Medically unexplained symptoms, somatisation disorder and hypochondriasis: course and prognosis. A systematic review

Exploring the course of functional somatic symptoms (FSS) from pre- to late adolescence and associated internalizing psychopathology - an observational cohort-study

BACKGROUND

Functional somatic symptoms (FSS), which commonly cannot be attributed to well-defined organic pathology, often co-occur with internalizing psychopathology and fluctuate throughout different life stages. We examined FSS courses throughout adolescence, and the association between preadolescent FSS, FSS severity and internalizing psychopathology at late adolescence.

METHODS

Data from the Copenhagen Child Cohort (CCC2000) were utilized from assessments at ages 11-12 years (preadolescence; T0) and 16-17 years (late adolescence; T1). Self-report questionnaire and interview data on FSS, internalizing psychopathology, chronic medical conditions, and sociodemographic data from Danish national registers were available for 1285 youths. FSS courses were categorized into persistent (high FSS at T0 & T1), remission (high FSS only at T0), incident (high FSS only at T1) or no FSS (no FSS at T0 & T1). Multiple linear and multinomial logistic regressions were conducted to investigate the FSS/psychopathology association.

RESULTS

1.8% of adolescents fell into the persistent FSS course group throughout adolescence. Higher preadolescent FSS predicted FSS (b = 0.07, p < .001), anxiety (b = 0.05, p < .001) and depression (b = 0.06, p < .001) at age 16/17, even after controlling for sex, parental education, a chronic medical condition and internalizing psychopathology in preadolescence. Persistent, incident, and remittent FSS courses were associated with significantly higher mean levels of anxiety and depression compared to the reference group (no FSS).

CONCLUSIONS

FSS during pre- and late adolescence might increase and co-occur with anxiety and depression throughout adolescence, potentially due to shared underlying risk factors and processes.

Comparison of death anxiety symptoms between generalized anxiety disorder and somatization disorder in geriatric patients attending a psychiatric outpatient clinic for the first time

Somatic complaints are among the important complaints frequently seen in Generalized Anxiety Disorder (GAD) and Somatic Symptom Disorder (SSD). Death anxiety has also increased significantly with the Covid-19 pandemic, especially in the elderly population. In this study, we compared the difference of the death anxiety level among patients with GAD, SSD and healthy controls. This cross-sectional study which was carried out in Artvin State Hospital's Psychiatric Outpatient Clinic included 59 participants (GAD = 21, SSD = 18, HC = 20). Three groups were subjected to detailed psychiatric examination by the same psychiatrist. Subsequently, anxiety, somatic symptoms and death anxiety were assessed using standardized tools (GAD-7, Templer Death Anxiety Scale, Somatic Symptom Scale). The GAD-7 Scale mean of the GAD group was significantly higher than SSD (p = 0.001) and Healthy Control (HC) (p = 0.001) groups. Death anxiety and Somatic Symptom levels in GAD and SSD groups were significantly higher than in healthy controls. (GAD, p = 0.001; SSD, p = 0.001) with no significant difference between GAD and SSD groups (p = 1). Healthy controls exhibited significantly lower scores in the three scales mean scores compared to the SSD and GAD groups (p = 0.001). Irrespective of specific psychiatric diagnoses, these findings highlight elevated death anxiety in the elderly, underscoring the need for tailored mental health interventions.

School Absenteeism Longer Than Two Weeks Is a Red Flag of Somatic Symptom and Related Disorders in Hospitalised Children and Adolescents: A Matched Cohort Study

Chronic school absenteeism is a common problem in childhood and adolescence, and it is frequently observed in patients with somatic symptom and related disorders (SSRDs). This study aimed to determine whether and to what extent the presence of school absenteeism may be a risk factor for the diagnosis of SSRDs in hospitalised patients. This matched cohort study included children and adolescents aged between 8 and 17 years, admitted to the paediatric ward of the IRCCS Burlo Garofolo in Trieste from 2021 to 2023, who were divided into two groups, the first including children with at least 15 days of absence from school for medical reasons and the second including children with regular school attendance, matched to the former group by age and sex. We consecutively enrolled 70 patients, 35 in the absentee group and 35 in the control group. In the absentee group, 30/35 (85.7%) patients were diagnosed with an SSRD, while in the control group, 1/35 (2.9%) was diagnosed with an SSRD. The absentee group had a 30-fold higher risk of being diagnosed with SSRDs than the control group (RR = 30 [95% CI = 4.3-208]; p < 0.001). This study shows that in hospitalised children, a history of school absenteeism of more than two weeks is an important risk factor for the diagnosis of SSRDs.

Evaluation and 1-year follow-up of patients presenting at a Lyme borreliosis expertise centre: a prospective cohort study with validated questionnaires

OBJECTIVES

To describe the course of symptoms reported by patients with symptoms attributed to Lyme borreliosis (LB) without being subsequently diagnosed with LB.

METHODS

We performed a prospective cohort study with patients presenting at the outpatient clinic of two clinical LB centres. The primary outcome was the prevalence of persistent symptoms, which were defined as clinically relevant fatigue (CIS, subscale fatigue), pain (SF-36, subscale bodily pain), and cognitive impairment (CFQ) for ≥ 6 months and onset < 6 months over the first year of follow-up. Outcomes were compared with a longitudinal cohort of confirmed LB patients and a general population cohort. Prevalences were standardised to the distribution of pre-defined confounders in the confirmed LB cohort.

RESULTS

Participants (n = 123) reported mostly fatigue, arthralgia, myalgia, and paraesthesia as symptoms. The primary outcome could be determined for 74.8% (92/123) of participants. The standardised prevalence of persistent symptoms in our participants was 58.6%, which was higher than in patients with confirmed LB at baseline (27.2%, p < 0.0001) and the population cohort (21.2%, p < 0.0001). Participants reported overall improvement of fatigue (p < 0.0001) and pain (p < 0.0001) but not for cognitive impairment (p = 0.062) during the follow-up, though symptom severity at the end of follow-up remained greater compared to confirmed LB patients (various comparisons p < 0.05).

CONCLUSION

Patients with symptoms attributed to LB who present at clinical LB centres without physician-confirmed LB more often report persistent symptoms and report more severe symptoms compared to confirmed LB patients and a population cohort.

Annual Research Review: Health anxiety in children and adolescents-developmental aspects and cross-generational influences

Health anxiety involves excessive worries about one's health along with beliefs one has an illness or may contract a serious disease. Concerning evidence suggests that health anxiety is on the rise in society, possibly further fueled by the COVID-19 pandemic. Recent classification systems acknowledge that impairing health-related worries and beliefs can emerge in early childhood with significant levels of symptoms persisting throughout childhood, and possibly continuous with diagnostic considerations in adulthood. This narrative review summarizes recent research advances in health anxiety in children and adolescents, focusing on various developmental aspects of health anxiety and related concepts in youths. Findings suggest that health anxiety symptoms in young age groups are associated with impairment, distress, and increased healthcare use, as well as substantial comorbidity with mainly other emotional problems and disorders. Furthermore, longitudinal studies suggest that childhood health anxiety can persist across adolescence, perhaps with links to chronic courses in adulthood. The growing literature was further reviewed, thus extending our understanding of early risk factors, including the potential role of exposure to serious illness and transgenerational transmission of health anxiety. Learning more about developmental trajectories will be highly relevant to inform strategies for early detection and prevention. While modified cognitive behavioral therapies in adults are successful in treating health anxiety, specific interventions have not yet been tested in youths. Given substantial overlaps with other psychopathology, it could be important to develop and explore more transdiagnostic and scalable approaches that take advantage of common factors in psychotherapy, while also including a wider perspective on potential familiar maladaptive illness cognitions and behaviors.

Program of algorithm for pharmacological treatment of major depressive disorder in China: Benefits or not?

Background

This research was designed to investigate Algorithm Guided Treatment (AGT) and clinical traits for the prediction of antidepressant treatment outcomes in Chinese patients with major depressive disorder (MDD).

Methods

This study included 581 patients who had reached treatment response and 406 patients remained non-responded observed after three months of treatment. Sociodemographic factors, clinical traits, and psychiatric rating scales for evaluating therapeutic responses between the two groups were compared. Logistic regression analysis was adopted to determine the risk factors of unresponsive to antidepressant (URA) in MDD. Kaplan-Meier survival analysis was utilized to compare the therapeutic response between AGT and treatment as usual (TAU).

Results

Compared to the MDD responsive to antidepressant (RA) group, the URA group had significantly lower rates of the following clinical traits: married status, anxious distress, moderate to severe depressive symptoms, and higher rates of comorbidity (p-value < 0.05). Logistic Regression Analysis showed that eight clinical traits from psychiatric rating scales, such as anxious characteristics, were correlated positively with URA, while the other eight symptoms, such as autonomic symptoms, were negatively correlated. Time to symptomatic remission was longer in TAU without statistically significant (p-value = 0.11) by log-rank testing.

Conclusions

The factors may affect the therapeutic responses and compliance of patients, increasing the non-response risk for antidepressants. Therapeutic responses might be improved by increasing the clarification and elucidation of different symptom clusters of patients. Benefits on treatment response to AGT were not found in our study, indicating a one-size-fits-all approach may not work.Trial Registration: We registered as a clinical trial at the International Clinical Trials Registry Platform (No. NCT01764867) and obtained ethical approval 2012-42 from SMHC.

Unwanted outcomes in cognitive behavior therapy for pathological health anxiety: a systematic review and a secondary original study of two randomized controlled trials

INTRODUCTION

Cognitive behavior therapy (CBT) is effective for pathological health anxiety, but little is known about unwanted outcomes.

AREAS COVERED

We investigated unwanted outcomes in the form of adverse events, overall symptom deterioration, and dropouts in CBT for pathological health anxiety based on a systematic review of 19 randomized controlled trials (PubMed, PsycInfo, and OATD; last updated 2 June 2023; pooled N = 2188), and then a secondary original study of two randomized controlled trials (pooled N = 336). In the systematic review, 10% of participants in CBT reported at least one adverse event and 17% dropped out. Heterogeneity was substantial. In the original investigation, 17% reported at least one adverse event, 0-10% met criteria for overall symptom deterioration, and 10-19% dropped out. In guided Internet-delivered CBT, dropouts were more common with lower education and lower credibility/expectancy ratings. Higher adherence was associated with a larger reduction in health anxiety.

EXPERT OPINION

Unwanted effects are routinely seen in CBT for pathological health anxiety, but, under typical circumstances, appear to be acceptable in light of the treatment's efficacy. There is a need for more consistent methods to improve our understanding adverse events, dropouts, and overall symptom deterioration, and how these outcomes can be prevented.

An interdisciplinary multimodal integrative healthcare program for somatic symptom disorder, with predominant (spinal) pain

OBJECTIVE

Although multimodal interventions are generally recommended in patients with long-term somatic symptom disorders (SSD), available evidence is limited. The current study evaluates the effectiveness of an outpatient secondary care interdisciplinary multimodal integrative healthcare program for patients with SSD and predominant (spinal) pain.

METHOD

The healthcare program consisted of two active treatment phases: main 20-week program and a 12-month relapse prevention program. Participants were 4453 patients diagnosed with SSD. The primary outcome was health-related quality of life (HRQoL) assessed using the RAND-36 (i.e., mental/physical component summary) and secondary outcomes included physical and psychological symptoms assessed using the Brief Symptom Inventory (BSI) and RAND-36 subscales. Mixed linear models were used to examine the effects of the multimodal healthcare program on primary/secondary outcomes over four time points: before start 20-week program (T0), halfway 20-week program (T1), end of 20-week program (T2) and end of relapse prevention program (T3).

RESULTS

Significant improvements were found from T0 to T2 for all primary variables (i.e., mental/physical component summary) and secondary variables (i.e., BSI/RAND-36 subscales), which were maintained until the end of the relapse prevention program (T3).

CONCLUSION

An interdisciplinary multimodal integrative treatment for SSD is effective for improving HRQoL and reducing physical and psychological symptoms.

Somatization in dermatology

Medically unexplained dermatologic symptoms, such as pruritus, numbness and burning are known as somatization. These cutaneous symptoms can be very difficult to treat because of an absence of an objective explanation and they may not fit neatly into any known dermatological or psychiatric condition. These disorders are more commonly encountered in primary care and in dermatology, rather than in psychiatry. Certain skin disorders, for example, pruritus, could be a manifestation of somatization and others may predispose to somatic symptoms, for example, atopic dermatitis and psoriasis. Although there has been increasing research in the interconnection between psychiatry and dermatology, psychodermatology is a relatively new crossover discipline in clinical practice and recognition of psychodermatological conditions, such as cutaneous somatic disorders, can be difficult. Somatization may occur with or without the existence of a dermatological disease. When a dermatological disorder is present, somatization should be considered when the patient is worrying too much about their skin, spending too much time and energy on it and especially if the patient also complains of many non-cutaneous symptoms. Purely cutaneous somatic conditions include for example, the genital pain syndromes or Gardner-Diamond syndrome, characterized by unexplained bruising, which usually affects women. Effective management tools may include mindfulness therapies, pharmacotherapy with selective serotonin reuptake inhibitors, tricyclic antidepressants and cognitive conduct therapy. Electroconvulsive therapy can also be considered in extremely rare cases for treatment of severe somatization on a background of mood disorders. This paper discusses somatization, its relationship to immunodermatoses and its relevance to clinical practice.

The 14-item short health anxiety inventory (SHAI-14) used as a screening tool: appropriate interpretation and diagnostic accuracy of the Swedish version

BACKGROUND

The 14-item Short Health Anxiety Inventory (SHAI-14) is a common measure of health anxiety but its screening properties have not been studied. The aims of this study were to evaluate the SHAI-14 as a screening instrument, identify cut-offs for clinically significant health anxiety and investigate which scores correspond to different severity levels.

METHOD

The study included 1729 psychiatric patients and 85 healthy controls. Participants completed the SHAI-14 and underwent a diagnostic interview. Cut-off scores were evaluated in three scenarios to approximate screening 1) in a psychiatric clinic, 2) in a low prevalence setting and, 3) of healthy volunteers (cut-off for remission). Receiver operating characteristics were used. Classification of severity was based on the distribution of SHAI-14 scores reported by patients with clinically significant health anxiety.

RESULTS

The area under the curve (AUC) values were high in all scenarios (above 0.95). The optimal cut-off scores on the SHAI-14 were 22 in the psychiatric context, 29 in a setting with low prevalence of psychiatric disorders and 18 versus healthy controls. SHAI-14 scores of 0-27 represented no or mild health anxiety, 28-32 moderate health anxiety and 33-42 substantial health anxiety.

CONCLUSION

Brief self-report measures used as screening instruments are a simple way of gathering information about the presence of specific symptoms and thus a way to detect the likelihood of a diagnosis. The SHAI-14 shows evidence of good diagnostic utility in both clinical and non-clinical settings. However, which cut-off score is to be used, depends on the intended purpose and the setting where the cut-off is used.

Recent developments on psychological factors in medically unexplained symptoms and somatoform disorders

Somatic symptoms which are not fully explained by a medical condition (medically unexplained symptoms) have a high relevance for the public health. They are very common both in the general population and in patients in health care, and may develop into chronic impairing conditions such as somatoform disorders. In recent years, the relevance of specific negative psychological factors for the diagnosis and the stability of somatoform disorders and for the impairment by medically unexplained symptoms gained more and more attention. This resulted-among others- in core changes in the diagnostic classification criteria of somatoform disorders. Against this background, the present "Perspective" will outline recent developments and findings in the area of medically unexplained somatic symptoms and somatoform disorders. Moreover, it will lay a special focus on evidence on specific negative psychological factors that may influence the course of unexplained somatic symptoms and disorders and the impairment caused by these symptoms.

Female sex and femininity independently associate with common somatic symptom trajectories

BACKGROUND

Multiple predictors have been associated with persistent somatic symptoms. However, previous studies problematically defined the persistence of symptoms, conflated participants' sex and gender, and focused on patient populations. Therefore, we studied associations between predictors, especially sex and gender, and longitudinal patterns of somatic symptoms in the general adult population. We also assessed whether predictors for persisting symptoms differ between sexes.

METHOD

To identify developmental trajectories of somatic symptoms, assessed by the SCL-90 SOM, we used latent class trajectory modeling in the Dutch Lifelines Cohort Study [N = 150 494; 58.6% female; median time to follow-up: 46.0 (min-max: 22.0-123.0) months]. To identify predictors of trajectories, we applied multiple logistic regression analyses. Predictors were measured by surveys at baseline and a composite gender index was previously developed.

RESULTS

A five-class linear LCGA model fitted the data best: 93.7% of the population had a stable symptom trajectory, whereas 1.5% and 4.8% of the population had a consistently increasing or decreasing symptom trajectory, respectively. Female sex predicted severe, stable symptom severity (OR 1.74, 95% CI 1.36-2.22), but not increasing symptom severity (OR 1.15, 95% CI 0.99-1.40). Femininity was protective hereof (OR 0.60, 95% CI 0.44-0.82 and OR 0.66, 95% CI 0.51-0.85, respectively). Merely a few predictors of symptom severity, for instance hours of paid employment and physical functioning, differed in strength between sexes. Yet, effect sizes were small.

CONCLUSION

Female sex and femininity predict symptom trajectories. No large sex differences in the strength of additional predictors were found, thus it may not be clinically useful to distinguish between predictors specific to male or female patients of persistent somatic symptoms.

Can you be cured if the doctor disagrees? A case study of 27 prayer healing reports evaluated by a medical assessment team in the Netherlands

THE SETTING: between 2015 and 2020 a medical assessment team evaluated 27 reports of prayer healing in the Netherlands.

OBJECTIVES

Three research questions were formulated. What are the medical and experiential findings? Are there medically remarkable and/or unexplained healings? Which explanatory frameworks can help us understand the findings?

METHODS

The reported healings were analyzed using both medical files and patient narratives, as part of a case study research design compiled by a multidisciplinary research team. An independent team of five medical consultants, representing different fields of expertise, evaluated the 27 case files. According to criteria these were selected from a larger group of 83 received reports. Experiential data was obtained by in-depth interviews and analyzed. Instances of healing could be classified as 'medically remarkable' or 'medically unexplained'. Subsequent analysis was transdisciplinary.

RESULTS

Eleven of the 27 healings assessed were evaluated as 'medically remarkable', none were labelled as 'medically unexplained'. Recurring characteristics were common to some degree in all healings, whether 'medically remarkable' or not: a temporal connection with prayer, instantaneity and unexpectedness of healing, strong emotional and physical manifestations, and a sense of 'being overwhelmed' and transformed. The healings were invariably interpreted as acts of God. Positive effects have persisted for 5 to 33 years, with 2 relapses.

CONCLUSIONS

Our findings on remarkable healings do not fit well in the traditional biomedical conceptual framework. All healings exhibited important non-medical aspects, whether or not they were assessed as medically remarkable. We need a broader multi-perspective approach in which all relevant data is considered to be valuable, both experiential and objective. This so-called horizontal epistemology may be helpful when trying to understand the findings, and it may bring about mutual understanding between patients, health practitioners and relevant disciplines.

[Functional somatic symptoms: Clinical varieties, diagnostic challenges, therapeutic principles]

Functional somatic symptoms are common and multiform. They occur in all genders and age groups, with and without somatic or mental comorbidity. Dysfunctional illness behaviour on the patients' (e. g., excessive attention or anxiety) and also on the caregivers' side (e. g., nocebo messages, redundant investigations or risky treatments) can promote chronification. Empathy, well balanced diagnostics, comprehensible information within individual multifactorial explanatory models, refocussing, activation, and - in more severe forms - additional measures such as psychotherapy are recommended.

Health anxiety and attentional control interact to predict uncertainty-related attentional biases

BACKGROUND AND OBJECTIVES

Current theories of health anxiety and a growing body of empirical literature suggest that those high in health anxiety symptoms might find uncertainty itself threatening and demonstrate attentional biases for uncertainty-related information (ABU). Moreover, a dual processes model of attention would suggest that individual differences in attentional control might modify such a relationship. The present study was designed to explore this proposed health anxiety-ABU relationship and also to consider attentional control as a moderator of theoretical and clinical relevance.

METHODS

Undergraduate participants (N = 148) completed a self-report measure of health anxiety symptoms and two performance-based tasks to assess ABU and attentional control.

RESULTS

Hierarchical regression analyses showed a significant interaction between health anxiety and attention control in predicting attentional disengagement from, but not engagement with, uncertainty-related words. Specifically, results of the simple slopes analysis suggested that those with elevated health anxiety symptoms and better attentional control may use top-down attentional control processes to disengage their attention from distressing uncertainty-related stimuli faster than those with worse attentional control.

LIMITATIONS

The analogue sample is a study limitation.

CONCLUSIONS

Results provide new insights into the nature of attentional biases within health anxiety. Results are discussed in light of recent work on attentional control and avoidance-based psychopathology.

Cost Effectiveness of Internet-Delivered Acceptance and Commitment Therapy for Patients with Severe Health Anxiety: A Randomised Controlled Trial

BACKGROUND

Health anxiety is a prevalent and debilitating disorder associated with extensive use of healthcare services and reduced quality of life (QoL). Regional variability in specialised clinics or specialist healthcare providers limits access to evidence-based treatment, which may be overcome by internet-delivered Acceptance and Commitment Therapy (iACT).

OBJECTIVE

This study investigated the cost effectiveness of iACT for severe health anxiety in adults.

METHODS

Based on a Danish randomised controlled trial (March 2016-March 2017), the economic evaluation compared costs and effects between iACT and an active control condition (iFORUM). Effectiveness was measured using self-report questionnaires. The cost analysis applied a societal perspective. Resource use and healthcare costs were extracted from the Danish National Registries. Linear regression analysis was applied using change in costs/effectiveness outcomes as the dependant variable. Time, group, and interaction between time and group were independent variables. The primary outcome was the proportion of clinically significant improvements, defined as a ≥ 25% reduction in two measures of health anxiety. The probability of cost effectiveness was presented in a cost-effectiveness acceptability curve for a range of threshold values for willingness to pay.

RESULTS

No significant differences were detected in healthcare costs between groups; however, the iACT group significantly improved in all effectiveness outcomes. The economic analysis showed that, from the healthcare perspective, iACT was associated with an incremental cost-effectiveness ratio of €33 per additional case of clinically significant improvement compared with iFORUM and that, from the societal perspective, iACT dominated iFORUM because it was more effective and less expensive.

CONCLUSIONS

We found no statistically significant differences in costs between groups; however, iACT for severe health anxiety may be cost effective, as evidenced by significant differences in effect.

TRIAL REGISTRY NUMBER

Clinicaltrials.gov, no. NCT02735434.

Network Analysis of Persistent Somatic Symptoms in Two Clinical Patient Samples

OBJECTIVE

Previous attempts to group persistent somatic symptoms (PSSs) with factor-analytic approaches have obtained heterogeneous results. An alternative approach that seems to be more suitable is the network theory. Compared with factor analysis, which focuses on the underlying factor of symptoms, network analysis focuses on the dynamic relationships and interactions among different symptoms. The main aim of this study is to apply the network approach to examine the heterogeneous structure of PSS within two clinical samples.

METHODS

The first data set consisted of n = 254 outpatients who were part of a multicenter study. The second data set included n = 574 inpatients, both with somatoform disorders. Somatic symptom severity was assessed with the Screening of Somatoform Disorder (SOMS-7T).

RESULTS

Results indicate that there are five main symptom groups that were found in both samples: neurological, gastrointestinal, urogenital, cardiovascular, and musculoskeletal symptoms. Although patterns of symptoms with high connection to each other look quite similar in both networks, the order of the most central symptoms (e.g., symptoms with a high connection to other symptoms in the network) differs.

CONCLUSIONS

This work is the first to estimate the structure of PSS using network analysis. A next step could be first to replicate our findings before translating them into clinical practice. Second, results may be useful for generating hypotheses to be tested in future studies, and the results open new opportunities for a better understanding for etiology, prevention, and intervention research.

Symptom change trajectories in patients with persistent somatic symptoms and their association to long-term treatment outcome

OBJECTIVE

This study investigated symptom change trajectory for patients with persistent somatic symptoms (PSS) during psychotherapy and the association of these patterns with pre-treatment characteristics and long-term outcome.

METHODS

Growth mixture modeling was used to identify trajectory curves in a sample of N = 210 outpatients diagnosed with PSS and treated either with conventional cognitive behavioral therapy (CBT) or CBT enriched with emotion regulation training (ENCERT).

RESULTS

We identified three subgroups of patients with similar symptom change patterns over the course of treatment (a "no change," "strong response," and "slow change" subgroup). Higher initial anxiety symptoms were significantly associated with the no change and strong response subgroups; symptom-related disability in daily routine with no changes. Patients with a strong response had the highest proportion of reliable improvement at termination and at six-month-follow-up.

CONCLUSION

Our results indicate that, instead of one common change pattern, patients with PSS respond differently to treatment. Due to the high association of symptom curves with long-term outcome, the identification and prediction of an individual's trajectory could provide important information for clinicians to identify non-responding patients that are at risk for failure. Selecting personalized treatment interventions could increase the effectiveness of psychotherapy.Trial registration: ClinicalTrials.gov identifier: NCT01908855..

Persistence rate of DSM-5 somatic symptom disorder: 4-year follow-up in patients from a psychosomatic outpatient clinic

BACKGROUND

Somatic Symptom and Related Disorders (SSD) were introduced by DSM-5 in order to improve the classification of somatoform disorders. There is a lack of longitudinal studies on course and predictors of SSD. The present study investigates the natural course of SSD in a four-year follow-up study in patients from a psychosomatic outpatient clinic.

MATERIAL AND METHODS

At baseline, n = 360 outpatients completed a semi-structured clinical interview to assess SSD, and additional self-report questionnaires (SSS-8, SSD-12, PHQ-8, GAD-7, SF-12). 112 patients were re-assessed after four years. Persistence rate and predictors for persisting SSD were evaluated.

RESULTS

The prevalence rate of SSD at baseline was 51.8%, and 47.3% at follow-up. We found a persisting SSD in 30.4% (n = 34) of the patients, a remission rate of 21.4% (n = 24) and an incidence rate of 16.9% (n = 19). 31.3% (n = 35) of the sample never received a SSD diagnosis. Significant predictors for persistence were a high psychological burden through somatic symptoms (OR: 1.13, 95% CI: 1.01-1.26) and general anxiety (OR: 1.38, 95% CI: 1.01-1.88) at baseline.

CONCLUSION

This study indicates that SSD is highly prevalent and persistent in patients from a psychosomatic setting. Our findings indicate that psychological and behavioral factors contribute to the maintenance of SSD and present potential targets for interventions. Future interventions for SSD could potentially be optimized by addressing psychological processes such as catastrophic thinking styles and symptom focusing.

Patients' Perspectives on the Usability of a Blended Approach to an Integrated Intervention for Patients With Medically Unexplained Physical Symptoms: Mixed Methods Study

Background

Medically unexplained physical symptoms are physical symptoms, such as pain, fatigue, and dizziness, that persist for more than a few weeks and cannot be explained after adequate medical examination. Treatment for preventing the chronicity of symptoms is recommended. A promising approach is identifying patients who are at risk and subsequently offering a blended care intervention that focuses on promoting self-management while using eHealth as a supportive tool. When these interventions match with a patient’s expectations, their effectiveness grows.

Objective

This study aimed to obtain more insights into usability from the patient perspective to improve future interventions.

Methods

A mixed methods design (ie, the use of qualitative and quantitative data) was used. Through semistructured interviews, in-depth insights were gained into patients’ perspectives on usability. The analysis process was continuous and iterative. Data were synthesized and categorized into different themes. The System Usability Scale, which measures the usability of a system, was used to compare participants that found usability to be low, medium, or high. This study was approved by the Medical Ethical Committee Utrecht (approval number: 17-391/C).

Results

Saturation was reached after interviewing 13 participants. The following four themes emerged from the interviews: motivations and expectations prior to participating in the program, the applicability of e-coaching, the role of health care professionals, and the integrated design of the blended approach.

Conclusions

The successful implementation of integrated blended care interventions based on patients’ perspectives requires matching treatments to patients’ individual situations and motivations. Furthermore, personalizing the relative frequency of face-to-face appointments and e-coaching can improve usability.

Healthcare professionals' perspectives on a blended care program in primary care; A qualitative study

Increasingly, healthcare policies have changed focus from cure and care to behaviour and health. Prevention is becoming more important, which requires a change in the role of healthcare professionals. Healthcare professionals' role is changing from being a therapist to taking on the role of a coach. To prevent chronicity in Medically Unexplained Physical Symptoms (MUPS), an integrated blended care program was developed. To apply this new program in daily practice, it is important to gain insight into the usability. From the healthcare professionals' point of view the concept of usability consists of performance, satisfaction and acceptability. In this qualitative study participants were recruited after participating in the PARASOL program. Demographics were collected. Semi-structured interviews were conducted and analysed using thematic analysis. Ten healthcare professionals (six physical therapists and four mental health nurses) were interviewed. Four themes on usability were identified: (1) Who fits in the program, (2) preparation, (3) experience with the program and (4) interprofessional collaboration. This study gathered healthcare professionals' experiences with and attitudes towards integrating healthcare and offering blended care programs. An integrated blended care program offers the possibility to personalize treatment. Findings show attention should be given to the new responsibilities of healthcare professionals, and their role in integrated and blended care. This new approach of delivering healthcare can facilitate interprofessional collaboration. Achieving sustainable change in patients however still requires instruction and support for healthcare professionals implementing behavioural change techniques.

Understanding Veterans' Causal Attributions of Physical Symptoms

BACKGROUND

Illness beliefs are significant contributors to health outcomes. Beliefs about the cause of physical symptoms are considered particularly important among those with medically unexplained symptoms and illnesses (MUS); yet little is known about causal beliefs among those with the most severe MUS (i.e., Veterans). The goal of the current study was to examine Veteran's causal attributions of their physical symptoms.

METHOD

A total of 91 combat Veterans with MUS were surveyed using a mixed-methods design about the cause of their physical symptoms, physical symptom severity, and PTSD symptoms. Causal attributions of physical symptoms were analyzed through thematic response analysis and grouped into categories. Chi-square analysis was used to assess the distribution of causal attribution types across Veterans with varying physical symptom severity and PTSD symptom severity.

RESULTS

Veterans with MUS reported an average of 7.9 physical symptoms, and attributed the cause of their symptoms to seven different categories ("Do not Know," "Stress/Mental Health," "Deployment/Environment," "Functional/Symptom," "Medically Explained," "Medically Unexplained Syndrome," and "Lifestyle"). Exploratory chi-square analysis revealed significant differences in causal attributions across physical symptom severity and severity of PTSD symptoms. Veterans with more severe PTSD and Veterans with more severe physical symptoms were more likely to attribute their MUS to stress/mental health or to a medically unexplained syndrome compared with those with low/no PTSD symptoms and physical symptom severity. Veterans with minimal PTSD and Veterans with minimal physical symptom severity were more likely to attribute the cause of their MUS to lifestyle choices (e.g., exercise/diet) compared with those with high PTSD and physical symptom severity.

CONCLUSION

Veterans with MUS endorse multiple, varied causal attributions for their physical symptoms, suggesting more complex causal beliefs than typically assumed. This has important implications for patient-provider communication and development of concordance around MUS treatment.

Predicting optimal treatment outcomes using the Personalized Advantage Index for patients with persistent somatic symptoms

Because individual patients with persistent somatic symptoms (PSS) respond differently to treatments, a better understanding of the factors that predict therapy outcomes are of high importance. Aggregating a wide selection of information into the treatment-decision process is a challenge for clinicians. Using the Personalized Advantage Index (PAI) this study aims to deal with this. Methods: Data from a multicentre RCT comparing CBT (N = 128) versus CBT enriched with emotion regulation training (ENCERT) (N = 126) for patients diagnosed with somatic symptom disorder were used to identify based on two machine learning approaches predictors of therapy outcomes. The identified predictors were used to calculate the PAI. Results: Five treatment unspecific predictors (pre-treatment somatic symptom severity, depression, symptom disability, health-related quality of life, age) and five treatment specific moderators (global functioning, early childhood traumatic events, gender, health anxiety, emotion regulation skills) were identified. Individuals assigned to their PAI-indicated optimal treatment had significantly lower somatic symptom severity at the end of therapy compared to those randomised to their non-optimal condition. Conclusion: Allowing patients to choose a personalised treatment seems to be meaningful. This could help to improve outcomes for PSS and reduce its high costs to the health care system.

The acceptability of primary care or community-based behavioural interventions for persistent physical symptoms: Qualitative systematic review

PURPOSE

Persistent physical symptoms (PPS) are often associated with profound physical disability and psychological distress. Interventions for PPS that promote behavioural change aim to reduce levels of symptoms and improve overall functioning in patients. The evidence for these interventions is mixed, with effective relationships between patients and health practitioners (HPs) reported as the key to the success of primary care interventions. The objectives of this systematic review were to synthesize the qualitative evidence and to evaluate the acceptability of behavioural interventions for PPS in primary care, from the perspective of both patients and HPs.

METHODS

A comprehensive literature search was conducted in seven major electronic bibliographic databases, to February 2019. The aim was to identify a broad range of literature including, qualitative research, mixed methods research, and qualitative data embedded in trial reports or process evaluations. Fifty-eight full papers were screened against the inclusion criteria. Nine studies were included and quality-assessed. A qualitative evidence synthesis was conducted using thematic synthesis.

RESULTS

Some patients and HPs reported positive gains from taking part in or delivering interventions, with appropriate support and explanation of their symptoms important for patients. Barriers appeared to be underpinned by the relationship between the patients and HPs, and by beliefs and attitudes held by both parties.

CONCLUSIONS

Patients should be provided with adequate information to make an informed decision about whether an intervention is appropriate for them, and interventions should not end suddenly or without adequate follow-up. HPs should receive training and supervision to address their lack of confidence, and improve their knowledge of PPS.

Continuity of health anxiety from childhood to adolescence and associated healthcare costs: a prospective population-based cohort study

BACKGROUND

Severe health anxiety (HA) is characterized by excessive and impairing worry and preoccupation with health issues and can cause increased and unnecessary medical examinations. HA in childhood and adolescence is scarcely explored, hindering the potential for prevention and early intervention.

METHODS

HA was assessed in 1,278 children/youths at two time points at ages 11 and 16 years in a general population-based birth cohort. Register-based data on costs related to nonhospital-based primary and secondary somatic health services were obtained over the follow-up period. The presence of functional somatic symptoms, emotional disorders and chronic somatic illness at baseline were included as covariates.

RESULTS

High HA (top 10% score) at age 11 predicted high HA at age 16 (relative risk [RR] 2.03, 95% CI: 1.26-3.31). The group with persistent HA was small (n = 17, 1.3%), resulting in broad confidence intervals. The statistical effect of HA at age 11 on HA at age 16 was heavily reduced after adjustment for sex and all covariates (RR: 1.49, 95% CI: 0.85-2.60). In the adjusted model, somatic illness at age 11 (RR: 1.91, 95% CI: 1.22-2.98) and female sex (RR: 3.33, 95% CI: 2.01-5.50) were independently associated with HA at age 16. Persistent HA was associated with approximately doubled healthcare costs compared to the group with consistently low HA. Incident HA at age 16 was associated with increased costs over follow-up. The increased costs were not explained by chronic somatic illness.

CONCLUSIONS

A small subgroup of children had persistent high levels of HA from late childhood to adolescence and displayed increased healthcare costs. Female sex and chronic somatic disorders at age 11 were independent risk factors of HA at age 16. These findings provide potential means of early identification and of therapeutic levers. Further intervention development and evaluation are needed.

Developing a clinical prediction rule for repeated consultations with functional somatic symptoms in primary care: a cohort study

OBJECTIVES

Patients who present in primary care with chronic functional somatic symptoms (FSS) have reduced quality of life and increased health care costs. Recognising these early is a challenge. The aim is to develop and internally validate a clinical prediction rule for repeated consultations with FSS.

DESIGN AND SETTING

Records from the longitudinal population-based ('Lifelines') cohort study were linked to electronic health records from general practitioners (GPs).

PARTICIPANTS

We included patients consulting a GP with FSS within 1 year after baseline assessment in the Lifelines cohort.

OUTCOME MEASURES

The outcome is repeated consultations with FSS, defined as ≥3 extra consultations for FSS within 1 year after the first consultation. Multivariable logistic regression, with bootstrapping for internal validation, was used to develop a risk prediction model from 14 literature-based predictors. Model discrimination, calibration and diagnostic accuracy were assessed.

RESULTS

18 810 participants were identified by database linkage, of whom 2650 consulted a GP with FSS and 297 (11%) had ≥3 extra consultations. In the final multivariable model, older age, female sex, lack of healthy activity, presence of generalised anxiety disorder and higher number of GP consultations in the last year predicted repeated consultations. Discrimination after internal validation was 0.64 with a calibration slope of 0.95. The positive predictive value of patients with high scores on the model was 0.37 (0.29-0.47).

CONCLUSIONS

Several theoretically suggested predisposing and precipitating predictors, including neuroticism and stressful life events, surprisingly failed to contribute to our final model. Moreover, this model mostly included general predictors of increased risk of repeated consultations among patients with FSS. The model discrimination and positive predictive values were insufficient and preclude clinical implementation.

The relationship of cortical activity induced by pain stimulation with clinical and cognitive features of somatic symptom disorder: A controlled functional near infrared spectroscopy study

OBJECTIVE

The neurobiological correlates of Somatic Symptom Disorder (SSD) introduced in the DSM-5 has been the focus of a limited investigation. We aimed to examine the cortical response to painful stimuli and its relationship to symptom severity as well as cognitive and psychological characteristics in proposed models of somatoform disorders.

METHODS

We measured hemodynamic responses by 52-channel functional near-infrared spectroscopy. We compared the cortical response to painful stimuli in index patients with SSD (N = 21) versus age, and gender matched healthy control subjects (N = 21). We used brush stimulation as the control condition. We analyzed the relationship of cortical activity with SSD symptom severity as well as somatosensory amplification (SSA), alexithymia, dysfunctional illness behaviour, worry, and neuroticism.

RESULTS

Patients with SSD had higher somatic symptom severity, SSA, alexithymia, neuroticism, illness-related worry, and behaviour. Somatic symptom severity was predicted by a model including SSA and subjective feeling of pain in the index patients. Activity in the left-angular and right-middle temporal gyri was higher in the SSD subjects than the controls during pain stimulation. Positive correlations were detected between mean pain threshold levels and left middle occipital gyrus activity, as well as between SSA-scores and right-angular gyrus activity during pain condition in the index patients with SSD.

CONCLUSION

We present the first evidence that representation of pain in terms of cortical activity is different in subjects with SSD than healthy controls. SSA has functional neuroanatomic correlates and predicts symptom severity in SSD and therefore is involved as a valid intermediate phenotype in SSD pathophysiology.

Development and User Experiences of a Biopsychosocial Interprofessional Online Course on Persistent Somatic Symptoms

Background: Communication between healthcare providers and patients with persistent somatic symptoms (PSS) is frequently hampered by mutual misunderstanding and dissatisfaction. Methods: We developed an online, interprofessional course to teach healthcare providers the knowledge, skills, and attitude they need to diagnose and treat PSS in a patient-centered manner based on the biopsychosocial model. The course consisted of six modules of 45-60 min. Each module contained different types of assignments, based on six cases: videos, discussion boards, reading assignments, polls, and quizzes. For this study, we included (1) medical residents, following the course as part of their residency training, and (2) healthcare providers (general practitioners, medical specialists, physiotherapists, nurses, and psychologists), following the course as continuing vocational training. Throughout the course, participants were asked to fill out online surveys, enquiring about their learning gains and satisfaction with the course. Results: The biopsychosocial approach was integrated across the modules and teached health care workers about recent insights on biological, psychological and social aspects of PSS. In total, 801 participants with a wide variety in clinical experience started the course; the largest groups of professionals were general practitioners (N = 400), physiotherapists (N = 124) and mental healthcare workers (N = 53). At the start of the course, 22% of the participants rated their level of knowledge on PSS as adequate. At the end of the course, 359 participants completed the evaluation questionnaires. Of this group, 81% rated their level of knowledge on PSS as adequate and 86% felt that following the course increased their competencies in communicating with patients with PSS (N = 359). On a scale from 1 to 10, participants gave the course a mean grade of 7.8 points. Accordingly, 85% stated that they would recommend the course to a colleague. Conclusion: Our course developed in a co-design process involving multiple stakeholders can be implemented, is being used, and is positively evaluated by professionals across a variety of health care settings.

Interoception, Stress, and Physical Symptoms in Stress-Associated Diseases

Abstract. The brain and peripheral bodily organs continuously exchange information. Exemplary, interoception refers to the processing and perception of ascending information from the body to the brain. Stress responses involve a neurobehavioral cascade, which includes the activation of peripheral organs via neural and endocrine pathways and can thus be seen as an example for descending information on the brain-body axis. Hence, the interaction of interoception and stress represents bi-directional communication on the brain-body axis. The main hypothesis underlying this review is that the dysregulation of brain-body communication represents an important mechanism for the generation of physical symptoms in stress-related disorders. The aims of this review are, therefore, (1) to summarize current knowledge on acute stress effects on different stages of interoceptive signal processing, (2) to discuss possible patterns of abnormal brain-body communication (i.e., alterations in interoception and physiological stress axes activation) in mental disorders and chronic physical conditions, and (3) to consider possible approaches to modify interoception. Due to the regulatory feedback loops underlying brain-body communication, the modification of interoceptive processes (ascending signals) may, in turn, affect physiological stress axes activity (descending signals), and, ultimately, also physical symptoms.

Effect of Internet vs Face-to-Face Cognitive Behavior Therapy for Health Anxiety: A Randomized Noninferiority Clinical Trial

IMPORTANCE

Health anxiety is a common and often chronic mental health problem associated with distress, substantial costs, and frequent attendance throughout the health care system. Face-to-face cognitive behavior therapy (CBT) is the criterion standard treatment, but access is limited.

OBJECTIVE

To test the hypothesis that internet-delivered CBT, which requires relatively little resources, is noninferior to face-to-face CBT in the treatment of health anxiety.

DESIGN, SETTING, AND PARTICIPANTS

This randomized noninferiority clinical trial with health economic analysis was based at a primary care clinic and included patients with a principal diagnosis of health anxiety who were self-referred or referred from routine care. Recruitment began in December 10, 2014, and the last treatment ended on July 23, 2017. Follow-up data were collected up to 12 months after treatment. Analysis began October 2017 and ended March 2020.

INTERVENTIONS

Patients were randomized (1:1) to 12 weeks of internet-delivered CBT or to individual face-to-face CBT.

MAIN OUTCOMES AND MEASURES

Change in health anxiety symptoms from baseline to week 12. Analyses were conducted from intention-to-treat and per-protocol (completers only) perspectives, using the noninferiority margin of 2.25 points on the Health Anxiety Inventory, which has a theoretical range of 0 to 54.

RESULTS

Overall, 204 patients (mean [SD] age, 39 [12] years; 143 women [70%]) contributed with 2386 data points on the Health Anxiety Inventory over the treatment period. Of 204 patients, 102 (50%) were randomized to internet-delivered CBT, and 102 (50%) were randomized to face-to-face CBT. The 1-sided 95% CI upper limits for the internet-delivered CBT vs face-to-face CBT difference in change were within the noninferiority margin in the intention-to-treat analysis (B = 0.00; upper limit: 1.98; Cohen d = 0.00; upper limit: 0.23) and per-protocol analysis (B = 0.01; upper limit: 2.17; Cohen d = 0.00; upper limit: 0.25). The between-group effect was not moderated by initial symptom level, recruitment path, or patient treatment preference. Therapists spent 10.0 minutes per patient per week in the online treatment vs 45.6 minutes for face-to-face CBT. The net societal cost was lower in the online treatment (treatment period point difference: $3854). There was no significant group difference in the number of adverse events, and no serious adverse event was reported.

CONCLUSIONS AND RELEVANCE

In this trial, internet-delivered CBT appeared to be noninferior to face-to-face CBT for health anxiety, while incurring lower net societal costs. The online treatment format has potential to increase access to evidence-based treatment for health anxiety.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02314065.

Behavioural modification interventions for medically unexplained symptoms in primary care: systematic reviews and economic evaluation

BACKGROUND

The term 'medically unexplained symptoms' is used to cover a wide range of persistent bodily complaints for which adequate examination and appropriate investigations do not reveal sufficiently explanatory structural or other specified pathologies. A wide range of interventions may be delivered to patients presenting with medically unexplained symptoms in primary care. Many of these therapies aim to change the behaviours of the individual who may have worsening symptoms.

OBJECTIVES

An evidence synthesis to determine the clinical effectiveness and cost-effectiveness of behavioural modification interventions for medically unexplained symptoms delivered in primary care settings was undertaken. Barriers to and facilitators of the effectiveness and acceptability of these interventions from the perspective of patients and service providers were evaluated through qualitative review and realist synthesis.

DATA SOURCES

Full search strategies were developed to identify relevant literature. Eleven electronic sources were searched. Eligibility criteria - for the review of clinical effectiveness, randomised controlled trials were sought. For the qualitative review, UK studies of any design were included. For the cost-effectiveness review, papers were restricted to UK studies reporting outcomes as quality-adjusted life-year gains. Clinical searches were conducted in November 2015 and December 2015, qualitative searches were conducted in July 2016 and economic searches were conducted in August 2016. The databases searched included MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO and EMBASE. Updated searches were conducted in February 2019 and March 2019.

PARTICIPANTS

Adult participants meeting the criteria for medically unexplained symptoms, including somatoform disorders, chronic unexplained pain and functional somatic syndromes.

INTERVENTIONS

Behavioural interventions were categorised into types. These included psychotherapies, exercise-based interventions, multimodal therapies (consisting of more than one intervention type), relaxation/stretching/social support/emotional support, guided self-help and general practitioner interventions, such as reattribution. Evidence synthesis: a network meta-analysis was conducted to allow a simultaneous comparison of all evaluated interventions in a single coherent analysis. Separate network meta-analyses were performed at three time points: end of treatment, short-term follow-up (< 6 months since the end of treatment) and long-term follow-up (≥ 6 months after the end of treatment). Outcomes included physical and psychological symptoms, physical functioning and impact of the illness on daily activities. Economic evaluation: within-trial estimates of cost-effectiveness were generated for the subset of studies where utility values (or quality-adjusted life-years) were reported or where these could be estimated by mapping from Short Form questionnaire-36 items or Short Form questionnaire-12 items outcomes.

RESULTS

Fifty-nine studies involving 9077 patients were included in the clinical effectiveness review. There was a large degree of heterogeneity both between and within intervention types, and the networks were sparse across all outcomes. At the end of treatment, behavioural interventions showed some beneficial effects when compared with usual care, in particular for improvement of specific physical symptoms [(1) pain: high-intensity cognitive-behavioural therapy (CBTHI) standardised mean difference (SMD) 0.54 [95% credible interval (CrI) 0.28 to 0.84], multimodal SMD 0.52 (95% CrI 0.19 to 0.89); and (2) fatigue: low-intensity cognitive-behavioural therapy (CBTLI) SMD 0.72 (95% CrI 0.27 to 1.21), relaxation/stretching/social support/emotional support SMD 0.87 (95% CrI 0.20 to 1.55), graded activity SMD 0.51 (95% CrI 0.14 to 0.93), multimodal SMD 0.52 (95% CrI 0.14 to 0.92)] and psychological outcomes [(1) anxiety CBTHI SMD 0.52 (95% CrI 0.06 to 0.96); (2) depression CBTHI SMD 0.80 (95% CrI 0.26 to 1.38); and (3) emotional distress other psychotherapy SMD 0.58 (95% CrI 0.05 to 1.13), relaxation/stretching/social support/emotional support SMD 0.66 (95% CrI 0.18 to 1.28) and sport/exercise SMD 0.49 (95% CrI 0.03 to 1.01)]. At short-term follow-up, behavioural interventions showed some beneficial effects for specific physical symptoms [(1) pain: CBTHI SMD 0.73 (95% CrI 0.10 to 1.39); (2) fatigue: CBTLI SMD 0.62 (95% CrI 0.11 to 1.14), relaxation/stretching/social support/emotional support SMD 0.51 (95% CrI 0.06 to 1.00)] and psychological outcomes [(1) anxiety: CBTHI SMD 0.74 (95% CrI 0.14 to 1.34); (2) depression: CBTHI SMD 0.93 (95% CrI 0.37 to 1.52); and (3) emotional distress: relaxation/stretching/social support/emotional support SMD 0.82 (95% CrI 0.02 to 1.65), multimodal SMD 0.43 (95% CrI 0.04 to 0.91)]. For physical functioning, only multimodal therapy showed beneficial effects: end-of-treatment SMD 0.33 (95% CrI 0.09 to 0.59); and short-term follow-up SMD 0.78 (95% CrI 0.23 to 1.40). For impact on daily activities, CBTHI was the only behavioural intervention to show beneficial effects [end-of-treatment SMD 1.30 (95% CrI 0.59 to 2.00); and short-term follow-up SMD 2.25 (95% CrI 1.34 to 3.16)]. Few effects remained at long-term follow-up. General practitioner interventions showed no significant beneficial effects for any outcome. No intervention group showed conclusive beneficial effects for measures of symptom load (somatisation). A large degree of heterogeneity was found across individual studies in the assessment of cost-effectiveness. Several studies suggested that the interventions produce fewer quality-adjusted life-years than usual care. For those interventions that generated quality-adjusted life-year gains, the mid-point incremental cost-effectiveness ratios (ICERs) ranged from £1397 to £129,267, but, where the mid-point ICER fell below £30,000, the exploratory assessment of uncertainty suggested that it may be above £30,000.

LIMITATIONS

Sparse networks meant that it was not possible to conduct a metaregression to explain between-study differences in effects. Results were not consistent within intervention type, and there were considerable differences in characteristics between studies of the same type. There were moderate to high levels of statistical heterogeneity. Separate analyses were conducted for three time points and, therefore, analyses are not repeated-measures analyses and do not account for correlations between time points.

CONCLUSIONS

Behavioural interventions showed some beneficial effects for specific medically unexplained symptoms, but no one behavioural intervention was effective across all medically unexplained symptoms. There was little evidence that these interventions are effective for measures of symptom load (somatisation). General practitioner-led interventions were not shown to be effective. Considerable heterogeneity in interventions, populations and sparse networks mean that results should be interpreted with caution. The relationship between patient and service provider is perceived to play a key role in facilitating a successful intervention. Future research should focus on testing the therapeutic effects of the general practitioner-patient relationship within trials of behavioural interventions, and explaining the observed between-study differences in effects within the same intervention type (e.g. with more detailed reporting of defined mechanisms of the interventions under study).

STUDY REGISTRATION

This study is registered as PROSPERO CRD42015025520.

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. 24, No. 46. See the NIHR Journals Library website for further project information.

Demographic and health-related factors associated with reduced work functioning in people with moderate medically unexplained physical symptoms: a cross-sectional study

BACKGROUND

Medically unexplained physical symptoms (MUPS) are a leading cause of reduced work functioning. It is not known which factors are associated with reduced work functioning in people with moderate MUPS. Insight in these factors can contribute to prevention of reduced work functioning, associated work-related costs and in MUPS becoming chronic. Therefore, the aim of this study was to identify which demographic and health-related factors are associated with reduced work functioning, operationalized as impaired work performance and absenteeism, in people with moderate MUPS.

METHODS

Data of 104 participants from an ongoing study on people with moderate MUPS were used in this cross-sectional study. Ten independent variables were measured at baseline to determine their association with reduced work functioning: severity of psychosocial symptoms (four domains, measured with the Four-Dimensional Symptom Questionnaire), physical health (RAND 36-Item Health Survey), moderate or vigorous physical activity (Activ8 activity monitor), age, sex, education level and duration of complaints. Two separate multivariable linear regression analyses were performed with backward stepwise selection, for both impaired work performance and absenteeism.

RESULTS

Absenteeism rate rose with 2.5 and 0.6% for every increased point on the Four-Dimensional Symptom Questionnaire for domain 'depression' (B = 0.025, SE = 0.009, p = .006) and domain 'somatization' (B = 0.006, SE = 0.003, p = .086), respectively. An R² value of 0.118 was found. Impaired work performance rate rose with 0.2 and 0.5% for every increased point on the Four-Dimensional Symptom Questionnaire for domain 'distress' (B = 0.002, SE = 0.001, p = .084) and domain 'somatization' (B = 0.005, SE = 0.001, p < .001), respectively. An R² value of 0.252 was found.

CONCLUSIONS

Severity of distress, probability of a depressive disorder and probability of somatization are positively associated with higher rates of reduced work functioning in people with moderate MUPS. To prevent long-term absenteeism and highly impaired work performance severity of psychosocial symptoms seem to play a significant role. However, because of the low percentage of explained variance, additional research is necessary to gain insight in other factors that might explain the variance in reduced work functioning even better.

Patients' experiences with fluctuations in persistent physical symptoms: a qualitative study

OBJECTIVES

To explore patients' experiences with fluctuations in persistent physical symptoms (PPS) and to understand which factors-from their viewpoint-play a role in these fluctuations.

DESIGN

Qualitative study using semistructured interviews and thematic content analysis.

SETTING

This qualitative study is part of a multicentre prospective cohort study on the course of PPS. Patients were recruited in general practices and specialised treatment facilities for PPS throughout the Netherlands.

PARTICIPANTS

Interviews were conducted with a sample of fifteen patients with PPS to explore their experiences with fluctuations in symptom severity.

RESULTS

We identified three themes in the analysis: (1) patterns in symptom fluctuations (2) perceived causes of symptom exacerbations and (3) Patients' strategies in gaining control over symptom exacerbations. Daily and weekly fluctuations in symptoms were an important element in patients' experiences. In particular anticipating on the worsening of symptoms impacted their daily routines and posed various challenges. Symptom exacerbations were attributed to overstepping physical limits and/or the impact of negative emotions. Resigning to physical limits, adjusting ones daily planning, weighing personal needs and learning to say 'no' were described as different strategies in gaining control over symptom exacerbations.

CONCLUSIONS

Fluctuations in the severity of symptoms-and in particular daily and weekly symptom exacerbations-are an important element of the symptom experience in patients with PPS and poses various challenges. Patients attributed symptom exacerbation to overstepping physical limits and/or negative emotions. Patients described different strategies in gaining control over symptom exacerbations.

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.

Psychological Interventions for Health Anxiety and Somatic Symptoms

Abstract. This study examined the effectiveness of psychological interventions for severe health anxiety (SHA) regarding somatic symptoms (SS) and health anxiety (HA). The databases Web of Science, EBSCO, and CENTRAL were searched on May 15, 2019, May 16, 2019, and August 5, 2019, respectively. Eighteen randomized controlled trials ( N = 2,050) met the inclusion criteria (i.e., hypochondriasis, illness anxiety disorder or somatic symptom disorder with elevated HA being assessed with validated interviews; use of standardized outcome measures). Two reviewers independently evaluated the studies’ risk of bias using the Revised Cochrane Risk-of-Bias Tool for randomized trials (RoB-2) tool. Overall, psychological interventions were significantly more effective than waitlist, treatment-as-usual, or placebo post-treatment ( gSS = 0.70, gHA = 1.11) and at follow-up ( gSS = 0.33, gHA = 0.70). CBT outperformed other psychological interventions or pharmacotherapy for HA post-treatment (Hedge’s  gHA = 0.81). The number of sessions did not significantly predict the effect sizes. In sum, psychological interventions were effective for SHA, but the generalizability of the results for SS is limited, because only two high-quality trials contributed to the comparisons.

Health Anxiety

Abstract. Health anxiety, characterized by excessive concern about one’s health, is a serious and costly public health problem. The disorder might become chronic if left untreated. Unfortunately many patients do not receive timely or proper treatment due to sparse treatment resources. Also, existing treatment programs, though effective for many, do not work for all. This paper discusses the conceptualization of health anxiety and future directions based on novel research findings. These include: (i) the content and characteristics of autobiographical memories and episodic future thoughts in severe health anxiety, (ii) related concepts such as cyberchondria with excessive Internet browsing on health issues and health anxiety by proxy, where parents display and might confer health anxiety towards their children, (iii) an epidemiological perspective on the association between health anxiety and subclinical psychotic experiences in preadolescence. Exploring these new dimensions could have important implications for the further development of preventive strategies and effective treatment.

Linguistic and interactional aspects that characterize consultations about medically unexplained symptoms: A systematic review

OBJECTIVE

The apparent absence of any specific underlying diseases challenges patient-provider communication about medically unexplained symptoms (MUS). Previous research focused on general communication patterns in these interactions; however, an overview of more detailed interactional and linguistic aspects is lacking. This review aims to gain a detailed understanding of communicative challenges in MUS consultations by synthesizing evidence from conversation and discourse analytic research.

METHODS

A systematic review of publications using eight databases (PubMed, Embase, CINAHL, PsychINFO, Web of Science, MLA International Bibliography, LLBA and Communication Abstracts). Search terms included 'MUS', 'linguistics' and 'communication'. Additional studies were identified by contacting experts and searching bibliographies. We included linguistic and/or interactional analyses of natural patient-provider interactions about MUS. Two authors independently extracted the data, and quality appraisal was based on internal and external validity.

RESULTS

We identified 18 publications that met the inclusion criteria. The linguistic and interactional features of MUS consultations pertained to three dimensions: 1) symptom recognition, 2) double trouble potential (i.e. patients and providers may have differing views on symptoms and differing knowledge domains), and 3) negotiation and persuasion (in terms of acceptable explanations and subsequent psychological treatment). We describe the recurrent linguistic and interactional features of these interactions.

CONCLUSIONS

Despite the presence of a double trouble potential in MUS consultations, validation of symptoms and subtle persuasive conduct may facilitate agreement on illness models and subsequent (psychological) treatment.

Three decades of increase in health anxiety: Systematic review and meta-analysis of birth cohort changes in university student samples from 1985 to 2017

Health anxiety can be defined as a multifaceted trait that is primarily characterised by a fear of, or preoccupation with, serious illness. Whereas low levels of health anxiety can be helpful, clinically significant levels are associated with personal suffering and substantial societal costs. As general anxiety is probably on the rise, and the Internet has increased access to health-related information, it is commonly speculated that health anxiety has increased over the past decades. We tested this hypothesis based on a systematic review and meta-analysis of birth cohort mean health anxiety in Western university student samples from 1985 to 2017. Sixty-eight studies with 22 413 student participants were included. The primary analysis indicated that the mean score on the Illness Attitudes Scales had increased by 4.61 points (95 % CI: 1.02, 8.20) from 1985 to 2017. The percentage of general population Internet users in the study year of data collection was not predictive of student mean health anxiety. In conclusion, this study corroborates the hypothesis of an increase in health anxiety, at least in the student population, over the past decades. However, this increase could not be linked to the introduction of the Internet.

DSM-5 Personality Disorders and Traits in Patients With Severe Health Anxiety

Severe health anxiety (SHA)/hypochondriasis (HY) is often associated with personality pathology; however, studies report inconsistent results. In general populations, 12% have a personality disorder (PD). We assessed physician-referred psychiatric outpatients with SHA enrolled for a treatment study (n = 84) with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) axis II (SCID-II), Personality Inventory for DSM-5 (PID-5), Whiteley Index 7, and Short Health Anxiety Inventory, and the healthy controls (n = 84) with PID-5 only. There were 71.4% of the patients who met criteria for PDs: avoidant (22.6%), obsessive-compulsive (16.7%), depressive (16.7%), dependent (7.1%), paranoid (3.6%), borderline (2.4%), and not otherwise specified (32.1%). Severity of personality pathology was associated with severity of health anxiety. In group comparisons, PID-5 trait domains of negative affectivity, detachment, low antagonism, and low disinhibition, and facets of anxiousness, separation insecurity, and low attention seeking emerged as unique predictors of SHA. Personality pathology is common among individuals with SHA/HY. Further research is needed to understand the nature of the relationship between health anxiety and personality pathology and to determine whether treatments that target both SHA/HY and personality pathology will improve short- and long-term outcomes.

Somatic complaints in early adulthood predict the developmental course of compassion into middle age

OBJECTIVE

The aim of the present study was to investigate (i) whether somatic complaints predict the developmental course of compassion in adulthood, and (ii) whether this association depends on alexithymic features.

METHODS

The participants came from the population-based Young Finns study (N = 471-1037). Somatic complaints (headache, stomachache, chest pain, backache, fatigue, exhaustion, dizziness, heartburn, heartbeat, and tension) were evaluated with a self-rating questionnaire in 1986 when participants were aged between 18 and 24 years. Compassion was assessed with the Compassion Scale of the Temperament and Character Inventory (TCI) in 1997, 2001, and 2012. The data were analyzed using growth curve models.

RESULTS

We obtained a significant compassion-age interaction (B = -0.137, p = .02) and a compassion-age squared interaction (B = 0.007, p = .006), when predicting the course of somatic complaints. Specifically, in participants without frequent somatic complaints, compassion steadily increased with age in adulthood. In participants with frequent somatic complaints, however, compassion remained at a lower level until the age of 40 years, then started to increase, and achieved the normal level of compassion approximately at the age of 50 years. The association between somatic complaints and compassion over age was found to be independent of alexithymic features. The analyses were adjusted for a variety of covariates (age, gender, use of health care in childhood, depression in childhood, parental socioeconomic factors, parental care-giving practices, stressful life events, parental alcohol intoxication, and participants' socioeconomic factors in adulthood).

CONCLUSION

Frequent somatic complaints may predict delayed development of compassion in adulthood. This association was found to be independent of alexithymic features.

Introducing the System for Observing Medical Alliances (SOMA): A Tool for Studying Concordance in Patient-Physician Relationships

We developed the System for Observing Medical Alliances (SOMA) to study relationships between medical providers and patients with medically unexplained symptoms (MUS). Based on literature in health psychology, medicine, and the psychotherapeutic alliance, the SOMA operationalizes three medical alliance dimensions: Engagement in the Consultation Process, Trust in the Provider, and Concordance of Illness Beliefs and Treatment Recommendations. Specific behavioral indicators, tallied as observed by trained judges, are used as the basis for rating each dimension. In a sample of 33 medical consultations with veterans who had MUS, interrater reliabilities ranged from .79 to .94. Notably, the other dimension ratings accounted for 40% of the variability in Concordance, with Trust in the Provider contributing unique variance. In addition to research, psychologists in integrated health settings can use the SOMA to consult and train medical providers on communication skills that enhance concordance.

Imagery rescripting of early memories in health anxiety disorder: A feasibility and non-randomized pilot study

BACKGROUND AND OBJECTIVES

Health anxiety is a common problem and is associated with frequent primary care visits, increased health care costs, and poor prognosis and low recovery rates. Previous research shows that imagery rescripting (IR) is a promising treatment technique for various disorders. To date, IR has not been examined as a viable treatment for health anxiety. The purpose of the present feasibility and pilot study was to test one session of IR of early anxiety-laden health-related memories in a small sample of patients suffering from HA.

METHODS

A within-groups design was used with a sample of 18 patients suffering from HA, who first underwent a control condition (reading about CBT), and then one week later a session of IR. After another week, the effects were measured on self-reported health anxiety and early anxiety provoking health-related mental images (memories).

RESULTS

After the IR intervention, significant reductions of health anxiety and health worry, as well as image and memory distress, vividness and frequency were observed.

LIMITATIONS

Among the most important limitations are the absence of an active control group, the small size of the sample, the absence of a longer follow-up, and the use of only self-report measures.

CONCLUSIONS

The results suggest that IR is a feasible technique in the treatment of health anxiety, and that more controlled research along these lines may be worthwhile.

Identifying subgroups based on self-management skills in primary care patients with moderate medically unexplained physical symptoms

OBJECTIVE

Medically Unexplained Physical Symptoms (MUPS) are a major burden on both patients and society and frequently develop into chronic MUPS. Self-management interventions may prevent moderate MUPS from becoming chronic. Tailoring interventions to the patient population is strongly recommended. This can be facilitated by identifying subgroups based on self-management skills. This study aimed to identify these subgroups and their clinical profiles in primary care patients with moderate MUPS.

METHODS

A cross-sectional study was performed on baseline measurements from a randomized clinical trial (PARASOL-study). To identify subgroups based on self-management skills, a hierarchical cluster analysis was conducted for adults with moderate MUPS from primary health care centers. Self-management skills were measured with the Health education impact Questionnaire. Cluster variables were seven constructs of this questionnaire. Additionally, specific patient profiles were determined by comparing the identified clusters on the clinical variables pain, fatigue and physical functioning.

RESULTS

Four subgroups were identified: High-Self-Management Skills (SMS) (n = 29), Medium-SMS (n = 55), Low-SMS (n = 49) and Active & Low Distress-SMS (n = 20). The latter showed a distinctly different pattern on cluster variables, while the other subgroups differed significantly on means of the cluster variables (p < .001). On clinical variables, significant differences between subgroups were mainly found on fatigue and physical functioning.

CONCLUSION

This study found four specific subgroups based on self-management skills in moderate MUPS-patients. One subgroup demonstrated a distinctly different pattern on self-management skills. In other subgroups, more similar patterns on self-management skills were found that negatively correlated with pain and fatigue and positively correlated with physical functioning.