Chronic headaches and the neurobiology of somatization

Engagement with emotional concerns in general practice: a thematic analysis of GP consultations

BACKGROUND

Emotional concerns (defined as any expression of low mood, anxiety, or psychosocial stress) are an important part of the biopsychosocial care model used in modern medical practice. Previous work has demonstrated variable engagement with emotional concerns and that improved communication has been associated with reductions in emotional distress.

AIM

To examine how emotional concerns are engaged with during routine GP consultations.

DESIGN & SETTING

Secondary study using the Harnessing Resources from the Internet (HaRI) database. The available dataset contains 231 recordings from 10 GPs across eight urban and suburban practices recorded in 2017 and 2018.

METHOD

The dataset was reviewed to identify any consultations containing emotional concerns (as defined as any expression of low mood, anxiety, or psychosocial stress) before being imported into NVivo (version 12) to facilitate thematic analysis and coding. Reflexive inductive thematic analysis resulted in two major themes.

RESULTS

The two main themes were as follows: engagement with emotional concerns as dynamic throughout consultations; and GPs engage with emotional concerns both diagnostically and therapeutically. In theme 1, this dynamism relates to competing areas of focus, immediate versus delayed engagement and reiteration of concerns throughout consultations. Emotional concerns can be engaged with in a similar way to physical concerns (theme 2) using a diagnostic and treatment-based approach; however, in addition to this, therapeutic listening and conversation is utilised.

CONCLUSION

Awareness of the dynamic nature of emotional concerns within consultations and encouraging engagement with concerns in a flexible and patient-oriented manner may help improve doctor-patient communication. In addition, investigating how GPs and patients build shared understanding around emotional concerns may identify methods to reduce patients' emotional distress.

Psychiatric comorbidity in new daily persistent headache: A cross-sectional study

BACKGROUND

New daily persistent headache (NDPH) is a type of chronic daily headache. NDPH can have migrainous (NDPH-CM) or tension-type character (NDPH-CTTH). Recently, NDPH patients have shown to have associated anxiety and depression. We compared anxiety, depressive symptoms, somatization and pain catastrophization among NDPH, healthy controls and patients with chronic low-back pain and between NDPH-CM and NDPH-CTTH.

METHODS

We assessed the study population for depressive symptoms by Patient Health Questionnaire-9, anxiety by Generalized Anxiety Disorder Scale - 7, somatoform disorder using DSM IV (TR) criteria and pain catastrophizing by using Pain Catastrophizing Scale.

RESULTS

Fifty-five patients each with NDPH (mean age 28.24 ± 12.05 years, 45.5% females) and age/sex matched healthy individuals and patients with chronic low-back pain were enrolled. Among NDPH patients, somatoform disorder was seen in 32.7%, severe anxiety in 65.5%, severe depressive symptoms in 40%, significant pain catastrophization in 85.5%. NDPH patients had significantly higher frequency of all psychiatric co-morbidities as compared to healthy controls and patients with chronic low-back pain. NDPH-CM patients had significantly higher frequency of depression and pain catastrophizing behaviour as compared to NDPH-CTTH.

CONCLUSION

Anxiety, depressive symptoms, somatization and pain catastrophizing were significantly more prevalent in NDPH when compared to healthy individuals and patients with chronic low back pain. Such effects should be sought for, as they might contribute to refractoriness to treatment.

SIGNIFICANCE

Anxiety, depressive symptoms, somatization and pain catastrophizing were significantly more prevalent in new daily persistent headache when compared to healthy individuals and patients with chronic low back pain. Such effects should be sought for, as they might contribute to refractoriness to treatment.

Headache from the doctors' perspective

BACKGROUND

General practitioners (GPs) and neurologists are involved in treating headache patients in Portugal. Having migraine themselves might influence the way they perceive and treat migraine patients.

OBJECTIVE

To identify clinicians' perceptions about migraine, their own headache status and management of their own migraine.

METHODS

An observational cross-sectional survey of GPs and neurologists using anonymous questionnaires including demographic data, headache and migraine status and migraine perception questions.

RESULTS

Of 348 respondent physicians, 20% were neurologists and 53% were females with an average age of 48 years. The majority had an interest in migraine and considered it disabling (93%), although 65-85% reported management difficulties, GPs more often than neurologists. Satisfaction with current treatment options was high (69-79%). 63 physicians suffered from migraine and 81% felt it influenced their perception of the disease. Portuguese physicians preferentially treat their own migraines with NSAIDs (33%), analgesics (29%) and triptans (20%).

CONCLUSION

Portuguese physicians treating migraine patients have realistic perceptions about the disease and those with migraine feel their perception is influenced by their experience. Although reporting management difficulties, the majority of physicians are satisfied with current treatment options for migraine.

Occupational Stress and Physical Symptoms among Family Medicine Residents

Background

The purpose of this study was to examine the levels of occupational stress and physical symptoms among family medicine residents and investigate the effect of subscales of occupational stress on physical symptoms.

Methods

A self-administered questionnaire survey of 1,152 family medicine residents was carried out via e-mail from April 2010 to July 2010. The response rate was 13.1% and the R (ver. 2.9.1) was used for the analysis of completed data obtained from 150 subjects. The questionnaire included demographic factors, resident training related factors, 24-items of the Korean Occupational Stress Scales and Korean Versions of the Wahler Physical Symptom Inventory.

Results

The total score of occupational stress of family medicine residents was relatively low compared to that of average workers. The scores of 'high job demand', 'inadequate social support', 'organizational injustice', and 'discomfort in occupational climate' were within the top 50%. Parameters associated with higher occupational stress included level of training, on-duty time, daily patient load, critical patient assigned, total working days, night duty day, sleep duration, and sleep quality. The six subscales of occupational stress, except for 'Job insecurity', had a significant positive correlation with physical symptom scores after adjustment had been made for potential confounders (total score, r = 0.325 and P < 0.001; high job demand, r = 0.439 and P < 0.001).

Conclusion

After the adjustment had been made for potential confounders, the total score of occupational stress and six subscales in family medicine residents showed a significant positive correlation with physical symptom scores.

Functional network connectivity of pain-related resting state networks in somatoform pain disorder: an exploratory fMRI study

BACKGROUND

Without stimulation, the human brain spontaneously produces highly organized, low-frequency fluctuations of neural activity in intrinsic connectivity networks (ICNs). Furthermore, without adequate explanatory nociceptive input, patients with somatoform pain disorder experience pain symptoms, thus implicating a central dysregulation of pain homeostasis. The present study aimed to test whether interactions among pain-related ICNs, such as the default mode network (DMN), cingular-insular network (CIN) and sensorimotor network (SMN), are altered in somatoform pain during resting conditions.

METHODS

Patients with somatoform pain disorder and healthy controls underwent resting functional magnetic resonance imaging that lasted 370 seconds. Using a data-driven approach, the ICNs were isolated, and the functional network connectivity (FNC) was computed.

RESULTS

Twenty-one patients and 19 controls enrolled in the study. Significant FNC (p < 0.05, corrected for false discovery rate) was detected between the CIN and SMN/anterior DMN, the anterior DMN and posterior DMN/SMN, and the posterior DMN and SMN. Interestingly, no group differences in FNC were detected.

LIMITATIONS

The most important limitation of this study was the relatively short resting state paradigm.

CONCLUSION

To our knowledge, our results demonstrated for the first time the resting FNC among pain-related ICNs. However, our results suggest that FNC signatures alone are not able to characterize the putative central dysfunction underpinning somatoform pain disorder.

[Etiopathogenetic aspects of somatoform disorders]

The etiopathology of somatoform disorders can only be understood against the background of an integrated biopsychosocial model. Cultural and historical influences must be taken into account as well as contemporary settings of scientific or medical priorities. In this context the emphasis on neurobiological findings can be interpreted as the non-accidental struggle for legitimacy of both patients and physicians. Altogether the available data on factors influencing the formation and maintenance of somatoform symptoms has to be described as both diverse and unspecific and thus points to a challenging research program in the coming years.

Consultation-liaison psychiatry for patients with headaches

Screening of headache patients for psychiatric disorders is needed, because of the well-known high rates of comorbidity with depression and anxiety. Screening for both depression and anxiety is highly advisable in order to identify subjects who need psychiatric consultation and therapy. Screening tools for depression and anxiety range from informal questions to self-report instruments to structured interviews and the choice is up to the clinician and the setting of the clinical evaluation. Data on psychiatric disorders and medication overuse are till now not consistent. The treatment of mood and anxiety disorders in headache patients needs to take into account the possible drug interactions with headache therapies. The collaboration between neurologists and consultation-liaison psychiatrists helps the identification of headache patients who need a psychiatric therapeutic program and follow-up.