Somatoform disorders in the general hospital inpatient setting

Somatoform, factitious, and related diagnoses in the national hospital discharge survey: addressing the proposed DSM-5 revision

BACKGROUND

The DSM-5 working group on the somatoform (SFD) and factitious (FD) disorders has recommended substantial revisions of these categories. The recommendations are based, in part, on anecdotal evidence that the diagnoses are infrequently used.

OBJECTIVE

To assess the assignment rates for SFD, FD, and related diagnoses among general medical inpatients.

METHOD

The National Hospital Discharge Survey was queried for instances of SFD and FD, along with related diagnoses identifying medical cases in which psychological factors play a role. Diagnoses of major depression and generalized anxiety disorder were queried for comparison purposes.

RESULTS

The target diagnoses were assigned far less frequently than published prevalence and recognition rates suggest. Nearly half of the assigned target diagnoses were generic diagnoses (esp. physiological malfunction due to psychological factors) other than SFD or FD. However, the apparent degree of underassignment of the target diagnoses was not dramatically greater than the underassignment observed for major depression and generalized anxiety disorder.

CONCLUSION

The results provide empirical support for the impression that physicians do not assign SFD and FD diagnoses in recognized cases, but do not strongly support the assertion that these diagnoses are uniquely problematic.

Diagnostic classification and demographic features in 283 patients with somatoform disorder

A total of 283 patients with somatoform disorder (SFD) seen in a psychiatry clinic were surveyed and their diagnostic subtypes, demographic features, and comorbidities, analyzed. The results indicate that: (i) SFD comprises 5.8% of first-visit outpatients; (ii) undifferentiated SFD (USFD) and SFD not otherwise specified (SFD-NOS) account for the majority of patients; (iii) there are 1.7-fold more women than men; (iv) age of onset is lower in patients with somatization disorder or body dysmorphic disorder and higher in patients with hypochondriasis or pain disorder; (v) the mean number of years of education was 11.2 years; and (vi) comorbid illness were seen in 24.8% of patients, and included mood disorder, anxiety disorder, and personality disorder, as well as borderline intellectual functioning and mental retardation. The data indicate that the majority of patients with SFD are given a diagnosis of residual category, such as USFD or SFD-NOS, and that the age of onset varies depending on the diagnostic subtype. SFD was more frequently seen in women, associated with comorbidities.

Somatoform disorders in neurological practice

PURPOSE OF REVIEW

Patients with medically unexplained symptoms continue to intrigue, fascinate and frustrate clinicians. They are common in general medicine and often present with apparent neurological disorder. This review aims to provide insight into the recent literature that has sought to clarify epidemiology, diagnostic issues, aetiologic understanding and treatment of patients with psychogenic disorders who usually first present to neurologists.

RECENT FINDINGS

Somatoform disorders are common in neurological practice. A number of papers have addressed issues of epidemiology and identified that medically unexplained symptoms in neurological populations are higher than originally thought. A number of recent review papers have served to summarize areas of considerable information (e.g. treatments) and areas of rapid growth in knowledge (e.g. neuroimaging). Studies investigating the role of psychological factors are well represented and clarify our psychopathological understanding of somatoform disorders in patients presenting to neurologists. Treatment studies are few and continue to be limited by population sizes and study designs.

SUMMARY

Somatoform disorders are common in neurological populations. Comorbidity related to somatoform disorders with known organic neurological conditions requires further study. On account of the limitations of treatment studies, evidence-based clinical management of these patients is awaited.

Psychogenic movement disorders

Psychogenic movement disorders (PMD) are challenging to diagnose and to treat. Since the nineteenth century, PMDs were recognized and described in painstaking detail. In the modern neurology clinic, PMDs may comprise 2-25% of the patient population. Recognition of the various types of PMDs, differentiation from organic illness and an approach to PMDs are described in this article.

Somatoform disorders in consultation-liaison psychiatry: a comparison with other mental disorders

Consultation-liaison (C-L) psychiatry has an important role in the management of somatoform disorders (SD). Characteristics of SD patients in C-L psychiatry are largely unknown and are presented in this paper. We analyzed 13,314 Dutch psychiatric consultations from 1984 to 1991 and compared patients diagnosed with SD to patients with other mental disorders and to those without a mental disorder. The comparison included socio-demographic variables, consult characteristics, medical history, current somatic morbidity, information about additional diagnostic tests, hospital admission time and aftercare management. Of the 544 SD patients 39.5% (n = 215) were diagnosed with a conversion disorder that illustrates the highly selected nature of SD patients in C-L psychiatry. Employment among SD patients decreased significantly from 58% in the group aged 20-29 years to 6% in the group aged 50-59 years. This decrease was significantly larger as compared to other mental disorders and no mental disorders and was virtually unaffected by correction for potential confounding by gender. Contrary to our expectation no difference between the three groups was observed in claims for disability benefits. Of the SD patients 74.5% were referred for aftercare management, significantly more than the other two groups which is considered a promising development in C-L psychiatry.

Referrals to a liaison psychiatry out-patient clinic in a UK general hospital: a report on 900 cases

OBJECTIVE

To describe the demographic and clinical characteristics of consecutive referrals to an out-patient liaison psychiatry clinic in a large university hospital in the UK.

METHOD

We studied 900 patients using a standardized proforma. Assessments of functional capacity were made using the Global Assessment of Functioning (GAF) scale, and each patient was assigned a psychiatric diagnosis using ICD-10 criteria.

RESULTS

Four of five of all referrals presented with somatic complaints, and 41% had a concurrent physical illness. The most common psychiatric diagnoses were somatoform disorders (55%) and neurasthenia (11%). Although more than half (59%) had no previous psychiatric history, a surprisingly high number (35%) had significant functional impairment (scores of < 50 on the GAF scale). The lack of adequate psychological treatment services often provided a barrier to optimal management of some of the more disabled patients.

CONCLUSION

The general hospital liaison psychiatry clinic provides an acceptable setting in which to assess and manage patients referred from non-psychiatric colleagues.

Consultation-liaison psychiatrists' management of somatoform disorders

The authors studied interventions recommended by consultation-liaison (C-L) psychiatrists when they diagnosed somatoform disorder prospectively in a cohort of 4,401 consecutive inpatients referred to the C-L psychiatry service of a general teaching hospital, using standardized MICRO-CARES methodology. A DSM-III-R somatoform disorder was diagnosed in 2.9%, somatoform pain disorder in 1.4%, conversion disorder in 0.7%, hypochondriasis or somatization disorder undifferentiated/not otherwise specified in 0.6%, and somatization disorder in 0.2%. In 3.4%, somatoform disorder was considered a differential diagnosis. Psychiatric comorbidity included mood disorder (39%), personality disorder (37%), and psychoactive substance use disorder (19%). Recommendations were made about antidepressants in 40% of the patients, anxiolytics in 18%, sedatives in 18%, and antipsychotics in 10%. Psychiatrists recommended the following: more laboratory tests for 14%; additional medical/surgical consultations for 11%; an increase in the vigor of medical treatment for 13%; and psychological treatment for 76%; also they stressed an earlier discharge of 16%. Psychiatrists were more likely to request a prolongation of inpatient stay for patients with comorbid somatoform, mood, anxiety, and personality disorder. Differences in characteristics and treatment of the subgroups tended to be consistent with their constructs and comorbid psychiatric diagnoses.

Somatoform disorders: comorbidity with other DSM-III-R psychiatric diagnoses in Greece

From a total sample of 1,448 psychiatric outpatients, 175 (12.1%) received a diagnosis of a somatoform disorder according to DSM-III-R criteria. One hundred twenty-two (70%) of these patients had another current axis I diagnosis, and this rate increased to 79% (139 of 175) when lifetime psychiatric diagnoses were recorded. The most frequent comorbid diagnoses were depressive disorders, i.e., dysthymia and major depression, and then anxiety disorders, mainly panic disorder. One hundred ten (63%) of the somatoform patients met the criteria for a personality disorder, significantly higher than the rate (52%) for the rest of the total sample (n = 1,273), who were used as a control group. The most frequent comorbid personality disorders were histrionic, dependent, and personalities of cluster B in general. Hypochondriasis was the only somatoform disorder that was additionally significantly related to obsessive-compulsive personality disorder. Somatoform patients with a concomitant personality disorder manifested more severe overall psychopathology as measured by the Minnesota Multiphasic Personality Inventory (MMPI) and a worse level of functioning than those without. The results of the present study show that (1) patients with somatoform disorders have a high rate of comorbidity with other clinical syndromes and personality disorders, and (2) the presence of a personality disorder is related to more severe overall psychopathology and a worse level of functioning. All of the above indicate that special attention must be paid to the interaction between somatoform disorders, other clinical syndromes, and personality structure at the level of both clinical and research practice.

Therapeutic models for somatoform disorders in liaison psychiatry

Somatoform disorders are usually supposed to be seen in the clinical field of consultation-liaison (C-L) psychiatry. This study reviewed medical records of physically ill inpatients who were also treated by psychiatrists for concurrent psychiatric illnesses during a 5-year period. The prevalence of somatoform disorders was 40 out of 1581 cases (2.5%), which was unexpectedly low. From the perspective of C-L psychiatry, the authors propose three therapeutic models for somatoform disorders: 1. physician-oriented with psychiatric advice; 2. psychiatrist-oriented; and 3. cooperative physician/psychiatrist-oriented. The third model is particularly recommended because the patient can undergo physical examinations until the relationship between somatic complaints and psychosocial factors is recognized. Moreover, the psychiatrist can build an alliance with a patient, while the patient completes a 'testing phase' to determine whether the psychiatrist can be relied on or not. The third model is useful as such and can be used at least in the initial phase.

Epidemiology of somatoform disorders: a community survey in Florence

Since the exclusion of somatic causes is necessary for somatoform disorders (SMD) to be diagnosed, there is little information on the prevalence of such disorders in the community. As the method we have previously developed [general practitioners (GPs) with psychiatric training who interview samples representative of the general population] seemed to be appropriate to deal with the problem, we carried out a community survey focused on somatoform disorders. The prevalence rates of DSM-III-R somatoform disorders were studied in two wards of the city of Florence. In order to be representative of the general population, 673 subjects randomly selected were interviewed by their own GP. Four GPs, all with specific training in psychiatry, participated in the interviewing process. The 1-year prevalence figures were as follows: 0.7% body dysmorphic disorder; 4.5% hypochondriasis; 0.6% somatoform pain disorder; 0.3% conversion disorder; 0.7% somatization disorder; 13.8% undifferentiated somatoform disorder. No specific comorbidity was found between somatoform disorders and mood or anxiety disorders. Although the sample investigated was small, this study may be seen as one of the first in an area where knowledge is still scant. The prevalence rates of somatoform disorders were generally found to be slightly lower than expected.

The medical context of hypochondriacal traits

OBJECTIVE

This study examines the effects of two medical contexts on the relationship of hypochondriacal traits and their potential correlates.

METHOD

Correlates of hypochondriacal traits were compared from a matched sample of fifty-five general medical inpatients with a sample of fifty-five medical inpatients referred for psychiatric evaluation. Patients completed questionnaires assessing emotional distress and health attitudes, beliefs, and behaviors, and their attending physician completed ratings of the patient's illness and illness behavior.

RESULTS

Patients referred for psychiatric consultation exhibited significantly higher levels of hypochondriacal illness presentation than the matched nonreferred sample. Moderated regression analyses revealed three trends regarding the interactive effects of group status on the relationship of hypochondriacal traits to their potential correlates: 1) presence of angry feelings and interpersonal friction was positively associated with hypochondriacal concerns for the psychiatric referred patients only, 2) the tendency to deny life stresses and attribute all problems to the effects of illness was positively associated with a misinterpretation of the severity of their illness and hypochondriacal illness presentation for the psychiatric referred patients, whereas this association was negative for the nonreferred medical patients, and 3) the association of reports of emotional distress symptoms with hypochondriacal illness preparation was negative for the psychiatric referred patients and positive for the nonreferred medical patients.

CONCLUSIONS

Study results suggest that hypochondriasis may not represent a uniform nosological disorder and that the context of its study can significantly influence etiologic findings.

Establishing a consultation-liaison psychiatry clinical database in an Australian general hospital

This paper describes the institution of a clinical database in the consultation-liaison psychiatry service of an Australian general hospital psychiatry unit. One of the problems faced was that many researchers and clinicians in Australia use the ICD-9 rather than the DSM-III-R classification system. Nevertheless, it was possible to use the DSM-III-R-based MICRO-CARES clinical database management system in this project. The data obtained during the first 12 months of its use are presented. Despite differences in the patient demographic characteristics, the data obtained are within the ranges described for North American and European sites. The local benefits of such a clinical database are described, and it is argued that such a database is also necessary for interhospital and international collaborative studies and comparisons.

General health, health care utilization, and medical comorbidity in dysthymia

OBJECTIVE

This article reviews the literature on the general health, health care utilization, prevalence, medical comorbidity, and treatment of dysthymia in medical settings.

METHOD

The literature was searched by using MEDLINE and by reviewing the bibliographies of recent publications. Studies were selected that included health data on patients with dysthymia or chronic depression according to DSM-III, DSM-III-R, ICD-9, or RDC criteria, or patients who were described as having persistent depressive symptoms.

RESULTS

This review shows that dysthymic patients are at increased risk for poor general health and frequently use medical services. Compared to the general population, dysthymia is more prevalent in primary care and among patients with various medical and neurological conditions, sleep disorders, chronic fatigue, hypothyroidism, and somatoform disorders. Pharmacotherapy is effective, but has not been well studied. Non-tricyclic antidepressants might be especially useful. Psychotherapy studies are virtually non-existent.

CONCLUSIONS

Although dysthymia is considered a minor depressive condition, these findings show that it is a significant public health problem, comparable to major depression. Recent efforts to improve the recognition and treatment of major depression in medical settings, therefore, should be extended to include the entire spectrum of depressive disorders. Future studies should investigate the type and pattern of medical comorbidity and health care utilization, different antidepressant and psychosocial therapies, and the clinical and biological correlates of treatment response in different chronic depressive subtypes in medical settings and compare them to major depressive and subsyndromal depressive conditions.

The prevalence of pain in hospitalized patients and resolution over six months

Pain was assessed in 2415 randomly selected hospitalized patients. Fifty percent of the sample reported pain at the time of the interview, and 67% had experienced pain during the past 24 h. High levels of pain were more frequent in postpartum women, patients with diseases of the musculoskeletal systems and after injury or poisoning, but in all diagnostic categories there were patients whose lowest pain level in the preceding 24 h was moderate or severe. Patients who had undergone a surgical procedure during the past 7 days were more likely to report moderate or severe pain, but 21% of non-surgical patients reported moderate or severe pain. Twenty percent of those with pain reported that it had existed for more than 6 months. Patients reported significant impairment of function and distress as a consequence of pain. Use of analgesic medications was low overall and even lower for non-surgical patients. A decrease in pain over 3 weeks was predicted by pain of shorter duration, a shorter duration of hospitalization in the past year, and if a surgical procedure had been performed. None of these variables predicted pain resolution between 3 weeks and 3 or 6 months. Impairment of function did not increase with continuing pain but distress did. Medication use remained low at follow-up. The data indicate that current strategies to improve pain management need to be critically reviewed.

Differentiating major depression from adjustment disorder with depressed mood in the medical setting

Although the psychiatric consultant in the general hospital setting is frequently called on to distinguish major depression from adjustment disorder, no studies to date have examined whether the two diagnoses are in fact distinguishable. Analysis of computerized data base records from 944 cases seen by psychiatric consultants from 1981-1987 revealed 59 cases of major depression and 130 cases of adjustment disorder with depressed mood. Patients with major depression were more likely to be older (p less than 0.001), widowed (p less than 0.001), and living alone (p less than 0.005). Patients with adjustment disorder with depressed mood received higher ratings on Axis IV (p less than 0.01), and lower severity of illness ratings (p less than 0.001) were seen later in the hospital stay (p less than 0.05), and they were more likely to be rated by the consultant as improved by the time the case was terminated (p less than 0.001). The results suggest that the two disorders may be distinguished in the consultation population and that adjustment disorder with depressed mood may have descriptive validity in the medical inpatient setting.