compared to the control group (F(1, 141) = 6.22; p = 0.014), as did stress (F(1, 141) = 8.23; p = 0.005). Burnout not significantly affected.
Pikó [59]	Cross-sectional descriptive, first phase of longitudinal cohort study	Describe frequency of common mental health-related somatic symptoms and variations in self-assessed health status in medical students at Albert Szent-Cyorgyi Medical University, Hungary.	n = 691; Age range: 18–31; 60.6% female	SPHQ; Psychological variable(s): stress; Men: backache (9.2% often, 15.8% sometimes), sleeping problems (5.5% often, 13.2% sometimes) and chronic fatigue (3.3% often, 10.7% sometimes). Female: Chronic fatigue (3.3% often, 16.9% sometimes), backache, tension headaches, and poor sleep. Women more likely than men to have experienced mental health-related somatic symptoms (p < .0001), and prevalence of tension headaches and chronic fatigue were significantly higher in women (p < 0.0001).
Ruzhenkova et al. [47]	Cross-sectional descriptive	Development of differentiated approaches to psychopharmacothe-rapy in autonomic dysfunction in medical students at Belgorod State University Medical Institute, Russia.	n = 166; Mean age: 18 (0.9); 77.1% female	PSS, Diagnostic research criteria ICD-10 for SAD*; Psychological variable(s): stress, depression, anxiety; 80.1% had symptoms of autonomic instability. 9% reached clinical levels of somatoform autonomic dysfunction (SAD), 3.6% were subclinical. Symptoms of autonomic instability in students with SAD were particularly severe during exams. Prevalence of symptoms of SAD: tachycardia 86%, palpitations 37%, shortness of breath 57%, difficulty breathing 33%, non-satisfaction with inspiration 43%, muscular tension 52.3%, muscular tremors 67%, rapid urination 19%, headaches 67%, anxiety 90%, difficult falling asleep 71%, and unpleasant dreams 33%. Anxiety present in 86%, 62% reached clinical levels.
Scheuch et al. [44]	Quasi-experimental repeated measures	Explore changes to physiological and biochemical parameters under mental load in medical students at Karl-Marx-University of Leipzig, Germany.	n = 64; Mean age: 24.3 exp group; 43.8% female	Immunological parameters, physical and mental task performance, max ergometry, mental health-related somatic complaints; Psychological variable(s): stress (‘mental load’); No significant changes in leucocytes, eosinophil granulocytes, lymphocytes, or cortisol pre/post exams. Delayed reactions improved after exams (5.2% (3) to 4.4 (3), p < .001) as did false reactions (2.3% (2) to 1.4 (2), p < .001). Trends in somatic complaints went up (2.3 (3.2) to 4.1 (3.7)) and psychological complaints went down (3.8 (3.6) to 1.8 (2.5)) pre/post exams.
Sekas and Wile [49]	Cross-sectional descriptive	Determine prevalence and incidence of stress-associated illnesses and possible sources of stress among students enrolled in MD, PhD, or MD-PhD programs at Case Western Reserve University, USA.	n = 334; Mean age: not reported; 3.0% female	Frequency of stress-related illnesses, stress questionnaire unspecified; Psychological variable(s): stress; Reported frequency of stress-related illnesses decreased from before medical school to during medical school (according to students’ memory). In men: episodes of depression 50% prior, 18.8% during, and insomnia 24.5% prior, 13.8% during. In women: depression 72.7% prior, 23.6 during, headaches 45.5% prior, 13.6% during, insomnia 30% prior, 15.5% during.
Smith et al. [36]	Cross-sectional descriptive	Determine prevalence and distribution of MSP among Chinese medical students at a university teaching hospital in Mainland China.	n = 207; Mean age: not reported; % female not reported	SNQ; Psychological variable(s): stress (‘mental pressure’); 67.6% had MSP in any body site in past 1 year, 46.9% in past week, 31.9% currently. Mental pressure was significantly correlated with LBP (OR 2.9, CI 1.4–5.9, p = .0030).
Sohrabi et al. [60]	Cross-sectional descriptive	Explore prevalence of probable mental disorders during the internship period of medical students at Shahid Beheshti University of Medical Sciences, Iran.	n = 404; Mean age: 24.7 (2.01); 53.8% female	SCL-90-R*; Psychological variable(s): depression, anxiety, OCD, interpersonal sensitivity, hostility, paranoia, psychoticism; The frequency of somatization was 16.3%. Depression was 16.8% and anxiety 18.8%.
Tan et al. [30]	Cross-sectional descriptive	Determine the prevalence of IBS and symptom subgroups in students at a medical school in Malaysia.	n = 533; Mean age: 22 (1.8); 57.0% female	Rome I, psychological and somatic questionnaire unspecified; Psychological variable(s): depression, anxiety; The psychological and mental health-related somatic symptoms of anxiety (OR = 2.0, CI = 1.1,3.5, p = 0.02), depression (OR = 2.1, CI = 1.3,3.7, p = 0.002), insomnia (OR = 2.3, CI = 1.3,4.1, p = 0.006), headache (OR = 1.7, CI = 1.0,2.8, p = 0.04), and backache OR = 2.0, CI = 1.2,3.4, (p = 0.006) were all more common in the participants who had IBS.
Tang et al. [45]	Cross-sectional descriptive	Examine associations of suicidality with psychological distress, somatic symptoms, and stressors in medical students at a large, research-intensive institution, China.	n = 662; Mean age: 19.85 (1.6); 59.4% female	Three Qs from the Chinese NCS; K6, PHQ-15*, ASLEC; Psychological variable(s): stress, suicidality; Prevalence of somatic symptoms: 5.7% medium or high (57.9% minimal, 36.4% low, 4.3% medium, and 1.4% high). General pain/fatigue was correlated with suicidal ideation (OR 6.11, 95% CI 2.99–12.48, p < 0.001) and planning suicide (OR 18.83, 95% CI 2.75–128.89, p = 0.003).
Vitaliano et al. [46]	Cross-sectional descriptive; two cohorts	Examine distribution and pattern of psychological distress in first-year medical students at the beginning and end of the year at the University of Washington Medical School, USA.	n = 175 per cohort; Mean age: 25.0 (3.2) male; 26.7 (4.1) female; 37% female	SCAS, BDI, LES, FTAS*, AES, biomarkers, WCCL, SNL; Psychological variable(s):stress, depression; Increased depression during the first year of medical school in men (t(194) = −3.42, p < .001) and women (t(107) = −3.38, p < .001). Stress also increased in men (t(194) = −5.13, p < .001) and women (t(107) = −4.07, p < .001). Problem-focused coping, and seeking of social support, resulted in less distress.
Wege et al. [61]	Cross-sectional descriptive; two cohorts	Discover prevalence of common mental disorders and the use of psychotropic substances in medical students at the University of Dusseldorf, Germany.	n = 590; Mean age: 21.13 (3.91); ∼70% female over two cohorts	PHQ*; Psychological variable(s): depression, anxiety, panic disorders, anger; Total prevalence of moderate to high somatization 15.7%, with significantly greater rates in women (19.9%) vs. men (5.2%, p < 0.005). Prevalence of major depression 4.7%, prevalence of ‘other depressive symptoms’ (subthreshold) 5.8%, panic disorders 4.4%, ‘other anxiety disorders’ 1.9%.

AES: Anger Expression Scale; ASLEC: Adolescent Self-Rating Life Events Checklist; BDI-II: Becks Depression Inventory II; CBI-S: Copenhagen Burnout Inventory for college students; CEDS-R: Center for Epidemiological Depression Scale-Revised; CSI: Coping Strategies Inventory; ESS: Enugu Somatization Scale; FTAS: Framingham Type A Behavior Pattern Scale; FFMQ: Five Facet Mindfulness Questionnaire; FGID: Functional gastrointestinal disorders; GAD-7: Generalized Anxiety Disorder; HSCL: Hopkins Symptom Checklist; HAD: Hospital Anxiety and Depression Scale; IBS: Irritable Bowel Syndrome; K6: Brief Kessler-6; LES: Life Experiences Survey; LBP: low back pain; MBI-SS: Maslach Burnout Inventory-Student Survey; MEHS-R: Medical Education Hassles Scale-Revised; MSP: Musculoskeletal pain; MSQ: Mini Sleep Questionnaire; Depression Scale; NCS: National Comorbidity Survey; NEOFFI: NEO-Five-Factor-Inventory for personality self-assessment; OBI-S: Oldenburg Burnout Inventory for college students; PHQ: Patient Health Questionnaire; PHQ-9: depression; PHQ-15: for somatization; PSP: Mental health-related somatic Problems Scale; PSS: Perceived Stress Scale; Rome III: questionnaire on functional gastrointestinal disorders; SAD: Somatoform autonomic dysfunction; SCAS: The Symptom Checklist Anxiety Scale; SCL-90-R: Symptoms Checklist 90 Revised; SNL: The Social Network List; SNQ: Standardized Nordic Questionnaire; SOMS-2: Screening for Somatoform Disorders; SPHQ: Self-perceived health questionnaire; SRQ-20: Self-Reporting Questionnaire-20; SSS-8: Somatic Symptom Scale-8; STAI-Y: State Trait Anxiety Inventory; VASQ: Veins Autonomic Symptoms Questionnaire; WCCL: Ways of Coping Checklist ; WPSI: Wahler Physical Symptoms Inventory

* Direct measure of psychosomatic symptoms.

Table 2. Validity & reliability of mental health-related somatic symptom outcome measures.

Mental health-related somatic outcome measure	Validity	Reliability
Enugu Somatization Scale (ESS)	Intrinsic validity: 0.9654 [54]	Cronbach’s α: 0.932, internal consistency: 0.936 [54]
Framingham Type A Behavior Pattern Scale (FTAS)	Not found	Cronbach’s α: 0.68 [63]
Patient Health Questionnaire-15 (PHQ-15)	PHQ-9: sensitivity 89% and specificity 97% in college students [64]; GAD-7: sensitivity 73.3%, specificity 67.3%; PHQ-15: sensitivity 78%, specificity 71% (for DSM-IV somatoform disorder diagnosis) [65]	PHQ-9 Cronbach’s α: 0.88; GAD-7 Cronbach’s α: 0.89; PHQ-15 Cronbach’s α: 0.82 [66]
Psychosomatic Problems Scale (PPS)	Multidimensionality: 0.80% at 0.01 alpha [67]	Person Separation Index: 0.83 [67]
Symptoms Checklist 90 – Revised (SCL-90-R)	Comparative Fit Index: 0.967–0.995 [68]	Cronbach’s α: 0.89–0.93 [68]
Screening for Somatoform Disorders (SOMS-2)	Sensitivity: 86.0%; Specificity: 95.5% [69]	Cronbach’s α: 0.83 [69]
Self-Reporting Questionnaire-20 (SRQ-20)	Sensitivity: 63.0%
Specificity: 88.0% [70]	Cronbach’s α: 0.84 [71]
Somatic Symptom Scale-8 (SSS-8)	Mental health-related somatic symptoms were correlated with anxiety (r = 0.55 [95% CI, 0.52–0.58]), depression (r = 0.57 [95% CI, 0.54 to 0.60]), health (r = −0.24 [95% CI, –0.28 to −0.20]), and health care utilization (incidence rate ratio, 1.12 [95% CI, 1.10 to 1.14]) [69]	Cronbach’s α: 0.81 [72]
Veins Autonomic Symptoms Questionnaire (VASQ)	Not found	Not found
Wahler Physical Symptoms Inventory (WPSI)	F = 48.75 (p < .001) difference in means [73]	Test-retest reliability: 0.81 [73]
Diagnostic criteria for somatoform autonomic dysfunction (SAD)	Prevalence of somatization: 0.8–5.9% with strict DSM/ICD criteria application. Estimates higher with less strict application [74]	Diagnoses from the DSM vs. ICD varied significantly. Data from questionnaire vs. clinical interviews also varied [74]

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Data availability statement

Data sharing is not applicable to this article as no new data were created or analyzed in this study.