Is severity a clinically meaningful specifier of somatic symptom disorder?

Neuropsychological features of somatic symptom disorder and depression/anxiety in Taiwan: An analysis based on the comorbidity status

Individuals with somatic symptom disorder (SSD) often have comorbid depression or anxiety, but whether SSD is associated with specific neuropsychological functions has yet to be fully examined. We analyzed which neuropsychological features are more closely associated with SSD, anxiety, and depression. In this case-control study, we recruited 140 individuals with SSD, 104 individuals with affective disorders without SSD, and 159 healthy controls in Taiwan. We collected DSM-5 diagnoses, questionnaire scores, and performance on eight tasks from the Cambridge Neuropsychological Test Automated Battery (CANTAB) for each participant. Several CANTAB tasks involving attention, executive function, and social cognition showed significant group differences. In the adjusted analysis, the tasks significantly associated with SSD were the Match to Sample Visual Search (MTS) and the Emotion Recognition Task (ERT). Among the questionnaires, the Cognitions about Body and Health Questionnaire showed the most significant associations with the tasks, specifically with Rapid Visual Information Processing, MTS, Paired Associates Learning, Spatial Working Memory, Intra-Extra Dimensional Set Shift, and ERT. We conclude that the MTS and ERT tasks show significant relationships with both SSD diagnosis and related questionnaires. These tasks primarily involve selective attention and negative emotion regulation.

Psychological risk factors of somatic symptom disorder: A systematic review and meta-analysis of cross-sectional and longitudinal studies

OBJECTIVE

Current diagnostic concepts of somatic symptom disorder (SSD) in DSM-5 and bodily distress disorder (BDD) in ICD-11 require certain psychological criteria, but researchers have called for further specification. Therefore, in a first step, this systematic review and meta-analysis aimed to summarize the current evidence on psychological factors associated with SSD/BDD and/or disorder-relevant clinical outcomes such as symptom severity and impairment.

METHODS

Psychological factors were systematically searched using Pubmed, Cochrane Library and Psycinfo via EBSCO. Studies providing original data in English or German, after 2009 were included. Cross-sectional, cohort and case-control studies investigating at least one psychological factor in individuals with SSD/BDD in the context of disorder-relevant outcomes were included.

RESULTS

Forty-three eligible studies (n = 3760 patients) in SSD (none in BDD) provided data on at least one psychological factor, 37 in case-control format, 10 cross-sectional and 5 longitudinal. Meta-analyses of the case-control studies found patients with SSD to be more impaired by depression (SMD = 1.80), anxiety (SMD = 1.55), health anxiety (SMD = 1.31) and alexithymia (SMD = 1.39), compared to healthy controls. Longitudinal results are scarce, mixed, and require refining, individual studies suggest self-concept of bodily weakness, anxiety and depression to be predictive for persistent SSD and physical functioning.

CONCLUSION

This review provides a detailed overview of the current evidence of psychological factors in relation to SSD/BDD. Future studies on SSD and BDD should include under-studied psychological factors, such as negative affect, fear avoidance, or emotion regulation. More longitudinal studies are needed to assess the predictive value of these factors.

Scoping review update on somatic symptom disorder that includes additional Chinese data

Somatic symptom disorder (SSD) is a new diagnosis introduced into the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), which is expected to solve the diagnostic difficulties of patients with medically unexplained symptoms. Based on the previous work, this review aims to comprehensively synthesise updated evidence related to SSD from recent years in English publications and, more extensively, from data published in Chinese language journals. The scoping review update was based on an earlier scoping review and included Chinese language publication data from China National Knowledge Internet (CNKI), WANFANG and WEIPU between January 2013 and May 2022 and data from PubMed, PsycINFO, and Cochrane Library between June 2020 and May 2022. Initially, 2 984 articles were identified, of which 63 full texts were included for analysis. In China, SSD is mainly applied in scientific research, but it also shows good predictive validity and clinical application potential. The mean frequency of SSD was 4.5% in the general population, 25.2% in the primary care population and 33.5% in diverse specialised care settings. Biological factors, such as brain region changes and heart rate variability, are associated with the onset of SSD. Psychological impairment related to somatic symptoms is the best predictor of prognosis. While adolescent SSD was significantly associated with family function, SSD overall is associated with an increased dysfunction of cognition and emotion, decreased quality of life, and high comorbidity with anxiety and depressive disorders. Further research is needed on suicide risk and cultural and gender-related issues. Updating the data of Chinese language studies, our research enriches the evidence-based findings related to the topics addressed in the text sections of the SSD chapter of DSM-5. However, research gaps remain about SSD reliability, population-based prevalence, suicide risk, and cultural and gender-related issues.

The comorbidity of somatic symptom and major depressive disorders in the times of COVID-19 lockdown in adolescence: A case-report study

Physical symptoms with normal clinical examinations have been reported without detectable structural or biochemical abnormalities in the comorbidity of somatic symptom disorder and major depressive disorder. This association can have a debilitating effect on their academic and social performance. This case report is about a 13-year-old Afghani immigrant boy with no previous psychiatric history who developed severe body pain leading to a disability during the COVID-19 lockdown and social isolation. During further evaluation, all his clinical examinations were normal, and the diagnosis of major depressive disorder and somatic symptom disorder was confirmed. Cognitive behavioral therapy includes cognitive therapy, changing lifestyle, and a motivational support method. Medical treatment with olanzapine, fluvoxamine, and gabapentin was started. During follow-up, there was improvement in the patient's mood, and the patient began to walk and communicate. It is important to suspect an association of somatic symptom disorder and major depressive disorder in patients with severe body pain and multiemotional factors. Psychiatrists should keep in mind that emotional factors can play a significant role in causing and maintaining physical symptoms.

Effectiveness of psychosomatic therapy for patients with persistent somatic symptoms: Results from the CORPUS randomised controlled trial in primary care

OBJECTIVE

To evaluate the effectiveness of psychosomatic therapy versus care as usual in primary care for patients with persistent somatic symptoms (PSS).

METHODS

We conducted a pragmatic, two-armed, randomised controlled trial among primary care patients with PSS in the Netherlands that included 39 general practices and 34 psychosomatic therapists. The intervention, psychosomatic therapy, consisted of 6-12 sessions delivered by specialised exercise- and physiotherapists.

PRIMARY OUTCOME MEASURE

patient's level of functioning.

SECONDARY OUTCOMES

severity of physical and psychosocial symptoms, health-related quality of life, health-related anxiety, illness behaviour and number of GP contacts.

RESULTS

Compared to usual care (n = 85), the intervention group (n = 84) showed no improvement in patient's level of functioning (mean difference - 0.50 [95% CI -1.10 to 0.10]; p = .10), and improvement in health-related anxiety (mean difference - 1.93 [95% CI -3.81 to -0.04]; p = .045), over 12 months. At 5-month follow-up, we found improvement in physical functioning, somatisation, and health-related anxiety. The 12-month follow-up revealed no therapy effects. Subgroup analyses showed an overall effect in patient's level of functioning for the group with moderate PSS (mean difference - 0.91 [95% CI -1.78 to -0.03]; p = .042). In the year after the end of therapy, the number of GP contacts did not differ significantly between the two groups.

CONCLUSION

We only found effects on some secondary outcome measures, and on our primary outcome measure especially in patients with moderate PSS, the psychosomatic therapy appears promising for further study.

TRIAL REGISTRATION

the trial is registered in the Netherlands Trial Registry, https://trialsearch.who.int/Trial2.aspx?TrialID=NTR7356 under ID NTR7356.

Population-based prevalence of somatic symptom disorder and comorbid depression and anxiety in Taiwan

OBJECTIVE

The nationwide prevalence of somatic symptom disorder (SSD) has not yet been investigated in Asia. SSD is often comorbid with depression and anxiety, and the effects of these conditions on medical utilization await clarification. We hence performed a study in Taiwan to explore these issues.

METHODS

Using telephone-based sampling and interview, we obtained data for 3161 participants whose age, gender and living area were compatible with the Taiwan population. We gathered scores of the Patient Health Questionnaire-15 (PHQ-15), Health Anxiety Questionnaire (HAQ) and Patient Health Questionnaire-4 (PHQ-4). Individuals with a PHQ-15 score of at least 4 and a HAQ score of at least 17 were considered to have SSD. Descriptive statistics were used to clarify the prevalence and normative data of the questionnaires. We used multiple logistic regression analyses to investigate the relation between diagnoses and medical utilization.

RESULTS

The prevalence of SSD was 5.00% and women had a higher SSD prevalence than men; participants aged 40-49 years had the highest SSD prevalence. In SSD patients, 33.58% had depression or anxiety. After correcting for demographics, SSD and anxiety (but not depression) were associated with a significantly high level of outpatient/emergency department attendance. Comorbid depression or anxiety did not significantly increase the medical utilization of SSD patients.

CONCLUSION

The nationwide SSD prevalence in Taiwan is compatible with the description in the DSM-5. The comorbidity of SSD and depression/anxiety is common, but depression or anxiety does not significantly increase the SSD patients' medical utilization.

Use of machine learning to diagnose somatic symptom disorder: Are the biomarkers beneficial for the diagnosis?

OBJECTIVES

We used machine learning to incorporate three types of biomarkers (respiratory sinus arrhythmia, RSA; skin conductance, SC; finger temperature, FT) for examining the performance of diagnosing somatic symptom disorder (SSD).

METHODS

We recruited 97 SSD subjects and 96 controls without psychiatric history or somatic distress. The values of RSA, SC and FT were recorded in three situations (resting state, under a cognitive task and under paced breathing) and compared for the two populations. We used machine learning to combine the biological signals and then applied receiver operating characteristic curve analysis to examine the performance of diagnosing SSD regarding the distinct indicators and situations. Subgroup analysis for subjects without depression/anxiety was also conducted.

RESULTS

FT was significantly different between SSD patients and controls, especially in the resting state and under paced breathing. However, the biomarkers (0.75-0.76) did not reveal an area under the curve (AUC) comparable with the psychological questionnaires (0.86). Combining the biological and psychological indicators gave a high AUC (0.86-0.92). When excluding individuals with depression/anxiety, combining three biomarkers (0.79-0.83) and adopting psychological questionnaires (0.78) revealed a similar AUC.

CONCLUSIONS

The performance of RSA/SC/FT was unsatisfactory for diagnosing SSD but became comparable when excluding comorbid depression/anxiety.

The association between heart rate variability and skin conductance: a correlation analysis in healthy individuals and patients with somatic symptom disorder comorbid with depression and anxiety

Objective

To investigate the correlations between heart rate variability (HRV) and skin conductance (SC) in two populations under three different situations.

Methods

This cross-sectional study enrolled patients with somatic symptom disorder comorbid with depression and anxiety and healthy individuals without a psychiatric history. The biological signals were measured under three conditions: resting state, during a cognitive task and during paced breathing. Pearson’s correlation analysis and the generalized estimating equation were used to examine the correlations between SC and HRV in the two populations under the three situations.

Results

The study enrolled 97 patients with somatic symptom disorder comorbid with depression and anxiety and 96 healthy individuals. In healthy individuals, the ratio of low-frequency power to high frequency power (LF/HF) and normalized LF (LF%) were significantly correlated with SC in the resting state and during a cognitive task, but the correlation coefficients were low level. In patients with somatic symptom disorder comorbid with depression and anxiety, LF/HF and LF% did not show significant correlations with SC under any situation.

Conclusions

The two different populations and three situations might have affected the significance of the LF/HF-SC and LF%-SC correlations. The generally low correlations indicate that LF/HF and LF% cannot fully reflect the sympathetic cholinergic activity represented by SC.

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.

Psychometric Properties of the Chinese Version of the Cognitions About Body and Health Questionnaire

INTRODUCTION

The Cognitions About Body and Health Questionnaire (CABAH) is a self-rating questionnaire measuring cognitions about health. The psychometric properties of its Chinese version and its performance on evaluating somatic symptom disorder (SSD) were examined in this study.

METHODS

After translating the CABAH into Chinese, we collected data of the CABAH and another four questionnaires (Patient Health Questionnaire-15, Health Anxiety Questionnaire, Beck Depression Inventory-II, Beck Anxiety Inventory) in 208 SSD patients and 197 healthy individuals. We used exploratory factor analysis (EFA) to explore the structure of the Chinese CABAH. Internal consistency and criterion-related validity were analyzed. An independent t-test and receiver operating characteristic (ROC) curve analysis were used to evaluate the performance of the CABAH for evaluating SSD.

RESULTS

Six factors were suggested by EFA. Five (bodily weakness, health habits, catastrophizing interpretation of specific bodily complaints, somatosensory amplification, catastrophizing interpretation of general bodily complaints) are conceptually associated with the original CABAH. The sixth factor (reverse, with three items) is different from the original construct. Cronbach's alpha for the CABAH was 0.885. The CABAH score was moderately correlated with scores of the other four questionnaires. Scores for the whole CABAH and scores of the six factors were all significantly higher in SSD patients than in healthy individuals. The results of ROC curve analysis were as follows: area under the curve=0.700; suggested cutoff=58/59; Youden's J=0.295.

CONCLUSION

The reliability and validity of the Chinese CABAH were fair, although the three items in the reverse factor should be interpreted cautiously.