Somatization. Theories and research

The author lists the main theories of somatization and some of the pertinent empirical studies. The studies suggest that there is no single theory that can adequately explain somatization, which is not only multifactorially determined but is an exceedingly complex phenomenon. There is consistent empirical support for some of the theories, such as somatization being a function of depression or of anxiety, and little or inconsistent research support for some other theories, such as its being a symbolic method of communication or an attempt at conflict resolution. The contributions of the various etiological factors differ from one individual to the next, and it requires sometimes lengthy exploration before the extent of the various contributions can be gleaned.

The metabolic neuropeptides of the corpus cardiacum from the potato beetle and the American cockroach are identical

Two neuropeptides with adipokinetic activity in Locusta migratoria and hypertrehalosaemic activity in Periplaneta americana were purified by high performance liquid chromatography from the corpus cardiacum of the Colorado potato beetle, Leptinotarsa decemlineata. The sequences of both peptides, designated Led-CC-I and Led-CC-II, were determined by pulsed-liquid phase sequencing employing Edman degradation after deblocking enzymatically the N-terminal pyroglutamate residue. The C-terminal of both peptides were blocked and neither molecule was cleaved by carboxypeptidase. Both peptides were found to be octapeptides; Led-CC-I has the primary structure pGlu-Val-Asn-Phe-Ser-Pro-Asn-Trp-NH2, and Led-CC-II has the primary sequence pGlu-Leu-Thr-Phe-Thr-Pro-Asn-Trp-NH2. These structures are identical to the two hypertrehalosaemic hormones from the American cockroach. Preliminary experiments show that the synthetic peptides are apparently involved in the control of amino acid metabolism during flight of the potato beetle.

Pep5, a new lantibiotic: structural gene isolation and prepeptide sequence

A wobbled 14-mer oligonucleotide was derived from the amino acid sequence of the 34-residue propeptide of the lantibiotic Pep5 (Kellner et al. 1989). Using this hybridization probe, the structural gene of Pep5, pepA, was located on the 18.6 kbp plasmid pED503. The nucleotide sequence of pepA codes for a prepeptide with 60 residues and proves that Pep5 is ribosomally synthesized. The N-terminus of the prepeptide has a high alpha-helix probability and a characteristic proteolytic cleavage site precedes the C-terminal 34-residue propeptide. Our present theory is that maturation of Pep5 involves (a) enzymic conversion of Thr, Ser and Cys into dehydrated amino acids and sulfide bridges, (b) membrane translocation and cleavage of the modified prepeptide.

Anxiety, depression, and somatization in DSM-III hypochondriasis

To assess the severity of distress and of somatization in hypochondriasis, the authors administered several validated self-rating scales of depression, anxiety, somatic symptoms, and anger/hostility to 21 psychiatric outpatients with the DSM-III diagnosis of hypochondriasis and to matched groups of other nonpsychotic psychiatric patients, family practice patients, and employees. Anxiety and somatic symptoms were highest in hypochondriacal patients; depression and anger/hostility did not differ from those of other psychiatric patients but were higher than in the other groups. The findings do not support the theory that hypochondriasis is a defense against anxiety or that it is a masked depression or depressive equivalent. The findings are consistent with the view that the interaction of severe anxiety and severe somatic symptoms is a common feature of the psychopathology of hypochondriasis.

Structural gene isolation and prepeptide sequence of gallidermin, a new lanthionine containing antibiotic

Peptide antibiotics containing lanthionine and 3-methyllanthionine bridges, named lantibiotics are of increasing interest. A new lantibiotic, gallidermin, has been isolated from Staphyloccus gallinarum. Here we report the isolation of its structural gene which we name gdmA. In all lantibiotics so far studied genetically, three peptides can be formally distinguished: (i) the primary translation product, which we call the prepeptide; (ii) the propeptide lacking the leader sequence and (iii) the mature lantibiotic. Unlike the plasmid-coded epidermin, gdmA is located on the chromosome. The gdmA locus codes for a 52 amino acid residue prepeptide, consisting of an alpha-helical leader sequence of hydrophilic character, which is separated from the C-terminus (propeptide) by a characteristic proteolytic processing site (Pro-2 Arg-1 Ile1). Although pro-gallidermin differs from pro-epidermin (a recently isolated lantibiotic) only by a single amino acid residue exchange. Leu instead of Ile, the N-terminus of the prepeptide differs by an additional two exchanges.

Anxiety and depression in patients with the abdominal pelvic pain syndrome

The authors matched gynecologic patients with the abdominal pelvic pain syndrome (N = 41) with other gynecologic patients. They administered to both groups self-rating scales of anxiety, depression, anger-hostility, and somatization of the Hopkins Symptom Checklist and of the Symptom Questionnaire, a questionnaire about disruptions in early home life, and a questionnaire of recent stressful events. Patients with pain rated themselves on the average significantly more anxious, depressed, and hostile, and had more somatic symptoms than other patients; 56% of the patients with pain rated themselves within the normal ranges on all scales. There were no significant differences between the two groups in reports of disruptions of early home life and recent losses. The findings are consistent with the view that patients with the abdominal pelvic pain syndrome are psychologically a heterogeneous group; in many patients, depression and anxiety may be consequences of persistent pain.

Psychological status of previously infertile couples after a successful pregnancy

Potential long-term effects of psychological dysfunction associated with infertility were investigated in a descriptive study of 32 previously infertile couples. Comparison was made with the performance of 20 never infertile couples matched for age, number of children, education, and income level, using a standard psychological assessment tool, the Hopkins symptom check list. While infertile, women had slightly elevated mean scores on three subscales: depression, interpersonal sensitivity, and hostility. After resolution of infertility, these scores did not improve. In addition, depression scores were elevated among the previously infertile women compared with a matched, never infertile group. Infertile men scored within the normal range for depression and interpersonal sensitivity and had a borderline mean score for hostility, which was markedly reduced after a normal pregnancy.

Gallidermin: a new lanthionine-containing polypeptide antibiotic

Gallidermin is a new member of the class of lanthionine-containing peptide antibiotics, which are summarized under the common name lantibiotics. The lantibiotic gallidermin is produced by Staphylococcus gallinarum (F16/P57) Tü3928, and it exhibits activities against the Propionibacteria, involved in acne disease. Gallidermin differs from the recently discovered tetracyclic 21-residue peptide antibiotic epidermin only in a Leu/Ile exchange in position 6. The isolation procedures for gallidermin included adsorption directly from the culture broth, ion-exchange chromatography of the amphiphilic and basic polypeptide followed by desalting, and final purification by reversed-phase HPLC. The structural elucidation of the polypeptide containing four thioether bridges involved mainly a combination of automated gas-phase sequencing, thermospray liquid chromatography/mass spectrometry and fast-atom-bombardment mass spectrometry.

Prepeptide sequence of epidermin, a ribosomally synthesized antibiotic with four sulphide-rings

The genetic basis for the biosynthesis of large polypeptide antibiotics such as nisin has not been explained so far. We show here that the structural gene epiA encoding the antibiotic epidermin from Staphylococcus epidermidis is located on a 54-kilobase plasmid and codes for a 52-amino-acid prepeptide, which is processed to the tetracyclic 21-peptide amide antibiotic. The mature sequence of epidermin corresponds to the C-terminal 22-peptide segment of pre-epidermin and contains the precursor amino acids Ser, Thr and Cys, from which the unusual amino-acid constituents are derived. The more lipophilic epidermin is cleaved at a hydrophilic turn between Arg-1 and Ile+1 from the N-terminal segment-30 to -1, which probably assumes a partially amphiphilic alpha-helix conformation. We propose that the N-terminus (-30 to -1) plays a cooperative role during modification reactions and prevents toxicity of the mature epidermin to the producing strain before the antibiotic is cleaved off and secreted.

Distress and attitudes in patients perceived as hypochondriacal by medical staff

The aim of this study was to examine the characteristics of patients perceived by general physicians as hypochondriacal. The authors requested physicians at a general hospital to refer patients for a study of hypochondriasis. In order to measure depression, anxiety, and somatic symptoms, the authors administered several rating and self-rating scales, and to measure hypochondriacal attitudes they administered the Illness Attitude Scales (IAS) and the Illness Behavior Questionnaire (IBQ). The referred patients (N = 29) had more psychiatric disorders, were more depressed and more anxious, and had more severe somatic symptoms than matched medical patients who had not been referred. Self-rated hypochondriacal fears and beliefs did not differ significantly between the groups. Five of the referred patients (17%) whose initial diagnosis was hypochondriasis were subsequently found to have physical diseases that accounted for their symptoms. The implications of these findings for treatment are discussed.

Hypochondriacal fears and beliefs in agoraphobia

In order to evaluate hypochondriacal fears and beliefs in agoraphobia, the authors administered the self-rated Illness Attitude Scales to 18 agoraphobic patients. The patients reported hypochondriacal concerns similar to those of patients with hypochondriasis. After agoraphobia had been treated with exposure therapy in ten patients, hypochondriacal concerns did not differ significantly from those of normals. The findings suggest that hypochondriacal concerns are substantial in agoraphobia and that these wane when anxiety decreases.

Prolactin, cortisol, and antidepressant treatment

In four depressed patients with abnormal dexamethasone suppression test results before treatment, plasma prolactin levels significantly increased after successful amitriptyline therapy. Such an increase did not take place in five depressed patients with normal dexamethasone suppression test findings.

Fears and beliefs in patients with the pelvic pain syndrome

In order to explore attitudes and beliefs in patients with the pelvic pain syndrome, the authors matched gynaecological patients with this syndrome (N = 41) with other gynaecological patients. They administered the Illness Behavior Questionnaire and Illness Attitude Scales (that measure attitudes, fears and beliefs about illness) to both groups. In spite of thorough investigations, 18 patients (44%) with the pelvic pain syndrome believed that their physician had not diagnosed their illness correctly and feared that they had a serious disease. The findings appear to have implications for treatment.

The value of self-report assessment in studies of anxiety disorders

This review compares the sensitivities of a physician-rated scale, the Hamilton Anxiety Scale (HAS), and a patient-rated scale, the Hopkins Symptom Checklist (HSCL), in detecting the anti-anxiety effects of benzodiazepines in a large sample of placebo-controlled trials. Scales and subscales were compared within the same study, a methodologic feature unique to this review. The total score, psychic factor, and somatic factor of the HAS were equally sensitive to the effects of benzodiazepines. The total score, anxiety factor, and somatization factor of the HSCL also were equally sensitive. The HAS total score, however, was consistently more sensitive than any of the HSCL scores. There was no evidence that physicians used side effects to make their ratings more sensitive. Sedative side effects, however, adversely affected the sensitivity of patient ratings. The data suggest that patient ratings reflect a cost-benefit computation taking account of both antianxiety and sedative effects.

A symptom questionnaire

The Symptom Questionnaire (SQ) is a yes/no questionnaire with brief and simple items. It contains state scales of depression, anxiety, anger-hostility, and somatic symptoms. It was developed from earlier versions to make the scales more sensitive for clinical research. The scales have been extensively validated. The psychometric properties of the SQ are somewhat different from those of similar scales. In double-blind, crossover studies, they tended to be more sensitive than other scales in discriminating between the effects of a psychotropic drug and placebo and were found to be highly sensitive in discriminating between distress levels of groups. In studies with small or moderately sized samples in which the sensitivity of scales is important or in populations that include subjects with poor verbal skills, the SQ seems to have advantages. The SQ is suitable for the measurement of distress and hostility in research and as a checklist in clinical work.

Hypochondriacal concerns and somatic symptoms in patients with chronic airflow obstruction

In order to explore hypochondriacal concerns in patients with Chronic Airflow Obstruction (CAO) the authors administered the Illness Attitude Scales and the somatization, anxiety, depression and anger-hostility scales of the Hopkins Symptom Checklist to 50 patients with CAO and to matched family practice patients. Somatic symptoms were significantly correlated with fears of disease and hypochondriacal concerns in family practice patients, but were unrelated in CAO. Patients with CAO, although more anxious, depressed and with more severe somatic symptoms than family practice patients, had fewer hypochondriacal concerns. In this respect patients with CAO were unlike any other group previously studied.

Nonpsychotic patients referred to a consultation service

In order to examine characteristics of nondangerous and nonpsychotic patients referred to a consultation service, the authors administered self-rating scales and questionnaires to fifty referred medical patients and nonreferred controls. Recalled abuse in childhood appeared a stronger predictor for referral than some other commonly researched ones such as parental death, divorce or separation in childhood or recent losses. Anxiety, hostility and depression were significantly higher in referred patients, whereas hypochondriacal attitudes did not differ between the two groups. The findings appear to have implications for treatment.

Upper respiratory tract infections increase self-rated hostility and distress

The authors administered a personality inventory, the Eysenck Personality Inventory and a distress scale, the Symptom Questionnaire, to all patients in a walk-in clinic of a general hospital during an influenza epidemic. Hostility, depression, anxiety and somatic symptoms were significantly higher in patients with upper respiratory tract infections (p less than .005); the majority scored in the range of psychiatric patients, regardless of whether patients had clinically classical influenza or merely symptoms and signs of another respiratory tract infection. There were no differences in the personality traits of extraversion or neuroticism between any of the groups, suggesting that hostility and distress were consequences of the viral infections and were largely unaffected by preexisting personality traits.

Nocturnal prolactin and cortisol secretion and recovery from melancholia

Spontaneous prolactin and cortisol patterns were determined at 20 min intervals over 3 hr during the night in eight patients with melancholia, both during illness and after treatment with amitriptyline. Mean plasma prolactin levels were greater after recovery in the seven patients who responded to treatment. Mean cortisol secretion decreased upon recovery from melancholia, and such changes in two patients paralleled normalization of dexamethasone suppression test responses. The influence of assumptions of lack of interaction on the statistical significance of the analysis of variance with repeated measures for prolactin and cortisol values was evaluated.

Fears, beliefs, and attitudes in DSM-III hypochondriasis

In order to explore fears, beliefs, and attitudes of patients with DSM-III hypochondriasis, the authors administered the self-rated Illness Attitude Scales to 21 patients with hypochondriasis, matched family practice patients, nonpatient employees, and nonhypochondriacal psychiatric patients. Hypochondriacal patients reported more fears of and false beliefs about disease; they attended more to bodily sensations, had more fears about death, and distrusted physicians' judgments more, yet sought more medical care than other subjects. They did not take better precautions about their health. The self-report of overt attitudes suggests a characteristic syndrome, consistent with the DSM-III description of hypochondriasis. Two of the subscales of the Illness Attitude Scales yielded characteristic responses in hypochondriasis.