What every clinician should know about symptom clusters

By Naveed Saleh, MD, MS | Fact-checked by Jessica Wrubel
Published August 3, 2022

Key Takeaways

  • A symptom cluster is defined as two or more symptoms that happen concurrently and impact each other, typically with a common etiology.

  • The concept of symptom clusters is reinforced by a theoretical framework, and examples include vomiting, nausea, pain, depression and fatigue. Diseases with symptom clusters include menopause, PTSD, and cancer.

  • Psychotherapy could be directed at the management of symptom clusters.

In medicine, symptoms aren’t merely siloed off. Many symptoms and problems co-occur to form symptom clusters. Sleep problems, for example, frequently co-occur with depressive symptoms.

The concept of symptom clusters appears to be popular in nursing literature, but it could just as easily apply to the practice of the physician. The implications are widely applicable.

Learning more about symptom clusters could add useful insight when assessing patients and planning their treatment.

Core characteristics

A symptom cluster specifically refers to two or more interrelated symptoms that happen at the same time and affect one another. They usually have a common cause.

According to a 2022 article published in Revista da Escola de Enfermagem da USP (a publication of the School of Nursing at the University of São Paulo), experts debate over the core characteristics of a symptom cluster.[]

“Some authors are based on the correlation and simultaneous occurrence among symptoms, others focus on their effects on health outcomes, and others consider that common mechanism and etiology are the main aspects to be considered in defining a cluster,” the investigators wrote.

They also pointed out the following related theoretical principles:

  • The theory of symptom management states that symptom control is attainable only after taking management strategies, symptom experience, and outcomes into account.

  • The symptom self-management theory considers various factors—including multidimensionality, patient characteristics, and stressors—to facilitate self-symptom control.

  • The theory of unpleasant symptoms states that the existence of one symptom or a group of them can interact with the others.

  • The concept of self-efficacy can refer to the ability to use behaviors to recognize, ease, and prevent disease outcomes. A patient with high self-efficacy in symptom management could recognize symptoms more readily and feel empowered to change behaviors to decrease symptom severity and improve their health status.

Examples of symptom clusters

Debate exists as to whether symptom clusters should include a minimum of two or three symptoms.

Common symptom clusters include anxiety-depression, nausea-vomiting, and pain-depression-fatigue.

Writing in BMC Medical Research Methodology, Dutch researchers used machine learning to decipher symptom clusters in a cohort of cancer survivors.[] Many of their findings recapitulated those in the literature, including support for a cognitive functioning and psychological distress cluster and depression-anxiety-insomnia cluster in those who tested high for well-being risk.

The researchers found that when compared with moderate-to-high-risk scorers on tests of well-being, high-risk scorers demonstrated more clustering between physical and psychosocial symptoms.

The authors of an article published in Nursing Research assessed symptom clusters in perimenopausal/postmenopausal women with or without metabolic syndrome.[] Their study was based on cross-sectional data from the Study of Women's Health Across the Nation (Visit 5).

They found that symptom clusters differed in light of metabolic-syndrome status. These findings serve as an example of how detailed symptom clusters can be, and highlight various dimensions including psychological, somatic, urinary, genital, sexual, and sleep.

PTSD is another disease in which symptom clusters are prominent.

PTSD is another disease in which symptom clusters are prominent.The three symptom clusters with this illness are avoidance-numbing, re-experience, and hyperarousal.[]

How symptom clusters can help

The Revista da Escola de Enfermagem da USP researchers pointed to the value of using symptom clusters in your assessment of the patient. Simpler interventions for symptom management could focus treatment on the central symptom of a symptom cluster, with the hypothesis being that by treating the central symptom, the others will improve as well.

Alternatively, the clinician could choose to target various symptoms in a symptom cluster, although this approach would be more complex.

The investigators also suggested that cognitive-behavioral therapy or psychoeducational programs could help with the management of symptom clusters.

The BMC authors predicted that once confirmed, data on cancer symptom clusters could yield causal models determining the shared etiology of symptoms, with further characterization by tumor type.

At present, the data can help clinicians recognize the psychosocial aspects of symptom clusters and help their patients with these concerns.

What this means for you

The concept of symptom clusters—two or more symptoms happening concurrently—is popular in nursing literature, but its clinical relevance extends to all clinicians, including physicians. Pragmatic applications of this research include treating the main symptom in a symptom cluster—or ensuring that not only the physical aspects of a symptom cluster are treated, but also the psychiatric issues.

Read Next: Associations between depressive symptom clusters and care utilization and costs among community‐dwelling older adults
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