Towards positive diagnostic criteria: a systematic review of somatoform disorder diagnoses and suggestions for future classification

Case-controlled field study of the ICD-11 clinical descriptions and diagnostic requirements for Bodily Distress Disorders

AIMS

Mental disorders characterized by preoccupation with distressing bodily symptoms and associated functional impairment have been a target of major reconceptualization in the ICD-11, in which a single category of Bodily Distress Disorder (BDD) with different levels of severity replaces most of the Somatoform Disorders in ICD-10. This study compared the accuracy of clinicians' diagnosis of disorders of somatic symptoms using either the ICD-11 or ICD-10 diagnostic guidelines in an online study.

METHODS

Clinically active members of the World Health Organization's Global Clinical Practice Network (N = 1065) participating in English, Spanish, or Japanese were randomly assigned to apply ICD-11 or ICD-10 diagnostic guidelines to one of nine pairs of standardized case vignettes. The accuracy of the clinicians' diagnoses as well as their ratings of the guidelines' clinical utility were assessed.

RESULTS

Overall, clinicians were more accurate using ICD-11 compared to ICD-10 for every presentation of a vignette characterized primarily by bodily symptoms associated with distress and impairment. Clinicians who made a diagnosis of BDD using ICD-11 were generally correct in applying the severity specifiers for the condition.

LIMITATIONS

This sample may represent some self-selection bias and thus may not generalize to all clinicians. Additionally, diagnostic decisions with live patients may lead to different results.

CONCLUSIONS

The ICD-11 diagnostic guidelines for BDD represent an improvement over those for Somatoform Disorders in ICD-10 in regard to clinicians' diagnostic accuracy and perceived clinical utility.

The framework for systematic reviews on psychological risk factors for persistent somatic symptoms and related syndromes and disorders (PSY-PSS)

Introduction

Numerous psychological factors are believed to play a pivotal role in the development and maintenance of persistent somatic symptoms (PSS) in all fields of medicine. However, very few of these factors have been empirically investigated in relation to PSS. The aim of this study is firstly to propose a framework and define search terms for systematic reviews on the empirical evidence and diagnostic value of psychological risk factors for PSS and PSS-related outcomes (PSY-PSS). Secondly, the application of the framework is illustrated using the example of a systematic review on the relevance of psychological factors in somatic symptom disorders (SSD; DSM-5) and bodily distress disorders (BDD; ICD-11).

Methods

Following a narrative review approach, two comprehensive lists of search terms to identify studies in (1) relevant patient groups with PSS and (2) relevant psychological factors were generated by reviewing the current literature and employing an iterative process of internal revision and external expert feedback.

Results

We identified 83 relevant symptoms, syndromes and disorders for which we defined a total of 322 search terms (list 1). We further comprised 120 psychological factors into 42 subcategories and 7 main categories (list 2). The introduced lists can be combined to conduct systematic reviews on one or more specific psychological factors in combination with any symptom, syndrome or disorder of interest. A protocol of the application of this framework in a systematic review and meta-analysis on psychological etiological factors of SSD and BDD is presented following the PRISMA guidelines.

Discussion

This framework will help to gather systematic evidence on psychological factors in order to improve the understanding of the etiology of PSS, to refine future diagnostic conceptualizations of PPS, and to develop optimized mechanism-based interventions for individuals with PPS and related syndromes and disorders.

Unexpected symptoms after concussion: Potential links to functional neurological and somatic symptom disorders

OBJECTIVE

Reporting of unexpected symptoms after concussion might, in some people, reflect a Functional Neurological Disorder (FND), Somatic Symptom Disorder (SSD), or exaggeration (feigning). This study aimed to determine whether reporting unexpected symptoms after concussion was associated with risk factors for FND/SSD, exaggeration, or both.

METHOD

Adults with persistent symptoms following concussion (N = 77; 61% women) rated the presence and severity of unexpected neurological symptoms (from the Screening for Somatoform Symptoms scale, e.g., paralysis) and somatic symptoms (from the Patient Health Questionnaire-15, e.g., stomach pain) that did not overlap with post-concussion symptom scale items. The independent variables were risk factors for exaggeration (neuropsychological performance validity test failure and personal injury litigation) and predisposing and perpetuating factors for developing FND and/or SSD (e.g., fear avoidance behavior).

RESULTS

When adjusting for all covariates, fear avoidance behavior was most strongly related to unexpected neurological symptoms (B = 0.11, 95% confidence interval = 0.05-0.18, p < .001), while current anxiety scores were most strongly related to unexpected somatic symptoms (B = 0.34, 95% confidence interval = 0.15-0.52, p < .001). Performance validity test failure and litigation were not significant predictors in either model.

CONCLUSION

Unexpected neurological and other somatic symptoms after concussion should not be dismissed as exaggeration. Psychological factors thought to perpetuate FND and SSD (e.g., fear avoidance behavior) may contribute to unexpected symptoms following concussion. More research is needed at the intersection of FND, SSD, and persistent post-concussive symptoms.

Decreased Autonomic Reactivity and Psychiatric Comorbidities in Neurological Patients With Medically Unexplained Sensory Symptoms: A Case-Control Study

Up to 48% of patients with medically unexplained symptoms seen in neurological practice suffer from sensory symptoms, which could be of functional nature or secondary to psychiatric disorders. These patients show high medical care utilization causing elevated healthcare costs. Despite the high prevalence, little is known about clinical characteristics and pathophysiological mechanisms. For functional disorders such as irritable bowel syndrome, a reduction of heart rate variability (HRV) has been shown, suggesting a dysfunction of the autonomic nervous system (ANS). The aim of this study was to investigate psychological data and functional changes of the ANS in patients with medically unexplained sensory symptoms (MUSS). In this exploratory pilot study, 16 patients (11 females, 31.6 ± 11.9 years) with MUSS, who were recruited at a single tertiary neurological center, underwent a structured clinical interview (SCID) to evaluate psychiatric comorbidities. Patients and age- and sex-matched healthy volunteers filled in questionnaires, and individual sensory thresholds (perception, pain) were detected by quantitative sensory testing (QST). HRV was assessed at baseline and under three different experimental conditions (tonic pain stimulus, placebo application, cold-face test). All tests were repeated after 6–8 weeks. SCID interviews revealed clinical or subclinical diagnoses of psychiatric comorbidities for 12 patients. Questionnaires assessing somatization, depression, anxiety, and perceived stress significantly discriminated between patients with MUSS and healthy controls. While there was no difference in QST, reduced ANS reactivity was found in patients during experimental conditions, particularly with regard to vagally mediated HRV. Our pilot study of neurological patients with MUSS reveals a high prevalence of psychiatric comorbidities and provides evidence for altered ANS function. Our data thus give insight in possible underlying mechanisms for these symptoms and may open the door for a better diagnostic and therapeutic approach for these patients in the future.

Association between Stroop tasks and heart rate variability features in patients with somatic symptom disorder

OBJECTIVE

Patients with somatic symptom disorder (SSD) may have declined parasympathetic activity and selective attention to negative information. We combined Stroop tasks and heart rate variability (HRV) measurements to explore the brain mechanism of SSD.

METHODS

104 SSD patients (64 women) and 100 healthy adults (76 women) received three Stroop tasks (the "cognitive" color-word Stroop, "emotional" emotion Stroop, and "cognitive and emotional" face-word Stroop) with low and high interference conditions. The key HRV indexes included high-frequency power (HF) and standard deviation of normal to normal RR intervals (SDNN). The generalized estimating equation model was used to examine the effects of SSD on three Stroop tasks performance (accuracy and reaction time) and HRV (HF and SDNN) controlling for sex, age, body mass index, and the levels of anxiety and depression.

RESULTS

For Stroop tasks, the significant group difference in emotion Stroop task with the high level of interference (SSD patients had lower accuracy than healthy ones) was only found in women. As for HRV, only men during color-word Stroop, women during emotion Stroop revealed significant between-group differences; SDNN in SSD men was higher than healthy men, and HF in SSD women was lower than healthy women controlling for the confounding factors. The significantly longer reaction time in SSD women than in healthy women diminished in the adjusted analysis.

CONCLUSION

Emotion Stroop task and HRV helps distinguish SSD patients from healthy adults, particularly in women. Sex-specific measures for early detection and intervention for SSD are suggested.

ICD-10-Coding of Medically Unexplained Physical Symptoms and Somatoform Disorders-A Survey With German GPs

Background: General practitioners (GPs) are reluctant to use codes that correspond to somatization syndromes.

Aim: To quantify GPs' views on coding of medically unexplained physical symptoms (MUPS), somatoform disorders, and associated factors.

Design and Setting: Survey with German GPs.

Methods: We developed six survey items [response options “does not apply at all (1)”—“does fully apply (6)”], invited a random sample of 12.004 GPs to participate in the self-administered cross-sectional survey and analysed data using descriptive statistics and logistic regression analyses.

Results: Response rate was 15.2% with N = 1,731 valid responses (54.3% female). Participants considered themselves familiar with ICD-10 criteria for somatoform disorders (M = 4.52; SD =.036) and considered adequate coding as essential prerequisite for treatment (M = 5.02; SD = 1.21). All other item means were close to the scale mean: preference for symptom or functional codes (M = 3.40; SD = 1.21), consideration of the possibility of stigmatisation (M = 3.30; SD = 1.35) and other disadvantages (M = 3.28; SD = 1.30) and coding only if psychotherapy is intended (M = 3.39; SD = 1.46). Exposure, guideline knowledge, and experience were most strongly associated with GPs' self-reported coding behaviour.

Conclusions: Subjective exposure, guideline knowledge, and experience as a GP, but no sociodemographic variable being associated with GPs' subjective coding behaviour could indicate that GPs offer a relatively homogeneous approach to coding and handling of MUPS and somatoform disorders. Strengthening guideline knowledge and implementation, and practise with simulated patients could increase the subjective competence to cope with the challenge that patients with MUPS and somatoform disorders present.

Co-occurrence of depressive, anxiety, and somatic symptoms: trajectories from adolescence to midlife using group-based joint trajectory analysis

BACKGROUND

Co-occurrence of mental and somatic symptoms is common, and recent longitudinal studies have identified single trajectories of these symptoms, but it is poorly known whether the symptom trajectories can also co-occur and change across the lifespan. We aimed to examine co-occurring symptoms and their joint trajectories from adolescence to midlife.

METHODS

Longitudinal data were derived from Northern Sweden, where 506 girls and 577 boys aged 16 years participated at baseline in 1981 (99.7% of those initially invited), and have been followed up in four waves until the age of 43. Survey data were collected about depressive, anxiety, and somatic symptoms. Potential joint development of this three-component symptom set was examined with multiple response trajectory analysis, a method that has not been previously used to study co-occurrence of these symptoms.

RESULTS

We identified a five trajectory solution as the best: "very low" (19%), "low" (31%), "high" (22%), "late sharply increasing" (16%) and a "very high increasing" (12%). In the "late sharply increasing" and "very high increasing" groups the scores tended to increase with age, while in the other groups the levels were more stable. Overall, the results indicated that depressive, anxiety, and somatic symptoms co-exist from adolescence to midlife.

CONCLUSIONS

The multiple response trajectory analysis confirmed high stability in the co-occurrence of depressive, anxiety, and somatic symptoms from adolescence to midlife. Clinicians should consider these findings to detect symptoms in their earliest phase in order to prevent the development of co-occurring high levels of symptoms.

Common therapeutic strategies in psychological treatments for medically unexplained somatic symptoms

Objective: Medically unexplained somatic symptoms (MUSS) represent a frequent complaint in health care services. While psychological treatments have demonstrated some effect in patients with MUSS, further progress may be achieved by a synthesis of clinical strategies used in diverse treatment models. The aim of this study was to identify clinical strategies shared across multiple psychological treatments intended for the treatment of adult patients with MUSS. Method: Descriptions of psychological treatments for patients with MUSS were searched in the PsycINFO, PsycARTICLES, and Medline databases and manually. N = 135 resources met inclusion criteria and were subjected to qualitative analysis. Results: Similarities across treatments were captured in 8 broad categories and 18 subcategories that covered aspects of the therapeutic relationship, specific skills (bodily, emotional, and relational) for patients to develop, search for the meaning of symptoms, and the orientation on life beyond symptoms. Conclusions: Despite the differences in technique, it was possible to identify common therapeutic strategies in psychological treatments for patients with MUSS. These overarching treatment strategies, many of which have already obtained empirical support, may inspire further research and the development of comprehensive treatments with enhanced efficacy. Limitations of the present study include the lack of focus on specific syndromes.

Somatic symptom disorder in the general population: Associations with medical status and health care utilization using the SSD-12

OBJECTIVE

Somatic Symptom Disorder (SSD) is characterized by excessive thoughts, feelings, and behaviors associated with physical symptoms. DSM-5 criteria for SSD focus on these psychological features (criterion B) rather than the presence or absence of an identifiable medical disorder. This study examines the role of medical disorder in the assessment of SSD and associations of SSD with health care utilization.

METHOD

Participants (N = 448, mean age 46.7 ± 16.9 years, 53.8% women) were recruited from the general community and completed the SSD-12 to quantify DSM-5 Criterion B for SSD. Participants also provided demographic and medical background information.

RESULTS

The SSD-12 total score was elevated in individuals with a major medical disorder (N = 97: cardiovascular disease, cancer, pulmonary disease or other: SSD-12 = 11.6 ± 8.8), and also among those with medical conditions commonly treated in primary care (N = 46: e.g., migraine, asthma: SSD-12 = 8.3 ± 7.1), compared to those free of these disorders (SSD-12 = 5.8 ± 7.0), which remained significant in age- and sex-adjusted models. Normative values are reported. High SSD-12 scores (≥15) were associated with more health care utilization (adjusted OR primary care visits = 3.35, 95%CI = 1.64-6.87).

CONCLUSIONS

The SSD-12 is a useful tool for the assessment of SSD. Medical comorbidity is associated with higher SSD-12 scores. Future studies are needed to determine whether SSD is more common in medical patients or whether correction of normative values is needed for screening purposes.

No moderating impact of a medically unexplained etiology on the relationship between psychological profile and chronic pain

OBJECTIVES

The objective of the present study was to test the moderating impact of an unknown pain etiology on the relationship between psychological factors and chronic pain intensity and disability.

METHODS

N = 471 chronic pain sufferers presented to an online Cognitive Behavioral Therapy randomized control trial, known as the Pain Course. Participants' etiology was classified as medically unexplained or medically explained via interview and self-reported data. Standardized psychological measures at baseline were used in a non-hierarchical cluster analysis, which allocated chronic pain participants into mutually exclusive groups.

RESULTS

Four distinct clusters were identified: Psychologically healthy, mild psychological distress, high psychological distress, and average. The profile with high psychological distress experienced the greatest pain intensity (mean: 6.44 (SD = 1.66)) and disability (mean: 17.53 (SD: 3.65)). This relationship was not moderated by preceding pain etiology being medically explained or unexplained (χ² (3) = 0.45, p = 0.93 and χ² (3) = 7.07, p = 0.07 respectively).

CONCLUSION

These findings indicate that an unknown pain etiology has little role in altering the relationship between psychological factors and pain disability in individuals experiencing chronic pain. This suggests that the psychological association with pain disability and intensity experienced by people with medically unexplained symptoms is similar to people with medically explained symptoms.

Coding of medically unexplained symptoms and somatoform disorders by general practitioners - an exploratory focus group study

BACKGROUND

Medically unexplained symptoms (MUS) and somatoform disorders are common in general practices, but there is evidence that general practitioners (GPs) rarely use these codes. Assuming that correct classification and coding of symptoms and diseases are important for adequate management and treatment, insights into these processes could reveal problematic areas and possible solutions. Our study aims at exploring general practitioners' views on coding and reasons for not coding MUS/somatoform disorders.

METHODS

We invited GPs to participate in six focus groups (N = 42). Patient vignettes and a semi-structured guideline were used by two moderators to facilitate the discussions. Recordings were transcribed verbatim. Two researchers analyzed the data using structuring content analysis with deductive and inductive category building.

RESULTS

Three main categories turned out to be most relevant. For category a) "benefits of coding" GPs described that coding is seen as being done for reimbursement purposes and is not necessarily linked to the content of their reference files for a specific patient. Others reported to code specific diagnoses only if longer consultations to explore psychosomatic symptoms or psychotherapy are intended to be billed. Reasons for b) "restrained coding" were attempting to protect the patient from stigma through certain diagnoses and the preference for tentative diagnoses and functional coding. Some GPs admitted to c) "code inaccurately" attributing this to insufficient knowledge of ICD-10-criteria, time constraints or using "rules of thumb" for coding.

CONCLUSIONS

There seem to be challenges in the process of coding of MUS and somatoform disorders, but GPs appear not to contest the patients' suffering and accept uncertainty (about diagnoses) as an elementary part of their work. From GPs' points of view ICD-10-coding does not appear to be a necessary requirement for treating patients and coding might be avoided to protect the patients from stigma and other negative consequences. Our findings supply a possible explanation for the commonly seen difference between routine and epidemiological data. The recent developments in the DSM-5 and the upcoming ICD-11 will supposedly change acceptance and handling of these diagnoses for GPs and patients. Either way, consequences for GPs' diagnosing and coding behavior are not yet foreseeable.

Duration of untreated illness in patients with somatoform disorders

OBJECTIVE

A long duration of untreated mental illness (DUI) has been found to be associated with negative long-term outcomes. Although somatic symptom and related disorders are frequent in the general population and in primary care, data regarding the DUI of these disorders is scarce. The aim of this study was to investigate the DUI in patients with somatoform disorders.

METHODS

In a cross-sectional study, primary care patients at high risk of having a somatoform disorder were identified using the Patient Health Questionnaire (PHQ). In a second step, life-time somatoform disorder diagnosis was established using the Composite International Diagnostic Interview (CIDI). Additionally, DUI was retrospectively assessed via self-reporting and sociodemographic information was collected. Survival analysis was used to estimate the DUI and to identify patient-related predictors of DUI.

RESULTS

A total of 139 patients with somatoform disorders were included in the analyses. The mean DUI in these patients was 25.2years (median 23.1years). Higher education significantly predicted shorter DUI, whereas gender and age of onset were unrelated to DUI.

CONCLUSIONS

The results reveal a substantial delay in adequate treatment of patients with somatoform disorders. The reported DUI emphasizes the importance of improvements in the management of patients with these disorders.

Intragenerational social mobility and functional somatic symptoms in a northern Swedish context: analyses of diagonal reference models

BACKGROUND

Research indicate that social class mobility could be potentially important for health, but whether this is due to the movement itself or a result of people having been integrated in different class contexts is, to date, difficult to infer. In addition, although several theories suggest that transitions between classes in the social hierarchy can be stressful experiences, few studies have empirically examined whether such movements may have health effects, over and above the implications of "being" in these classes. In an attempt to investigate whether intragenerational social mobility is associated with functional somatic symptoms in mid-adulthood, the current study tests three partially contrasting theories.

METHOD

The dissociative theory suggests that mobility in general and upward mobility in particular may be linked to psychological distress, while the falling from grace theory indicates that downward mobility is especially stressful. In contrast, the acculturation theory holds that the health implications of social mobility is not due to the movement itself but attributed to the class contexts in which people find themselves. Diagonal Reference Models were used on a sample of 924 individuals who in 1981 graduated from 9^th grade in the municipality of Luleå, Sweden. Social mobility was operationalized as change in occupational class between age 30 and 42 (measured in 1995 and 2007). The health outcome was functional somatic symptoms at age 42, defined as a clustering self-reported physical symptoms, palpitation and sleeping difficulties during the last 12 months.

RESULTS

Overall mobility was not associated with higher levels of functional somatic symptoms compared to being immobile (p = 0.653). After controlling for prior and current class, sex, parental social position, general health, civil status, education and unemployment, the association between downward mobility was borderline significant (p = 0.055) while upward mobility was associated with lower levels of functional somatic symptoms (p = 0.03).

CONCLUSION

The current study did not find unanimous support for any of the theories. Nevertheless, it sheds light on the possibility that upward mobility may be beneficial to reduce stress-related health problems in mid-life over and above the exposure to prior and current class, while downward mobility can be of less importance for middle-age health complaints.

The Association of Sensory Responsiveness with Somatic Symptoms and Illness Anxiety

BACKGROUND

Somatoform Disorders or Somatic Symptom and Related Disorders are a major public health problem.The pathophysiology underlying these disorders is not yet understood.

PURPOSE

The aim of this study was to explore if sensory responsiveness could contribute to a better understanding of pathophysiological mechanisms underlying two key symptoms of Somatoform Disorders, namely somatic symptoms and illness anxiety.

METHODS

We measured vibrotactile perception thresholds with the HVLab Perception Meter and examined their association with somatic symptoms, illness anxiety and trait anxiety. A sample of 205 volunteers participated in the study.

RESULTS

Sensory responsiveness was neither associated with somatic symptoms (β = -0.01; 95% confidence interval (CI), -0.37, 0.39) nor trait anxiety (β = -0.07; 95% CI, -0.30, 0.07). However, lower vibrotactile perception thresholds were associated with increased scores of the overall illness anxiety scale (β = -0.65; 95% CI, -1.21, -0.14) and its constituent subscale disease conviction (β = -2.07; 95% CI, -3.94, -0.43).

CONCLUSIONS

Our results suggest that increased sensory responsiveness is associated with illness anxiety and hence should be examined further as potential target within the etiopathology of somatoform disorders.

Life Course Pathways of Adversities Linking Adolescent Socioeconomic Circumstances and Functional Somatic Symptoms in Mid-Adulthood: A Path Analysis Study

While research examining the health impact of early socioeconomic conditions suggests that effects may exist independently of or jointly with adult socioeconomic position, studies exploring other potential pathways are few. Following a chain of risk life course model, this prospective study seeks to examine whether pathways of occupational class as well as material and social adversities across the life course link socioeconomic disadvantage in adolescent to functional somatic symptoms in mid-adulthood. Applying path analysis, a multiple mediator model was assessed using prospective data collected during 26 years through the Northern Swedish Cohort. The sample contained 987 individuals residing in the municipality of Luleå, Sweden, who participated in questionnaire surveys at age 16, 21, 30 and 42. Socioeconomic conditions (high/low) in adolescence (age 16) were operationalized using the occupation of the parents, while occupational class in adulthood (manual/non-manual) was measured using the participant’s own occupation at age 21 and 30. The adversity measurements were constructed as separate age specific parcels at age 21 and 30. Social adversity included items pertaining to stressful life events that could potentially harm salient relationships, while material adversity was operationalized using items concerning unfavorable financial and material circumstances. Functional somatic symptoms at age 42 was a summary measure of self-reported physical symptoms, palpitation and sleeping difficulties that had occurred during the last 12 months. An association between socioeconomic conditions at age 16 and functional somatic symptoms at age 42 (r = 0.068) which was partially explained by people’s own occupational class at age 21 and then material as well as social adversity at age 30 was revealed. Rather than proposing a direct and independent health effect of the socioeconomic conditions of the family, the present study suggests that growing up in an unfavorable socioeconomic environment might be a source for a chain of adverse material and social living situations, which in turn affects adult health.

Catastrophizing misinterpretations predict somatoform-related symptoms and new onsets of somatoform disorders

BACKGROUND

Somatoform disorders are characterized by multiple recurring symptoms that resemble physical illnesses but defy medical explanation. Psychological models suggest that catastrophizing misinterpretations of harmless physical symptoms play a key role. However, the question of whether such biases predict somatoform-related symptoms and the onset of somatoform disorders has not been adressed. Hence, the aim of the present study was to further advance our understanding of the role of catastrophizing misinterpretations in somatoform disorders.

METHODS

In the present study, we used data from the Dresden Predictor Study (N=1538), in which an epidemiologic sample of young German women was tested at two time points approximately 17 months apart. Each participant completed a diagnostic interview, an interpretation questionnaire for somatoform and hypochondriacal symptoms, and three measures of such symptomatology: somatization subscale of the Symptom Checklist-90-Revised (SCL-90-R), Whiteley Index (WI), Body Sensations Questionnaire (BSQ).

RESULTS

At follow-up, 33 women were diagnosed with new onsets of lifetime somatoform disorder. Results showed that catastrophizing misinterpretations assessed at baseline were predictive of somatoform-related symptoms at follow-up, i.e., symptoms assessed with the WI and BSQ. Moreover, catastrophizing misinterpretations were predictive of new onsets of somatoform disorders, even after controlling for general threat-related misinterpretations and indices of somatoform symptoms (i.e., SCL-90-R and BSQ).

CONCLUSIONS

This is the first prospective, longitudinal study to demonstrate that catastrophizing misinterpretations have incremental validity as predictors of future somatoform-related symptomatology and somatoform disorders.

Addressing challenges of validity and internal consistency of mental health measures in a 27- year longitudinal cohort study - the Northern Swedish Cohort study

Background

There are inherent methodological challenges in the measurement of mental health problems in longitudinal research. There is constant development in definitions, taxonomies and demands concerning the properties of mental health measurements. The aim of this paper was to construct composite measures of mental health problems (according to today’s standard) from single questionnaire items devised in the early 1980s, and to evaluate their internal consistency and factorial invariance across the life course using the Northern Swedish Cohort.

Methods

All pupils in the last year of compulsory school in Luleå in 1981 (n = 1083) form a prospective cohort study where the participants have been followed with questionnaires from the age of 16 (in 1981) until the age of 43 (in 2008). We created and tested the following composite measures from self-reports at each follow-up: depressive symptoms, anxiety symptoms, functional somatic symptoms, modified GHQ and positive health. Validity and internal consistency were tested by confirmatory factor analysis, including tests of factorial invariance over time.

Results

As an overall assessment, the results showed that the composite measures (based on more than 30-year-old single item questions) are likely to have acceptable factorial invariance as well as internal consistency over time.

Conclusions

Testing the properties of the mental health measures used in older studies according to the standards of today is of great importance in longitudinal research. Our study demonstrates that composite measures of mental health problems can be constructed from single items which are more than 30 years old and that these measures seem to have the same factorial structure and internal consistency across a significant part of the life course. Thus, it can be possible to overcome some specific inherent methodological challenges in using historical data in longitudinal research.

Devenir des troubles somatoformes dans le DSM-5 : disparition ou renouveau ?

La catégorie « trouble : symptômes somatiques » du DSM-V répond à une exigence d’intelligibilité et d’acceptabilité du trouble, pour les patients comme pour les professionnels de santé, tout en renvoyant à une réalité éprouvante au quotidien pour les patients qui en souffrent, consommateurs d’examens et de soins médicaux, plus que psychiatriques. Elle recouvre une diversité de configurations, depuis les troubles les plus banals et passagers jusqu’aux manifestations les plus durables et/ou les plus résistantes, voire à celles que l’on peut considérer comme largement redevables aux effets « iatrogènes » d’approches médicales inappropriées ou aux réactions revendicatives de la part de malades ou de leurs associations, à la recherche d’une identité socialement reconnue. Avec le DSM-V, non seulement l’existence d’une pathologie médicale concomitante n’exclue pas le diagnostic, mais la présence de facteurs de stress ou d’anomalies psychologiques n’est plus exigée comme condition nécessaire à la survenue du trouble, ce qui permet de dépasser à la fois l’opposition réductrice entre organique et fonctionnel et la recherche d’une psychogenèse à tout prix. Et pourtant le trouble reste considéré comme un trouble mental, en raison de la place occupée par la rumination anxieuse dans sa définition. Quant aux facteurs psychosociaux, il peut être utile de différencier ceux qui interviennent en tant que facteurs prédisposants, précipitants ou d’entretien, voire de renforcement. Un tel assouplissement dans l’approche du trouble peut permettre d’espérer une facilitation des prises en charges conjointes ou une meilleure efficience des adressages de ces patients auprès d’un spécialiste en santé mentale. Il importe aussi de savoir, contrairement à une idée reçue, que la présence d’une préoccupation somatique n’est pas sans conséquence pour l’avenir somatique, puisqu’elle prédit une mortalité accrue par causes naturelles, raison de plus pour considérer le trouble comme « sérieux » et pour s’engager dans sa prise en charge.

Classification of somatic syndromes in ICD-11

PURPOSE OF REVIEW

As a part of the its current revision of the International Classification of Diseases (ICD), the WHO is proposing major changes to the somatoform section of the chapter on Mental and Behavioral Disorders. This article reviews the basis for these changes and presents the highlights of the new category being proposed.

RECENT FINDINGS

As currently classified in ICD-10, somatoform disorders have major problems that limit their clinical utility. Among these are the negative criterion specifications for the diagnosis of the disorders, the rarity of the prototype categories, and the imprecise boundaries between them. To respond to these problems, a new category of Bodily Distress Disorder (BDD) is proposed to replace the current categories. The proposed category is defined by a simplified set of criterion specifications that are based on the presence of positive psycho-behavioral features.

SUMMARY

The new category, still in proposal stage, offers the prospect of responding to the need for a reliable diagnosis of clinically significant somatic preoccupations that are common in the community as well as in routine clinical practice. It is expected that improved diagnosis should aid the correct identification of these conditions and enhance the ability of clinicians to provide effective treatment.

A sudden onset of a pseudo-neurological syndrome after HPV-16/18 AS04-adjuvated vaccine: might it be an autoimmune/inflammatory syndrome induced by adjuvants (ASIA) presenting as a somatoform disorder?

In last centuries, vaccines reduced the incidence of several infectious diseases. In last decades, some vaccines aimed at preventing also some cancers, where viruses play a causative role. However, several adverse events have been described after vaccines, but a causal relationship has been established only in a minority of cases. Here, we describe a pseudo-neurological syndrome occurred shortly after the administration of the bivalent HPV vaccine. Some autoimmune disorders, including neurological demyelinating diseases, have been reported after HPV vaccines, but the patient showed no organic lesions. The patient was diagnosed as having a functional somatoform syndrome, which was supposed to be autoimmune/inflammatory syndrome induced by adjuvants (ASIA), seen the temporal link with vaccination and the presence of anti-phospholipid autoantibodies. Immunological mechanisms of vaccines-and of adjuvants-have not been completely elucidated yet, and although there is no evidence of statistical association with many post-vaccination events, a causal link with vaccine cannot be excluded in some individuals.

Psychological and interactional characteristics of patients with somatoform disorders: Validation of the Somatic Symptoms Experiences Questionnaire (SSEQ) in a clinical psychosomatic population

OBJECTIVE

The new DSM-5 Somatic Symptom Disorder (SSD) emphasizes the importance of psychological processes related to somatic symptoms in patients with somatoform disorders. To address this, the Somatic Symptoms Experiences Questionnaire (SSEQ), the first self-report scale that assesses a broad range of psychological and interactional characteristics relevant to patients with a somatoform disorder or SSD, was developed. This prospective study was conducted to validate the SSEQ.

METHODS

The 15-item SSEQ was administered along with a battery of self-report questionnaires to psychosomatic inpatients. Patients were assessed with the Structured Clinical Interview for DSM-IV to confirm a somatoform, depressive, or anxiety disorder. Confirmatory factor analyses, tests of internal consistency and tests of validity were performed.

RESULTS

Patients (n=262) with a mean age of 43.4 years, 60.3% women, were included in the analyses. The previously observed four-factor model was replicated and internal consistency was good (Cronbach's α=.90). Patients with a somatoform disorder had significantly higher scores on the SSEQ (t=4.24, p<.001) than patients with a depressive/anxiety disorder. Construct validity was shown by high correlations with other instruments measuring related constructs. Hierarchical multiple regression analyses showed that the questionnaire predicted health-related quality of life. Sensitivity to change was shown by significantly higher effect sizes of the SSEQ change scores for improved patients than for patients without improvement.

CONCLUSION

The SSEQ appears to be a reliable, valid, and efficient instrument to assess a broad range of psychological and interactional features related to the experience of somatic symptoms.

How well do parental and peer relationships in adolescence predict health in adulthood?

AIM

Although health effects of social relationships are well-researched, long-term health consequences of adolescent family as well as peer relationships are poorly understood. The aim of the study was to explore the prospective importance of parental and peer social relationships in adolescence on internalising and functional somatic symptoms in adulthood.

METHODS

Data were drawn from four waves of the Northern Swedish Cohort Study, response rate 94.3%, N=1001. Outcome variables were internalising and functional somatic symptoms at the ages of 21, 30 and 42. Relationship variables at age 16 were poor parental contact and three indicators of poor peer relationships. Associations were assessed in multivariate ordinal logistic regressions with adjustment for confounders and baseline health.

RESULTS

Results show that the main relationships-related predictors of adult internalising symptoms were self-rated poor peer relationships in terms of spending time alone during after-school hours and poor parental relationship. Functional somatic symptoms on the other hand were most strongly associated with poor parental contact and not being happy with classmates at age 16.

CONCLUSIONS

The quality of parental and peer relationships in adolescence predicts adult mental and functional somatic health as much as 26 years later, even when accounting for confounders and adolescent symptomatology. This study extends past research by exploring how both adolescent parental and peer relationships (self-reported as well as teacher reported) predict adult self-reported health.

Do the various categories of somatoform disorders differ from each other in symptom profile and psychological correlates

BACKGROUND

In routine clinical practice, the subcategories of various somatoform disorders are rarely used by the primary care physicians and there is lack of data to suggest any difference in the clinical manifestations of these subcategories.

AIM

To compare the symptom profile, anxiety, depression, alexithymia, somato-sensory amplification and hypochondriasis of patients with persistent somatoform pain disorder with other subtypes of somatoform disorder.

METHOD

A total of 119 patients diagnosed with somatoform disorders according to the International Classification of Diseases-10th Revision (ICD-10) were evaluated for prevalence of somatic symptoms, anxiety, depression, alexithymia, hypochondriacal worry and somato-sensory amplification.

RESULTS

No significant differences were found in the prevalence of various somatic complaints between those with persistent somatoform pain disorder group and those diagnosed with other somatoform disorders. Co-morbid anxiety and depression were seen in two-thirds of the patients, but again there was no difference in the prevalence of the same between the two groups. Similarly, no significant differences were found on alexithymia, hypochondriasis and somato-sensory amplification scales between the persistent somatoform pain disorder group and the group with other somatoform disorders.

CONCLUSION

There are no significant differences between the various subcategories of somatoform disorders with regard to the prevalence of somatic symptoms, anxiety or depression and psychological correlates of alexithymia, hypochondriasis and somato-sensory amplification.

Attachment in romantic relationships and somatization

Adult attachment representations have been considered to play a role in the development and treatment of somatizing behavior. In this study, the associations between the two attachment dimensions avoidance and anxiety and dimensions of psychopathology (somatization, depression, and general anxiety) were explored. The sample consists of 202 outpatients diagnosed with a somatoform disorder. Data were collected via self-report measures. A path analysis shows that the two attachment dimensions are not directly associated with somatization. There are, however, significant indirect associations between attachment and somatization mediated by depression and general anxiety, which are more pronounced for attachment anxiety than for attachment avoidance. The findings reveal that a low level of attachment security in romantic relationships, especially an anxious stance toward the partner, comes along with poor mental health, which in turn is related to a preoccupation with somatic complaints. Implications for the treatment of somatizing patients are discussed.

Managing the consultation with patients with medically unexplained symptoms: a grounded theory study of supervisors and registrars in general practice

BACKGROUND

Patients with medically unexplained symptoms (MUS) commonly present in general practice. They often experience significant disability and have difficulty accessing appropriate care. Many feel frustrated and helpless. Doctors also describe feeling frustrated and helpless when managing these patients. These shared negative feelings can have a detrimental effect on the therapeutic relationship and on clinical outcomes. The aim of this study was to explore how novice and experienced GPs manage patients with MUS and how these skills are taught and learned in GP training.

METHODS

A constructivist grounded theory study with 24 general practice registrars and supervisors in GP training practices across Australia.

RESULTS

Registrars lacked a framework for managing patients with MUS. Some described negative feelings towards patients that were uncomfortable and confronting. Registrars also were uncertain about their clinical role: where their professional responsibilities began and ended. Supervisors utilised a range of strategies to address the practical, interpersonal and therapeutic challenges associated with the care of these patients.

CONCLUSIONS

Negative feelings and a lack of diagnostic language and frameworks may prevent registrars from managing these patients effectively. Some of these negative feelings, such as frustration, shame and helplessness, are shared between doctors and patients. Registrars need assistance to identify and manage these difficult feelings so that consultations are more effective. The care of these patients also raises issues of professional identity, roles and responsibilities. Supervisors can assist their registrars by proactively sharing models of the consultation, strategies for managing their own feelings and frustrations, and ways of understanding and managing the therapeutic relationship in this difficult area of practice.

Dysfunctional illness perception and illness behaviour associated with high somatic symptom severity and low quality of life in general hospital outpatients in China

OBJECTIVE

In primary care populations in Western countries, high somatic symptom severity (SSS) and low quality of life (QoL) are associated with adverse psychobehavioural characteristics. This study assessed the relationship between SSS, QoL and psychobehavioural characteristics in Chinese general hospital outpatients.

METHODS

This multicentre cross-sectional study enrolled 404 patients from 10 outpatient departments, including Neurology, Gastroenterology, Traditional Chinese Medicine [TCM] and Psychosomatic Medicine departments, in Beijing, Shanghai, Chengdu and Kunming. A structured interview was used to assess the cognitive, affective and behavioural features associated with somatic complaints, independent of their origin. Several standard instruments were used to assess SSS, emotional distress and health-related QoL. Patients who reported low SSS (PHQ-15<10, n=203, SOM-) were compared to patients who reported high SSS (PHQ-15≥10, n=201, SOM+).

RESULTS

As compared to SOM- patients, SOM+ patients showed significantly more frequently adverse psychobehavioural characteristics in all questions of the interview. In hierarchical linear regression analyses adjusted for anxiety, depression, gender and medical conditions (SSS additionally for doctor visits), high SSS was significantly associated with "catastrophising" and "illness vulnerability"; low physical QoL was associated with "avoidance of physical activities" and "disuse of body parts"; low mental QoL was associated with "need for immediate medical help."

CONCLUSION

In accordance with the results from Western countries, high SSS was associated with negative illness and self-perception, low physical QoL with avoidance behaviour, and low mental QoL with reassurance seeking in Chinese general hospital outpatients.

[Critical Approach to Somatomorphic Disorders in Children]

Somatomorphic disorders have common somatic manifestations without medical explanation, that can affect daily life. There are evaluation difficulties regarding symptom report or observation in children due to their age, parental influence and associated factors. The aim of this work is to acknowledge diagnosis difficulties and clinic tools to approach somatomorphic disorders in children. A systematic search in the information published for the last ten years was carried out. Historical evolution of the concept of somatization has generated difficulties to approach this issue. Some signs could indicate a somatomorphic disorder; however, there are very little evaluating tools for children. Currently, said tools are only based on lists of symptoms without fully answering to all questions. Somatomorphic disorders or somatic symptoms in children are still a gap to be closed.

Comparing non-specific physical symptoms in environmentally sensitive patients: prevalence, duration, functional status and illness behavior

OBJECTIVE

Little is known about the potential clinical relevance of non-specific physical symptoms (NSPS) reported by patients with self-reported environmental sensitivities. This study aimed to assess NSPS in people with general environmental sensitivity (GES) and idiopathic environmental intolerance attributed to electromagnetic fields (IEI-EMF) and to determine differences in functional status and illness behavior.

METHODS

An epidemiological study was conducted in the Netherlands, combining self-administered questionnaires with the electronic medical records of the respondents as registered by general practitioners. Analyses included n=5789 registered adult (≥18 years) patients, comprising 5073 non-sensitive (NS) individuals, 514 in the GES group and 202 in the IEI-EMF group.

RESULTS

Participants with GES were about twice as likely to consult alternative therapy compared to non-sensitive individuals; those with IEI-EMF were more than three times as likely. Moreover, there was a higher prevalence of symptoms and medication prescriptions and longer symptom duration among people with sensitivities. Increasing number and duration of self-reported NSPS were associated with functional impairment, illness behavior, negative symptom perceptions and prevalence of GP-registered NSPS in the examined groups.

CONCLUSION

Even after adjustment for medical and psychiatric morbidity, environmentally sensitive individuals experience poorer health, increased illness behavior and more severe NSPS. The number and duration of self-reported NSPS are important components of symptom severity and are associated with characteristics similar to those of NSPS in primary care. The substantial overlap between the sensitive groups strengthens the notion that different types of sensitivities might be part of one, broader environmental illness.

Mixed emotional and physical symptoms in general practice: what diagnoses do GPs use to describe them?

AIMS

To determine what diagnostic terms are utilized by general practitioners (GPs) when seeing patients with mixed emotional and physical symptoms.

METHOD

Prototype cases of depression, anxiety, hypochondriasis, somatization and undifferentiated somatoform disorders were sourced from the psychiatric literature and the author's clinical practice. These were presented, in paper form, to a sample of GPs and GP registrars who were asked to provide a written diagnosis.

RESULTS

Fifty-two questionnaires were returned (30% response rate). The depression and anxiety cases were identified correctly by most participants. There was moderate identification of the hypochondriasis and somatization disorder cases, and poor identification of the undifferentiated somatoform case.

CONCLUSION

Somatization and undifferentiated somatoform disorders were infrequently recognized as diagnostic categories by the GPs in this study. Future research into the language and diagnostic reasoning utilized by GPs may help develop better diagnostic classification systems for use in primary care in this important area of practice.

Barriers to the diagnosis of somatoform disorders in primary care: protocol for a systematic review of the current status

BACKGROUND

Somatoform-type disorders and functional medically unexplained symptoms are extremely common in primary care settings. These disorders, however, are consistently underdiagnosed and under-recognised which precludes effective treatment. Given that somatoform symptoms are associated with high impairment, healthcare costs and both physician and patient frustration, it is critical to improve early detection. The first step in improving patient care is to identify the current barriers which obstruct successful diagnosis to enable the design of targeted interventions. We aim to conduct a systematic review to identify the possible physician-, patient- and society-related factors and other practical constraints which may impede successful diagnosis. In the process, we will also be able to recognise the differences in methodological techniques, recommend potential avenues for future research and comment on the literature in this field as a whole.

METHODS/DESIGN

We aim to conduct a systematic review of the relevant peer-reviewed literature published in English or German in the past 10 years in MEDLINE, EMBASE, PsycINFO and the Cochrane Database of Systematic Reviews. Additional studies may be identified from the reference lists of included studies. Title and abstract screening and data extraction from full text manuscripts will be conducted by two independent reviewers. Because we are including a combination of qualitative and quantitative studies, the review will provide a broad understanding of the current situation. Wherever possible, the method and reporting of the review will adhere to the guidelines outlined in the PRISMA statement and bias will be assessed using the Cochrane collaboration's recommendations. We envisage that data will be synthesised using a multilevel (qualitative and quantitative) approach which combines textual narrative and thematic analysis. Barriers will be categorised as modifiable or non-modifiable according to a conceptual framework. The review has been registered in an international registry of systematic reviews PROSPERO (CRD42013002540).

DISCUSSION

We hope that this study will provide an insight into the barriers to diagnosis of somatoform-type disorders and the results can be used to target appropriate interventions to improve care for these patients.

At the borders of medical reasoning: aetiological and ontological challenges of medically unexplained symptoms

Medically unexplained symptoms (MUS) remain recalcitrant to the medical profession, proving less suitable for homogenic treatment with respect to their aetiology, taxonomy and diagnosis. While the majority of existing medical research methods are designed for large scale population data and sufficiently homogenous groups, MUS are characterised by their heterogenic and complex nature. As a result, MUS seem to resist medical scrutiny in a way that other conditions do not. This paper approaches the problem of MUS from a philosophical point of view. The aim is to first consider the epistemological problem of MUS in a wider ontological and phenomenological context, particularly in relation to causation. Second, the paper links current medical practice to certain ontological assumptions. Finally, the outlines of an alternative ontology of causation are offered which place characteristic features of MUS, such as genuine complexity, context-sensitivity, holism and medical uniqueness at the centre of any causal set-up, and not only for MUS. This alternative ontology provides a framework in which to better understand complex medical conditions in relation to both their nature and their associated research activity.

Descriptive and predictive validity of somatic attributions in patients with somatoform disorders: a systematic review of quantitative research

OBJECTIVE

Research on hypochondriasis and other somatoform disorders (SFD) has provided evidence that patients with SFD tend to attribute their symptoms to organic dysfunctions or disease. However, recent studies appear to discredit this. There is no systematic evidence on whether patients with SFD predominantly rely on somatic attributions, despite calls to include somatic attributions as a positive criterion of somatic symptom disorder (SSD) in the upcoming Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

METHODS

This study is a systematic review of quantitative studies which assess the descriptive and predictive validity of somatic attribution in SFD. The literature search was restricted to studies with patients who met the DSM-IV criteria for SFD.

RESULTS

Somatic attribution style in SFD has acceptable descriptive but insufficient predictive validity. This confirms that the overlap between somatic and psychological attributions is often substantial. Attribution style can discriminate between SFD patients with and without comorbidity.

CONCLUSION

A somatic attribution style does not qualify as a positive criterion in SSD. However, there is an urgent need for further research on causal illness perceptions in the full spectrum of medically unexplained symptoms in order to confirm this result. Given its high prevalence, research on psychological attribution style is warranted. Re-attribution does not provide a framework sophisticated enough to address the needs of patients in primary care.

Assessment of depression in medical patients: a systematic review of the utility of the Beck Depression Inventory-II

To perform a systematic review of the utility of the Beck Depression Inventory for detecting depression in medical settings, this article focuses on the revised version of the scale (Beck Depression Inventory-II), which was reformulated according to the DSM-IV criteria for major depression. We examined relevant investigations with the Beck Depression Inventory-II for measuring depression in medical settings to provide guidelines for practicing clinicians. Considering the inclusion and exclusion criteria seventy articles were retained. Validation studies of the Beck Depression Inventory-II, in both primary care and hospital settings, were found for clinics of cardiology, neurology, obstetrics, brain injury, nephrology, chronic pain, chronic fatigue, oncology, and infectious disease. The Beck Depression Inventory-II showed high reliability and good correlation with measures of depression and anxiety. Its threshold for detecting depression varied according to the type of patients, suggesting the need for adjusted cut-off points. The somatic and cognitive-affective dimension described the latent structure of the instrument. The Beck Depression Inventory-II can be easily adapted in most clinical conditions for detecting major depression and recommending an appropriate intervention. Although this scale represents a sound path for detecting depression in patients with medical conditions, the clinician should seek evidence for how to interpret the score before using the Beck Depression Inventory-II to make clinical decisions.

Somatic symptom disorder: an important change in DSM

This paper describes the rationale for the new diagnosis of somatic symptom disorder (SSD) within DSM5. SSD represents a consolidation of a number of previously listed diagnoses. It deemphasizes the centrality of medically unexplained symptoms and defines the disorder on the basis of persistent somatic symptoms associated with disproportionate thoughts, feelings, and behaviors related to these symptoms. Data are presented concerning reliability, validity, and prevalence of SSD, as well as tasks for future research, education, and clinical practice.

Psychological and behavioral variables associated with the somatic symptom severity of general hospital outpatients in China

OBJECTIVE

In high-income countries, the number and severity of somatic symptoms - irrespective of etiology--are associated with adverse psychobehavioral and functional characteristics. This study aimed to assess these key features among Chinese general hospital outpatients with high levels of somatic symptoms.

METHODS

This multicenter, cross-sectional study evaluated four outpatient departments of internal medicine and Traditional Chinese Medicine in Beijing and Kunming and enrolled a total of 281 consecutive patients. The patients answered questionnaires concerning somatic symptom severity [Patient Health Questionnaire (PHQ-15)], illness perception (Brief Illness Perception Questionnaire), illness behavior (Scale for the Assessment of Illness Behavior), emotional distress (Hospital Anxiety and Depression Scale) and health-related quality of life (12-Item Short Form Health Survey). Subsamples reporting high scores of somatic symptom severity (PHQ-15 ≥10, SOM+) versus low scores (PHQ-15 <10, SOM-) were compared.

RESULTS

Twenty-eight percent (79/281) of all outpatients showed high somatic symptom severity. The strongest correlations between high somatic symptom severity and psychobehavioral variables were found for high emotional distress, female gender, living alone, low physical quality of life and high dysfunctional illness behavior. The proportion of the explained variance was 36.1%.

CONCLUSION

In Chinese outpatients, high somatic symptom severity is frequent and associated with psychobehavioral characteristics. With the PHQ-15 cutoff of 10, SOM+ patients could be differentiated from SOM- patients using these characteristics.

Behavioural and psychological management of somatic symptom disorders: an overview

The number of patients who seek help at primary and secondary care for somatic symptoms which cannot be explained by any known medical condition is enormous. It has been proposed to rename 'somatoform disorders' in DSM-IV as 'somatic symptom disorders' in DSM-5. This is supposed to include disorders such as somatization disorder, hypochondriasis, undifferentiated somatoform disorder, pain disorder and factitious disorder. The reason for the renaming and grouping is that all these disorders involve presentation of physical symptoms and/or concern about medical illness. In the literature, there is considerable variation adopted with respect to diagnosis and in the approaches adopted for intervention. However, the common feature of these disorders is the chronicity, social dysfunction, occupational difficulties and the increased healthcare use and high level of dissatisfaction for both the clinician and the patient. A number of behavioural and psychological interventions for somatic symptoms have been carried out at primary, secondary and tertiary care settings and recently there have been more attempts to involve the primary care physicians in the psychological interventions. This review aims at giving an overview of the components of the behavioural and other psychological interventions available for addressing medically unexplained somatic symptoms and to present their efficacy.

Proof firm downsizing and diagnosis-specific disability pensioning in Norway

Background

We wanted to investigate if firm downsizing is related to an increased rate of disability pensions among the former employed, especially for those with musculoskeletal and psychiatric diagnoses, and for those having to leave the firm.

Methods

Statistics Norway provided a linked file with demographic information and all social security grants from the National Insurance Administration for 1992–2004 for all inhabitants in Norway. Our sample was aged 30–55 years in 1995, being alive, employed and not having a disability pension at the end of 2000. Downsizing was defined as percent change in number of employed per firm from 1995 to end 2000. Employment data were missing for 25.6% of the sample.

Results

Disability pension rates in the next four years were 25% higher for those experiencing a 30-59% downsizing than for those not experiencing a reduction of the workforce. 1-29% and 60-100% downsizing did not have this effect. Stayers following down-sizing had higher disability pension rates than leavers. What we have called complex musculoskeletal and psychiatric diagnoses were relatively most common.

Conclusion

Moderate downsizing is followed by a significant increase in disability pension rates in the following four years, often with complex musculoskeletal and psychiatric diagnoses.

Construct validity and descriptive validity of somatoform disorders in light of proposed changes for the DSM-5

OBJECTIVE

Current diagnostic criteria for somatoform disorders demand revisions due to their insufficient clinical as well as scientific usability. Various psychological and behavioral characteristics have been considered for the proposed new category Somatic Symptom Disorder (SSD). With this study, we were able to jointly assess the validity of these variables in an inpatient sample.

METHODS

Using a cross-sectional design, we investigated N=456 patients suffering from somatoform disorder, anxiety, or depression. Within one week after admission to the hospital, informed consent was obtained and afterwards, a diagnostic interview and a battery of self-report questionnaires were administered. Logistic regression analyses were performed to determine which variables significantly add to construct and descriptive validity.

RESULTS

Several features, such as somatic symptom severity, health worries, health habits, a self-concept of being weak, and symptom attribution, predicted physical health status in somatization. Overall, our model explained about 50% of the total variance. Furthermore, in comparison with anxious and depressed patients, health anxiety, body scanning, and a self-concept of bodily weakness were specific for DSM-IV somatoform disorders and the proposed SSD.

CONCLUSIONS

The present study supports the inclusion of psychological and behavioral characteristics in the DSM-5 diagnostic criteria for somatoform disorders. Based on our results, we make suggestions for a slight modification of criterion B to enhance construct validity of the Somatic Symptom Disorder.

Emerging themes in the revision of the classification of somatoform disorders

The somatoform disorders, as currently defined in DSM-IV and ICD-10, have been criticized for their complexity and poor clinical utility. In this paper we consider these criticisms as well as the conceptual question of whether there is sufficient evidence for classifying them as mental and behavioural disorders. The review suggests that, as currently defined, somatoform disorders do not fulfil a recently articulated set of criteria for mental and behavioural disorders. In particular, the disorders are not defined according to positive psychological and behavioural disorders and evidence is sparse to support their classification as different and distinct diagnoses. Any revision of the disorders should not be based on 'medically unexplained' symptoms. Rather, the relevant diagnoses should include a combination of bothersome somatic symptoms with several other psychological features including beliefs about somatic symptoms and evidence of marked concerns about health and illness. Finally, the review presents a set of proposals for the revision of these disorders, by the Somatic Disorders and Dissociative Disorders Working Group of the WHO International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders, which attempt to take account of the criticisms and current understanding of somatic experiences.

Non-specific, functional, and somatoform bodily complaints

BACKGROUND

4-10% of the general population and 20% of primary care patients have what are called "non-specific, functional, and somatoform bodily complaints." These often take a chronic course, markedly impair the sufferers' quality of life, and give rise to high costs. They can be made worse by inappropriate behavior on the physician's part.

METHODS

The new S3 guideline was formulated by representatives of 29 medical and psychological specialty societies and one patient representative. They analyzed more than 4000 publications retrieved by a systematic literature search and held two online Delphi rounds and three consensus conferences.

RESULTS

Because of the breadth of the topic, the available evidence varied in quality depending on the particular subject addressed and was often only of moderate quality. A strong consensus was reached on most subjects. In the new guideline, it is recommended that physicians should establish a therapeutic alliance with the patient, adopt a symptom/coping-oriented attitude, and avoid stigmatizing comments. A biopsychosocial diagnostic evaluation, combined with sensitive discussion of signs of psychosocial stress, enables the early recognition of problems of this type, as well as of comorbid conditions, while lowering the risk of iatrogenic somatization. For mild, uncomplicated courses, the establishment of a biopsychosocial explanatory model and physical/social activation are recommended. More severe, complicated courses call for collaborative, coordinated management, including regular appointments (as opposed to ad-hoc appointments whenever the patient feels worse), graded activation, and psychotherapy; the latter may involve cognitive behavioral therapy or a psychodynamic-interpersonal or hypnotherapeutic/imaginative approach. The comprehensive treatment plan may be multimodal, potentially including body-oriented/non-verbal therapies, relaxation training, and time-limited pharmacotherapy.

CONCLUSION

A thorough, simultaneous biopsychosocial diagnostic assessment enables the early recognition of non-specific, functional, and somatoform bodily complaints. The appropriate treatment depends on the severity of the condition. Effective treatment requires the patient's active cooperation and the collaboration of all treating health professionals under the overall management of the patient's primary-care physician.

Cognitive-perceptual factors in noncardiac chest pain and cardiac chest pain

OBJECTIVE

Noncardiac chest pain (NCCP) is a common condition associated with considerable patient distress and substantial healthcare costs. Our aim was to investigate associations between illness perceptions, anxiety sensitivity, somatic amplification, and experience of chest pain, and to assess whether a multifactorial model including these factors can distinguish patients with NCCP from patients with cardiac chest pain (CCP).

METHODS

A total of 240 patients with chest pain answered questionnaires concerning anxiety sensitivity (Anxiety Sensitivity Index-3), somatic amplification (Somatosensory Amplification Scale), illness perceptions (Illness Perception Questionnaire-Brief, health concerns, and heart disease conviction), and pain characteristics (intensity, disability, and frequency) before the evaluation of chest pain causation. They were classified as having NCCP or CCP by cardiac angiography. Partial correlation analyses and binary logistic regression analyses were performed.

RESULTS

Seventy percent of patients with chest pain were classified as having NCCP. A range of cognitive-perceptual factors were associated with the experience of chest pain. On multivariate analyses, the only psychological factor found to differentiate NCCP from CCP was elevated somatic amplification (relative risk = 1.06, 95% confidence interval = 1.00-1.13).

CONCLUSIONS

The current DSM-5 proposal with regard to somatic symptom disorder recommends using psychological factors as diagnostic criteria for medically unexplained symptoms while placing less emphasis on the criterion of lack of somatic causation. In this study, an association between pain characteristics and cognitive-perceptual factors was found both for patients with NCCP and for patients with CCP. We found no evidence for a specific profile of psychological characteristics distinguishing patients with NCCP from patients with CCP, except for somatic amplification.