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Scamvougeras A, Howard A. Somatic Symptom Disorder, Medically Unexplained Symptoms, Somatoform Disorders, Functional Neurological Disorder: How DSM-5 Got It Wrong. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2020; 65:301-305. [PMID: 32191123 PMCID: PMC7265612 DOI: 10.1177/0706743720912858] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Anton Scamvougeras
- UBC Neuropsychiatry Program, Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - Andrew Howard
- UBC Neuropsychiatry Program, Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
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Stone L. Being a botanist and a gardener: using diagnostic frameworks in general practice patients with medically unexplained symptoms. Aust J Prim Health 2012; 19:90-7. [PMID: 22951035 DOI: 10.1071/py11120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Accepted: 04/26/2012] [Indexed: 11/23/2022]
Abstract
Patients with multiple medically unexplained symptoms commonly seek treatment in primary care. Many of these patients seem to have a psychological 'core' to their illness that affects the way they experience, conceptualise and communicate their distress. There is considerable debate around diagnosis for this group of patients. Existing diagnoses include somatoform disorders in psychiatry and functional disorders in the medical specialties. Some clinicians use the term 'heartsink' patients, which reflects the interpersonal frustration inherent in some therapeutic relationships. A good diagnosis should be clinically useful, helping clinicians and patients understand and manage illness. Diagnosis should also provide a reliable classification for research and evidence-based treatment. The allegory of the botanist and the gardener has been used to describe diagnosis. For the botanist, a good diagnosis produces a taxonomy that is rigorous and reliable. For the gardener, it informs the way a garden is described and understood in a specific context. Clinicians need both: a 'botanical' type of classification to bring rigour to research and therapy, and clinical 'gardening', which allows for multiple perspectives and diagnostic frameworks. Clinical reasoning is a form of research with therapeutic intent. Botany and gardening represent a mixed-methods approach that can enrich diagnosis. The challenge is to integrate multiple perspectives in clinically helpful ways that help us retain both richness and rigour.
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Affiliation(s)
- Louise Stone
- University of Sydney, Camperdown, NSW 2050, Australia.
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Abstract
There is a wide debate among the researchers and clinicians over the diagnostic categories subsumed under the rubric of somatoform disorders (SDs). Recent proposals vary from radical views that call for removing this category altogether to the conservative views that suggests cosmetic changes in the diagnostic criteria of SDs. We have the reviewed the relevant literature through PUBMED search supplemented with manual search on current concepts of SD.
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Affiliation(s)
- Amlan K. Jana
- Department of Psychiatry, KPC Medical College and Hospital, Kolkata, West Bengal, India
| | | | - Joyita Mazumdar
- Central Institute of Psychiatry, Kanke, Ranchi, Jharkhand, India
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Pain associated with specific anxiety and depressive disorders in a nationally representative population sample. Soc Psychiatry Psychiatr Epidemiol 2010; 45:89-104. [PMID: 19360362 DOI: 10.1007/s00127-009-0045-1] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2008] [Accepted: 03/23/2009] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To examine in a nationally representative sample (a) the differential association of specific anxiety and depressive disorders defined according to DSM-IV with pain disorder (PD) and pain symptoms, and (b) whether pain-associated anxiety and depressive disorders and their comorbidity have different implications in terms of impairment, disability, health care utilization, and substance use. METHOD A nationally representative community study was conducted in Germany. Symptoms, syndromes and diagnoses of mental disorders, and pain were assessed in N = 4,181 participants aged 18-65 years using the DSM-IV/M-CIDI. RESULTS Logistic regressions revealed that pain is associated with both specific anxiety and depressive disorders, with increasing significant odds ratios (OR) for medically explained pain symptoms (EPS; OR range: 1.9-2.0), to unexplained pain symptoms (UPS; OR range: 2.4-7.3), to PD (OR range: 3.3-14.8). PD and UPS persistently showed associations after adjusting for comorbid other anxiety and depressive disorders and physical illnesses. All types of pain, particularly PD/UPS, are associated with decreased quality of life, greater impairment in role functioning, disability, health care utilization, and substance use. Depressive disorders, even more so anxiety disorders and their comorbidity account for a substantial proportion of variance in these functional correlates. CONCLUSIONS Pain is strongly associated with specific anxiety and depressive disorders. In light of the individual and societal burden due to pain, and the demonstrated role of comorbid anxiety or/and depression, our results call for further investigation of the underlying mechanisms for this association as well as targeted treatments for these comorbidities.
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Beesdo K, Hoyer J, Jacobi F, Low NCP, Höfler M, Wittchen HU. Association between generalized anxiety levels and pain in a community sample: evidence for diagnostic specificity. J Anxiety Disord 2009; 23:684-93. [PMID: 19278819 DOI: 10.1016/j.janxdis.2009.02.007] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2008] [Revised: 01/22/2009] [Accepted: 02/05/2009] [Indexed: 12/22/2022]
Abstract
BACKGROUND It is unclear whether generalized anxiety disorder (GAD) has a specific relationship to pain syndromes, going beyond the established association of pain with anxiety syndromes in general. METHODS Mental disorders were assessed in a community sample (N=4181; 18-65 years) using the DSM-IV/M-CIDI. Several threshold definitions were used to define GAD and medically unexplained pain. RESULTS The association between pain and GAD (odds ratio, OR=5.8 pain symptoms; OR=16.0 pain disorder) is stronger than the association between pain and other anxiety disorders (OR=2.4 pain symptoms; OR=4.0 pain disorder). This association extends to subthreshold level definitions of GAD with some indication for a non-linear dose-response relationship. The GAD-pain link cannot sufficiently be explained by demographic factors, comorbid mental or physical disorders. CONCLUSIONS The association of pain and generalized anxiety is not artifactual. Compared to other anxiety syndromes, it appears to be stronger and more specific suggesting the need to explore clinical and public health implications.
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Affiliation(s)
- Katja Beesdo
- Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Chemnitzer Str. 46, 01187 Dresden, Germany.
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Walker LS, Beck JE, Garber J, Lambert W. Children's Somatization Inventory: psychometric properties of the revised form (CSI-24). J Pediatr Psychol 2009; 34:430-40. [PMID: 18782857 PMCID: PMC2722132 DOI: 10.1093/jpepsy/jsn093] [Citation(s) in RCA: 194] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2008] [Revised: 08/11/2008] [Accepted: 08/12/2008] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVE To conduct a multimethod psychometric evaluation to refine the Children's Somatization Inventory (CSI) and to investigate its dimensionality. METHOD The CSI was administered to 876 pediatric patients with chronic abdominal pain at their initial visit to a pediatric gastroenterology clinic. Tools from three psychometric models identified items that most effectively measured the construct of somatization and examined its dimensionality. RESULTS Eleven statistically weak items were identified and removed, creating a 24-item CSI (CSI-24). The CSI-24 showed good psychometrics according to the three measurement models and correlated .99 with the original CSI. The CSI-24 has one dominant general factor but is not strictly unidimensional. CONCLUSIONS The CSI-24 is a reliable and psychometrically sound refinement of the original CSI. Findings are consistent with the view that somatization has a strong general factor that represents a continuum of symptom reporting, as well as minor components that represent specific symptom clusters in youth with chronic abdominal pain.
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Affiliation(s)
- Lynn S Walker
- Division of Adolescent Medicine and Behavioral Science, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN 37232-3571, USA.
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Leiknes KA, Finset A, Moum T, Sandanger I. Overlap, Comorbidity, and Stability of Somatoform Disorders and the Use of Current Versus Lifetime Criteria. PSYCHOSOMATICS 2008; 49:152-62. [DOI: 10.1176/appi.psy.49.2.152] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
PURPOSE OF REVIEW Current issues in consultation-liaison psychiatry, which is now labeled psychosomatic medicine as a formal subspecialty by the American Board of Psychiatry and Neurology, are discussed. RECENT FINDINGS There is continued interest in how to best manage depression and anxiety in a primary-care setting. Collaborative care that utilizes a psychiatrist within the treatment center, as well as case management by a nurse, have been reviewed and meta-analyses suggest it is an efficient and effective approach. The diagnostic issues within psychosomatic medicine are also an area of concern as the Diagnostic and Statistical Manual of Mental Disorders, 5 edition, is in the planning stages. How to improve both the reliability and validity of somatoform disorders will be a major challenge. Organ transplantation is a clinical challenge for patients, donors and healthcare providers. Issues in assessment and management continue to evolve. Ethical questions also arise due to the shortage of available organs. SUMMARY Psychosomatic medicine continues to manage patients in medical settings that cut across a continuum from primary-care to complex medical and surgical centers. The clinical problems containing a medical-psychiatric interface offer a clinical challenge but also an area for new knowledge and better interventions.
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Porcelli P, McGrath RE. Introduction to the special issue on personality assessment in medical settings. J Pers Assess 2008; 89:211-5. [PMID: 18001222 DOI: 10.1080/00223890701629607] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
This special issue of the Journal of Personality Assessment brings together 3 review articles and 5 research studies on personality assessment in medical settings that should help clinicians become more familiar with the current status of this field. In 1 review article, Sirri, Fabbri, Fava, and Sonino (2007/this issue) summarize evidence of a new approach to the assessment of psychological syndromes in somatizing patients based on the Diagnostic Criteria for Psychosomatic Research (Fava et al., 1995). The other reviews focus on 2 personality constructs widely used in investigations with medical patients. Kupper and Denollet (2007/this issue) review the Type D personality, whereas Lumley, Neely, and Burger (2007/this issue) provide an overview of alexithymia. Of the research articles, 2 also focus on alexithymia, specifically on the factor structure of the 20-item Toronto Alexithymia Scale (Bagby, Parker, & Taylor, 1994), which is the best-validated and most commonly used measure of alexithymia (Bagby, Taylor, Quilty, & Parker, 2007/this issue; Gignac, Palmer, & Stough, 2007/this issue). The other 3 research studies examine the relationship between specific personality dimensions (behavioral problems relevant to medicine, resiliency, and interpersonal sensitivity) and medical outcomes (adherence to treatment, coping with injury, and postsurgical sexual functioning) from medical samples of patients with HIV, spinal cord injury, and prostate carcinoma (Berry, Elliott, & Rivera, 2007/this issue; Cruess, Meagher, Antoni, & Millon, 2007/this issue; Siegel et al., 2007/this issue). Each article touches on the role person variables can play in the expression of medical problems.
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Löwe B, Mundt C, Herzog W, Brunner R, Backenstrass M, Kronmüller K, Henningsen P. Validity of current somatoform disorder diagnoses: perspectives for classification in DSM-V and ICD-11. Psychopathology 2008; 41:4-9. [PMID: 17952015 DOI: 10.1159/000109949] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2006] [Accepted: 11/16/2006] [Indexed: 12/15/2022]
Abstract
BACKGROUND The impending revisions of DSM-IV and ICD-10 provide an excellent opportunity to improve the diagnostic accuracy of the current somatoform disorder classification. To prepare for these revisions, this study systematically investigates the validity of the current classification of somatoform disorders. METHODS We searched Medline, Psycinfo and reference lists to investigate convergent, divergent, criterion and predictive validity of the current somatoform disorder classification. RESULTS Substantial associations of somatoform disorders with functional impairment and elevated health care costs give evidence for the clinical and societal importance of somatoform disorders and for the convergent validity of the current operationalization. The specificity of the current somatoform disorder classification, i.e. their divergent validity, is demonstrated by the fact that functional somatic syndromes and their consequences are only partially explained by association with anxiety and depression. However, the imprecision of the diagnostic criteria, which are not based on positive criteria but on the exclusion of organic disease, largely limits the criterion validity of the current classification systems. Finally, studies investigating the predictive potential of somatoform disorders are lacking, and to date predictive validity has to be considered as low. CONCLUSIONS The insufficient criterion and predictive validity of the present somatoform classification underlines the need to revise the diagnostic criteria. However, an abolishment of the whole category of somatoform disorders would ignore the substantial convergent and divergent validity of the current classification and would exclude patients with somatoform symptoms from the current health care system. A careful revision of the current somatoform disorder diagnoses, based on positive criteria of psychological, biological and social features, has the potential to substantially improve the reproducibility and clinical utility of the existing classification system.
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Affiliation(s)
- Bernd Löwe
- Department of Psychosomatic and General Internal Medicine, Center of Psychosocial Medicine, University of Heidelberg, Heidelberg, Germany.
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Abstract
Classification is not a trivial matter. In Burmese Days, George Orwell writes, "It is devilish to suffer from a pain that is all but nameless. Blessed are they who are stricken only with classifiable diseases! Blessed are the poor, the sick, the crossed in love, for at least other people know what is the matter with them and will listen to their belly-achings with sympathy." Patients who have somatoform disorders are particularly susceptible to this Orwellian lamentation. They are afflicted by symptoms that defy simple explanations. As detailed in this article, there is a spectrum of medical and psychiatric factors that can cause or contribute to somatic symptom burden. Research is continuing to reveal the central mechanisms that may provide a common pathway for physical and psychologic symptoms. The dualism that places some somatic symptom disorders on Axis I and others on Axis III gradually may fade in the coming decades as what the unifying causes are among common symptoms and the multicausal nature of many symptoms are discovered. Meanwhile, the classification systems should continue to operate on pragmatic principles where mechanistic explanations are lacking. This will allow grouping patients into categories that inform research, scientific and patient communication, prognostication, and clinical management. Coupling a heuristic classification system with evidence-based measures for assessing severity and monitoring treatment outcomes are important steps in the optimal care of symptomatic patients.
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Affiliation(s)
- Kurt Kroenke
- Indiana University School of Medicine, Indianapolis, IN, USA.
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Leiknes KA, Finset A, Moum T, Sandanger I. Current somatoform disorders in Norway: prevalence, risk factors and comorbidity with anxiety, depression and musculoskeletal disorders. Soc Psychiatry Psychiatr Epidemiol 2007; 42:698-710. [PMID: 17598059 DOI: 10.1007/s00127-007-0218-8] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2007] [Accepted: 05/29/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND The future existence of somatoform disorders (SDs) has recently been debated. The objectives of this study were to investigate the prevalence of current SDs (defined as the presence of multisomatoform disorder [MSD] or somatoform disorders not otherwise specified [SDnos], without psychosocial impairment) and severe current SDs (MSD or SDnos with psychosocial impairment) in Norway. Differences in markers of severe current SDs, anxiety/depression and self-reported musculoskeletal disorders were explored. In addition, psychological distress and utilization of healthcare in subclasses (defined according to comorbidity with anxiety, depression and musculoskeletal disorders) of severe current SDs were examined. METHODS We interviewed 1,247 respondents using the Composite International Diagnostic Interview (CIDI) in the Oslo-Lofoten general population survey in 2000-2001. Six-month prevalence rates (%) and 95% confidence intervals (CIs) for current SDs were investigated by gender and age. Risk factors of disorders, psychological distress, healthcare utilization and use of medication were explored using logistic regression analyses. RESULTS The overall prevalence rate for severe current SDs was 10.2%. When psychosocial impairment was excluded as a criterion, the rate increased to 24.6%. Anxiety was strongly correlated with severe current SDs. Comorbidity of severe current SDs with anxiety/depression was 45%, and with musculoskeletal disorders, 43%. Analysis of healthcare utilization and use of medication showed that the presence of a comorbid psychiatric condition was more important than the presence of somatoform disorders alone. CONCLUSION Somatoform symptoms alone (with no psychiatric comorbidity) should not be considered a psychiatric disorder.
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Affiliation(s)
- Kari Ann Leiknes
- Dept. of Behavioural Sciences in Medicine, Institute of Basic Medical Sciences, University of Oslo, P.B. 1111, Blindern, 0317, Oslo, Norway.
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Brown RJ. Introduction to the special issue on medically unexplained symptoms: background and future directions. Clin Psychol Rev 2007; 27:769-80. [PMID: 17707564 DOI: 10.1016/j.cpr.2007.07.003] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
This special issue is devoted to the topic of medically unexplained symptoms (MUS), a heterogeneous group of conditions characterized by persistent physical symptoms that cannot be explained by medical illness or injury. Although psychological factors have long been regarded as central to these problems, patients with MUS have typically been managed within medical settings and referrals to mental health services have been relatively rare. In recent years, however, interest in the psychological nature and treatment of MUS has expanded, culminating in the development of tailored psychological interventions for these conditions. This, coupled with the increasing willingness of practitioners to diagnose conditions such as chronic fatigue syndrome, fibromyalgia and irritable bowel syndrome, has led to an increase in the number of patients who are referred for psychological treatment. At present, however, many psychological therapists are unfamiliar with the literature on MUS. With this in mind, this special issue presents a series of papers that provide an overview of what is known about the nature, aetiology and treatment of medically unexplained illness. This introductory paper provides general information about the clinical presentation, diagnosis, classification, terminology and epidemiology of MUS in adults, and concludes with an examination of important areas for future development in the field. Subsequent papers address the psychological mechanisms [Deary, V., Chalder, T., & Sharpe, M. (2007-this issue). The cognitive behavioural model of medically unexplained symptoms: A theoretical and empirical review. Clinical Psychology Review; Iverson, A., Chalder, T., & Wessely, S. (2007-this issue). Gulf war illness: Lessons from medically unexplained illness. Clinical Psychology Review; Rief, W., & Broadbent, E. (2007-this issue). Explaining medically unexplained symptoms: Models and mechanisms. Clinical Psychology Review; Roelofs, K., & Spinhoven, P. (2007-this issue). Trauma and medically unexplained symptoms: Towards an integration of cognitive and neuro-biological accounts. Clinical Psychology Review] and management [Deary, V., Chalder, T., & Sharpe, M. (2007-this issue). The cognitive behavioural model of medically unexplained symptoms: A theoretical and empirical review. Clinical Psychology Review] of these conditions. A separate overview of the literature on MUS in children and adolescents is provided by Eminson [Eminson, J. (2007-this issue). Medically unexplained symptoms in children and adolescents. Clinical Psychology Review].
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Kroenke K, Sharpe M, Sykes R. Revising the Classification of Somatoform Disorders: Key Questions and Preliminary Recommendations. PSYCHOSOMATICS 2007; 48:277-85. [PMID: 17600162 DOI: 10.1176/appi.psy.48.4.277] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
As the DSM-V process unfolds, Somatoform Disorders are a diagnostic category for which major revisions seem warranted. The Conceptual Issues in Somatoform and Similar Disorders (CISSD) project recently convened three workshops, involving 24 experts. The CISSD identified key questions related to stakeholders; terminology; appropriate axis (I versus III); medically unexplained criteria; status of functional somatic syndromes; and symptom counts, grouping, lifetime recall, and checklists. Preliminary recommendations include substantial revision of the category of Somatization Disorder, elimination of Undifferentiated Somatoform Disorder and Pain Disorder, terminology changes, and potential shifting of certain disorders to different DSM categories or axes.
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Affiliation(s)
- Kurt Kroenke
- Indiana University School of Medicine and Regenstreif Institute, Indianapolis, IN 46202, USA.
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