A pathologist's perspective of the somatoform disorders

OBJECTIVE: The object of this study was to revisit the evidence that somatoform disorders should be classified as mental and not physical disorders, as viewed through the eyes of a pathologist rather than a psychiatrist. METHODS: An academic clinical pathologist was asked to review recent widening in the concepts of physical disease and to comment on whether these changes made the criteria for designating somatoform disorders as mental disorders more workable or less workable. RESULTS: The review showed that somatoform disorders share many characteristics with certain types of physical conditions, especially those with multiorgan manifestations and multifactor causes. The criteria used to separate somatoform disorders from physical diseases are now less clear than when this distinction was first proposed. CONCLUSION: Discussions for reviewing the status of the somatoform disorders for DSM-V need input from a wide range of medical disciplines besides psychiatry.     

Medically unexplained physical symptoms: the feasibility of group cognitive-behavioural therapy in primary care

OBJECTIVE: The aim of this study was to estimate the number of patients with medically unexplained physical symptoms (MUPS) that could be eligible for group cognitive-behavioural treatment (CBT) and to assess the acceptability of this treatment. METHODS: For 3 months, all consultations of one general practitioner (GP) were screened for MUPS. Patients with MUPS who were considered eligible for group CBT were interviewed and offered treatment. RESULTS: From January to March 1999, 1084 consultations of 796 patients were screened. The GP classified the symptoms of 104 patients aged 25-79 as unexplained. Of these, 71 patients were not considered to be eligible for treatment, mainly due to a psychological attribution of the symptoms. The research interview was offered to 33 patients, 16 of them declined and 12 were interviewed. Seven out of the 12 eligible patients accepted treatment. CONCLUSION: In primary care, 18% of patients aged 25-79 years was estimated to have MUPS. For only a minority of these patients, group CBT was considered suitable and acceptable.     

Illusory touch and tactile perception in somatoform dissociators

Objective

The psychological mechanisms of somatoform dissociation (i.e., pseudoneurological symptoms) are poorly understood. This study evaluated recent theoretical predictions regarding the role of tactile perception in the development of somatoform dissociative symptoms.

Methods

Eighty nonclinical participants scoring either high or low on the Somatoform Dissociation Questionnaire (SDQ-20) completed the Somatic Signal Detection Task (SSDT), a novel perceptual paradigm designed to simulate the occurrence of somatoform symptoms in the laboratory. Prior to the SSDT, participants completed a memory task designed to produce either minimal or maximal activation of tactile representations in memory.

Results

The high SDQ-20 group exhibited a more liberal response criterion (c) on the SSDT than the low SDQ-20 group after controlling for negative affectivity, somatosensory amplification and depression. This effect was mainly attributable to an increased number of false alarms (i.e., illusory experiences of touch) in the high SDQ-20 group rather than an increased hit rate. General perceptual ability (i.e., tactile sensitivity) was comparable between the two groups. The memory manipulation had no effect on SSDT performance.

Conclusions

Somatoform dissociators appear more likely to experience illusory perceptual events under conditions of sensory ambiguity than nondissociators, despite comparable perceptual abilities more generally. These findings support theories that identify distorted perceptual processing as a feature of somatoform dissociation. The SSDT has potential as a tool for further research in this area.     

Causal symptom attributions in somatoform disorder and chronic pain

Objective

Somatoform disorders (SFD) are defined by symptoms that lack medical explanation. This study examined the type and pattern of patients' causal attributions using a new semistructured interview technique

Methods

The Causal Attributions Interview allows to assess and weigh 15 common explanations of physical symptoms. Attributions given by 79 patients with SFD were compared with those obtained from 187 chronic pain patients.

Results

The test-retest reliabilities of the interview-elicited attributions were satisfactory to good. SFD patients attributed most of their symptoms to mental/emotional problems (46.9%) and somatic disease (41.1%), while the pain sample preferred physical overloading/exhaustion (56.1%), daily hastiness/time pressure (41.7%), somatic disease (39.6%), and weather influence (39.0%). On average, SFD patients chose 2.57 and pain patients 3.86 different attributions for each symptom. These numbers were substantially larger than those of initial spontaneous attributions. Correspondence analysis revealed underlying dimensions with three groups labeled “environmental,” somatic,” and “psychological/stress.” While pure environmental attributions were rare (1.1%), somatic factors were chosen for 28.3% of the symptoms, psychological/stress for 22.1%, and the combination of both for 25.6%. Approximately 10% were attributed in a multicausal sense to all three groups. Depression was found to correlate positively with psychological/stress and negatively with somatic attributions.

Conclusion

The results do not support the perspective that SFDs generally result from poor acknowledgement of emotional factors. SFD and chronic pain showed distinguishable attributional patterns.     

The identification in primary care of patients who have been repeatedly referred to hospital for medically unexplained symptoms: A pilot study

Objectives

The study aimed (a) to test a method of identifying patients who have been repeatedly referred (RR) from primary care to medical outpatient clinics where they have received multiple diagnoses of medically unexplained symptoms (MUS) and (b) to describe the prevalence and characteristics of these patients.

Methods

RR patients with MUS (RRMUS) were arbitrarily defined as those with (a) five or more referrals in a 5-year period and (b) a specialist final diagnosis of MUS for at least three of these referrals. A two-stage method of identifying these patients was piloted in one primary care practice: Stage 1 used computerized health service data to identify RR; Stage 2 used manual case note review to identify referrals that ended with specialist diagnoses of MUS. The RRMUS patients identified were asked to complete a questionnaire, a psychiatric diagnostic interview, and their GPs were asked to rate how “difficult to manage” they were.

Results

The process was feasible and reasonably accurate. From 6770 registered patients aged 18 to 65 years, 23 (0.3%) were identified as RRMUS. They accounted for 157 referrals over the 5-year period. Sixteen agreed to further assessment, and 8 (50%) had a current anxiety or depressive disorder. GPs rated only 8 (50%) as “difficult to manage.”

Conclusion

This two-stage procedure offers a practical method of identifying RRMUS patients in primary care as a first step in achieving more cost-effective care. These patients have substantial psychiatric morbidity.     

Mindfulness-based cognitive therapy (MBCT) for patients with medically unexplained symptoms: Process of change

Background

A recent randomized controlled trial provided preliminary evidence for the effectiveness of mindfulness based cognitive therapy (MBCT) for the top 10% frequent attenders in primary care with persistent medically unexplained symptoms (MUS). This qualitative study aims to explore working mechanisms and possible barriers of MBCT in this population.

Methods

Twelve participants of the trial were interviewed about their experiences. This was done before and after the MBCT course, and 12 months later. Written evaluations of participants and notes of participant observers were used for data-triangulation.

Results

In total, 35 qualitative interviews were conducted. MBCT initiated a process of change, starting with awareness of the present moment, the associated sensory experiences, thoughts and emotions and accepting rather than resisting these. Participants started to recognize their own behavioral patterns and change them, thus improving self-care. Self-compassion seemed to result from and facilitate this process. Main barriers were concurrent social problems and the inability or unwillingness to accept symptoms.

Conclusions

MBCT can start a process of change in patients with persistent MUS. Awareness and acceptance of painful symptoms and emotions are key factors in this process. Change of unhelpful behavioral patterns and increased self-care and self-compassion can result from this process.     

Diagnosing somatisation disorder (P75) in routine general practice using the International Classification of Primary Care

Objective

(i) To analyze general practitioners' diagnosis of somatisation disorder (P75) using the International Classification of Primary Care (ICPC)-2-E in routine general practice. (ii) To validate the distinctiveness of the ICD-10 to ICPC-2 conversion rule which maps ICD-10 dissociative/conversion disorder (F44) as well as half of the somatoform categories (F45.0-2) to P75 and codes the other half of these disorders (F45.3-9), including autonomic organ dysfunctions and pain syndromes, as symptom diagnoses plus a psychosocial code in a multiaxial manner.

Methods

Cross-sectional analysis of routine data from a German research database comprising the electronic patient records of 32 general practitioners from 22 practices. For each P75 patient, control subjects matched for age, gender, and practice were selected from the 2007 yearly contact group (YCG) without a P75 diagnosis using a propensity-score algorithm that resulted in eight controls per P75 patient.

Results

Of the 49,423 patients in the YCG, P75 was diagnosed in 0.6% (302) and F45.3-9 in 1.8% (883) of cases; overall, somatisation syndromes were diagnosed in 2.4% of patients. The P75 coding pattern coincided with typical characteristics of severe, persistent medically unexplained symptoms (MUS). F45.3-9 was found to indicate moderate MUS that otherwise showed little clinical difference from P75. Pain syndromes exhibited an unspecific coding pattern. Mild and moderate MUS were predominantly recorded as symptom diagnoses. Psychosocial codes were rarely documented.

Conclusions

ICPC-2 P75 was mainly diagnosed in cases of severe MUS. Multiaxial coding appears to be too complicated for routine primary care. Instead of splitting P75 and F45.3-9 diagnoses, it is proposed that the whole MUS spectrum should be conceptualized as a continuum model comprising categorizations of uncomplicated (mild) and complicated (moderate and severe) courses. Psychosocial factors require more attention.     

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.     

Causal illness attributions in somatoform disorders: associations with comorbidity and illness behavior

OBJECTIVE: To compare causal illness beliefs between patients with unexplained physical symptoms and different comorbid disorders and to assess the association of causal illness beliefs with illness behavior. METHODS: We examined a sample of 233 patients attending treatment in primary care. Inclusion criteria were "unexplained physical symptoms." All patients were investigated using structured interviews and self-rating scales [Screening for Somatoform Symptoms (SOMS), Beck Depression Inventory (BDI), Beck Anxiety Inventory, and a 12-item instrument to assess causal attributions]. By means of factor analysis, the following illness attributions were considered: vulnerability to infection and environmental factors, psychological factors, organic causes including genetic and aging factors, and distress (including exhaustion and time pressure). RESULTS: Most patients reported multiple illness attributions. The more somatoform symptoms patients had, the more explanations in general they considered. Especially for vulnerability and organic illness beliefs, patients with somatoform symptoms had increased scores. Comorbidity with depression and with anxiety disorders was associated with more psychological attributions. Even when the influence of somatization, depression, and anxiety is controlled for, illness beliefs still showed associations with illness behavior. Organic causal beliefs and vulnerability attributions were associated with a need for medical diagnostic examinations, increased expression of symptoms, increased illness consequences, and bodily scanning. CONCLUSIONS: Multiple causal attributions can coexist demonstrating different associations with comorbid depression and illness behavior.     

医学上不能解释的慢性疼痛主诉患者临床特征和精神病学诊断

目的观察疼痛科医学上不能解释的慢性疼痛主诉(MUP)门诊患者的临床特征,完善其临床诊断。方法对疼痛科门诊87例MUP患者转诊至心理科门诊进行会诊-联络精神病学研究,记录患者相关疾病信息和疼痛科诊断,进行症状自评量表(SCL-90)和综合性医院焦虑抑郁量表(HAD)测查和面谈并作出精神病学诊断。结果MUP患者的躯体形式疼痛主诉以头、面、口腔部(56.3%)、胸部(49.4%)和腰背部(25.3%)为主,疼痛科诊断以不定陈述综合征(33.3%)、慢性头痛综合征(20.7%)、疼痛原因待查(心因性疼痛,29.9%)为主。男、女性MUP患者的疼痛科诊断存在显著性差异(P<0.05)。MUP患者的SCL-90各因子评分均显著高于中国常模(P<0.05)。HAD(d)评分≥8分为66.7%,HAD(a)评分≥8分为49.4%。MUP患者的精神病学诊断高达96.6%。结论 MUP患者焦虑抑郁情绪明显,躯体化症状多,会诊-联络精神病学研究有助于完善其临床诊断。     

米氮平治疗躯体形式障碍的疗效观察

目的观察米氮平治疗躯体形式障碍的疗效及安全性。方法将60例躯体形式障碍患者随机分为两组，每组各30例。分别应用米氮平和阿米替林治疗6周，并采用汉密尔顿抑郁量表（HAND）、汉密尔顿焦虑量表（HAMA）及不良反应量表（TESS），于治疗前及治疗后的第1、2、4、6周评定疗效和不良反应。结果两组治疗前后疗效均有极显著性差异（P〈0．01），但两组间的疗效则无显著性差异（P〉0．05）。从第1周末米氮平组评分即有显著下降，与阿米替林组比较则有显著性差异（P〈0．05），且不良反应明显少于阿米替林组。结论米氮平治疗躯体形式障碍安全、有效，且不良反应少。     

Functional neurological disorders in outpatient practice: An Australian cohort

Functional disorders are defined as neurological symptoms without causative organic pathology identified. They are a diverse and often neglected group of disorders. The aim of this was to determine the incidence and outcome of functional neurological disorders in an Australian neurology practice. Over a 17 month period, all patients presenting to a single outpatient neurology service were evaluated to determine the incidence and outcome of these disorders. A total of 884 patients were assessed and of these, 137 had a final diagnosis of functional neurological illness, equating to an incidence of 15% of all patients seen. Functional disorders were the third most common presentation overall. Patients with functional disorders were younger, more likely to be female and had a higher rate of current psychiatric comorbidity compared to other neurology patients. Sensory symptoms were the most common manifestation (48%) followed by limb weakness (37%) and psychogenic non-epileptic seizures (14%). Outcome information was available for 49% of patients at an average of 3 months follow-up. 45% had some improvement in their symptoms, 43% had static symptoms and 12% had worsening of symptoms. This study confirms the high incidence of functional disorders in outpatient neurology practice. Early improvement was seen in a substantial proportion of patients and is influenced by duration of symptoms.     

舍曲林治疗躯体形式障碍的临床研究

目的 观察舍曲林治疗躯体形式障碍的临床疗效和不良反应.方法 采用开放式临床研究方法,收集60例躯体形式障碍患者,接受可变剂量的舍曲林治疗8周.在治疗前和治疗后第1、2、4、8周末分别采用症状自评量表(SCL-90)躯体化因子和临床总体印象量表(CGI-SI)评定,用不良反应症状量表(TESS)评定并记录药物的不良反应.结果 57例完成8周试验.总有效率为80.7%,显效率49.1%.治疗后SCL-90躯体化因子评分和CGI-SI评分较治疗前明显降低,差异有统计学意义(P<0.01).常见的不良反应为头晕、嗜睡和体质量增加等,程度较轻.结论 舍曲林治疗躯体形式障碍的疗效肯定,不良反应少,安全性依从性好.     

The characteristics of fatigue in an older primary care sample

BACKGROUND: Primary care studies of younger adults have reported fatigue to be common and etiologically heterogeneous with both physical and psychological associations. This has led to considerable debate about whether fatigue may present independently of psychological disorder. Somatic symptoms in older people have been assumed to be almost entirely physical in origin. AIMS: To determine the characteristics of fatigue and its relationship with psychological disorder in older primary care attenders. METHOD: Ambulatory primary care patients aged 60 years and over completed self-report questionnaires and psychiatric interview at baseline and at 12 months. RESULTS: The overall prevalence of fatigue was 27.4% with most, but not all, cases being comorbid with psychological disorder. Psychological disorder (OR, 8.43; 95% CI, 2.98-23.88) was a greater predictor of fatigue than physical illness (OR, 4.74; 95% CI, 1.63-13.85). Neither a tendency for fatigue to evolve into psychological disorder, nor vice versa, was observed longitudinally (overall kappa, 0.68; P<.001). CONCLUSIONS: Fatigue is common in older primary care attenders and is not associated with physical illness alone. Despite the high rate of comorbidity with psychological disorder, independent and longitudinally stable forms of fatigue did present. The overall findings suggest that while fatigue does overlap with psychological phenomena, there may also be distinct forms of fatigue.     

Explaining medically unexplained symptoms: toward a multidimensional, theory-based approach to somatization

In spite of the apparent clinical importance of somatization, the concept does not have a single meaning. The focus of the present article is therefore not on scrutinizing existing diagnostic categories but rather on the different dimensions that relate to somatization and on the relevance of psychological models such as social learning theory, stress coping, illness cognition, and self-regulation models for explaining more carefully the predisposing, precipitating, and perpetuating factors of (different types of) somatization. This combined approach could lead to the definition of more homogeneous and, therefore, clinically more meaningful subgroups of somatization.     

Alexithymia and somatisation: quantitative review of the literature

OBJECTIVE: To present a quantitative review of the empirical literature on somatisation and alexithymia. METHODS: Medline and PsycLIT searches for relevant studies were conducted. Meta-analytical techniques were applied to quantify the strength of the associations that were found. RESULTS: A small to moderate relationship was found between general alexithymia and somatic symptom reporting. The alexithymia dimension measuring difficulty in identifying feelings showed the strongest association with symptom reports. The alexithymia dimension measuring externally oriented thinking was virtually unrelated to somatic symptom reports. Compared to healthy control populations, subjects suffering from a somatoform condition were significantly more alexithymic, with effect sizes ranging from moderate to large. The studies comparing somatoform to medical or psychiatric conditions yielded inconclusive results. CONCLUSIONS: By means of quantitative procedures, an association between general alexithymia and somatic symptom reporting was established. Due to the use of questionnaires that can only check for symptoms, not whether these symptoms are medically explained or not, it is however not possible to draw conclusions on somatisation properly defined. The inconsistent results found when comparing somatoform conditions to medical and psychiatric controls may be attributed to confounding variables. In future studies, these variables should be statistically controlled to establish a more consistent pattern of associations between somatoform conditions and alexithymia. It is, however, equally feasible that this inconsistency reflects the nonspecific character of the association between alexithymia and somatisation. The presence of only one prospective study does not allow to draw conclusions on alexithymia as a predisposing factor for somatisation.     

Prevalence of somatoform disorders in a psychiatric population: an Italian nationwide survey

The survey involved 50 centres comprising both hospital and community psychiatric care services throughout Italy. Overall, 2620 patients were recruited, and of those 2002 (76%) completed the Somatoform Disorders Schedule (SDS), a CIDI-derived interview. The NOS somatoform disorders (SDs) diagnosis appeared to be the most common (60%) (and they showed the highest number of co-morbid diagnoses), followed by pain disorders (8%). The prevalence of undifferentiated somatoform and hypochondriactal disorders was 1.6%: older age groups showed a tendency towards higher rates of the latter. In general, the study found that a significant percentage of patients with SDs are referred to psychiatric services, but mainly because of other psychopathological problems: in fact, somatic complaints are cross-sectionally present in different psychiatric nosological categories. This study also emphasizes some limitations of the current classification of SDs. Received: 9 August 1996 / Accepted: 14 July 1998     

氟西汀与阿米替林治疗躯体形式障碍的对照研究

目的 探讨氟西汀对躯体形式障碍的临床疗效及副反应。方法 采用随机分组的方法，将符合CCMD-3标准的63例躯体形式障碍患者分为氟西汀组(33)例、阿米替林组(30)例，治疗6周，用HAMD和TESS评定两组药的疗效及副反应。结果 氟西汀与阿米替林疗效相当，但在副反应方面差异有显著性，氟西汀副反应轻微。结论 氟西汀治疗躯体形式障碍安全、有效，值得临床应用。     

Validation of the Spanish version of the SCOFF questionnaire for the screening of eating disorders in primary care

OBJECTIVE: To assess the performance of the Spanish version of a new screening tool (the SCOFF) for the detection of eating disorders (EDs) in primary care. METHODS: Design: validation study. The psychiatric interview Schedules for Clinical Assessment in Neuropsychiatry (SCAN) was used as the "gold standard." Blinding was applied to administration of the SCOFF and the clinical interview. Setting: six primary health care centers in Zaragoza and Huesca, Spain. Participants: 203 female patients, between the ages of 15 and 53 years, with a probable diagnosis of ED. Main outcome measure: validity as assessed by sensitivity, specificity, positive predictive value and negative predictive value. In addition, test-retest reliability and the receiver operating characteristics (ROC) curve were calculated. RESULTS: The best threshold point in the Spanish version was 2+ positive answers, the same as that recommended in the original British study. This cutoff point provided 97.7% sensitivity and 94.4% specificity for the detection of EDs in primary care. For each specific ED, sensitivity and specificity with this threshold point were, respectively, the following: bulimia, 97.8% and 94.4%; anorexia, 93.1% and 94.4%; and ED not otherwise specified (EDNOS), 100% and 94.4%. CONCLUSIONS: The Spanish version of the SCOFF questionnaire shows excellent psychometric properties for the early detection of EDs in primary settings.     

The PROSPECTS study: Design of a prospective cohort study on prognosis and perpetuating factors of medically unexplained physical symptoms (MUPS)

Objective

This paper describes the rationale and methodology of the PROSPECTS study, a study which aims to assess the course and prognosis of medically unexplained physical symptoms (MUPS), in terms of symptom severity and physical and social functioning. Additionally, it aims to identify different course types and to determine which factors are associated with these course types. Based on these factors, one or more prediction models will be developed.

Methods

This study is a prospective, multicenter longitudinal cohort study with 1 baseline and 4 follow-up measurements during a 3 year period. 450 MUPS patients (age 18–70 years) will be included, divided over a primary care group, recruited in general practices, and a secondary/tertiary care group, recruited in specialized MUPS care programs.

Main study parameters/endpoints

Primary outcome measures are severity of symptoms and degree of functional impairment. Secondary outcome measures are health care consumption and level of depressive symptoms and anxiety. Potential predictors are based on current theoretical models describing the perpetuation of MUPS and include somatic, psychological and social factors.Latent Class Growth Mixture Modeling will be used to identify distinct course types. Logistic regression analysis will be used to identify risk factors associated with these course types. Finally, one or more multivariate prediction models for the course of MUPS will be developed and tested.

Conclusion

The PROSPECTS study aims to enhance our insight into the course of MUPS, thus contributing to better recognition of future patients at risk for persistent MUPS.