Individual variation in temporal relationships between stress and functional somatic symptoms

Objective

Medically unexplained or functional somatic symptoms (FSSs) constitute a major health problem because of their high prevalence and the suffering and disability they cause. Psychosocial stress is widely believed to be a precipitating or perpetuating factor, yet there is little empirical evidence to support this notion. Prior studies mainly focused on comparing groups, which has resulted in the obscuring of temporal complexity and individual differences. The aim of this study is to elucidate the relationship between stress and FSSs over time within individual patients.

Methods

Twenty patients (17 females, ages 29–59) with multiple, persistent FSSs were included in the study. They used electronic diaries to report stress and FSSs twice daily over the course of 12 weeks. For each individual data set, Vector autoregressive (VAR) modelling was used to investigate possible associations between daily average stress and FSSs scores.

Results

In six subjects (30%), an increase in stress was followed by an increase in one or more FSSs. In three subjects (15%), an increase in FSSs was followed by an increase in stress. Additionally, negative and mixed associations were found. Only two subjects (10%) showed no cross-lagged association between stress and FSSs in either direction. We did not find specific types of symptoms to be more stress-related than others.

Conclusion

Although stress does not seem to be a universal predictor of FSSs, an increase in stress precedes an increase in symptoms in some individuals. Identifying these individuals using time-series analysis might contribute to a more patient-tailored treatment.     

The role of emotion in psychotherapeutic change for medically unexplained symptoms

Objectives: Evidence of the contribution of emotional processes to the emergence, maintenance, and experience of medically unexplained symptoms (MUS) suggests that clinical approaches which target these processes could be beneficial. In this study, qualitative methods were used to examine patients’ perspectives and subjective experiences of emotional processes in the context of a psychotherapy assessment and treatment service for MUS provided in a hospital emergency department (ED). Methods: Seven semi-structured interviews were conducted with ED patients presenting with MUS who received a course of intensive short-term dynamic psychotherapy treatment. Results: Interpretative phenomenological analysis was employed with three superordinate themes emerging: Barriers to examining emotional processes; reflections on the therapeutic process; psychological change; and improved well-being. Obstacles to clinical engagement in treatment for MUS were described in relation to patients’ and therapists’ ability to identify, address, and utilize emotion processes. Specific elements of this work were identified as integral components of the psychotherapy change process for MUS. Conclusions: Directly observing the physical effects of emotional experiencing in MUS provides sensory evidence that can enable patients to make mind–body connections. Psycho-emotional processes warrant further study to explore the applicability to other conceptual models for assessing and treating MUS.     

A medical record review for functional somatic symptoms in children

Objective

The objectives of this study were to develop and test a systematic medical record review for functional somatic symptoms (FSSs) in paediatric patients and to estimate the inter-rater reliability of paediatricians' recognition of FSSs and their associated impairments while using this method.

Methods

We developed the Medical Record Review for Functional Somatic Symptoms in Children (MRFC) for retrospective medical record review. Described symptoms were categorised as probably, definitely, or not FSSs. FSS-associated impairment was also determined. Three paediatricians performed the MRFC on the medical records of 54 children with a diagnosed, well-defined physical disease and 59 with ‘symptom’ diagnoses. The inter-rater reliabilities of the recognition and associated impairment of FSSs were tested on 20 of these records.

Results

The MRFC allowed identification of subgroups of children with multisymptomatic FSSs, long-term FSSs, and/or impairing FSSs. The FSS inter-rater reliability was good (combined kappa=0.69) but only fair as far as associated impairment was concerned (combined kappa=0.29).

Conclusions

In the hands of skilled paediatricians, the MRFC is a reliable method for identifying paediatric patients with diverse types of FSSs for clinical research. However, additional information is needed for reliable judgement of impairment. The method may also prove useful in clinical practice.     

Is high-sensitive C-reactive protein a biomarker for functional somatic symptoms? A population-based study

Functional somatic symptoms (FSS) are symptoms unexplained in terms of underlying organic pathology. Alterations in the immune system function may be associated with FSS via induction of sickness behavior. We aimed to investigate whether low-grade immune system activation is positively associated with FSS in a population-based cohort of 881 adults (46% male, mean age 53.0, SD 11.4). Participants completed the somatization section of the Composite International Diagnostic Interview surveying the presence of 43 FSS. Innate immune function was assessed by measuring high-sensitive C-reactive protein (hs-CRP). Follow-up measurements of hs-CRP and FSS were performed approximately 2 years later. Regression analyses, with adjustments for gender, age, body mass index, anxiety, depression, smoking, alcohol use, and frequency of exercise, did not reveal a cross-sectional association (β = 0.01, t = 0.40, p = 0.693) or longitudinal association (β = −0.03, t = −0.93, p = 0.352) between hs-CRP and the total number of FSS. When examining different bodily clusters of FSS, hs-CRP was not associated with the gastrointestinal FSS cluster, but the association approached statistical significance for the general FSS cluster (OR 1.08, 95% CI 0.98–1.18) and musculoskeletal FSS cluster (OR 1.08, 95% CI 0.99–1.17). For the latter association, exploratory analyses revealed that mainly the pure musculoskeletal complaints were responsible (OR 1.12, 95% CI 1.03–1.21). We conclude that the level of hs-CRP is not a biomarker for the total number of FSS in the general population. The association between hs-CRP and musculoskeletal and general FSS needs further study.     

Exaggerated perception of normal physiological responses to stress and hypercapnia in young women with numerous functional somatic symptoms

OBJECTIVE: This study tested whether functional somatic symptoms are associated with exaggerated increases in self-reported anxiety and somatic complaints in response to stress and CO(2)-enriched air breathing, and whether this association exists in parallel to or in the absence of exaggerated physiological responses. METHODS: Out of 499 young somatically healthy undergraduate women, 18 participants high in functional somatic symptoms (HSS group) and 18 participants low in symptoms (LSS) were selected. They were submitted to mental stress, mild physical exercise and relaxation during conditions of normal breathing, breathing compressed normal air, and breathing compressed 5% CO(2)-enriched air. In all conditions, self-reported anxiety and somatic symptoms and respiratory and autonomic responses were assessed. RESULTS: HSS participants reported, as compared to LSS, more tenseness, anxiety, and somatic symptoms at baseline and increased responses to mental stress and during 5% CO(2) breathing, but not in response to exercise. However, no evidence was found for a corresponding exaggerated respiratory or autonomic response. CONCLUSIONS: A young, female, and nonclinical population with numerous functional somatic symptoms and high levels of anxiety is characterized by an exaggerated perception of a normal physiological response.     

ERP evidence for selective drop in attentional costs in uncertain environments: challenging a purely premotor account of covert orienting of attention

Several studies have proved that the reliability of endogenous spatial cues linearly modulates the reaction time advantage in the processing of targets at validly cued vs. invalidly cued locations, i.e. the “validity effect”. This would imply that with non-predictive cues, no “validity effect” should be observed. However, contrary to this prediction, one could hypothesize that attentional benefits by valid cuing (i.e. the RT advantage for validly vs. neutrally cued targets) can still be maintained with non-predictive cues, if the brain were endowed with mechanisms allowing the selective reduction in costs of reorienting from invalidly cued locations (i.e. the reduction of the RT disadvantage for invalidly vs. neutrally cued targets). This separated modulation of attentional benefits and costs would be adaptive in uncertain contexts where cues predict at chance level the location of targets. Through the joint recording of manual reaction times and event-related cerebral potentials (ERPs), we have found that this is the case and that relying on non-predictive endogenous cues results in abatement of attentional costs and the difference in the amplitude of the P1 brain responses evoked by invalidly vs. neutrally cued targets. In contrast, the use of non-predictive cues leaves unaffected attentional benefits and the difference in the amplitude of the N1 responses evoked by validly vs. neutrally cued targets. At the individual level, the drop in costs with non-predictive cues was matched with equivalent lateral biases in RTs to neutrally and invalidly cued targets presented in the left and right visual field. During the cue period, the drop in costs with non-predictive cues was preceded by reduction of the Early Directing Attention Negativity (EDAN) on posterior occipital sites and by enhancement of the frontal Anterior Directing Attention Negativity (ADAN) correlated to preparatory voluntary orienting. These findings demonstrate, for the first time, that the segregation of mechanisms regulating attentional benefits and costs helps efficiency of orienting in “uncertain” visual spatial contexts characterized by poor probabilistic association between cues and targets.     

Dysfunction of stress responsive systems as a risk factor for functional somatic syndromes

The etiology of functional somatic syndromes or disorders (FSDs) is generally considered to be a multifactorial interplay between psychological, biological, and social factors. One of the most investigated biological factors is stress responsive system dysfunction. Despite more than twenty years of research of the autonomic nervous system and the hypothalamic-pituitary-adrenal axis, however, it is yet unknown whether dysfunctions in these systems play a causal role in the etiology of FSDs and whether they are generic or FSD-specific. In this review, we will give an overview of available evidence on whether or not alterations in these stress responsive systems can be considered causal risk factors of FSDs. We conclude that although not necessary factors for FSDs in general, lowered cardiac vagal activity and hypocortisolism may be pivotal in the etiology and treatment strategy in subgroups of subjects with a FSD. Such subgroups need to be better identified.     

抑郁症患者的躯体症状

目的:了解抑郁症患者的躯体症状特征。方法:采用自制调查表对符合中国精神障碍分类与诊断标准第3版抑郁发作的119例门诊及住院患者进行调查。根据汉密尔顿抑郁量表(HAMD)评分,将119例患者分为轻度、重度抑郁症两组,比较两组的一般资料及躯体症状。结果:两组的一般资料差异无显著性,而重度抑郁组躯体症状与轻度抑郁组差异显著。结论:抑郁症的躯体症状非常突出,应引起足够重视。     

Methodological issues concerning lifetime medically unexplained and medically explained symptoms of the Composite International Diagnostic Interview: a prospective 11-year follow-up study

OBJECTIVE: The objectives of this study were (a) to elucidate the methodological problems arising when examining lifetime symptom data by exploring the accuracy of recall of medically unexplained symptoms (MUS) and medically explained symptoms (MES) in the general population, based on interviews using the Composite International Diagnostic Interview (CIDI) Somatoform Section C, in 1990 and 2001, and (b) to find predictors for failure at follow-up to recall symptoms reported previously at baseline (i.e., symptoms "lost"). METHODS: Four hundred twenty-one persons (response rate, 69.6%; 242 women and 179 men) were reinterviewed in 2001 from a baseline population of 605. Thirty-eight clinically significant MUS and MES were assessed. Linear multiple regression analyses with the numbers of MUS-lost (medically unexplained symptoms lost to recall) and MES-lost (medically explained symptoms lost to recall) as dependent variables were undertaken to find factors affecting symptom loss. RESULTS: A wide range of individual symptoms (22-100%) were lost to recall at follow-up, indicating a large degree of measurement error, mainly due to faulty recall. The number of symptoms recalled when they were grouped was better (approximately 50% for "1-3" symptoms). Recall variability and MUS/MES transition over time undermined the credibility of this distinction. Gender and age emerged as significant (P<.01) predictors for MUS-lost, and a decrease in physical morbidity for MES-lost. Men tended to forget more symptoms than women, and younger respondents with high levels of baseline MUS remembered slightly better at follow-up. CONCLUSION: Lifetime symptom data elicited in community surveys by such instruments as the CIDI should be viewed with caution. Methodological errors weakening data credibility could lead to false impressions of true change over time. A MUS/MES distinction is difficult to maintain.     

Application of heart rate variability during blood pressure measurement in patients with somatic symptom disorder

ObjectiveThis study wants to test whether the heart rate variability (HRV) analysis using sphygmomanometers can effectively reflect the physical and emotional distress of somatic symptom disorder (SSD) cases and assist in further health management.MethodsThis study includes 66 female SSD cases and 32 male SSD cases. All cases received a 200-second blood pressure (BP) measurement, after which the numerical figure for the heart rate was obtained from the BP signal for HRV analysis. All cases also filled out Patient Health Questionnaire-15 (PHQ-15), Beck Depression Inventory-II (BDI-II), Beck Anxiety Inventory (BAI) to understand the extent of their somatic distress, depression, and anxiety. The relationship between psychological conditions and HRV indicators are examined statistically. Receiver operating characteristic (ROC) curve analysis was used to understand whether HRV indicators can assist in the determination of psychosomatic problems.ResultsConsidering all and female SSD cases, low-frequency power (LF) and PHQ-15 in the HRV index have the most significant correlations. In male SSD cases, root mean square of successive NN interval differences (RMSSD) and BDI-II have the highest correlations. The results of ROC curve analysis indicate that LF is useful to judge the severity of female SSD cases, while RMSSD has reference value in determining whether male patients of SSD cases have depression or not. In addition, physical stress index (PSI) can also help determine the degree of depression in male SSD cases.ConclusionThe use of BP in HRV analysis can help in the monitoring of somatic distress and depression issues in SSD cases. LF, RMSSD, PSI are potential physiological indicators.     

Pain characteristics of older persons with medically unexplained symptoms,older persons with medically explained symptoms and older persons with depression

ABSTRACT

Objectives: The main objective of the current study is to compare chronic pain characteristics of older patients with Medically Unexplained Symptoms (MUS), to those of patients with Medically Explained Symptoms (MES), and to those of patients with Major Depressive Disorder (MDD).

Method: By combining data from the OPUS and NESDO study, we compared pain characteristics of 102 older (>60 years) MUS-patients to 145 older MES-patients and 275 older MDD-patients in a case-control study design. Group differences were analyzed using ANCOVA, adjusted for demographic and physical characteristics. Linear regression was applied to examine the association between pain characteristics and somatization (BSI-53 somatization scale) and health anxiety (Whitely Index).

Results: Older MUS-patients have approximately two times more chance of having chronic pain when compared to older MES-patients (OR = 2.01; p = .013) but equal chances as opposed to MDD-patients. After adjustments, MUS-patients report higher pain intensity and disability scores and more pain locations when compared to MES-patients, but equal values as MDD-patients. Health anxiety and somatization levels were positively associated with the number of pain sites in MUS-patients, but not with pain severity or disability.

Conclusion: Older MUS-patients did not differ from MDD-patients with respect to any of the chronic pain characteristics, but had more intense and disabling pain, and more pain locations when compared to older MES-patients.     

阿立哌唑对伴躯体症状抑郁症的辅助治疗作用

目的：探讨氟伏沙明合并阿立哌唑治疗伴躯体症状抑郁症的疗效及安全性。方法：60例伴躯体症状抑郁症患者随机分为氟伏沙明合并阿立哌唑组（合用组）和氟伏沙明组（单用组）,各30例,疗程8周。采用汉密尔顿抑郁量表（HAMD）,治疗中出现的症状量表（TESS）评定疗效和不良反应。结果：治疗后两组HAMD评分较治疗前均有显著下降（P均〈0.01）,两组比较差异有显著性（P〈0.05）,合用组在治疗1周末评分差异已有显著性（P〈0.01）,单用组在治疗2周末差异才有显著性（P〈0.01）,合用组HAMD因子分在焦虑/躯体化和绝望感方面下降较单用组快。两组TESS评分差异无显著性（P〉0.05）。结论：氟伏沙明合并阿立哌唑治疗伴躯体症状抑郁症疗效较好,且较安全。     

Development of a paradigm for measuring somatic disturbance in clinical populations with medically unexplained symptoms

OBJECTIVE: This study aimed to develop an experimental paradigm, using healthy controls, to measure change in tactile sensitivity and response bias for subsequent testing of patients with medically unexplained symptoms (MUS). METHODS: Participants judged whether or not they detected a weak tactile pulse (presented in 50% of trials). Performance in two conditions (tactile pulses presented with or without a concomitant light) was compared using signal detection analysis to assess whether a task-irrelevant light can invoke the sensation of touch, even in its absence. RESULTS: The results showed that the presence of a concurrent light significantly improved participants' detection of the tactile stimulus by 13.7% [t(18)=4.24, P<.001]. Also, more false alarms (perceiving that the touch was present when it was not) were made when the light was present [t(18)=2.10, P=.05]. Although differences in sensitivity between the light conditions were not significant [t(18)=1.14, P=.268], participants were more likely to report a touch, regardless of whether a touch was presented or not, in the light-present condition [t(18)=-3.84, P=.001]. CONCLUSION: When discriminating weak vibration pulses on the finger from no stimulation, a simultaneous light was capable of creating the sensation of touch, even when it was not present. The findings of this research will be of interest to those studying psychosomatic disorders or MUS, where patients experience physical symptoms without an identifiable organic cause. This paradigm provides an experimental measure of such distortions in perception, which may elucidate underlying mechanisms of action.     

How do neurologists discuss functional symptoms with their patients: a conversation analytic study

Objective

Consultations with patients with functional symptoms can be challenging. This study describes some of the interactional and linguistic resources doctors use when they deliver the diagnosis of a functional disorder and recommend psychological treatment to patients presenting with medically unexplained neurological symptoms.

Methods

Twenty out-patient consultations between three experienced neurologists and patients with non-epileptic seizures (NES, N = 17) or other functional neurological symptoms (FNS, n = 3) were recorded and analysed using Conversation Analysis (CA). Encounters were split into activity sequences (1: history-taking; 2: discussion of examination and test results; 3: diagnosis; 4: aetiology; 5: treatment recommendations). The doctors' formulation effort (FE) in each activity sequence was graded (1: little, 2: some, 3: marked FE).

Results

The doctors' communication behaviour was characterised by FE and accounting activities. FE increased during the course of the encounters and was most marked when doctors discussed the aetiology of symptoms and made psychological treatment recommendations. However, FE was evident even at the beginning of the encounters, and when patients fully aligned with the doctor.

Conclusion

This study provides interactional evidence why doctors may experience these consultations as challenging. While FE and accounting activities were sometimes linked to objective interactional problems (patients' resistance), doctors also seemed to engage in these practices for no clear interactional reasons, suggesting a degree of defensiveness or prior concern about the consultation. The extent of FE and accounting activities may display doctors' interactional distress but may also reflect a degree of delicacy when doctors explain the diagnoses of NES or FNS.     

An international study comparing the effect of medically explained and unexplained somatic symptoms on psychosocial outcome

OBJECTIVE: Cross-sectional studies show an association between somatic symptoms and psychiatric morbidity in primary care. However, medically explained and unexplained symptoms have been considered separately as distinct and unrelated. In addition, data on outcome in primary care are equivocal. We compare the effect of both constructs (medically explained and unexplained symptoms) on psychiatric morbidity and disability (social and physical) at 1 year follow-up. METHOD: Of 5447 patients presenting for primary care in 14 countries, 3201 participants were followed up (72% compliance). We measured physical, psychiatric, and social status using standardised instruments. RESULTS: Patients with five or more somatic symptoms had increased psychosocial morbidity and physical disability at follow-up, even after controlling for confounders such as sociodemographics and recognition or treatment by general practitioners. There was little difference in outcome between medically explained and unexplained symptoms. CONCLUSIONS: Somatic symptoms-irrespective of aetiology-are associated with adverse psychosocial and functional outcome in diverse cultures.