Symptoms, syndromes, and the value of psychiatric diagnostics in patients who have functional somatic disorders

Latent profile analysis of biopsychosocial measures in older patients with (un)explained persistent somatic symptoms

Patients with persistent somatic symptoms (PSS) often receive either somatic or psychiatric care, depending on whether symptoms are respectively medically explained (MES) or unexplained (MUS). This separation may not be as clinically relevant as previously assumed; however, research on data-driven subgroups within cohorts of older patients with PSS is not available. Our goal is to identify more clinically relevant homogeneous subgroups beyond the distinction of MUS and MES among older patients with PSS by using a data-driven approach. We performed two Latent Profile Analyses (LPAs), one focused on 6 somatic health measures, the other on 6 psychosocial measures, using data from a case-control study with participants (>60 years) with MUS (N = 118) or MES (N = 154), recruited from the general public, general practices and secondary healthcare. We identified two somatic-health based (strong, vulnerable) and four mental-health based (strong, vulnerable, lonely, non-acceptance) profiles. We found no statistically significant overlap between the somatic - and mental health profiles (κ = 0.019). Health related quality of life negatively associated with the mentally - and somatically vulnerable profiles. We conclude that singular focus on MUS/MES distinction in the care for older PSS patients may lead to undertreatment of the most vulnerable patients. Integrated care is recommended when treating persistent somatic symptoms in later life, regardless of the (un)explained origin of the symptoms.

Early Childhood Care in the Former East Germany and Mental Stress in Adulthood

BACKGROUND

It is still debated in Germany whether early childhood care outside the family might cause mental stress in adulthood. In the German Democratic Republic (GDR-the former East Germany before unification), children were often cared for outside the family from a very early age.

METHODS

To determine the relation between early childhood care outside the family and mental stress in adulthood, we carried out a survey among 1575 persons who were born and socialized in the GDR. They were classified into four care groups according to the age at which they were first cared for outside the family. Associations with depressiveness, somatization disorders, and anxiety disorders in adulthood were tested with logistic regression analysis. Care group-specific prevalences of experiences of abuse and neglect in childhood were estimated with analysis of variance.

RESULTS

Comparisons of persons cared for outside the family before the age of three, or from the age of three onward, with persons cared for within the family in their preschool years did not reveal any difference with respect to depressiveness (odds ratio [OR] = 0.95; 95% confidence interval [0.58; 1.55]; OR = 1.05 [0.63; 1.74]), somatization disorders (OR = 1.11 [0.74; 1.67]; OR = 1.09 [0.71; 1.66]), or anxiety disorders (OR = 0.87 [0.46; 1.64]; OR = 1.12 [0.59; 2.10]). Nor were there any intergroup differences with respect to experiences of abuse and neglect. Certain features of the very small group of children who had long-term care outside the family are discussed in the article.

CONCLUSION

No relation was found between earlychildhood care in day-care centers in the GDR and mental stress in adulthood. The data were too sparse for any conclusions about specific aspects of care outside the home (e.g., quality or child-rearing norms).

Clinical Interviewing: An Essential but Neglected Method of Medicine

Clinical interviewing is the basic method to understand how a person feels and what are the presenting complaints, obtain medical history, evaluate personal attitudes and behavior related to health and disease, give the patient information about diagnosis, prognosis, and treatment, and establish a bond between patient and physician that is crucial for shared decision making and self-management. However, the value of this basic skill is threatened by time pressures and emphasis on technology. Current health care trends privilege expensive tests and procedures and tag the time devoted to interaction with the patient as lacking cost-effectiveness. Instead, the time spent to inquire about problems and life setting may actually help to avoid further testing, procedures, and referrals. Moreover, the dialogue between patient and physician is an essential instrument to increase patient's motivation to engage in healthy behavior. The aim of this paper was to provide an overview of clinical interviewing and its optimal use in relation to style, flow and hypothesis testing, clinical domains, modifications according to settings and goals, and teaching. This review points to the primacy of interviewing in the clinical process. The quality of interviewing determines the quality of data that are collected and, eventually, of assessment and treatment. Thus, interviewing deserves more attention in educational training and more space in clinical encounters than it is currently receiving.

Central psychological symptoms from a network analysis of patients with anxiety, somatoform or personality disorders before psychotherapy

BACKGROUND

Cross-sectional network analysis examines the relationships between symptoms to explain how they constitute disorders. Up to now, research focuses mostly on depression, posttraumatic stress disorder, and rarely assesses larger networks of various symptoms measured with instruments independent of classifications. Studies on large groups of psychotherapy patients are also rare.

METHODS

Analyzing triangulated maximally filtered graph (TMFG) networks of 62 psychological symptoms reported by 4616 consecutive nonpsychotic adults in 1980-2015.

RESULTS

Case-dropping and nonparametric bootstrap proved the accuracy, stability and reliability of networks in patients' sex-, age-, and time of visit divided subgroups. Feeling that others are prejudiced against the patient was the most central symptom, followed by catastrophic fears, feeling inferior and underestimated. Sadness, panic, and sex-related complaints were less central than we expected. All analysed symptoms were connected, and we found only small sex-related differences between subsamples' networks. No differences were observed for time of visit and age of patients.

LIMITATION

Analyses were cross-sectional and retrospective, not allowing examination of directionality or causality. Further, data are at the between-person level; thus, it is unknown whether the network remains constant for any person over time. One self-report checklist and building binary network method may bias results. Our results indicate how symptoms co-occured before psychotherapy, not longitudinally. Our sample included public university hospital patients, all White-Europeans, predominantly females and university students.

CONCLUSIONS

Hostile projection, catastrophic fears, feeling inferior and underestimated were the most important psychological phenomena reported before psychotherapy. Exploring these symptoms would possibly lead to enhancement of treatments.

Psychometric Evaluation of the Whiteley Index-8 in Chinese Outpatients in General Hospitals

Background: Excessive and persistent health anxiety is a common and disabling but often unrecognized illness. Therefore, screening patients for health anxiety is recommended in primary care. The aim of the present study was to examine the psychometric properties of an updated version of the eight-item Whiteley Index (WI-8) among outpatients in general hospitals in China. Methods: The presented data were derived from a multicenter cross-sectional study. The Chinese version of the WI-8 was administered to a total of 696 outpatients. Cronbach's alpha was used to evaluate the internal consistency of the scale. The validity of the scale was evaluated based on factor analysis and correlation analyses. To assess the discriminant ability, receiver operating characteristic (ROC) analysis was conducted. Results: Cronbach's alpha was 0.937, and it decreased (0.925) after deleting the new 8th item. Factor analysis extracted one factor accounting for 69.2% of the variance. Moderate correlations were found (0.414-0.662) between the WI-8 and General Anxiety Disorder (GAD-7), Patient Health Questionnaire-9 (PHQ-9), Patient Health Questionnaire-15 (PHQ-15) and Somatic Symptom Disorder B-criteria (SSD-12). The ROC curve indicated excellent discriminatory ability to discriminate among patients with health anxiety (AUC = 0.822). Conclusions: The new WI-8 version is a reliable and valid tool to screen for health anxiety in general hospital patients. We recommend the WI-8 as a useful screening tool for health anxiety.

Making sense of symptoms, clinicians and systems: a qualitative evaluation of a facilitated support group for patients with medically unexplained symptoms

Objectives

Health services to date have inadequately addressed the physical and mental health needs of patients with medically unexplained symptoms. This qualitative study evaluates a piloted facilitated support group (FSG) developed for patients with medically unexplained symptoms to inform recommendations and resources for this patient population.

Methods

Using a qualitative descriptive design, we conducted and thematically analyzed semi-structured interviews with participants (n = 8) and facilitators (n = 4) to explore their experiences of the facilitated support group. Common themes that captured strengths and challenges of the facilitated support group were identified.

Results

The following key themes were identified through analysis of the data: Participants described 1) feeling validated through sharing similar experiences with peers; 2) learning practical symptom management and coping strategies; and 3) gaining new perspectives for navigating conversations with PCPs.

Conclusions

Our findings show that a facilitated support group may provide additional forms of support and resources for patients with medically unexplained symptoms, filling a gap in currently available clinical care offered by health care professionals. Potential implications: This paper highlights lessons learned that can inform the design and delivery of future supports and resources directed toward optimizing patient care for this underserved patient population. Our findings are relevant to those who are involved in direct patient care or involved in designing and implementing self-management programs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01495-9.

Short-term psychodynamic psychotherapy for functional somatic disorders: A systematic review and meta-analysis of within-treatment effects

OBJECTIVE

A recent meta-analysis of 17 randomized, controlled trials (RCTs) showed that Short-term Psychodynamic Psychotherapy (STPP) for functional somatic disorders (FSD) reduced somatic symptoms compared to wait list, minimal treatment, and treatment-as-usual controls. A clinically important yet unanswered question is how much improvement patients experience within STPP treatment.

METHODS

Following a systematic search, we identified STPP trials presenting data at baseline and post-treatment/follow-up. Meta-analyses determined the magnitude of changes in somatic symptoms and other outcomes from before to after STPP, and analyses examined effect sizes as a function of study, therapy, and patient variables.

RESULTS

We identified 37 trials (22 pre-post studies and 15 RCTs) totaling 2094 patients treated an average of 13.34 sessions for a range of FSD. Across all studies, somatic symptoms improved significantly from pre-treatment to short-term follow-up with a large effect size (SMD = -1.07), which was maintained at long-term follow-up (SMD = -0.90). After excluding two outlier studies, effects at short- and medium-term follow-up remained significant but were somewhat reduced in magnitude (e.g., short-term SMD = -0.73). Secondary outcomes including anxiety, depression, disability, and interpersonal problems had medium to large effects. Effects were larger for studies of STPP that were longer than 12 sessions or used an emotion-focused type of STPP, and for chronic pain or gastrointestinal conditions than for functional neurological disorders.

CONCLUSIONS

STPP results in moderate to large improvements in multiple outcome domains that are sustained in long-term follow-up. STPP is an effective treatment option for FSD and should be included in treatment guidelines.

Comparison of dialectical behavior therapy and anti-anxiety medication on anxiety and digestive symptoms in patients with functional dyspepsia

Background:

Functional dyspepsia is a common chronic digestive disorder. The purpose of this study was to compare the effectiveness of dialectical behavior therapy and anti-anxiety medication in patients with functional dyspepsia.

Materials and Methods:

The present study was a randomized, controlled clinical trial with sixty patients who were suffering from functional dyspepsia that identified by the ROME III criteria. Patients were divided into three groups by using pre- and posttest design, including Group A (dialectal treatment and pantoprazole), Group B (anxiolytic drug treatment and pantoprazole), and Group C (no intervention, only pantoprazole were used). The Beck Anxiety Inventory and the patient assessment of Gastrointestinal Symptom Severity Index Questionnaire were completed by the patients after receiving the written consent. Finally, the data were analyzed using the Statistical Package for the Social Sciences software version 20.

Results:

There was a significant improvement in the severity of dyspepsia after intervention in all three groups. The greatest decrease in the severity of functional dyspepsia was observed in the dialectical behavioral therapy group as compared to the other groups (Group A: −15.4 ± 6.61, Group B: −3.85 ± 2.77, and Group C: −7.8 ± 4.02; P = 0.001). Furthermore, the Beck Anxiety Inventory scores were statistically significantly improved in all three groups (Group A: −5.75 ± 2.53, Group B: −7.3 ± 3.19, and Group C: −2.60 ± 1.5; P = 0.001). There was a positive correlation between the change in dyspepsia score and change in anxiety score across different intervention groups (r = 0.55; P < 0.001).

Conclusion:

Dialectical behavioral therapy can be effective in reducing anxiety and improving the dyspepsia symptoms in patients with functional dyspepsia compared to anti-anxiety medication or conventional therapy. Therefore, communication between the physicians and psychologists and psychiatrists can have positive effects on the treatment of these patients.

Medically unexplained physical symptoms in patients visiting the emergency department: an international multicentre retrospective study

OBJECTIVE

The objective of this study was to assess the incidence and characteristics of patients presenting with physical symptoms that remain medically unexplained at the emergency department (ED).

PATIENTS AND METHODS

A retrospective chart study was carried out in three hospitals in The Netherlands and Belgium. All patients (age > 18 years) visiting the ED in 4 selected weeks in 2013 at the Erasmus University Medical Center (Erasmus MC) in Rotterdam, The Netherlands, and 1 selected week in 2013 at the Haaglanden Medical Center, Westeinde HMC in The Hague, The Netherlands, and the University Hospital Ghent (UZG), Belgium, were included. Descriptive statistics were used for data analysis.

RESULTS

A total of 2869 patients (Erasmus MC 1674, HMC 691, UZG 504) were included. Medically unexplained physical symptoms in the emergency department (EDMUPS) were present in 13.4% of all ED visits (Erasmus MC 12.5%, HMC 18.7%, UZG 9.1%). No EDMUPS were identified in trauma patients. When excluding trauma patients, EDMUPS were present in 18.5% (Erasmus MC 16.8%, HMC 26.5%, UZG 13.3%) of the visits. The characteristics of patients with and without EDMUPS differed significantly; patients with EDMUPS were more often younger, female, self-referred, frequent visitors, were prescribed less medication and more often had a psychiatric disease. Dutch and Belgian Hospital differed in the distribution of patients in triage categories and in the incidence of psychiatric illnesses.

CONCLUSION

Physical symptoms remain unexplained in a significant number of patients at the time of ED assessment.

Abdominal pain is a common and recurring problem in paediatric emergency departments

AIM

Abdominal pain is a frequent reason for paediatric emergency department visits, but specific research is lacking. Our aim was to obtain information on the diagnosis of abdominal pain and what healthcare services children with this condition need.

METHODS

This retrospective study focused on patients visiting the emergency department of the Children's Hospital Iceland in 2010 with abdominal pain and any subsequent visits up to 1 January 2015.

RESULTS

There were 11 340 visits to the emergency department in 2010 and 1118 children made 1414 (12%) visits due to abdominal pain. The majority (58%) with abdominal pain were girls (p < 0.001) and they were older than the boys, with an average age of 12 versus 10 years (p < 0.001). The most common diagnoses were non-specific abdominal pain (40%), constipation (22%) and viral infections (13%). During the follow-up period, 423/1118 children (38%) visited the emergency department 883 times, 58% were girls and the most common diagnosis was non-specific abdominal pain (37%). Of the 436 children initially diagnosed with non-specific abdominal pain, 154 (35%) revisited the emergency department during the follow-up period.

CONCLUSION

Abdominal pain was a common reason for visits to the paediatric emergency room and a third paid more than one visit.

Symptom hyper-expression in advanced cancer patients with anxiety and depression admitted to an acute supportive/palliative care unit

PURPOSE

The aim of this study was to compare symptom expression in advanced cancer patients with depression and anxiety and in patients with no such symptoms.

METHODS

Secondary analysis of a previous study assessing the role of an acute palliative supportive care unit (APSCU) in a comprehensive cancer center. Patients completed the Edmonton Symptom Assessment System (ESAS) at admission (T0) and 7 days after or at discharge (T7).

RESULTS

Three hundred-fourteen consecutive cancer patients admitted to the APSCU were surveyed. Eighty-six and 66 patients improved their level of depression and anxiety, respectively (passing from ≥ 4 to 0-3, from T0 to T7), after that palliative care intervention resulted in a significant improvement of the other symptoms. Changes were statistically significant for both symptoms (P < 0.0005). Patients admitted for uncontrolled pain were more likely to be anxious, while patients admitted for other symptoms or end-of-life care were more likely to be depressed. The presence of anxiety and depression (≥ 4/10 on ESAS) was significantly associated with a higher level of symptom expression at admission and at T7 (P < 0.0005). In patients presenting both psychological symptoms, symptom expression was significantly more relevant in comparison with patients not reporting moderate-severe psychological symptoms. Pain and depression were independently associated with anxiety at T0. Variables independently associated with depression at T0 were drowsiness, appetite, and anxiety.

CONCLUSIONS

Psychological symptoms of ESAS concur to hyper-express some symptoms and make symptom control more difficult. A clear association between anxiety and depression exists.

Itch and psyche: psychiatric aspects of pruritus

Itch, also referred to as pruritus, is an unpleasant cutaneous sensation provoking the desire to scratch. It is often an uncomfortable, subjective sensation responsible for decreased quality of life in a variety of psychodermatological conditions. Comorbid psychiatric conditions, including depression and anxiety, are frequently associated with itch and scratch cycle. The reciprocal and intricate relationship between the psyche and itch has been widely studied. The neurobiology of itch involves the complexity of specific mediators, itch-related neuronal pathways, and central processing of itch. The connection between itch and the psyche can be grouped under three headings: pruritic diseases with psychosocial sequelae, pruritic diseases aggravated by psychosocial factors, and psychiatric disorders causing pruritus. Itch and pain modulation go together in most circumstances and involve various substances including histamine, interleukins, protease-activated receptors, transient receptor potential receptors, opioids, and cannabinoids. The close interaction between keratinocytes and nerve endings modulating pain and itch also play a major role. Management of itch associated with its psychosomatic components is directed at an underlying cause and adopting a holistic approach to address not only dermatologic and somatosensory aspects, but also the cognitive, emotional, and psychosocial components. An integrated multidisciplinary team consisting of a dermatologist, psychiatrist, psychologist, and social worker is vital in addressing the multifaceted aspects of pruritus.

Patients with advanced cancer and depression report a significantly higher symptom burden than non-depressed patients

Objective

Clinical observations indicate that patients with advanced cancer and depression report higher symptom burden than nondepressed patients. This is rarely examined empirically. Study aim was to investigate the association between self-reported depression disorder (DD) and symptoms in patients with advanced cancer controlled for prognostic factors.

Method

The sample included 935 patients, mean age 62, 52% males, from an international multicentre observational study (European Palliative Care Research Collaborative – Computerised Symptom Assessment and Classification of Pain, Depression and Physical Function). DD was assessed by the Patient Health Questionnaire-9 and scored with Diagnostic and Statistical Manual of Mental Disorder-5 algorithm for major depressive disorder, excluding somatic symptoms. Symptom burden was assessed by summing scores on somatic Edmonton Symptom Assessment Scale (ESAS) symptoms, excluding depression, anxiety, and well-being. Item-by-item scores and symptom burden of those with and without DD were compared using nonparametric Mann-Whitney U tests. The relative importance of sociodemographic, medical, and prognostic factors and DD in predicting symptom burden was assessed by hierarchical, multiple regression analyses.

Result

Patients with DD reported significantly higher scores on ESAS items and a twofold higher symptom burden compared with those without. Factors associated with higher symptom burden were as follows. Diagnosis: lung (β = 0.15, p < 0.001) or breast cancer (β = 0.08, p < 0.05); poorer prognosis: high C-reactive protein (β = 0.08, p < 0.05), lower Karnofsky Performance Status (β = −0.14, p < 0.001), and greater weight loss (β = −0.15, p < 0.001); taking opioids (β = 0.11, p < 0.01); and having DD (β = 0.23, p < 0.001). The full model explained 18% of the variance in symptom burden. DD explained 4.4% over and above that explained by all the other variables.

Significance of results

Depression in patients with advanced cancer is associated with higher symptom burden. These results encourage improved routines for identifying and treating those suffering from depression.

A life-stress, emotional awareness, and expression interview for primary care patients with medically unexplained symptoms: A randomized controlled trial

OBJECTIVE

Lifetime trauma, relationship adversities, and emotional conflicts are elevated in primary care patients with medically unexplained symptoms (MUS), and these risk factors likely trigger or exacerbate symptoms. Helping patients disclose stressors, increase awareness and expression of inhibited emotions, and link emotions to physical symptoms may improve health. We developed an emotional awareness and expression interview that targets stressful life experiences and conflicts and then tested its effects on primary care patients with MUS.

METHOD

Patients (N = 75) with MUS were recruited at a family medicine clinic and randomized to an interview condition or treatment-as-usual (TAU) control condition. In a single 90-min interview in the clinic, the interviewer elicited disclosure of the patient's stressors, linked them to the patient's symptom history, and encouraged emotional awareness and expression about unresolved relationship trauma or conflict. At baseline and 6-week follow-up, patients completed self-report measures of their physical and psychological health.

RESULTS

Analyses of covariance, controlling for baseline symptoms, compared patients in the interview condition with TAU at 6-week follow-up. Compared with TAU, the interview led to significantly lower pain severity, pain interference, sleep problems, and global psychological symptoms.

CONCLUSIONS

This study provides preliminary evidence for the value of integrating a disclosure and emotional awareness and expression interview into the primary care setting for patients with MUS. (PsycINFO Database Record

Clinical features of outpatients with somatization symptoms treated at a Japanese psychosomatic medicine clinic

Background

Somatization is produced due to the summation of psychological factors, irrespective of the presence or absence of physical factors. A group of diseases with severe pain and other disorders exhibit so-called Medically Unexplained Symptoms (MUS), and the characteristics of patients with MUS are largely unexplained. In this paper, the characteristics of a series of new patients with somatization treated in a Japanese university hospital are discussed.

Method

The subjects were 871 patients who newly visited the Department of Psychosomatic Medicine, Toho University Omori Medical Center between January and December of 2015. Under the assumption that the definition of somatization is same as that of MUS, the correlation between somatization and the age, sex, academic background, chief complaints, reasons for visiting the medical center, diagnosis, symptoms, presence or absence of a referral form, continued treatment after the first visit, and marital status of these patients at the time of their respective examinations were evaluated.

Results

Of the patients studied, 68% suffered from somatization. Among them, 11% met the definition of Functional Somatic Symptoms (FSS) and 74% had somatization associated with mood disorder or anxiety disorder. Digestive symptoms were reported by 33%, headaches by 24%, and unusual sensations by 21%. Whereas no correlation was found between somatization symptoms and the patients’ academic background, marital history, or medical history after the first visit, a positive correlation (p < 0.05) was found between somatization and patients who had been referred by their doctor.

Conclusion

Many of the studied patients who suffered from somatization, regardless of age and sex, were referred to us by doctors from other hospitals. It was concluded that many patients difficult to diagnose or deal with are referred the Department of Psychosomatic Medicine of Japanese university hospitals, thus these hospitals must assume great responsibility for preventing mistaken diagnoses by conducting effective psychological treatment and thorough medical examinations.

An Attachment-Based Model of the Relationship Between Childhood Adversity and Somatization in Children and Adults

OBJECTIVE

An attachment model was used to understand how maternal sensitivity and adverse childhood experiences are related to somatization.

METHODS

We examined maternal sensitivity at 6 and 18 months and somatization at 5 years in 292 children in a longitudinal cohort study. We next examined attachment insecurity and somatization (health anxiety, physical symptoms) in four adult cohorts: healthy primary care patients (AC1, n = 67), ulcerative colitis in remission (AC2, n = 100), hospital workers (AC3, n = 157), and paramedics (AC4, n = 188). Recall of childhood adversity was measured in AC3 and AC4. Attachment insecurity was tested as a possible mediator between childhood adversity and somatization in AC3 and AC4.

RESULTS

In children, there was a significant negative relationship between maternal sensitivity at 18 months and somatization at age 5 years (B = -3.52, standard error = 1.16, t = -3.02, p = .003), whereas maternal sensitivity at 6 months had no significant relationship. In adults, there were consistent, significant relationships between attachment insecurity and somatization, with the strongest findings for attachment anxiety and health anxiety (AC1, β = 0.51; AC2, β = 0.43). There was a significant indirect effect of childhood adversity on physical symptoms mediated by attachment anxiety in AC3 and AC4.

CONCLUSIONS

Deficits in maternal sensitivity at 18 months of age are related to the emergence of somatization by age 5 years. Adult attachment insecurity is related to somatization. Insecure attachment may partially mediate the relationship between early adversity and somatization.

Medically unexplained somatic symptoms and bipolar spectrum disorders: A systematic review and meta-analysis

BACKGROUND

Patients with bipolar spectrum disorders (BSD) frequently report medically unexplained somatic symptoms. However, the prevalence and the consequences for treatment and outcome are currently unknown.

METHODS

To estimate the prevalence of somatic symptoms in BSD, we conducted a systematic review and meta-analysis of empirical studies published between 1980 and 2015. The odds for somatic symptoms in BSD were compared with unipolar depression (UPD) and general population or mixed psychiatric controls. Studies were retrieved from four electronic databases utilizing Boolean operations and reference list searches. Pooled data estimates were derived using random-effects methods.

RESULTS

Out of 2634 studies, 23 were eligible for inclusion, yielding an N of 106,785 patients. The estimated prevalence of somatic symptoms in BSD was 47.8%. The estimated prevalence of BSD in persons with somatic symptoms was 1.4%. Persons with BSD had a higher prevalence of somatic symptoms compared with population or mixed psychiatric controls (OR 1.82, 95% CI 1.14-2.92). Persons with BSD had a similar prevalence of somatic symptoms compared with UPD controls (OR 0.99, 95% CI 0.68-1.44).

LIMITATIONS

This study is correlational; thus causal inferences cannot be made. Reporting of somatic symptoms likely varies with BSD severity and subtype. Some studies reported insufficient information regarding comorbid medical conditions and medications.

CONCLUSIONS

Persons with BSD suffer from somatic symptoms at a rate nearly double that of the general population, a rate similar to persons with UPD. Our results suggest the utility of an integrated care model in which primary care and specialist physicians collaborate with mental health professionals to jointly address psychological and bodily symptoms.

[How burdensome is the treatment of patients with somatoform disorders?]

OBJECTIVES

This study examines the influence of self-perceived emotional stress during the treatment of patients with somatoform disorders. It asks whether emotional stress can be influenced by psychosomatic education.

METHODS

Via online questionnaire general practitioners were asked about the prevalence of patients presenting with somatoform disorders and emotional stress during treatment.

RESULTS

The prevalence of somatoform disorders in general practices was estimated at around 27.7 %. Practitioners educated in psychosomatic medicine estimate the prevalence of patients with somatoform disorders higher than practitioners without such education (n = 79; r = 0.242; p = 0.032). The treatment of patients presenting with somatoform disorders causes 42.6% more emotional stress among general practitioners compared with the treatment of an average patient (n = 79; t = 16.67; p ≤ 0.001). Doctors with additional education in psychosomatic medicine rate stress 17.2% lower than doctors without such education (n = 79; t = 1.875; p = 0.033).

CONCLUSIONS

General practitioners experience the treatment of patients presenting with somatoform disorders as emotionally stressful. This emotional stress is mainly explained by increases in time expenditure, but it can be reduced by additional psychosomatic education.

Psychosomatic patients in integrated care: Which treatment mediators do we have to focus on?

The field of psychosomatics has gained increasing significance; it has been struggling to establish its position as either an independent discipline or a subdomain of specific areas such as internal medicine or psychiatry. However, the rise of psychosomatic syndromes and disease patterns as well as an increase of specific integrated psychosomatic wards is a clear indication for the growing importance of interdisciplinary approaches to psychosomatic disorders. The study presents data from an 8-week inpatient treatment at a psychosomatic facility and investigates whether patients improved in their subjective symptom experience. A complex treatment approach, ranging from pharmacological treatment and group and individual psychotherapy to physiotherapy and ergotherapy was integrated into this intervention. In essence, containment of intrapsychic aggression derivatives played a central role in the treatment of psychosomatic symptoms. A significant factor contributing to a successful treatment is the doctor-patient relationship. All these factors were investigated in the present study.

Utilizing an integrated infrastructure for outcomes research: a systematic review

OBJECTIVE

To explore the ability of an integrated health information infrastructure to support outcomes research.

METHODS

A systematic review of articles published from 1983 to 2012 by Regenstrief Institute investigators using data from an integrated electronic health record infrastructure involving multiple provider organisations was performed. Articles were independently assessed and classified by study design, disease and other metadata including bibliometrics.

RESULTS

A total of 190 articles were identified. Diseases included cognitive, (16) cardiovascular, (16) infectious, (15) chronic illness (14) and cancer (12). Publications grew steadily (26 in the first decade vs. 100 in the last) as did the number of investigators (from 15 in 1983 to 62 in 2012). The proportion of articles involving non-Regenstrief authors also expanded from 54% in the first decade to 72% in the last decade. During this period, the infrastructure grew from a single health system into a health information exchange network covering more than 6 million patients. Analysis of journal and article metrics reveals high impact for clinical trials and comparative effectiveness research studies that utilised data available in the integrated infrastructure.

DISCUSSION

Integrated information infrastructures support growth in high quality observational studies and diverse collaboration consistent with the goals for the learning health system. More recent publications demonstrate growing external collaborations facilitated by greater access to the infrastructure and improved opportunities to study broader disease and health outcomes.

CONCLUSIONS

Integrated information infrastructures can stimulate learning from electronic data captured during routine clinical care but require time and collaboration to reach full potential.

The association between somatization and disability in primary care patients

BACKGROUND

Patient encounters for medically unexplained physical symptoms are common in primary health care. Somatization ('experiencing and reporting unexplained somatic symptoms') may indicate concurrent or future disability but this may also partly be caused by psychiatric disorders. The aim of this study was to examine the cross-sectional and longitudinal association between somatization and disability in primary care patients with and without anxiety or depressive disorder.

METHODS

Data were obtained from 1545 primary care patients, participating in the longitudinal Netherlands Study of Depression and Anxiety (NESDA). Somatization was assessed using the somatization scale of the Four-Dimensional Symptom Questionnaire (4DSQ). Disability was determined by the WHO Disability Assessment Schedule 2.0 (WHO-DAS II). The relationships between somatization and both the total and subdomain scores of the WHO-DAS II were measured cross-sectionally and longitudinally after one year of follow-up using linear regression analysis. We examined whether anxiety or depressive disorder exerted a modifying effect on the somatization-disability association.

RESULTS

Cross-sectionally and longitudinally, somatization was significantly associated with disability. Somatization accounted cross-sectionally for 41.8% of the variance in WHO-DAS disability and, longitudinally, for 31.7% of the variance in disability after one year of follow-up. The unique contribution of somatization to disability decreased to 16.7% cross-sectionally and 15.7% longitudinally, when anxiety and/or depressive disorder was added to the model.

CONCLUSION

Somatization contributes to the presence of disability in primary care patients, even when the effects of baseline demographic and health characteristics and anxiety or depressive disorder are taken into account.

Increased prevalence of two mitochondrial DNA polymorphisms in functional disease: Are we describing different parts of an energy-depleted elephant?

About 20% of the population suffers from "functional syndromes". Since these syndromes overlap greatly in terms of co-morbidity, pathophysiology (including aberrant autonomic activity) and treatment responses, common predisposing genetic factors have been postulated. We had previously showed that two common mitochondrial DNA (mtDNA) polymorphisms at positions 16519 and 3010 are statistically associated with the functional syndromes of migraine, cyclic vomiting syndrome and non-specific abdominal pain. Herein, among individuals with mtDNA haplogroup H (HgH), the presence of these two mtDNA polymorphisms were ascertained in additional functional syndromes: chronic fatigue syndrome, complex regional pain syndrome, sudden infant death syndrome, and major depressive disorder. Polymorphic prevalence rates were compared between disease and control groups, and within each disease group in participants with and without specific clinical findings. In all four conditions, one or both of the polymorphisms was significantly associated with the respective condition and/or co-morbid functional symptomatology. Thus, we conclude that these two mtDNA polymorphisms likely modify risk for the development of multiple functional syndromes, likely constituting a proportion of the postulated common genetic factor, at least among individuals with HgH. Pathophysiology likely involves broad effects on the autonomic nervous system.

PROFSS: a screening tool for early identification of functional somatic symptoms

OBJECTIVE

To develop and validate a brief screening tool for predicting functional somatic symptoms (FSS) based on clinical and non-clinical information from the general practitioner referral letter, and to assess its inter-rater reliability.

METHODS

The derivation sample consisted of 357 consecutive patients referred to an internal outpatient clinic by their general practitioner. Referral letters were scored for candidate predictors for the main outcome measure, which was a final diagnosis of FSS made by the internist. Logistic regression identified the following independent predictors: type of symptoms, somatic and psychiatric comorbidity, absence of abnormal physical findings by the general practitioner, previous specialist consultation, and the use of illness terminology. Temporal validation was performed in a cohort of 94 consecutive patients in whom predictors were scored by two independent raters.

RESULTS

In both the derivation and validation sample, the discriminatory power of the model was good with areas under the receiver operating characteristic curves of 0.84 (95%confidence interval: 0.80-0.88) after bootstrapping and 0.82 (95%confidence interval: 0.73-0.91), respectively. Calibration of the models was excellent in both samples and the interobserver agreement in the validation sample was very good (intraclass coefficient: 0.82 (95%confidence interval: 0.75-0.88)). Based on this model, we constructed the brief screening tool PROFSS (Predicted Risk Of Functional Somatic Symptoms). PROFSS identified patient groups with risks of FSS ranging from 17% (95%CI: 10-26%) to 92% (95%CI:86-96%).

CONCLUSION

The presence of FSS can be predicted with the brief screening tool PROFSS, based on a limited set of items present in the general practitioner referral letter.

How common is change of primary diagnosis during an episode of sickness benefit? A register study of medical sickness certificates issued 2010-2012 in Sweden

AIM

The aims of this study were to investigate how common it is to change primary diagnosis between different diagnostic chapters during a sick-leave spell, and to explore patterns of diagnostic changes.

METHODS

The unit for analysis was episode of sickness benefit, that is, sick leave >14 days, which commenced between 2010 and 2012 in Sweden. For each case, the primary diagnosis was retrieved from the first and last/latest medical sickness certificate, respectively. The number of days of sickness benefit was linked to the cases. Any change of primary diagnosis was analysed by diagnostic chapter according to the ICD-10, and this was done separately for women and men.

RESULTS

In total, 803,041 cases of sickness benefit (63% women) were included in the study. During a sick-leave spell, 7.1% of female cases and 6.6% of male cases changed their primary diagnosis to a diagnosis from another diagnostic chapter. The change of primary diagnosis increased with the number of days with sickness benefit. For female cases, this increase was from 2.0% for cases that lasted 15-30 days to 20.2% for cases that lasted >365 days. For male cases, the corresponding increase was from 1.8% to 21.2%. A change of primary diagnosis was least common among those initially sick-listed for mental disorders and musculoskeletal disorders. The patterns of diagnostic changes were rather similar for women and men.

CONCLUSIONS

A change of diagnosis during a sick-leave spell needs to be taken into consideration by the sickness insurance system and in the actions taken by its administration. Registry-based studies of sickness insurance need to consider diagnostic changes in both the study design and the interpretation of results.

Hedyotis diffusa Combined with Scutellaria barbata Are the Core Treatment of Chinese Herbal Medicine Used for Breast Cancer Patients: A Population-Based Study

Traditional Chinese medicine (TCM), which is the most common type of complementary and alternative medicine (CAM) used in Taiwan, is increasingly used to treat patients with breast cancer. However, large-scale studies on the patterns of TCM prescriptions for breast cancer are still lacking. The aim of this study was to determine the core treatment of TCM prescriptions used for breast cancer recorded in the Taiwan National Health Insurance Research Database. TCM visits made for breast cancer in 2008 were identified using ICD-9 codes. The prescriptions obtained at these TCM visits were evaluated using association rule mining to evaluate the combinations of Chinese herbal medicine (CHM) used to treat breast cancer patients. A total of 37,176 prescriptions were made for 4,436 outpatients with breast cancer. Association rule mining and network analysis identified Hedyotis diffusa plus Scutellaria barbata as the most common duplex medicinal (10.9%) used for the core treatment of breast cancer. Jia-Wei-Xiao-Yao-San (19.6%) and Hedyotis diffusa (41.9%) were the most commonly prescribed herbal formula (HF) and single herb (SH), respectively. Only 35% of the commonly used CHM had been studied for efficacy. More clinical trials are needed to evaluate the efficacy and safety of these CHM used to treat breast cancer.

Copy number variation at 22q11.2: from rare variants to common mechanisms of developmental neuropsychiatric disorders

Recently discovered genome-wide rare copy number variants (CNVs) have unprecedented levels of statistical association with many developmental neuropsychiatric disorders, including schizophrenia, autism spectrum disorders, intellectual disability and attention deficit hyperactivity disorder. However, as CNVs often include multiple genes, causal genes responsible for CNV-associated diagnoses and traits are still poorly understood. Mouse models of CNVs are in use to delve into the precise mechanisms through which CNVs contribute to disorders and associated traits. Based on human and mouse model studies on rare CNVs within human chromosome 22q11.2, we propose that alterations of a distinct set of multiple, noncontiguous genes encoded in this chromosomal region, in concert with modulatory impacts of genetic background and environmental factors, variably shift the probabilities of phenotypes along a predetermined developmental trajectory. This model can be further extended to the study of other CNVs and may serve as a guide to help characterize the impact of genes in developmental neuropsychiatric disorders.

Safety and efficacy of device closure for patent foramen ovale for secondary prevention of neurological events: Comprehensive systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Controversy persists regarding the management of patients with cryptogenic stroke and patent foramen ovale (PFO). We performed a meta-analysis of randomized controlled trials comparing PFO closure with medical therapy.

METHODS AND RESULTS

A prospective protocol was developed and registered using the following data sources: PubMed, Cochrane Register of Controlled Trials, conference proceedings, and Internet-based resources of clinical trials. Primary analyses were performed using the intention-to-treat method. Three randomized trials comparing percutaneous PFO closure vs. medical therapy for secondary prevention of embolic neurological events formed the data set. Baseline characteristics were similar. During long-term follow-up, the pooled incidence of the primary endpoint (composite of stroke, death, or fatal stroke) was 3.4% in the PFO closure arm and 4.8% in the medical therapy group [risk-reduction (RR) 0.7 (0.48-1.06); p=0.09]. The incidence of recurrent neurological events (secondary endpoint) was 1.7% for PFO closure and 2.7% for medical therapy [RR 0.66 (0.35-1.24), p=0.19]. There was no difference in terms of death or adverse events between the two groups.

CONCLUSIONS

While this meta-analysis of randomized clinical trials demonstrated no statistical significance in comparison to medical therapy, there was a trend towards overall improvement in outcomes in the PFO closure group.

Standardization of a screening instrument (PHQ-15) for somatization syndromes in the general population

BACKGROUND

The PHQ-15 is widely used as an open access screening instrument for somatization syndromes in different health care settings, thus far, normative data from the general population are not available. The objectives of the study were to generate normative data and to further investigate the construct validity of the PHQ-15 in the general population.

METHODS

Nationally representative face-to face household surveys were conducted in Germany between 2003 and 2008 (n=5,031). The survey questionnaires included, the 15-item somatization module from the Patient Health Questionnaire (PHQ-15), the 9-item depression module (PHQ-9), the Satisfaction With Life Scale (SWLS), the SF-12 for the measurement of health related quality of life, and demographic characteristics.

RESULTS

Normative data for the PHQ-15 were generated for both genders and different age levels including 5031 subjects (53.6% female) with a mean age (SD) of 48.9 (18.1) years. Somatization syndromes occured in 9.3% of the general population. Women had significantly higher mean (SD) scores compared with men [4.3 (4.1) vs. 3.4 (4.0)]. Intercorrelations with somatization were highest with depression, followed by the physical component summary scale of health related quality of life.

CONCLUSIONS

The normative data provide a framework for the interpretation and comparisons of somatization syndromes with other populations. Evidence supports reliability and validity of the PHQ-15 as a measure of somatization syndromes in the general population.

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.

Illness attribution of patients with medically unexplained physical symptoms in China

The illness behavior of patients with medically unexplained physical symptoms (MUS) depends largely on what the patient believes to be the cause of the symptoms. Little data are available on the illness attributions of patients with MUS in China. This cross-sectional study investigated the illness attributions of 96 patients with MUS in the outpatient departments of Psychosomatic Medicine, biomedicine (Neurology, Gynecology), and Traditional Chinese Medicine in Shanghai. Patients completed the Illness Perception Questionnaire (IPQ) for illness attribution, the Screening Questionnaire for Somatoform Symptoms, the Hospital Anxiety and Depression Scale for emotional distress, and questionnaires on clinical and sociodemographic data. The physicians also filled out a questionnaire regarding the cause of the illness (IPQ). In contrast to previous research, both physicians and patients from all three areas of medicine most frequently reported "psychological attributions." The concordance between the physicians' and the patients' illness attributions was low. Emotional distress was an important predictor of psychological attributions. Further research should include large-scale studies among patients from different regions of China and qualitative studies to deepen our understanding of cultural influences on illness attribution.

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.

Aphonia induced by conversion disorder during a Cesarean section

Aphonia induced by conversion disorder during surgery is a rare event. We report a woman 28 years of age who was undergoing a Cesarean section under epidural anesthesia. The patient sustained aphonia without detected neurologic deficits. Emergency consultations of a psychiatrist and neurologist were carried out in the operating room postoperatively. After a thorough medical and neurologic work-up, the consultative psychiatrist and the neurologist unanimously made the diagnosis of conversion disorder. Thirty-six hours after the operation, the patient's voice started to return. We venture on sharing the findings of this case with our fellow anesthesiologists in order to highlight discussion and illuminate the differential diagnosis. We have reviewed the literature and excluded an organic lesion as the culprit of the event.

Psychometric properties of the Turkish version of the Patient Health Questionnaire-Somatic, Anxiety, and Depressive Symptoms

OBJECTIVE

In this study, we examined the psychometric properties of the Turkish version of the Patient Health Questionnaire-Somatic, Anxiety, and Depressive Symptoms (PHQ-SADS) developed by Kroenke, Spitzer, and Williams.

METHOD

This study sample consisted of 200 outpatients admitted to Erenköy Mental Health Training and Research Hospital, Erenköy Physiotherapy and Rehabilitation Hospital, and Kartal Training and Research Hospital and 240 graduate students in Karadeniz Technical University. Participants were administered the 90-item Symptoms Checklist (SCL-90R) and the 7-item Whiteley Index, along with the PHQ-SADS. A month later, the PHQ-SADS was readministered to 60 of the students. To investigate the internal consistency of the scale and its subscales, corrected item-total correlations were examined to establish the effect on the Cronbach coefficients and internal consistency of each item of the subscales. Test-retest correlations were also analyzed for reliability. Factorial structure was investigated using principal component analysis. The validity of distinguishing congruent and specific groups was also investigated for validity.

RESULTS

Total scores on the scale showed an adequate test-retest consistency (r = 0.54, 0.52, and 0.76, respectively). All items showed adequate correlations (r > 0.26) in the test-retest analysis. Cronbach α values were 0.86 (control), 0.93 (patient), and 0.92 (total) on the test of internal consistency. When the questions were analyzed individually, the item-total correlation for item 7 of the PHQ somatization subscale was found to be inadequate in the control group. Exploratory factorial analysis and varimax rotation results showed that the scale provided a 4-factor structure. In the validity analysis, a significant difference between the patient and the control group mean values was determined. The SCL-90R, 7-item Whiteley Index, and SCL-90R somatization subscales were found to be sufficiently related to the number of symptoms to establish criterion-related validity.

CONCLUSION

Findings with respect to internal consistency, test-retest consistency, item-total correlation, factorial structure, distinguishing validity for specific groups, and criterion-related validity for the PHQ-SADS show that the scale is acceptable in terms of validity and reliability for the Turkish population.

Medically unexplained symptoms--a perspective from general practitioners in the developing world

OBJECTIVES

In this study, we explored the attitudes toward Medically Unexplained Symptoms (MUS) of 500 general practitioners (GPs) in Karachi, Pakistan. Using a questionnaire previously developed by Reid et al. (2001), we aimed to investigate whether GPs' attitudes toward medically unexplained symptoms are similar to those of GPs in the developed world.

METHODS

Five hundred GPs on the database of primary care centers at the Pakistan Institute of Learning and Living in Karachi were all sent a covering letter explaining the purpose of the survey with a case vignette, a questionnaire, and a stamped addressed envelope. One month later, non-respondents received a telephone call from an investigator to remind them of the study.

RESULTS

Of the 429 respondents, 68.5% (294) were male and 31.5% (135) female. Although 80.2% of respondents felt that the main role of GPs was to provide support and reassurance, 76.9% of respondents also agreed that GPs had a role in referring patients with MUS for further investigations to identify a cause. Two hundred and four (47.55%) respondents agreed that somatization was useful concept, only 146 (34.03%) felt that there was effective treatment for it.

CONCLUSION

For the most part, Pakistani GPs' attitudes toward MUS are not very different to those of their counterparts in the West. Both agree that the GP has an important role in providing reassurance and counseling. However, our survey also shows that Pakistani GPs are less likely to place emphasis on an underlying psychiatric diagnosis and tend to focus on looking for an underlying physical cause.

Association of somatic symptoms with depression and anxiety in clinical patients of general hospitals in Guangzhou, China

OBJECTIVES

In high-income countries, depression and anxiety are reported to be common reasons for patients visiting nonpsychiatric services. This study aimed to assess the rate of depression and anxiety, and their associations with somatic symptoms, in patients presenting to clinics of general hospitals in Guangzhou, China.

METHODS

In a hospital-based cross-sectional study of 2408 randomly selected clinical patients from 15 general hospitals, we assessed depression and anxiety via the Hospital Anxiety and Depression Scale (HADS), somatic symptoms via the Patient Health Questionnaire 15-Item Somatic Symptom Severity Scale (PHQ-15) and patients' view of the impact of somatic symptoms on their life, job and social relationships. Multiple logistic models were used to analyze the association of somatic symptoms with depression and anxiety, the underlying physical diseases and the self-rated somatic symptoms' impact on social functions.

RESULTS

Of the participants, 454 (19.0%) reported moderate to high somatic symptoms (PHQ-15 score ≥ 10), 367 (15.2%) had depression (HADS-D score ≥ 7), 167 (6.9%) had anxiety (HADS-A score ≥ 10), and 125 (5.2%) had both depression and anxiety (HADS-D ≥ 7 and HADS-A ≥ 10). Patients with depression and anxiety had higher somatic symptoms and rated these symptoms as having a greater negative impact on their social functions. Relevant to other systemic diseases, only digestive system disease was associated with higher somatic symptoms and self-rated negative social impact, and great negative emotions. Stepwise multiple logistic analyses demonstrated that female sex and depression and anxiety were the main factors for the high somatic symptoms of the population.

CONCLUSIONS

Among patients who visit hospital clinics in Guangzhou, China, somatic complaints are highly associated with depression and anxiety, and rarely associated with their underlying medical diseases. The findings indicate the importance of recognizing and managing depression and anxiety for these patients.

Current debates over nosology of somatoform disorders

There is a wide debate among the researchers and clinicians over the diagnostic categories subsumed under the rubric of somatoform disorders (SDs). Recent proposals vary from radical views that call for removing this category altogether to the conservative views that suggests cosmetic changes in the diagnostic criteria of SDs. We have the reviewed the relevant literature through PUBMED search supplemented with manual search on current concepts of SD.

Less specific arm illnesses

Unexplained symptoms are among the most common complaints addressed by health providers. Nonspecific (or less specific) arm pain, in particular, is characterized by vague, diffuse, uncharacteristic symptoms, and disproportionate pain and disability. Many of the conditions diagnosed and treated by hand specialists as specific abnormalities might be better considered nonspecific because no distinct, unique, characteristic pathology or pathophysiology can be identified. An approach that assumes that symptoms are directly related to underlying pathophysiology and ignores the important psychological and sociological contributions to illness risks hindering recovery.

Experts' opinions on the management of medically unexplained symptoms in primary care. A qualitative analysis of narrative reviews and scientific editorials

BACKGROUND

The feasibility as well as the suitability of several therapies for medically unexplained symptoms (MUS) in primary care applied by the family physician (FP) appeared to be low. FPs need effective and acceptable strategies to manage these functionally impaired patients.

OBJECTIVE

To review important and effective elements in the treatment of patients with MUS in primary care according to experts in MUS research.

METHODS

We performed a systematic search of narrative reviews and scientific editorials in Medline and PsycINFO and triangulated our findings by conducting a focus group with MUS experts.

RESULTS

We included 7 scientific editorials and 23 narrative reviews. According to MUS experts, the most important elements in the treatment of MUS are creating a safe therapeutic environment, generic interventions (such as motivational interviewing, giving tangible explanations, reassurance and regularly scheduled appointments) and specific interventions (such as cognitive approaches and pharmacotherapy). Furthermore, MUS experts indicate that a multi-component approach in which these three important elements are combined are most helpful for patients with MUS. In contrast to most specific interventions, opinions of MUS experts regarding generic interventions and creating a safe therapeutic relationship seem to be more based on theory and experience than on quantitative research.

CONCLUSIONS

MUS experts highlight the importance of generic interventions and doctor-patient communication and relationship. However, studies showing the effectiveness of these elements in the management of MUS in primary care is still scarce. Research as well as medical practice should focus more on these non-specific aspects of the medical consultation.

Somatic symptoms in patients with cancer experiencing pain or depression: prevalence, disability, and health care use

BACKGROUND

The adverse impact of a high somatic symptom burden is well established for primary care and other noncancer populations with chronic medical disorders.

METHODS

This study examines the impact of somatic symptom burden on disability and health care use in patients with cancer experiencing pain, depression, or both. We performed secondary analyses of baseline data from 405 patients with cancer enrolled in a telecare management trial for pain or depression. Somatic symptom burden was measured using a 22-item scale. Multivariable models were conducted to determine the association of somatic symptom burden with the Sheehan Disability Scale (SDS) score, the number of self-reported disability days in the past 3 months, and health care use. Models were adjusted for sociodemographic characteristics, medical comorbidity, and depression and pain severity.

RESULTS

Somatic symptoms were highly prevalent, with 15 of the 22 symptoms reported by more than 50% of patients. The somatic symptom burden was similar across different types and phases of cancer. The mean SDS score (scored 0-10 [not at all disabled to unable to carry out any activities]) was 5.4, and the mean number of self-reported disability days in the past 4 weeks was 16.9. In multivariable models, somatic symptom burden was associated with SDS score (P < .001) and the likelihood of at least 14 disability days in the past 4 weeks (odds ratio, 1.51; 95% confidence interval, 1.19-1.92) but not with increased health care use.

CONCLUSIONS

The somatic symptom burden is high in patients with cancer who experience pain or depression. Given the strong association with disability and the high prevalence of many types of symptoms, recognizing and managing somatic symptoms may be important in improving quality of life and functional status regardless of type or phase of cancer. Trial Registration clinicaltrials.gov Identifier: NCT00313573.

The Patient Health Questionnaire Somatic, Anxiety, and Depressive Symptom Scales: a systematic review

BACKGROUND

Depression, anxiety and somatization are the most common mental disorders in primary care as well as medical specialty populations; each is present in at least 5-10% of patients and frequently comorbid with one another. An efficient means for measuring and monitoring all three conditions would be desirable.

METHODS

Evidence regarding the psychometric and pragmatic characteristics of the Patient Health Questionnaire (PHQ)-9 depression, generalized anxiety disorder (GAD)-7 anxiety and PHQ-15 somatic symptom scales are synthesized from two sources: (1) four multisite cross-sectional studies (three conducted in primary care and one in obstetric-gynecology practices) comprising 9740 patients, and (2) key studies from the literature that have studied these scales.

RESULTS

The PHQ-9 and its abbreviated eight-item (PHQ-8) and two-item (PHQ-2) versions have good sensitivity and specificity for detecting depressive disorders. Likewise, the GAD-7 and its abbreviated two-item (GAD-2) version have good operating characteristics for detecting generalized anxiety, panic, social anxiety and post-traumatic stress disorder. The optimal cutpoint is > or = 10 on the parent scales (PHQ-9 and GAD-7) and > or = 3 on the ultra-brief versions (PHQ-2 and GAD-2). The PHQ-15 is equal or superior to other brief measures for assessing somatic symptoms and screening for somatoform disorders. Cutpoints of 5, 10 and 15 represent mild, moderate and severe symptom levels on all three scales. Sensitivity to change is well-established for the PHQ-9 and emerging albeit not yet definitive for the GAD-7 and PHQ-15.

CONCLUSIONS

The PHQ-9, GAD-7 and PHQ-15 are brief well-validated measures for detecting and monitoring depression, anxiety and somatization.

Lowered omega-3 PUFAs are related to major depression, but not to somatization syndrome

BACKGROUND

Studies indicated a depletion of omega-3 fatty acid levels and an imbalance between omega-3 and omega-6 PUFAs in depressive patients. Depletion of omega-3 PUFAs may be related to the immune and serotonergic pathophysiologies of depression by alterations in membrane fluidity and modulation of membrane receptors, enzyme activities and carriers. Previous studies also found serotonergic and immunological disturbances in subjects with somatoform symptoms. Based on these findings we aimed to investigate PUFA concentrations and its relations to other biological systems in depressed patients and in patients with somatoform symptoms.

METHODS

We examined 150 subjects divided in 4 groups, i.e. somatization syndrome; depression; depression and somatization syndrome; controls. Blood samples were analyzed for fatty acids, markers of the serotonergic system and the immune system.

RESULTS

The study was able to replicate earlier findings in patients with depression (lowered omega-3 PUFAs, increased omega-6/omega-3 ratios in serum cholesteryl esters). The somatization syndrome group showed no abnormalities in the mentioned fatty acid levels. Only depressive patients revealed associations between fatty acids with serotonergic and immunological markers.

LIMITATIONS

We used current state diagnoses, and the consideration of lifetime diagnoses and longitudinal studies could highlight further aspects of the reported results.

CONCLUSIONS

The findings are further confirming that the concepts of depression and somatoform disorders should not be merged indiscriminately together, even though they often occur together. We conclude that in depression and somatoform syndrome different biological mechanisms seem to be involved.

Responsiveness of motor and nonmotor symptoms of Parkinson disease to dopaminergic therapy

BACKGROUND

The duration of clinical control of motor symptoms of Parkinson disease (PD) treated with levodopa/carbidopa preparations eventually starts to shorten, a phenomenon known as end-of-dose "wearing off." The involvement of core nonmotor symptoms of "wearing off" (depressed mood, pain/aching, anxiety, and cloudy/slowed thinking) is not well understood.

METHODS

A post hoc analysis from a study to validate the self-rated 9-item, Wearing-Off Questionnaire (WOQ-9), which was designed to identify motor and nonmotor symptoms of "wearing off" in PD patients, was performed to compare the frequency and sensitivity of motor and nonmotor symptoms of "wearing off" from dopaminergic therapy.

RESULTS

Analysis of responses to the WOQ-9 from 216 PD patients found that individual nonmotor symptoms were reported by 25% to 50% and motor symptoms by 55% to 80% of patients. Individual nonmotor symptoms improved following the next dose of dopaminergic therapy in 43% to 53% of the patients who presented with such symptoms, whereas motor symptoms improved in 48% to 66% of the cases, suggesting both types of symptoms respond to dopaminergic therapies.

CONCLUSION

Nonmotor symptoms of PD appear sensitive to dopaminergic treatment. These symptoms resemble those seen with depressive, anxiety, and somatoform disorders suggesting potential shared mechanisms as well as possible treatment implications.

A guide to disorders causing transient loss of consciousness: focus on syncope

Episodes of transient loss of consciousness (TLOC) events pose diagnostic difficulties, as the causes are diverse, carry vastly different risks, and span various specialties. An inconsistent terminology contributes to the confusion. Here, we present a classification scheme for TLOC, based on ongoing multidisciplinary efforts including those of the Task Force on Syncope of the European Society of Cardiology. We also discuss the pathophysiology of TLOC and the key clinical features that aid diagnosis. TLOC is defined as an apparent loss of consciousness with an abrupt onset, a short duration, and a spontaneous and complete recovery. Syncope is defined as TLOC due to cerebral hypoperfusion, and is divided into reflex syncope (synonymous with neurally mediated syncope), syncope due to orthostatic hypotension, and cardiac syncope (arrhythmic or associated with structural cardiac disease). The other major groups of TLOC are generalized epileptic seizures, functional TLOC (psychogenic TLOC mimicking either epilepsy or syncope), and a further group of miscellaneous disorders. The management of patients who experience TLOC requires the recognition of the defining features of each of the major groups, and cooperation between different clinical specialties.

Prevalence, characteristics, and attribution of somatic symptoms in Spanish patients with major depressive disorder seeking primary health care

BACKGROUND

Somatic symptoms (SS) tend to dominate clinical symptomatology in patients with depression in primary care.

OBJECTIVE

The authors performed a cross-sectional nationwide epidemiological study on 1,150 primary-care patients with major depression and evaluated the prevalence of SS and physicians' attribution of their origin.

METHOD

Patients were administered the Structured Polyvalent Psychiatric Interview.

RESULTS

Ninety-three percent of patients had at least one SS fully or partially attributed to depression, and 45% of patients had four to nine. Painful symptoms, despite being the most frequent, were the least often attributed to depression (fewer than 25% of patients with pain) and significantly more often attributed to a combined origin.

CONCLUSION

Results suggest that primary-care physicians tend to associate pain with depression to a significantly lesser extent than any other somatic symptom (e.g., cardiopulmonary or gastrointestinal). Therefore, special attention should be given to painful symptoms in order to ensure efficient management of depression in primary care.

Fibromyalgia syndrome: a relevant recent construction of an ancient condition?

PURPOSE OF REVIEW

Fibromyalgia is considered the most common chronic pain syndrome. This syndrome is poorly understood and not widely accepted as a distinct clinical entity but an increasing number of pharmacological and nonpharmacological treatments are being developed for its management.

RECENT FINDINGS

The clinical description of fibromyalgia is now well established, but controversies on diagnostic criteria are increasing. Pathophysiological studies suggest that fibromyalgia is a painful rheumatic disorder in which pain primarily stems from central sensitization and from other neuronal changes, including alterations in peripheral neuronal systems. Central sensitization may also underlie associated symptoms, including anxiety, sleep disorders, fatigue, and other dysfunctions such as irritable bowel syndrome and bladder instability. Several agents, including serotonin-norepinephrine reuptake inhibitors (duloxetine and milnacipran), weak opioids (tramadol), and anticonvulsants (pregabalin), as well as nonpharmacological approaches, have been recently evaluated in clinical trials, demonstrating benefit in terms of pain reduction and improvement of core symptoms (i.e., fatigue and sleep disturbance).

SUMMARY

Despite the fact that pathophysiology and diagnostic criteria remain unclear, the level of scientific data collected on this recently described condition should convince clinicians of the existence of this syndrome, allowing improved management of the many patients suffering from chronic pain.