Pharmacological interventions for somatoform disorders in adults

Integrating psychiatry and family medicine in the management of somatic symptom disorders: Diagnosis, collaboration, and communication strategies

Somatic symptom disorders (SSDs) present a complex interplay of physical and psychological factors, necessitating an integrative approach to diagnosis and management. This article explores the collaborative efforts between family medicine and psychiatry in addressing SSDs, emphasizing the importance of a multidisciplinary strategy for comprehensive patient care. Effective diagnosis involves recognizing the significance of both somatic symptoms and the patient's psychological response, with tools like structured clinical interviews and self-report questionnaires playing crucial roles. Management strategies include psychotherapeutic interventions such as cognitive behavioral therapy (CBT), pharmacological treatments, and lifestyle modifications, all tailored to the patient's needs. Communication strategies are vital in validating patients' experiences while addressing underlying psychiatric issues. Techniques such as active listening, biopsychosocial framing, and the teach-back method foster trust and improve treatment adherence. Cultural considerations and the use of interpreters enhance communication with diverse patient populations. Training programs for healthcare providers further improve competency in managing SSDs. This integrative approach aims to enhance patient outcomes by addressing the multifaceted nature of SSDs through collaborative care, effective communication, and comprehensive treatment planning.

Vortioxetine as an alternative treatment for somatic symptom disorder: case report

Somatic symptom disorder (SSD) is characterized by persistent physical symptoms that cause significant distress and functional impairment. Despite the widespread use of serotonin reuptake inhibitors (SRIs) in treating SSD, some patients experience insufficient response, necessitating alternative therapeutic approaches. We report two cases of SSD that demonstrated significant improvement with vortioxetine, a novel antidepressant with multimodal serotonergic receptor activity. In Case 1, an 88-year-old female with throat discomfort and cough experienced an insufficient response to an SRI. After switching to vortioxetine, she achieved significant symptom relief within 10 days, with no relapse observed over the following four months. In Case 2, a 29-year-old female presenting with widespread somatic pain and palpitations, unresponsive to analgesics, achieved symptom resolution within two weeks with the initial use of vortioxetine. The therapeutic effects of vortioxetine were rapid and well-tolerated. These cases highlight the potential of vortioxetine for treating SSD, particularly in cases of insufficient response to SRIs, and suggest a possible overlap between SSD and obsessive-compulsive spectrum disorders through its action on serotonergic pathways.

A cognitive behavioural group treatment for somatic symptom disorder: a pilot study

BACKGROUND

Somatic symptom disorder (SSD) presents challenges to the healthcare system, including frequent medical visits, lack of symptom relief experienced by individuals with this condition, high associated medical costs, and patient dissatisfaction. This study examined the utility of a novel, low-barrier, brief cognitive behavioural therapy (CBT) group intervention for individuals with SSD.

METHODS

Participants were referred by their mental health providers or self-referral. Each participant underwent a telephone screen and in-person psychological and neuropsychological screen. Two cycles of the CBT-based group (n = 30), each consisting of six weekly two-hour sessions, were facilitated at a large outpatient mental healthcare facility in Ontario, Canada. The final sample consisted of 13 individuals of whom 11 completed the treatment. Clinical outcome measures were administered pre-, mid- and post-group, including the Generalized Anxiety Disorder-7, Perceived Stress Scale-4, Pain Self-Efficacy Questionnaire, Pain Disability Index, Revised Illness Perception Questionnaire, and sections of the Patient Health Questionnaire. Six healthcare utilization metrics were collected from electronic medical records at six months pre- and post-group. Paired samples t-tests were used to examine pre- to post-group differences in participants' somatic symptoms, psychological functioning, health, and degree of healthcare utilization.

RESULTS

When comparing pre- and post- group, we observed reductions in the mean scores for somatic symptom severity, depressive symptomatology, anxiety, perceived stress, and perceived disability related to pain. The change in depressive symptomatology yielded a small effect size (d = 0.30). Further, we observed downward trends across participants' pre- to post-group healthcare utilization, with small effect sizes observed for hospital admission (d = 0.36), days admitted to hospital (d = 0.47), and inpatient consults (d = 0.42). Differences between pre- and post-group measures of somatic symptom severity, psychological functioning, health, or healthcare utilization did not reach significance.

CONCLUSIONS

Current findings provide support for the potential effectiveness of an abbreviated CBT group for individuals with SSD in reducing psychiatric symptomatology. Further research is recommended, including randomized control trials, cost-benefit analyses, and comparisons between abbreviated versus longer-duration treatment programs for SSD.

TRIAL REGISTRATION

Not applicable.

The Importance of Early Diagnosis of Somatic Symptom Disorder: A Case Report

A somatic symptom disorder (SSD) diagnosis is made when a person places emphasis on physical symptoms such as pain, exhaustion, or shortness of breath so much that it causes significant suffering and/or functional issues. The individual's thoughts, sentiments, and activities are an overstated reaction to such symptoms. Regardless of whether the physical symptoms are connected to a diagnosable medical condition, the person experiences symptoms and believes they are ill. When a person exhibits symptoms that satisfy the diagnostic standards of an SSD, the disease should be identified. However, due to the disorder's frequent co-occurrence, particularly with anxiety and depressive disorders, support for these concurrent diagnoses should be sought. Cognitive-behavioral therapy, mindfulness-based therapy, and medication are all examples of effective treatments for SSD. It has been demonstrated that tricyclic antidepressants or selective serotonin reuptake inhibitors (SSRIs) aid in treating symptoms. The authors describe the case of an eight-year-old boy with complaints of abdominal pain that were unexplained by various tests. The pain lasted 10 years and was episodic (each episode lasted around 10 days; one particular episode lasted approximately six months). Multiple investigations were conducted, but no physiological reason for his symptoms was discovered. His evaluation was conducted by an interdisciplinary team that included neurologists, psychiatrists, surgeons, and doctors. The underlying cause was subsequently determined to be SSD. As people with SSD present to general practitioners and the emergency room rather than psychiatric facilities, this incident serves as a sobering reminder of the need to advocate for an accurate diagnosis of this condition.

The Amplification of Symptoms in the Medically Ill

The mechanism of symptom amplification, developed in the study of somatization, may be helpful in caring for patients with symptoms that, while they have a demonstrable medical basis, are nonetheless disproportionately severe and distressing. Amplified medical symptoms are marked by disproportionate physical suffering, unduly negative thoughts and concerns about them, and elevated levels of health-related anxiety. They are accompanied by extensive and sustained illness behaviors, disproportionate difficulty compartmentalizing them and circumscribing their impact, and consequent problems and dissatisfaction with their medical care. A distinction has long been made between "medically explained" and "medically unexplained" symptoms. However, a more comprehensive view of symptom phenomenology undermines this distinction and places all symptoms along a smooth continuum regardless of cause: Recent findings in cognitive neuroscience suggest that all symptoms-regardless of origin-are processed through convergent pathways. The complete conscious experience of both medically "explained" and "unexplained" symptoms is an amalgam of a viscerosomatic sensation fused with its ascribed salience and the patient's ideas, expectations, and concerns about the sensation. This emerging empirical evidence furnishes a basis for viewing persistent, disproportionately distressing symptoms of demonstrable disease along a continuum with medically unexplained symptoms. Thus, therapeutic modalities developed for somatization and medically unexplained symptoms can be helpful in the care of seriously ill medical patients with amplified symptoms. These interventions include educational groups for coping with chronic illness, cognitive therapies for dysfunctional thoughts, behavioral strategies for maladaptive illness behaviors, psychotherapy for associated emotional distress, and consultation with mental health professionals to assist the primary care physician with difficulties in medical management.

Diagnosis and Management of Functional Tic-Like Phenomena

Over the past 3 years, a global phenomenon has emerged characterized by the sudden onset and frequently rapid escalation of tics and tic-like movements and phonations. These symptoms have occurred not only in youth known to have tics or Tourette syndrome (TS), but also, and more notably, in youth with no prior history of tics. The Tourette Association of America (TAA) convened an international, multidisciplinary working group to better understand this apparent presentation of functional neurological disorder (FND) and its relationship to TS. Here, we review and summarize the literature relevant to distinguish the two, with recommendations to clinicians for diagnosis and management. Finally, we highlight areas for future emphasis and research.

Management of Somatization in COVID-19: A Narrative Review

Somatization refers to the condition in which psychological distress is shown in the form of somatic symptoms such as persistent headache, nausea, gastrointestinal discomfort, etc. Various predisposing factors, including familial such as high expressed emotion, poor parental care, genetic, biological, and demographic which includes age and gender, cognitive such as learning disabilities, psychiatric such as depression, anxiety, post-traumatic stress disorder, social, etc., play an essential role in saturation of the disease. During the time of the COVID-19 pandemic, psychological distress increased in the patients infected with the coronavirus due to some the factors such as social distancing from loved ones, lack of physical exercise, loss of income, loneliness due to quarantine, etc. Therefore, management and treatment of the disorder became essential, especially in coronavirus-infected patients, as it may lead to an increase in complications of the disease. Many studies have been conducted to identify the proper way to manage the condition. Treatments include pharmacological therapy and psychosocial interventions. Pharmacological therapy includes using various antidepressants, hypnotics, and sedatives such as benzodiazepines. For the treatment, mirtazapine is a secure and reliable antidepressant. Another drug, trizolobenzodiazepine adinazolam, was also very useful in treating patients. In some randomized experiments, alprazolam significantly outperformed amitryptiline in reducing the symptoms. Psychosocial interventions include sessions such as cognitive behavioral therapy (CBT), mindfulness-based cognitive therapy, relaxation training, meditation, and psychological interventions such as enhancing multidimensional social help, modifying cognitive assessment, directing positive coping, and inspiring positive emotions.

The Effectiveness of Add-on Treatment with Nutraceutical

Aim:evaluation of the effectiveness of the nutraceutical “Standard Zdorovia: Gastro” (“SZ Gastro”) in the treatment of patients with irritable bowel syndrome (IBS).

Materials and methods.52 patients (62 % women) diagnosed with IBS and IBS in combination with functional dyspepsia (FD) were included in the study and divided into two groups. Both groups received basic therapy according to the guidelines. The experimental group received as add-on the nutraceutical “SZ Gastro” (containing a standardized amount of menthol, gingerol and D-limonene); patients in the control group — placebo. The duration of the study was 30 days. The severity of somatic symptoms was assessed with the 7×7 questionnaire. Emotional state was assessed with the Four Dimensional Distress, Depression, Anxiety, and Somatization Questionnaire (4DSQ).

Results.Patients of the experimental and control groups did not differ from each other either in terms of demographics, basic treatment, or in the severity of symptoms at the beginning of the study.

The effectiveness of the treatment in the patients, who received add-on “SZ Gastro” was significantly higher than in the patients of the control group: in the control group the percentage of improvement of somatic symptoms was 22.35 %, in the experimental group it amounted to 49.18 % (χ2= 15.9;p= 0.0001). The percentage of patients with significant decrease of emotional disturbances was also higher in the experimental group: distress (χ2= 18.7;p= 0.0000), anxiety (χ2= 6.9;p= 0.0097) and somatization (χ2= 14.99;p= 0.0001). No significant side effects were registered in any of the groups.

Conclusions.Add-on of nutraceutical “SZ Gastro” to basic treatment is safe and significantly increases effectiveness of the therapy in the patients with IBS and IBS in combination with PD.

Diagnosis and Initial Treatment of Functional Movement Disorders in Children

Functional movement disorders (FMD) are complex neurobehavioral disorders that can be a significant source of disability for both children and their caregivers. While FMD in the adult population is better characterized, the aim of this paper is to review the pertinent clinical and historical features, diagnostic criteria, and multi-disciplinary management of FMD in the pediatric population. We highlight recent trends in pediatric FMD, including the increase in functional tic-like behaviors that has been observed during the COVID-19 pandemic.

Perceived working mechanisms of psychosomatic therapy in patients with persistent somatic symptoms in primary care: a qualitative study

OBJECTIVES

To explore the perceived working mechanisms of psychosomatic therapy according to patients with persistent somatic symptoms (PSS) and their psychosomatic therapists.

DESIGN

Qualitative study using semistructured face-to-face interviews and focus groups. All interviews were audiorecorded, transcribed verbatim and analysed, by two researchers independently, based on the thematic analysis.

SETTING

Alongside a randomised controlled trial to establish the (cost-)effectiveness of psychosomatic therapy in patients with PSS in primary care, we conducted a process evaluation with a qualitative study. Patients were recruited in general practice in three regions in the Netherlands.

PARTICIPANTS

Interviews were conducted with twenty patients with PSS who received psychosomatic therapy and 25 psychosomatic therapists. In addition, two focus groups were conducted with six and seven psychosomatic therapists, respectively.

INTERVENTION

Psychosomatic therapy, delivered by specialised exercise and physical therapists, is a multimodal and tailored treatment based on the biopsychosocial model.

OUTCOME MEASURES

Experiences, opinions and views from patients' and therapists' perspective on psychosomatic therapy were identified.

RESULTS

A total of 37 interviews with patients, 25 interviews and two focus groups with therapists were analysed. Three main themes emerged from the data of the patients: (1) continuous alternation of psychosocial conversations and body-oriented exercises; (2) awareness of body-mind connection and (3) good relationship with therapist. Four main themes emerged from the data of the therapists (1) building rapport; (2) continuously searching for common ground; (3) making patients aware of the interaction between body and mind; and (4) continuous alternation between exploration and treatment.

CONCLUSION

According to patients as well as therapists, the continuous alternation of psychosocial conversations and body-oriented exercises to provide awareness of the interaction between body and mind are the perceived working mechanism of psychosomatic therapy. Therapeutic alliance and finding common ground between patient and therapist are prerequisites for the success of psychosomatic therapy.

TRIAL REGISTRATION NUMBER

NL7157 (NTR7356).

Epidemiological Features and Clinical Manifestations of Patients With Somatoform Disorder at a Tertiary Medical City in Riyadh, Saudi Arabia

Background Somatoform disorder (SD), known as the presence of physical symptoms suggesting a physical condition, for which there are no demonstrable organic findings or established physiological mechanisms with positive evidence that the symptoms are related to psychological causes. The aim of this study was to highlight the epidemiological characteristics, demographic features, comorbidities, and clinical presentations of patients with SD. Materials and methods This was a retrospective study of SD patients at King Abdulaziz Medical City in Riyadh, Saudi Arabia. We reviewed the patients' electronic health records from January 2015 to December 2020 for collecting the patients' demographic information, including gender, age, marital status, and occupation. The types of SD, presenting symptoms of each disorder, department to which patients initially presented, comorbidities, and management were also documented. The diagnosis of SD was based on the International Classification of Diseases, Tenth Revision (ICD-10). Results In total, 89 patients were included in the study. The majority (n=50, 56.2%) were female, with a mean age of 42.7±17.1 years. More than half of the sample was married (n=54, 60.7%). The most common subtype of SD was somatization disorder followed by conversion disorder, pain disorder, and hypochondriasis, diagnosed in 69 (77.5%), 12 (13.5%), 5 (5.6%), and three (3.4%) patients, respectively. Neurological symptoms and pain were the most frequent presenting symptoms for all the somatoform patients. More than half of the sample (n=48, 53.9%) initially presented at an outpatient clinic. Conclusions The number of SD patients was less than expected, and a third did not receive any treatment. This emphasizes the need for more SD awareness among clinicians in various medical specialties. Appropriate SD and other mental disorders education for physicians may support achieving a better identification of SD and subsequently an improved quality of life for the patients.

The randomized clinical trial results of the anxiety treatment in patients with somatoform dysfunction and neurotic disorders

The existing treatments for somatoform dysfunction (SfD), reaction to severe stress (RSS), and adjustment disorders (AjD) are insufficiently effective and safe. Anxiolytic drug Tenoten proved effective in clinical trials (CT). The aim of this multicenter double-blind placebo-controlled randomized CT was to investigate the safety and efficacy of Tenoten in the treatment of anxiety in adults with SfD, RSS, AjD and other neurotic disorders (oNDs). 390 adult patients with SfD, RSS and AjD or oNDs with the Hospital Anxiety and Depression scale-anxiety (HADS-A) score ≥ 11 were randomized into 4 groups (n = 127 in Tenoten group 1 (4 tablets/day); n = 131 in Tenoten group 3 (8 tablets/day), n = 132 in combined Placebo group 2 + 4). The changes from baseline in the mean Hamilton Anxiety Rating Scale (HAM-A) score in groups 1 and 3 after 12 weeks were the primary outcome. The decrease of the HAM-A score from 18.81 ± 5.81 to 7.26 ± 4.63 (in group 1) and from 18.38 ± 4.3 to 6.40 ± 4.02 (in group 3) was observed post-treatment (p_{group 1/placebo} = 0.0055, p_{group 3/placebo} < 0.0001). Overall, 46 adverse events (28 in the Tenoten groups and 18 in the Placebo) were reported without any difference between the study groups. Tenoten performed significantly more effective than placebo in the anxiety treatment of adults with SfD, RSS, AjD and oNDs (clinicaltrials.gov NCT03036293).

The effects of music listening on somatic symptoms and stress markers in the everyday life of women with somatic complaints and depression

Despite a growing body of literature documenting the health-beneficial effects of music, empirical research on the effects of music listening in individuals with psychosomatic disorders is scarce. Using an ambulatory assessment design, we tested whether music listening predicts changes in somatic symptoms, subjective, and biological stress levels, and examined potential mediating processes, in the everyday life of 58 women (M = 27.7 years) with somatic symptom disorder (SSD) and depressive disorders (DEP). Multilevel models revealed that music listening predicted lower subjective stress ratings (p ≤ 0.02) irrespective of mental health condition, which, in turn, predicted lower somatic symptoms (p ≤ 0.03). Moreover, specific music characteristics modulated somatic symptoms (p = 0.01) and autonomic activity (p = 0.03). These findings suggest that music listening might mitigate somatic symptoms predominantly via a reduction in subjective stress in women with SSD and DEP and further inform the development of targeted music interventions applicable in everyday life.

Somatic Symptoms and Sleep Disorders: A Literature Review of Their Relationship, Comorbidities and Treatment

This study aimed to investigate the relationship between somatic symptom disorder (SSD) and sleep disorders, following three research questions: (1) How are these disorders correlated? (2) What are the comorbidities reported in these patients? and (3) What are the most effective pharmacological and non-pharmacological treatments for both conditions? PubMed, Scopus, OVID, Medline, and ProQuest databases were searched for relevant articles published between 1957–2020. Search terms included “somatic symptoms disorder”, “sleep disorders”, “insomnia”, “somatoform”, “somatization”, “therapeutic”, “psychotherapy”, and alternative, formerly used terms for SSD. Forty papers were finally included in the study. Prevalence of insomnia in SSD patients ranged between 20.4–48%, with this being strongly correlated to somatic symptoms and psychosocial disability. The most relevant comorbidities were generalized anxiety disorder, depression, fatigue, negative mood, substance use, orthorexia, alexithymia, anorexia, weight loss, poor eating habits, and acute stress disorder. Patients receiving antidepressant therapy reported significant improvements in insomnia and somatic symptoms. In terms of non-pharmacological interventions, cognitive-behavioral therapy (CBT) showed improvements in sleep outcomes, while the Specialized Treatment for Severe Bodily Distress Syndromes (STreSS) may represent an additional promising option. Future research could include other medical and psychosocial variables to complete the picture of the relationship between sleep disorders and somatic symptoms.

Fatigue as the Chief Complaint – Epidemiology, Causes, Diagnosis, and Treatment

BACKGROUND

Fatigue is a main or secondary reason for 10-20% of all consultations with a primary care physician.

METHODS

This review is based on pertinent publications retrieved by a comprehensive, selective literature search on the epidemiology, etiology, and diagnostic evaluation of fatigue as a leading symptom of disease, as well as on the treatment of its common causes. Information was also included from the literature search we conducted for the German clinical practice guideline on fatigue that was issued by the German College of General Practitioners and Family Physicians (Deutsche Gesellschaft für Allgemeinmedizin und Familienmedizin, DEGAM).

RESULTS

Fatigue can be due to any of a broad spectrum of diseases, including decompensation of already known conditions. Sleep disorders and sleep-related disorders of breathing, depression (18.5%), and excessive psychosocial stress are the most common causes of persistent fatigue. Previously undiagnosed cancer is a rare cause, accounting for only 0.6% of cases (95% confidence interval [0.3; 1.3]). Anemia and other organic causes are rare as well (4.3% [2.7; 6.7]). Investigations beyond the history, physical examination, and simple laboratory tests are needed only in the presence of additional symptoms or findings. If the diagnosis remains unclear, watchful waiting and regularly scheduled follow-up help prevent an excessive focus on somatic causes, leading to overdiagnosis. Irrespective of specific causes, psychoeducative and psychotherapeutic approaches should be discussed with the patient, as well as an individually adapted exercise program.

CONCLUSION

The work-up of fatigue as a chief complaint should be guided by investigating common and/or potentially dangerous disorders. Since the latter are rare, an exclusively somatic focus should be avoided in order to prevent overdiagnosis.

Making sense of symptoms, clinicians and systems: a qualitative evaluation of a facilitated support group for patients with medically unexplained symptoms

Objectives

Health services to date have inadequately addressed the physical and mental health needs of patients with medically unexplained symptoms. This qualitative study evaluates a piloted facilitated support group (FSG) developed for patients with medically unexplained symptoms to inform recommendations and resources for this patient population.

Methods

Using a qualitative descriptive design, we conducted and thematically analyzed semi-structured interviews with participants (n = 8) and facilitators (n = 4) to explore their experiences of the facilitated support group. Common themes that captured strengths and challenges of the facilitated support group were identified.

Results

The following key themes were identified through analysis of the data: Participants described 1) feeling validated through sharing similar experiences with peers; 2) learning practical symptom management and coping strategies; and 3) gaining new perspectives for navigating conversations with PCPs.

Conclusions

Our findings show that a facilitated support group may provide additional forms of support and resources for patients with medically unexplained symptoms, filling a gap in currently available clinical care offered by health care professionals. Potential implications: This paper highlights lessons learned that can inform the design and delivery of future supports and resources directed toward optimizing patient care for this underserved patient population. Our findings are relevant to those who are involved in direct patient care or involved in designing and implementing self-management programs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01495-9.

Cognitive-behavioural therapy compared with standardised medical care for adults with dissociative non-epileptic seizures: the CODES RCT

BACKGROUND

Dissociative (non-epileptic) seizures are potentially treatable by psychotherapeutic interventions; however, the evidence for this is limited.

OBJECTIVES

To evaluate the clinical effectiveness and cost-effectiveness of dissociative seizure-specific cognitive-behavioural therapy for adults with dissociative seizures.

DESIGN

This was a pragmatic, multicentre, parallel-arm, mixed-methods randomised controlled trial.

SETTING

This took place in 27 UK-based neurology/epilepsy services, 17 liaison psychiatry/neuropsychiatry services and 18 cognitive-behavioural therapy services.

PARTICIPANTS

Adults with dissociative seizures in the previous 8 weeks and no epileptic seizures in the previous year and meeting other eligibility criteria were recruited to a screening phase from neurology/epilepsy services between October 2014 and February 2017. After psychiatric assessment around 3 months later, eligible and interested participants were randomised between January 2015 and May 2017.

INTERVENTIONS

Standardised medical care consisted of input from neurologists and psychiatrists who were given guidance regarding diagnosis delivery and management; they provided patients with information booklets. The intervention consisted of 12 dissociative seizure-specific cognitive-behavioural therapy 1-hour sessions (plus one booster session) that were delivered by trained therapists, in addition to standardised medical care.

MAIN OUTCOME MEASURES

The primary outcome was monthly seizure frequency at 12 months post randomisation. The secondary outcomes were aspects of seizure occurrence, quality of life, mood, anxiety, distress, symptoms, psychosocial functioning, clinical global change, satisfaction with treatment, quality-adjusted life-years, costs and cost-effectiveness.

RESULTS

In total, 698 patients were screened and 368 were randomised (standardised medical care alone, n = 182; and cognitive-behavioural therapy plus standardised medical care, n = 186). Primary outcome data were obtained for 85% of participants. An intention-to-treat analysis with multivariate imputation by chained equations revealed no significant between-group difference in dissociative seizure frequency at 12 months [standardised medical care: median of seven dissociative seizures (interquartile range 1-35 dissociative seizures); cognitive-behavioural therapy and standardised medical care: median of four dissociative seizures (interquartile range 0-20 dissociative seizures); incidence rate ratio 0.78, 95% confidence interval 0.56 to 1.09; p = 0.144]. Of the 16 secondary outcomes analysed, nine were significantly better in the arm receiving cognitive-behavioural therapy at a p-value < 0.05, including the following at a p-value ≤ 0.001: the longest dissociative seizure-free period in months 7-12 inclusive post randomisation (incidence rate ratio 1.64, 95% confidence interval 1.22 to 2.20; p = 0.001); better psychosocial functioning (Work and Social Adjustment Scale, standardised treatment effect -0.39, 95% confidence interval -0.61 to -0.18; p < 0.001); greater self-rated and clinician-rated clinical improvement (self-rated: standardised treatment effect 0.39, 95% confidence interval 0.16 to 0.62; p = 0.001; clinician rated: standardised treatment effect 0.37, 95% confidence interval 0.17 to 0.57; p < 0.001); and satisfaction with treatment (standardised treatment effect 0.50, 95% confidence interval 0.27 to 0.73; p < 0.001). Rates of adverse events were similar across arms. Cognitive-behavioural therapy plus standardised medical care produced 0.0152 more quality-adjusted life-years (95% confidence interval -0.0106 to 0.0392 quality-adjusted life-years) than standardised medical care alone. The incremental cost-effectiveness ratio (cost per quality-adjusted life-year) for cognitive-behavioural therapy plus standardised medical care versus standardised medical care alone based on the EuroQol-5 Dimensions, five-level version, and imputed data was £120,658. In sensitivity analyses, incremental cost-effectiveness ratios ranged between £85,724 and £206,067. Qualitative and quantitative process evaluations highlighted useful study components, the importance of clinical experience in treating patients with dissociative seizures and potential benefits of our multidisciplinary care pathway.

LIMITATIONS

Unlike outcome assessors, participants and clinicians were not blinded to the interventions.

CONCLUSIONS

There was no significant additional benefit of dissociative seizure-specific cognitive-behavioural therapy in reducing dissociative seizure frequency, and cost-effectiveness over standardised medical care was low. However, this large, adequately powered, multicentre randomised controlled trial highlights benefits of adjunctive dissociative seizure-specific cognitive-behavioural therapy for several clinical outcomes, with no evidence of greater harm from dissociative seizure-specific cognitive-behavioural therapy.

FUTURE WORK

Examination of moderators and mediators of outcome.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN05681227 and ClinicalTrials.gov NCT02325544.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 43. See the NIHR Journals Library website for further project information.

Diagnostic and treatment barriers to persistent somatic symptoms in primary care - representative survey with physicians

Background

Many patients consult their primary care physician with persistent somatic symptoms such as pain or sickness. Quite often these consultations and further diagnostic measures yield no medical explanation for the symptoms – patients and physicians are left in uncertainty. In fact, diagnostic and treatment barriers in primary care hinder timely health-care provision for patients suffering from persistent somatic symptoms (PSS). The significance of individual barriers is still unknown. We compare and quantify these barriers from the perspective of primary care physicians and identify subpopulations of primary care physicians who experience particular barriers as most severe.

Methods

We mailed a questionnaire to primary care physicians (PCP) in Germany and asked them which barriers they consider most important. We invited a random sample of 12,004 primary care physicians in eight federal states in Germany. Physicians provided anonymous mailed or online responses. We also mailed a postcard to announce the survey and a mail reminder. Main measures were Likert rating scales of items relating to barriers in the diagnosis and treatment of PSS in primary care. Information on demography and medical practice were also collected.

Results

We analyzed 1719 data sets from 1829 respondents. PCPs showed strongest agreement with statements regarding (1.) their lack of knowledge about treatment guidelines, (2.) their perceptions that patients with PSS would expect symptom relief, (3.) their concern to overlook physical disease in these patients, and (4.) their usage of psychotropic drugs with these patients. More experienced PCPs were better able to cope with the possibility of overlooking physical disease than those less experienced.

Conclusions

The PCPs in our survey answered that the obligation to rule out severe physical disease and the demand to relieve patients from symptoms belong to the most severe barriers for adequate treatment and diagnosis. Moreover, many physicians admitted to not knowing the appropriate treatment guidelines for these patients. Based on our results, raising awareness of guidelines and improving knowledge about the management of persistent somatic symptoms appear to be promising approaches for overcoming the barriers to diagnosis and treatment of persistent somatic symptoms in primary care.

Trial registration

German Clinical Trials Register (Deutschen Register Klinischer Studien, DRKS)

https://www.drks.de/drks_web/setLocale_EN.do

The date the study was registered: October 2^nd 2017

The date the first participant was enrolled: February 9^th 2018

DRKS-ID: DRKS00012942

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01397-w.

How to recognize and manage psychosomatic pain in the pediatric emergency department

Aim

Children and adolescents affected by somatization and somatic symptom disorder commonly refer to emergency services. Due to the absence of specific guidelines for the emergency setting and to a possible lack of knowledge, these patients are at risk of being unrecognized and mismanaged. This study aims at proposing a clinical practice to approach and manage these patients and their families in the emergency setting.

Methods

This manuscript derived from the work of a research group of italian pediatric emergency physicians and anesthesiologists, with an expertise in pain management, members of the PIPER group. The research group reviewed the literature about psychosomatic pain and somatic symptom disorder and developed a clinical practice specific for the pediatric emergency setting.

Results

The manuscript provides information about the main clinical features shared by patients with psychosomatic pain and about current diagnostic criteria and appropriate management in the emergency setting. Furthermore, it highlights the possible pitfalls in which the emergency physician may run into dealing with these patients.

Conclusion

This clinical practice should be seen as a starting point toward a better understanding of patients with psychosomatic pain and a standardization of care in the pediatric emergency setting.

Helpful explanatory models for somatoform symptoms (HERMES): study protocol of a randomised mixed-methods pilot trial

INTRODUCTION

Persistent somatic symptoms (PSS) are common both in the general population and primary care. They are bothersome in terms of psychological and somatic symptom burden. Health professionals often struggle with communication, as there is a lack of scientifically supported explanatory models for PSS or a focus merely on somatic aspects of the complaints, which both frustrate patients' needs. The objective of the present study is therefore to develop a psychoeducational intervention based on a current evidence-based explanatory model, to examine its feasibility and form the basis for a large-scale randomised controlled trial.

METHODS AND ANALYSIS

In a randomised controlled mixed-methods pilot trial, 75 adult psychosomatic outpatients with PSS (duration of symptoms ≥6 months) and accompanying psychological (Somatic Symptom B-Criteria Scale total score ≥18) and somatic symptom burden (Patient Health Questionnaire-15 score >10) and no prior psychosomatic treatment will be eligible. Participants will be presented with either the explanatory model without (intervention group 1, n=25) or with elements of personalisation (intervention group 2, n=25). Participants in the control group (n=25) will receive information on current PSS guidelines. Participants will be blinded to group assignment and interventions will be shown on tablet computers at the outpatient clinic. After 1 month, qualitative follow-up telephone interviews will be conducted. As primary outcomes, mean changes in psychological and somatic symptom burden will quantitatively be compared between groups, respectively. Behavioural change mechanisms and feasibility of the three interventions will be evaluated using quantitative and qualitative measures.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the medical ethics board of the Hamburg Medical Chamber (PV5653). Results from this study will be published in peer-reviewed journals and presented at national and international conferences.

TRIAL REGISTRATION NUMBER

DRKS00018803.

Improvement of functional neurological disorder after administration of esketamine nasal spray: a case report

Functional neurological disorder (FND) is a complex neuropsychiatric condition characterized by the presence of neurological symptoms and signs (either motor or sensory) that cannot be explained by any known medical or mental disease. It is frequently presented with psychiatric comorbidities, such as major depression. Its prognosis is poor, with low improvement or recovery rates at 1 year after their onset, and no particular treatment has demonstrated significant efficacy in this regard. Here, we describe the management of a patient affected by treatment-resistant depression (TRD) and FND characterized by mixed paralysis (sensory and motor) in the left arm, and who was successfully treated with esketamine nasal spray, achieving remission in both disorders. The US Food and Drug Administration and the European Medicines Agency recently approved esketamine, the S-enantiomer of ketamine, for treatment of TRD. It is a fast-acting drug that provides a rapid-onset improvement of depressive symptoms. We have presented the first case, to our knowledge, of functional neurological symptoms being successfully treated with esketamine in a patient with comorbid TRD. While the novelty of this data implies a clear need for further research, it is suggested that esketamine might be a useful tool for the treatment of FND, acting through different theorized mechanisms that are in tune with recent advances in knowledge of the etiopathology of FND.

Psychogenic Pseudosyncope: Clinical Features, Diagnosis and Management

Psychogenic Pseudosyncope (PPS) is the appearance of Transient Loss of Consciousness (TLOC) in which movements are absent, but there are no hemodynamic and electroencephalographic modifications as are induced by gravitational challenges which characterize syncope and true loss of consciousness. For younger and adult populations, a detailed history is crucial for the diagnosis. Clinical clues that should raise the suspicion for PPS include prolonged duration of the LOC, eye closure during the episode, unusual triggers, no recognizable prodromes and the high frequency of attacks. The presence of an established diagnosis of syncope should not deter from the concomitant diagnosis of PPS. The gold standard for a proper diagnosis of PPS is the documentation by a tilt test of normal hemodynamic and electroencephalographic parameters, when recorded during an attack. Treatment of PPS, based on the clear and empathetic communication of the diagnosis, can lead to an immediate reduction of attack frequency and lower the need to call on emergency services. Pharmacological treatment of associated psychiatric disorders and psychological interventions may be beneficial in patients with PPS. Cognitive-behavioural therapy holds the most reliable evidence of efficacy. In the present review, we aimed to address PPS with historical aspects, main clinical features and diagnostic tests, current diagnostic classification, underlying neurobiological abnormalities, management and therapy.

Clinical Correlates of Functional Motor Disorders: An Italian Multicenter Study

Background

Functional motor disorders (FMDs) are abnormal movements that are significantly altered by distractive maneuvers and are incongruent with movement disorders seen in typical neurological diseases.

Objective

The objectives of this article are to (1) describe the clinical manifestations of FMDs, including nonmotor symptoms and occurrence of other functional neurological disorders (FND); and (2) to report the frequency of isolated and combined FMDs and their relationship with demographic and clinical variables.

Methods

For this multicenter, observational study, we enrolled consecutive outpatients with a definite diagnosis of FMDs attending 25 tertiary movement disorders centers in Italy. Each patient underwent a detailed clinical evaluation with a definition of the phenotype and number of FMDs (isolated, combined) and an assessment of associated neurological and psychiatric symptoms.

Results

Of 410 FMDs (71% females; mean age, 47 ± 16.1 years) the most common phenotypes were weakness and tremor. People with FMDs had higher educational levels than the general population and frequent nonmotor symptoms, especially anxiety, fatigue, and pain. Almost half of the patients with FMDs had other FNDs, such as sensory symptoms, nonepileptic seizures, and visual symptoms. Patients with combined FMDs showed a higher burden of nonmotor symptoms and more frequent FNDs. Multivariate regression analysis showed that a diagnosis of combined FMDs was more likely to be delivered by a movement disorders neurologist. Also, FMD duration, pain, insomnia, diagnosis of somatoform disease, and treatment with antipsychotics were all significantly associated with combined FMDs.

Conclusions

Our findings highlight the need for multidimensional assessments in patients with FMDs given the high frequency of nonmotor symptoms and other FNDs, especially in patients with combined FMDs.

Factors influencing adherence to therapeutic recommendations made after diagnostic reassessment of medically unexplained symptoms in children and adolescents

BACKGROUND

Medically unexplained symptoms (MUS) are common among children and adolescents and may be highly impairing. Even after long diagnostic and/or therapeutic trajectories, many of these children and their parents feel dissatisfied with the advice and therapies they were given.

OBJECTIVES

After a 2-week hospitalisation for somatic and psychiatric reassessment, children and their families were given recommendations for further treatment. This study evaluates which of these recommendations were carried out (primary outcome measure) and which factors influenced the (non-)adherence to therapeutic advice.

METHODS

Parents of 27 children aged 7-17 with impairing MUS took part in a structured telephone survey to assess adherence to and perceived effectiveness of therapeutic recommendations (cross-sectional study). Influencing factors were analysed retrospectively.

RESULTS

Psychotherapy was recommended to all 27 patients and their families; 19 of them (70.4%) carried out this advice. When physiotherapy was recommended, adherence proved lower (6/22 children; 27.3%). No influencing factors were found to have a statistically significant correlation with adherence. Effect sizes may be indicative of clinically relevant influential factors, but should be considered cautiously.

CONCLUSION

Results suggest that more efforts need to be made to ensure adherence to therapeutic recommendations. Known risk factors for non-adherence to treatments for chronic somatic disorders may not apply for children with somatoform disorders.

Personalized, Web-Based, Guided Self-Help for Patients With Medically Unexplained Symptoms in Primary Care: Protocol for a Randomized Controlled Trial

Background

Medically unexplained symptoms (MUS) constitute a major health problem because of their high prevalence, the suffering and disability they cause, and the associated medical costs. Web-based interventions may provide an accessible and convenient tool for managing MUS. We developed a personalized, Web-based, guided self-help intervention for MUS in primary care (Grip self-help) and would compare its effectiveness with that of usual care.

Objective

This paper aims to describe the rationale, objectives, and design of a pragmatic randomized controlled trial (RCT) assessing the effectiveness of Grip self-help.

Methods

For a pragmatic multicenter RCT, 165 adult patients with mild to moderate MUS will be recruited through general practices in the Netherlands. Randomization will be performed at general practice level. Over the course of several months, patients in the intervention group will receive a personalized set of Web-based self-help exercises, targeting the unhelpful cognitions, emotions, behaviors, and social factors that are relevant to them. The intervention is guided by a general practice mental health worker. The control group will receive care-as-usual. Primary outcome is physical health-related quality of life (RAND-36 or 36-item general health survey, physical component score). Secondary outcomes include severity of physical and psychological symptoms, mental health–related quality of life, cost-effectiveness, and acceptability. Assessments will take place at baseline, end of treatment, and at 16-, 26-, and 52-week follow-ups.

Results

Recruitment started in December 2018, and enrolment is ongoing. The first results are expected to be submitted for publication in December 2021.

Conclusions

To our knowledge, this is the first study to combine the concepts of electronic health, self-help, and personalized medicine in the treatment of MUS. By improving the quality of life and reducing symptoms of patients with MUS, Grip self-help has the potential to reduce costs and conserve scarce health care resources.

Trial Registration

Dutch Trial Register NTR7390; https://www.trialregister.nl/trial/7390.

International Registered Report Identifier (IRRID)

PRR1-10.2196/13738

Functional Somatic Symptoms

BACKGROUND

Approximately 10% of the general population and around one third of adult patients in clinical populations suffer from functional somatic symptoms. These take many forms, are often chronic, impair everyday functioning as well as quality of life, and are cost intensive.

METHODS

The guideline group (32 medical and psychological professional societies, two patients' associations) carried out a systematic survey of the literature and ana- lyzed 3795 original articles and 3345 reviews. The aim was to formulate empirically based recommendations that were practical and user friendly.

RESULTS

Because of the variation in course and symptom severity, three stages of treatment are distinguished. In early contacts, the focus is on basic investigations, reassurance, and advice. For persistent burdensome symptoms, an extended, simultaneous and equitable diagnostic work-up of physical and psychosocial factors is recommended, together with a focus on information and self-help. In the pres- ence of severe and disabling symptoms, multimodal treatment includes further elements such as (body) psychotherapeutic and social medicine measures. Whatever the medical specialty, level of care, or clinical picture, an empathetic professional attitude, reflective communication, information, a cautious, restrained approach to diagnosis, good interdisciplinary cooperation, and above all active interventions for self-efficacy are usually more effective than passive, organ- focused treatments.

CONCLUSION

The cornerstones of diagnosis and treatment are biopsychosocial ex- planatory models, communication, self-efficacy, and interdisciplinary mangagement. This enables safe and efficient patient care from the initial presentation onwards, even in cases where the symptoms cannot yet be traced back to specific causes.

[Pain therapy for children and adolescents with hemophilia : Recommendations by an expert panel]

BACKGROUND

Children and adolescents with severe hemophilia commonly suffer from acute and chronic pain as a consequence of hemophilia-related bleeding. Intervention-related pain also plays a major role. Despite its high prevalence in this patient group, hemophilia-related pain is not always adequately addressed and sufficiently treated.

OBJECTIVES

This paper discusses how to improve pain management for children and adolescents (0-18 years) with hemophilia and which specific features in this population should influence decisions in pain management.

MATERIALS AND METHODS

An expert panel discussed challenges in pain treatment in children and adolescents with hemophilia. Recommendations are based on evidence and clinical experience.

RESULT

Pain management in children with hemophilia needs improvement. Children with hemophilia are at risk of developing chronic pain and of suffering traumatization due to insufficient pain management. Pain therapy can be challenging in these children as both their age and the underlying disease limit the options in particular in pain medication. The expert panel developed recommendations to improve pain management in children with hemophilia.

Persistent physical symptoms reduction intervention: a system change and evaluation (PRINCE)-integrated GP care for persistent physical symptoms: protocol for a feasibility and cluster randomised waiting list, controlled trial

INTRODUCTION

Persistent physical symptoms (PPS), also known as medically unexplained symptoms are associated with profound physical disability, psychological distress and high healthcare costs. England's annual National Health Service costs of attempting to diagnose and treat PPS amounts to approximately £3 billion. Current treatment relies on a positive diagnosis, life-style advice and drug therapy. However, many patients continue to suffer from ongoing symptoms and general practitioners (GPs) are challenged to find effective treatments. Training GPs in basic cognitive behavioural skills and providing self-help materials to patients could be useful, but availability in primary care settings is limited.

METHODS AND ANALYSIS

A cluster randomised waiting list, controlled trial will be conducted to assess the feasibility of an integrated approach to care in general practice. Approximately 240 patients with PPS will be recruited from 8 to 12 GP practices in London. GP practices will be randomised to 'integrated GP care plus treatment as usual' or waiting list control. Integrated GP care plus treatment as usual will include GP training in cognitive behavioural skills, GP supervision and written and audio visual materials for both GPs and participants. The primary objectives will be assessment of trial and intervention feasibility. Secondary objectives will include estimating the intracluster correlation coefficient for potential outcome measures for cluster effects in a sample size calculation. Feasibility parameters and identification of suitable primary and secondary outcomes for future trial evaluations will be assessed prerandomisation and at 12 and 24 weeks' postrandomisation, using a mixed-methods approach.

ETHICS AND DISSEMINATION

Ethical approval was granted by the Camberwell St Giles Ethics Committee. Results will be disseminated via peer-reviewed publications and conference presentations. This trial will inform researchers, clinicians, patients and healthcare providers about the feasibility and potential cost-effectiveness of an integrated approach to managing PPS in primary care.

TRIAL REGISTRATION NUMBER

NCT02444520; Pre-results.

Hospitalized Patients with Medically Unexplained Physical Symptoms: Clinical Context and Economic Costs of Healthcare Management

Medically Unexplained Physical Symptoms (MUPS) are physical symptoms without a medical explanation. This study collected data from hospitalized patients presenting MUPS, aiming to draw a clinical and socio-demographic profile of patients with MUPS, to explore psychopathological correlations of Somatic Symptoms Disorder (SSD) diagnosis, and to estimate economic costs related to hospital management for MUPS. The cross-sectional study consisted in the evaluation of data referring to hospitalized patients admitted between 2008 and 2018 in a teaching hospital in Northern Italy. A total of 273 patients presenting MUPS have been hospitalized. The sample showed a prevalence of female, married and employed patients. The most frequent wards involved are Neurology, Internal Medicine and Short Unit Stay. The most common symptoms found are headache, pain, syncope and vertigo. There is no evidence that a history of medical disease is associated with a diagnosis of SSD. A personality disorder diagnosis in patients with MUPS was associated with increased probability of having a diagnosis of SSD. A marginally significant positive association emerged with anxiety disorders, but not with depressive disorder. The overall estimated cost of hospitalization for patients with MUPS is 475'409.73 €. The study provides the investigation of a large number of patients with MUPS and a financial estimate of related hospitalization costs.

Prevalence of medically unexplained symptoms in adults who are high users of health care services: a systematic review and meta-analysis protocol

INTRODUCTION

Medically unexplained symptoms (MUS) are common in primary-care and secondary-care settings. Persistent symptoms of MUS are associated with a variety of poor outcomes including increased disability, poor quality of life and high healthcare costs. The aim of this systematic review is to review the relevant literature to determine the prevalence of MUS in patients who are high users of healthcare and/or who accrue high healthcare costs.

METHODS AND ANALYSIS

This review will include studies with cases that are either high users of general healthcare or are patients who accrue high healthcare costs, aged ≥18 years and where a recognised measure of MUS, either a standardised clinical interview or questionnaire, was employed. The following citation databases MEDLINE, PsycINFO, EMBASE, CINAHL, PROSPERO and the Cochrane library will be systematically searched from inception to 30 June 2018. The Cochrane library was included because of the significant proportion of non-observational studies currently published in the database. The prevalence of MUS and associated disorders along with the costs or use of healthcare associated with the presence of MUS will be estimated with 95% CI. If possible, study results will be pooled into a meta-analysis. However, if heterogeneity is high, data analysis will be presented descriptively.

ETHICS AND DISSEMINATION

Ethical approval is not required for this systematic review since only data from existing studies will be used. Results of this review will be disseminated in peer-reviewed publications and at national and international conferences.

PROSPERO REGISTRATION NUMBER

CRD42018100388.

The Four-Cluster Spectrum of Mind-Body Interrelationships: An Integrative Model

Despite the shift toward a biopsychosocial paradigm of medicine, many physicians and mental health professionals (MHPs) find it difficult to treat patients with psycho-somatic disorders. This situation is particularly troublesome due to the high prevalence of these conditions. Although progress has been made over the last few decades in understanding mechanisms underlying the mind-body relationship, disparities remain between research and its clinical implementation. One possible reason for this is the lack of a comprehensive, agreed-upon model that incorporates a biopsychosocial framework and is rooted in an understanding of the various psychobiological pathways. Such a model would enable better communication between physicians and MHPs, allowing them to provide coordinated, stratified treatment. In this paper, four archetypal case studies, together with standard care options are presented to illustrate the current state of affairs. A four-tiered conceptual model of mind-body interrelationships based on pathophysiological and psychopathological mechanisms is suggested to help optimize the treatment of somatic complaints. This Four-Cluster model consists of: (1) Organic Conditions: Structural, or degenerative processes that can affect mood and psychological responses but are not clearly exacerbated by stress. (2) Stress Exacerbated Diseases: Biological disorders with a distinct pathophysiology, such as inflammatory or autoimmune diseases, whose progression is clearly exacerbated by stress. (3) Functional Somatic Syndromes: Conditions wherein heightened sensitivity to stimuli together with hyper-reactivity of the autonomic system form a "vicious cycle" of mutually enhancing learning processes. These processes involve biological mechanisms, such as central sensitization and psychological mechanisms such as catastrophization and selective attention. (4) Conversion Disorder: Physical manifestations of psychological distress, expressed somatically. Symptoms are solely an expression of problems in patients' psychic functioning and are not caused by biological pathology. Finally, suggested management of the aforementioned case studies is presented through the lens of the Four-Cluster model and a proposed integration of our model with existing theories is discussed. As it is rooted in an understanding of psychobiological pathways of illness, the proposed model enables a new way to discern which form of mind-body interaction is manifesting in different diseases and proposes a way to coordinate treatment plans accordingly, to enhance the accuracy and efficacy of care.

Dysfunction in Serotonergic and Noradrenergic Systems and Somatic Symptoms in Psychiatric Disorders

Somatic symptoms include a range of physical experiences, such as pain, muscle tension, body shaking, difficulty in breathing, heart palpitation, blushing, fatigue, and sweating. Somatic symptoms are common in major depressive disorder (MDD), anxiety disorders, and some other psychiatric disorders. However, the etiology of somatic symptoms remains unclear. Somatic symptoms could be a response to emotional distress in patients with those psychiatric conditions. Increasing evidence supports the role of aberrant serotoninergic and noradrenergic neurotransmission in somatic symptoms. The physiological alterations underlying diminished serotonin (5-HT) and norepinephrine (NE) signaling may contribute to impaired signal transduction, reduced 5-HT, or NE release from terminals of presynaptic neurons, and result in alternations in function and/or number of receptors and changes in intracellular signal processing. Multiple resources of data support each of these mechanisms. Animal models have shown physiological responses, similar to somatic symptoms seen in psychiatric patients, after manipulations of 5-HT and NE neurotransmission. Human genetic studies have identified many single-nucleotide polymorphisms risk loci associated with somatic symptoms. Several neuroimaging findings support that somatic symptoms are possibly associated with a state of reduced receptor binding. This narrative literature review aimed to discuss the involvement of serotonergic and noradrenergic systems in the pathophysiology of somatic symptoms. Future research combining neuroimaging techniques and genetic analysis to further elucidate the biological mechanisms of somatic symptoms and to develop novel treatment strategies is needed.

Efficacy of a guided internet-based intervention (iSOMA) for somatic symptoms and related distress in university students: study protocol of a randomised controlled trial

INTRODUCTION

Persistent and distressing somatic symptoms are common in younger age cohorts such as university students. However, the majority does not receive adequate psychosocial care. Internet-based and mobile-based interventions may represent low threshold and effective extensions to reduce somatic and associated mental symptom severity. The planned study aims to investigate the feasibility and efficacy of an internet-based intervention in reducing somatic and psychological symptoms in an international population of university students with somatic symptom burden.

METHODS AND ANALYSIS

This parallel two-armed randomised controlled trial evaluates an 8-week guided intervention, including web-based consecutive modules based on cognitive behavioural therapy (CBT) principles against a waitlist control group. Guidance will be provided by trained psychologists with weekly written supportive feedback. As part of the 'Studicare' project, the present study aims to recruit n=154 university students indicating somatic symptom burden at baseline in German-speaking universities. Self-report assessments will take place at baseline and after intervention completion (8, 16 weeks after randomisation). The primary outcome will be the severity of somatic symptoms and associated mental distress. Secondary outcomes include depression, (health) anxiety, disability, intervention satisfaction and adherence.

ETHICS AND DISSEMINATION

Ethics approval has been granted. Results from this study will be published in peer-reviewed journals and presented at international conferences.

TRIAL REGISTRATION NUMBER

DRKS00014375; Pre-results.

Medically Unexplained Physical Symptoms in Hospitalized Patients: A 9-Year Retrospective Observational Study

Introduction: "Medically Unexplained Physical Symptoms" (MUPS) defines a subgroup of patients presenting physical symptoms of unclear origin. The study aims to profile clinical and socio-demographic characteristics of patients with MUPS. Materials and Methods: This 9-years observational retrospective study assesses all patients admitted between 2008 and 2016 in the divisions of neurology and gastroenterology. Socio-demographic and clinical variables were evaluated: gender, age, diagnosis or diagnostic hypothesis, presence of psychiatric comorbidities, psychiatric evaluation, pharmacological treatment, number of admissions/visits. Results: Among 2,479 neurological patients 10.1% presented MUPS. Patients were more frequently women (63.5%), with a mean age of about 50 years. Reported symptoms were headache (22.6%), seizures (8.7%), vertigo (5.9%), fibromyalgia (5.5%), paresthesia (5.1%), visual disturbances (5.1%), amnesia (3.9%). The diagnosis was somatoform disorder in 6.3% of cases, conversion disorder in 2.7%, and somatic symptom disorder in 1.5% only. 2,560 outpatients were evaluated in gastroenterology division. 9.6% (n = 248) of patients had MUPS; 62.1% of them were women. The most affected age group ranged between 15 and 45 years. The most frequent diagnoses were functional abdominal pain (50%), dysmotility-like dyspepsia (26.6%), irritable bowel syndrome (10.4%), meteorism of unknown cause (2.4%), hiccup (1.6%), burning mouth syndrome (1.2%). No patients received a diagnosis of somatic symptom disorder. Discussion: Patients with MUPS are more often women, of middle age, with self-referred specific symptomatology. While neurological patients received a diagnostic-therapeutic approach in line with the literature, gastroenterological patients mainly received antipsychotics. A more comprehensive assessment and a development of psychoeducational interventions are needed to improve patients' quality and quantity of life.

Management of somatic symptom disorder

This review paper gives an overview of the management of somatic symptom disorder. It starts with a description of the clinical problem of patients with persistent bodily distress, discusses classificatory, epidemiological, and etiological issues and then describes the evidence and practical principles of dealing with these patients who are often seen as "difficult" to treat. It is concluded that the best-suited approach is stepped care with close cooperation of primary care, a somatic specialist, and mental health care professionals operating on the basis of a biopsychosocial model of integrating somatic as well as psychosocial determinants of distress and therapeutic factors.

Management of Functional Somatic Syndromes and Bodily Distress

Functional somatic syndromes (FSS), like irritable bowel syndrome or fibromyalgia and other symptoms reflecting bodily distress, are common in practically all areas of medicine worldwide. Diagnostic and therapeutic approaches to these symptoms and syndromes vary substantially across and within medical specialties from biomedicine to psychiatry. Patients may become frustrated with the lack of effective treatment, doctors may experience these disorders as difficult to treat, and this type of health problem forms an important component of the global burden of disease. This review intends to develop a unifying perspective on the understanding and management of FSS and bodily distress. Firstly, we present the clinical problem and review current concepts for classification. Secondly, we propose an integrated etiological model which encompasses a wide range of biopsychosocial vulnerability and triggering factors and considers consecutive aggravating and maintaining factors. Thirdly, we systematically scrutinize the current evidence base in terms of an umbrella review of systematic reviews from 2007 to 2017 and give recommendations for treatment for all levels of care, concentrating on developments over the last 10 years. We conclude that activating, patient-involving, and centrally acting therapies appear to be more effective than passive ones that primarily act on peripheral physiology, and we recommend stepped care approaches that translate a truly biopsychosocial approach into actual management of the patient.

The Effectiveness of High-frequency Repetitive Transcranial Magnetic Stimulation in Persistent Somatoform Pain Disorder: A Case Series

Somatoform pain disorders (SPD) are common, disabling and do not respond well to existing treatment modalities. We investigated the usefulness of 18 sessions of high frequency repetitive transcranial magnetic stimulation delivered at the left dorsolateral prefrontal cortex (DLPFC) in five right-handed patients with SPD. All patients reported significant improvement in pain relief and activities of daily living. High-frequency repetitive transcranial magnetic stimulation (rTMS) delivered at the left DLPFC may be useful in SPD.

A European Research Agenda for Somatic Symptom Disorders, Bodily Distress Disorders, and Functional Disorders: Results of an Estimate-Talk-Estimate Delphi Expert Study

Background: Somatic Symptom Disorders (SSD), Bodily Distress Disorders (BDD) and functional disorders (FD) are associated with high medical and societal costs and pose a substantial challenge to the population and health policy of Europe. To meet this challenge, a specific research agenda is needed as one of the cornerstones of sustainable mental health research and health policy for SSD, BDD, and FD in Europe. Aim: To identify the main challenges and research priorities concerning SSD, BDD, and FD from a European perspective. Methods: Delphi study conducted from July 2016 until October 2017 in 3 rounds with 3 workshop meetings and 3 online surveys, involving 75 experts and 21 European countries. EURONET-SOMA and the European Association of Psychosomatic Medicine (EAPM) hosted the meetings. Results: Eight research priorities were identified: (1) Assessment of diagnostic profiles relevant to course and treatment outcome. (2) Development and evaluation of new, effective interventions. (3) Validation studies on questionnaires or semi-structured interviews that assess chronic medical conditions in this context. (4) Research into patients preferences for diagnosis and treatment. (5) Development of new methodologic designs to identify and explore mediators and moderators of clinical course and treatment outcomes (6). Translational research exploring how psychological and somatic symptoms develop from somatic conditions and biological and behavioral pathogenic factors. (7) Development of new, effective interventions to personalize treatment. (8) Implementation studies of treatment interventions in different settings, such as primary care, occupational care, general hospital and specialty mental health settings. The general public and policymakers will benefit from the development of new, effective, personalized interventions for SSD, BDD, and FD, that will be enhanced by translational research, as well as from the outcomes of research into patient involvement, GP-patient communication, consultation-liaison models and implementation. Conclusion: Funding for this research agenda, targeting these challenges in coordinated research networks such as EURONET-SOMA and EAPM, and systematically allocating resources by policymakers to this critical area in mental and physical well-being is urgently needed to improve efficacy and impact for diagnosis and treatment of SSD, BDD, and FD across Europe.

Prevalence and strong association of high somatic symptom severity with depression and anxiety in a Chinese inpatient population

BACKGROUND

The prevalence of the high somatic symptom severity (HSSS) and its associations with sociodemographic factors, depression, and anxiety has not been surveyed in inpatient populations at general hospitals.

METHODS

A sample including 1329 inpatients in a Chinese general hospital was surveyed using Chinese version of 15-item patient health questionnaire (PHQ-15), 9-item patient health questionnaire, and generalized anxiety disorder 7-item scale.

RESULTS

A total of 27.8% (n = 369) of the participants had HSSS (PHQ-15 ≥ 10). The multivariate regression showed that HSSS was significantly associated with depression (adjusted odds ratio [aOR], 5.219), anxiety (aOR, 5.810), or depression or anxiety (aOR, 5.338) but neither with sex, age, marital status, education status, household income, nor 7 kinds of physical disease systems.

DISCUSSION

The symptom profile and high prevalence of HSSS, and its association with clinically significant depression and anxiety in this inpatient population were mostly consistent to that documented by studies in other populations.

Functional Somatic Syndrome: Assessment and Management

Functional somatic syndrome (FSS) occurs in as many as 30% of patients in general medical practice, but it is infrequently a topic of formal instruction. Many physicians feel uncomfortable with medically unexplained symptoms and are unfamiliar with how to assess or manage them. Traditional medical approaches can be ineffective and can contribute to iatrogenic or adverse physiologic effects in patients. Physicians treating patients with FSS should not only consider standard medical tests, but they should also try to gain a deeper behavioral understanding of the mind-body connections that underlie the presenting symptoms. Osteopathic physicians, with their emphasis on holistic patient care, are in a key position to treat patients with FSS. This review provides a brief recapitulation of the literature and illustrates key factors in the assessment and management of FSS.

Associations of treatment effects between follow-up times and between outcome domains in interventions for somatoform disorders: Review of three Cochrane reviews

BACKGROUND

Interventions for somatoform disorders typically address a range of outcomes. We aimed to examine treatment effects across outcome domains and specifically assess the association, at study level, between short and long term treatment effects and between treatment effects in different outcome domains.

METHODS

We used data from recent systematic reviews of interventions for somatoform disorders to address three questions: We described outcome domains and measures by compiling forest plots of standardised mean difference. We examined the association of changes in outcome between short and long-term and between different outcome domains by non-parametric correlation.

RESULTS

We analysed data from 47 studies across four outcome domains: physical symptoms, health-related quality of life, depression and anxiety. Short-term and long-term treatment effects within each outcome domain were broadly similar and were correlated Reported reduction in physical symptoms was correlated with reductions in depression (rho=0.73, p=0.002) and anxiety (0.70, p<0.001) and increase in quality of life (0.54, p=0.03).

CONCLUSION

Short term changes in outcome measures are correlated with longer term changes; outcome changes are correlated across domains independently of the type of treatment.

The CIPRUS study, a nurse-led psychological treatment for patients with undifferentiated somatoform disorder in primary care: study protocol for a randomised controlled trial

BACKGROUND

Up to a third of patients presenting medically unexplained physical symptoms in primary care may have a somatoform disorder, of which undifferentiated somatoform disorder (USD) is the most common type. Psychological interventions can reduce symptoms associated with USD and improve functioning. Previous research has either been conducted in secondary care or interventions have been provided by general practitioners (GPs) or psychologists in primary care. As efficiency and cost-effectiveness are imperative in primary care, it is important to investigate whether nurse-led interventions are effective as well. The aim of this study is to examine the effectiveness and cost-effectiveness of a short cognitive behavioural therapy (CBT)-based treatment for patients with USD provided by mental health nurse practitioners (MHNPs), compared to usual care.

METHODS

In a cluster randomised controlled trial, 212 adult patients with USD will be assigned to the intervention or care as usual. The intervention group will be offered a short, individual CBT-based treatment by the MHNP in addition to usual GP care. The main goal of the intervention is that patients become less impaired by their physical symptoms and cope with symptoms in a more effective way. In six sessions patients will receive problem-solving treatment. The primary outcome is improvement in physical functioning, measured by the physical component summary score of the RAND-36. Secondary outcomes include health-related quality of life measured by the separate subscales of the RAND-36, somatization (PHQ-15) and symptoms of depression and anxiety (HADS). Problem-solving skills, health anxiety, illness perceptions, coping, mastery and working alliance will be assessed as potential mediators. Assessments will be done at 0, 2, 4, 8 and 12 months. An economic evaluation will be conducted from a societal perspective with quality of life as the primary outcome measure assessed by the EQ-5D-5L. Health care, patient and lost productivity costs will be assessed with the Tic-P.

DISCUSSION

We expect that the intervention will improve physical functioning and is cost-effective compared to usual care. If so, more patients might successfully be treated in general practice, decreasing the number of referrals to specialist care.

TRIAL REGISTRATION

Dutch Trial Registry, identifier: NTR4686 , Registered on 14 July 2014.