Relevance of cognitive and behavioral factors in medically unexplained syndromes and somatoform disorders

Helpful explanatory models for persistent somatic symptoms (HERMES): Results of a three-arm randomized-controlled pilot trial

OBJECTIVE

This three-arm randomized controlled trial aimed to test the efficacy of an etiological model for persistent somatic symptoms (PSS) translated into video-animated explanatory models in comparison to a control group, and to examine additional value of personalization of the explanatory models (i.e. possibility to choose information based on mechanisms of symptom persistence).

METHODS

Outpatients with PSS were shown one of three 15-min video animations: a) explanatory model without personalization, b) explanatory model with personalization, c) no explanatory model control group. Changes in somatic symptom severity (PHQ-15) and psychological burden related to somatic symptoms or associated health concerns (SSD-12) from baseline to one-month follow-up were the primary outcome. Health-related quality of life (SF-12) and perceived usefulness (USE) were also assessed.

RESULTS

Seventy-five patients with PSS were allocated to the study arms (Mage = 44.2 ± 13.3 years, 56% female). The study arms did not differ significantly on the primary outcomes. However, no explanatory model participants reported significantly greater mental quality of life improvements than explanatory model without personalization participants (Mdiff = 7.50 [0.43; 14.56]). Further, explanatory model with personalization participants rated the individual fit of the intervention significantly higher than no explanatory model participants (Mdiff = 2.05 [0.17; 3.93]). All groups rated credibility of the intervention as very high.

CONCLUSION

The HERMES materials seemed to have been too brief to improve symptom related outcomes. However, all three interventions were positively evaluated regarding their usefulness, particularly in case of additional personalization. Future studies should investigate potential effects of an increased intervention dose.

TRIAL REGISTRATION

DRKS00018803.

Patients' acceptance of explanatory models for persistent somatic symptoms: A qualitative analysis within the HERMES study

OBJECTIVE

The aim of this qualitative study was to provide an in-depth analysis of participants' experiences with video-animated explanatory models developed within the three-arm randomized controlled HERMES study ('Helpful explanatory models for somatic symptoms') and suggestions for further intervention improvement.

METHODS

Semi-structured qualitative interviews were conducted with psychosomatic outpatients with persistent somatic symptoms (PSS) after they were randomized to view one of three psychoeducational videos on a tablet computer: a) an explanatory model without personalization or b) an explanatory model with personalization in the two experimental groups or c) PSS guidelines without an explanatory model in the control group. Qualitative interviews were audiotaped, transcribed and analyzed applying thematic analysis.

RESULTS

Seventy-five patients with PSS were allocated to the study arms, mean duration of interviews was 8.19 min (SD = 3.19, range 4.02-19.49 min). Although all participants gave positive feedback regardless of their allocated study arm, those in the explanatory model without and with personalization groups were especially likely to rate the psychoeducational interventions as helpful. Results highlighted previous illness course, symptom perceptions and patient characteristics as key factors related to patients' response to the video interventions and optimal personalization of the explanatory model.

CONCLUSION

The present study not only demonstrated the acceptance of all three psychoeducational interventions developed within the HERMES study, but also provided valuable insights into potential key factors that may increase their impact and potential starting points for tailored psychoeducation in patients with PSS.

Personal identity, somatic symptoms, and symptom-related thoughts, feelings, and behaviors in adolescence: Examining between- and within-person associations and the role of depressive symptoms

Recent literature highlights the complex relationship between personal identity and body-related pathology, yet there is a lack of integrative longitudinal research on the relationship between identity and somatic symptoms. The present study investigated the longitudinal associations between identity functioning and (psychological characteristics of) somatic symptoms, and examined the role of depressive symptoms in this relationship. A total of 599 community adolescents (Time 1: 41.3% female; M_age = 14.93, SD = 1.77, range = 12-18 years) participated in three annual assessments. Using cross-lagged panel models, a bidirectional relationship between identity and (psychological characteristics of) somatic symptoms, mediated by depressive symptoms, emerged at the between-person level; whereas only a unidirectional relationship from psychological characteristics of somatic symptoms to identity functioning, mediated by depressive symptoms, emerged at the within-person level. Identity and depressive symptoms were bidirectionally related at both levels. The present study suggests that adolescent identity development is closely related to somatic and emotional distress.

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

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

Somatic symptom disorder: a scoping review on the empirical evidence of a new diagnosis

BACKGROUND

In 2013, the diagnosis of somatic symptom disorder (SSD) was introduced into the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This review aims to comprehensively synthesize contemporary evidence related to SSD.

METHODS

A scoping review was conducted using PubMed, PsycINFO, and Cochrane Library. The main inclusion criteria were SSD and publication in the English language between 01/2009 and 05/2020. Systematic search terms also included subheadings for the DSM-5 text sections; i.e., diagnostic features, prevalence, development and course, risk and prognostic factors, culture, gender, suicide risk, functional consequences, differential diagnosis, and comorbidity.

RESULTS

Eight hundred and eighty-two articles were identified, of which 59 full texts were included for analysis. Empirical evidence supports the reliability, validity, and clinical utility of SSD diagnostic criteria, but the further specification of the psychological SSD B-criteria criteria seems necessary. General population studies using self-report questionnaires reported mean frequencies for SSD of 12.9% [95% confidence interval (CI) 12.5-13.3%], while prevalence studies based on criterion standard interviews are lacking. SSD was associated with increased functional impairment, decreased quality of life, and high comorbidity with anxiety and depressive disorders. Relevant research gaps remain regarding developmental aspects, risk and prognostic factors, suicide risk as well as culture- and gender-associated issues.

CONCLUSIONS

Strengths of the SSD diagnosis are its good reliability, validity, and clinical utility, which substantially improved on its predecessors. SSD characterizes a specific patient population that is significantly impaired both physically and psychologically. However, substantial research gaps exist, e.g., regarding SSD prevalence assessed with criterion standard diagnostic interviews.

Psychobiological Mechanisms in Somatic Symptom Disorder and Depressive Disorders: An Ecological Momentary Assessment Approach

OBJECTIVE

Persistent somatic symptoms cause strong impairment in persons with somatic symptom disorder (SSD) and depressive disorders (DDs). Specific negative psychological factors (NPFs), such as catastrophizing, negative affectivity, and behavioral avoidance, are assumed to contribute to this impairment and may maintain symptoms via dysregulations of biological stress systems. We examined the associations between NPF and somatic symptoms in the daily life of women with SSD or DD and investigated the mediating role of psychobiological stress responses.

METHODS

Twenty-nine women with SSD and 29 women with DD participated in an ecological momentary assessment study. For 14 days, intensity of and impairment by somatic symptoms, NPF, and stress-related biological measures (cortisol, alpha-amylase) were assessed five times per day using an electronic device and saliva samples. Multilevel models were conducted.

RESULTS

The greater the number of NPF, the higher the concurrent and time-lagged intensity of and impairment by somatic symptoms in both groups (12.0%-38.6% of variance explained; χ2(12) p < .001 for all models). NPFs were associated with higher cortisol levels in women with DD and with lower levels in women with SSD (interaction NPF by group: B = -0.04, p = .042 for concurrent; B = -0.06, p = .019 for time-lagged). In women with SSD, lower cortisol levels were associated with higher intensity at the next measurement time point (group by cortisol: B = -1.71, p = .020). No mediation effects were found.

CONCLUSIONS

NPFs may be considered as transdiagnostic factors in the development and treatment of impairing somatic symptoms. Our findings will allow the development of new treatment strategies that use ecological momentary intervention approaches focusing on NPF.

Outcomes in the treatment of psychogenic nonepileptic seizures (PNES) with CBTip: Response in seizure frequency, depression, anxiety, and quality of life

RATIONALE

Psychogenic Nonepileptic Seizures (PNES) are seizure-like episodes without EEG abnormality, and are of psychological origin. Cognitive Behavioral Therapy (CBT), a type of psychological counseling, is known to be the best intervention to treat PNES and the underlying psychiatric symptoms. Yet, many remain untreated because of limited access to specialized counseling programs. In this study, first we intended to see if the positive outcomes of the CBTip can be replicated in our patient population using within-group comparison. We also aimed to examine the outcomes of patients who received a variable dose of treatment than the established treatment protocol.

METHOD

We obtained retrospective patient reported outcomes (PRO) data from patients treated with Cognitive Behavioral Therapy-informed psychotherapy (CBT-ip) from January 2015 to January 2020 in an outpatient tertiary care epilepsy center. The CBTip program is a 12-session intervention delivered weekly by a seizure counselor. Although the program comprises 12 sessions of treatment, we included patients who attended at least 7 sessions consistent with previous research that used a similar cutoff. We had a total of 160 patient PROs included in the analysis. Outcome variables including seizure frequency, depression, anxiety, and quality of life were examined using self-report outcome scores. Demographic and other clinical and psychosocial confounding variables were controlled.

RESULTS

In the first analysis in which we compared pre-treatment scores with 3-month posttreatment scores, there was no significant change in seizure frequency, depression, anxiety, and quality-of-life outcomes. In the second analysis when we compared pre- and posttreatment scores in patients who completed the treatment in longer than 3-month time, there were significant improvement in primary and secondary outcomes. For seizure frequency, 10 patients had data for "seizures per day in the last 6 months" and 5 participants (50%) improved by 50% or more in the number of seizures per day. There were also significant reductions in depression and anxiety scores but not in quality of life.

IMPLICATION AND CONCLUSIONS

Our analysis showed that patients treated with CBTip with a minimum of 7 sessions in 3 months did not have significant improvement. However, attending at least 7 sessions of CBTip in longer than 3 months was effective for seizure control, depression, and anxiety. The observational and exploratory nature of our study, however, limits the generalizability of our findings outside of the single tertiary clinical care setting.

Helpful explanatory models for somatoform symptoms (HERMES): study protocol of a randomised mixed-methods pilot trial

INTRODUCTION

Persistent somatic symptoms (PSS) are common both in the general population and primary care. They are bothersome in terms of psychological and somatic symptom burden. Health professionals often struggle with communication, as there is a lack of scientifically supported explanatory models for PSS or a focus merely on somatic aspects of the complaints, which both frustrate patients' needs. The objective of the present study is therefore to develop a psychoeducational intervention based on a current evidence-based explanatory model, to examine its feasibility and form the basis for a large-scale randomised controlled trial.

METHODS AND ANALYSIS

In a randomised controlled mixed-methods pilot trial, 75 adult psychosomatic outpatients with PSS (duration of symptoms ≥6 months) and accompanying psychological (Somatic Symptom B-Criteria Scale total score ≥18) and somatic symptom burden (Patient Health Questionnaire-15 score >10) and no prior psychosomatic treatment will be eligible. Participants will be presented with either the explanatory model without (intervention group 1, n=25) or with elements of personalisation (intervention group 2, n=25). Participants in the control group (n=25) will receive information on current PSS guidelines. Participants will be blinded to group assignment and interventions will be shown on tablet computers at the outpatient clinic. After 1 month, qualitative follow-up telephone interviews will be conducted. As primary outcomes, mean changes in psychological and somatic symptom burden will quantitatively be compared between groups, respectively. Behavioural change mechanisms and feasibility of the three interventions will be evaluated using quantitative and qualitative measures.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the medical ethics board of the Hamburg Medical Chamber (PV5653). Results from this study will be published in peer-reviewed journals and presented at national and international conferences.

TRIAL REGISTRATION NUMBER

DRKS00018803.

Influence of resilience on the relations among acculturative stress, somatization, and anxiety in latinx immigrants

OBJECTIVE

In cultures where psychological distress is stigmatized, the presentation of emotional distress as somatic complaints is a frequent occurrence. Understanding factors that contribute to the presentation of somatization in Latinx immigrants is crucial due to its tie to poor quality of life. The purpose of this study was to explore relations among acculturative stress, anxiety, somatization, and resilience in a sample of Latinx immigrants living in the United States.

METHODS

Data were collected from 204 Latinx immigrants across diverse community settings.

RESULTS

Acculturative stress was positively related to both anxiety and somatization, and the relation between acculturative stress and somatization occurred through anxiety. Resilience moderated the relations between acculturative stress and somatization, and between anxiety and somatization.

CONCLUSION

This study suggests that Latinx immigrants presenting with somatic symptoms may benefit from the examination of a possible comorbid presentation of anxiety or acculturative stressors. An integrated behavioral healthcare approach is recommended when working with Latinx immigrants evaluating the impact of minority stressors on health. Clinicians are encouraged to incorporate cultural protective factors that reinforce the development and sustenance of resilience.

Coping with Medically Unexplained Physical Symptoms: the Role of Illness Beliefs and Behaviors

BACKGROUND

Medically unexplained syndromes (MUS) are both prevalent and disabling. While illness beliefs and behaviors are thought to maintain MUS-related disability, little is known about which specific behavioral responses to MUS are related to disability or the way in which beliefs and behaviors interact to impact functioning. The purpose of the present study was to examine the relationship between illness beliefs and disability among patients with MUS, and assess the extent to which behaviors mediate this relationship.

METHODS

The study examined data from the baseline assessment of a multi-site randomized controlled trial (RCT). Participants were 248 veterans with MUS. Illness beliefs, behavioral responses to illness, and disability were assessed through self-report questionnaire. Data were analyzed using mediation analysis.

RESULTS

Threat-related beliefs predicted greater disability through decreased activity and increased practical support seeking. Protective beliefs predicted less disability through reductions in all-or-nothing behavior and limiting behavior.

CONCLUSIONS

These outcomes suggest that all-or-nothing behavior, limiting behavior, and practical support seeking are important in the perpetuation of disability among those with MUS. This has implications for improving MUS treatment by highlighting potential treatment targets.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02161133.

Early maladaptive schemas in patients with somatoform disorders and somatization

Maladaptive schemas are stable relational patterns that develop through harmful childhood experiences with primary caregivers. Schemas within somatoform disorders are rarely explored even though these disorders are clinically important due to high prevalence, co-morbidity, and cost for the health care system. This study investigates schemas according to Young's schema theory in patients with somatoform disorders in comparison with healthy controls and patients with depressive or anxiety disorders. Further associations between schemas and somatization were explored. We included 134 patients with a somatoform disorder and 39 age-matched healthy controls, 83 patients with a unipolar depression, and 34 patients with an anxiety disorder. The clinical sample consists of day care patients, diagnosed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, but without a personality disorder. Primary measures were the Young Schema Questionnaire (YSQ-S2), the Screening for Somatoform Disorders (SOMS-7T), the Beck Depression Inventory, Second Edition, and the Childhood Trauma Questionnaire. Analyses of variance indicated that somatoform patients scored higher on almost all schemas than do healthy controls (p < 0.001, η²  = 0.148). The highest mean scores were reached for the schemas "self-sacrifice" and "unrelenting standards," with significant higher values in the patient sample. However, when compared with patients with depressive or anxiety disorders, somatoform patients scored equally or even lower. High somatization was associated with generally higher schema activation. This effect was to a great extent mediated by depressive symptoms. Only the schema "vulnerability to harm or illness" was exclusively related to somatization. These findings suggest that schemas should be systematically assessed within psychotherapy of somatoform patients.

Predicting the course of persistent physical symptoms: Development and internal validation of prediction models for symptom severity and functional status during 2 years of follow-up

OBJECTIVE

Increased knowledge about predictors of the course of persistent physical symptoms (PPS) is needed to identify patients at risk for long-term PPS in clinical settings. Therefore, we developed prediction models for the course of PPS in terms of symptom-severity and related functional status during a 2-year follow-up period.

METHODS

We used data of the PROSPECTS cohort study, consisting of 325 PPS patients from several health care settings. Symptom severity (PHQ-15), physical functioning (RAND 36 PCS) and mental functioning (RAND 36 MCS) were assessed at baseline and 6, 12 and 24 months afterwards. We applied mixed model analyses to develop prediction models for all outcomes, using all follow-up measurements. Potential predictors were based on empirical and theoretical literature and measured at baseline.

RESULTS

For symptom severity, physical functioning and mental functioning we identified predictors for the adverse course of PPS included physical comorbidity, higher severity and longer duration of PPS at baseline, anxiety, catastrophizing cognitions, embarrassment and fear avoidance cognitions, avoidance or resting behaviour and neuroticism. Predictors of a favourable course included limited alcohol use, higher education, higher levels of physical and mental functioning at baseline, symptom focusing, damage cognitions and extraversion. Explained interpersonal variance for all three models varied between 70.5 and 76.0%. Performance of the models was comparable in primary and secondary/tertiary care.

CONCLUSION

The presented prediction models identified several relevant demographic, medical, psychological and behavioural predictors for adverse and favourable courses of PPS. External validation of the presented models is needed prior to clinical implementation.

The Longitudinal Effect of Vertigo and Dizziness Symptoms on Psychological Distress: Symptom-Related Fears and Beliefs as Mediators

Despite the frequent observation that vertigo and dizziness (VD) disorders may trigger or exacerbate secondary psychiatric comorbidities, there is limited understanding of the mechanisms underlying this development. To address this gap, we investigated whether symptom-related fears and cognitions as indicated by questionnaire-based measures are mediators of the longitudinal effect of VD symptoms on anxiety and depression after 1 year. We analyzed data from a large study with patients of a treatment center specialized in vertigo (N = 210). Simple and multiple parallel mediation models strengthened our hypothesis that fear of bodily sensations and cognitions about these symptoms play a mediating role in the relationship between VD symptoms and psychopathology at follow-up after baseline scores of the outcome were controlled for. Results are discussed within a cognitive theory framework and point to the potential benefits of interventions that modify symptom-related beliefs and fears via cognitive psychotherapy in this therapeutically underserved population.

Preliminary evidence: the stress-reducing effect of listening to water sounds depends on somatic complaints: A randomized trial

BACKGROUND

Listening to natural sounds is applied in health contexts in order to induce relaxation. However, it remains unclear whether this effect is equally efficacious in all individuals or whether it depends on interindividual differences. Given that individuals differ in how they are impaired by somatic complaints, we investigated whether somatic complaints moderate the stress-reducing effect of listening to water sounds.

METHODS

Sixty healthy women (Mage = 25 years) were randomly allocated to 3 different conditions (listening to water sounds, a relaxing piece of music, or no auditory stimulus: n = 20 per condition) for 10 minutes before they were exposed to a standardized psychosocial stress task. Salivary cortisol was assessed before, during, and after the stress task. For binary logistic regression analyses, participants were divided into 2 groups: 1 group with a high salivary cortisol release and 1 group with low cortisol release. The Freiburg Complaints Inventory was used to assess occurrence of somatic complaints.

RESULTS

A significant moderating effect of somatic complaints on cortisol secretion was found in the group listening to water sounds (χ(1) = 5.87, P < .015) but not in the other 2 groups, explaining 35.7% of the variance and correctly classifying 78.9% of the cases.

CONCLUSION

The stress-reducing effect of listening to water sounds appears to depend on the occurrence of somatic complaints. This effect was not found in the music or silence condition. Individuals with somatic complaints may benefit from other, potentially more powerful forms of stress-reducing interventions, that is, combinations of visual and auditory stimuli.

TRIAL REGISTRATION

not applicable (pilot study).

The Heterogeneity of Illness Behaviors in Patients with Medically Unexplained Physical Symptoms

PURPOSE

To investigate the heterogeneity of illness behavior in patients with medically unexplained physical symptoms (MUPS), we clustered patients in regard to their degree of engaging in different aspects of illness behavior and identified related variables with these behaviors.

METHOD

A sample of N = 224 patients attending treatment in primary care with a history of MUPS (at least two symptoms) was investigated by analyzing different aspects of illness behavior with the self-reported number of doctor visits during the last 6 months and the Scale for the Assessment of Illness Behavior (SAIB; e.g., expression of symptoms).

RESULTS

Two distinct clusters were identified by cluster analysis: a low (n = 106) and a high (n = 118) illness behavior clusters. The high illness behavior cluster exhibited a significantly higher rate of health anxiety than the low illness behavior cluster. Regression analysis revealed a particular effect of sex in the high illness behavior cluster: whereas being male was associated with increased illness behavior as measured by the SAIB, being female was linked to a higher number of doctor visits. Increased health anxiety was associated with the SAIB illness behavior in both clusters. Depression and anxiety did not show incremental associations with all aspects of illness behavior.

CONCLUSION

Knowledge of the pattern of illness behavior in patients with MUPS enables us to improve psychological treatments that directly address specific aspects of illness behavior or health anxiety. Differences between sexes in illness behaviors require more differentiated consideration in future research.

Increasing the treatment motivation of patients with somatic symptom disorder: applying the URICA-S scale

BACKGROUND

Therapeutic intervention programs for somatic symptom disorder (SSD) show only small-to-moderate effect sizes. These effects are partly explained by the motivational problems of SSD patients. Hence, fostering treatment motivation could increase treatment success. One central aspect in SSD patients might be damage to motivation because of symptomatic relapses. Consequently, the aim of the present study was to investigate associations between motivational relapse struggle and therapeutic outcome in SSD patients.

METHODS

We assessed 84 inpatients diagnosed with SSD in the early, middle and late stages of their inpatient treatment. The maintenance subscale of the University of Rhode Island Change Assessment-Short (URICA-S) was applied as a measure to assess motivational relapse struggle. Additionally, patients completed measures of treatment outcome that focus on clinical symptoms, stress levels and interpersonal functioning.

RESULTS

The results from multiple regression analyses indicate that higher URICA-S maintenance scores assessed in early stages of inpatient treatment were related to more negative treatment outcomes in SSD patients.

CONCLUSIONS

SSD patients with ambivalent treatment motivation may fail in their struggle against relapse over the course of therapy. The URICA-S maintenance score assessed at therapy admission facilitated early identification of SSD patients who are at greater risk of relapse. Future studies should incorporate randomized controlled trials to investigate whether this subgroup could benefit from motivational interventions that address relapse.

Clinical value of DSM IV and DSM 5 criteria for diagnosing the most prevalent somatoform disorders in patients with medically unexplained physical symptoms (MUPS)

OBJECTIVE

This study aimed (1) to describe frequencies of DSM IV somatisation disorder, undifferentiated somatoform disorder and pain disorder versus DSM 5 somatic symptom disorder (SSD) in a multi-setting population of patients with medically unexplained physical symptoms (MUPS), (2) to investigate differences in sociodemographic and (psycho)pathological characteristics between these diagnostic groups and (3) to explore the clinical relevance of the distinction between mild and moderate DSM 5 SSD.

METHODS

We used baseline data of a cohort of 325 MUPS patients. Measurements included questionnaires about symptom severity, physical functioning, anxiety, depression, health anxiety and illness perceptions. These questionnaires were used as proxy measures for operationalization of DSM IV and DSM 5 diagnostic criteria.

RESULTS

92.9% of participants fulfilled criteria of a DSM IV somatoform disorder, while 45.5% fulfilled criteria of DSM 5 SSD. Participants fulfilling criteria of DSM 5 SSD suffered from more severe symptoms than those only fulfilling criteria of a DSM IV somatoform disorder(mean PHQ-15 score of 13.98 (SD 5.17) versus 11.23 (SD 4.71), P-value<0.001). Furthermore their level of physical functioning was significantly lower. Compared to patients with mild SSD, patients with moderate SSD suffered from significantly lower physical functioning and higher levels of depression.

CONCLUSION

Within a population of MUPS patients DSM 5 SSD criteria are more restrictive than DSM IV criteria for somatoform disorders. They are associated with higher symptom severity and lower physical functioning. However, further specification of the positive psychological criteria of DSM 5 SSD may improve utility in research and practice.

Physical symptom attributions: a defining characteristic of somatoform disorders?

OBJECTIVES

We examined whether primary care patients were more likely to perceive a current health problem as 'physical illness only' as opposed to entailing psychological difficulties if they had a comorbid somatoform disorder compared to patients who had (a) both comorbid somatoform disorder and anxiety/depression or (b) comorbid anxiety and/or depression, and a reference group of (c) patients with well-defined physical disease. We examined whether attributions predicted future health expenditures.

METHODS

A total of 1209 of 1785 patients completed questions on patient-perceived illness. The physicians diagnosed the current health problem. A stratified subsample was interviewed using the Schedules for Clinical Assessment in Neuropsychiatry. Health expenditure was obtained from registers for a 2-year period.

RESULTS

The belief that the current health problem was only physical was endorsed by 86% of patients presenting physical disease, 58% of patients with somatoform disorders, 29% of patients with both somatoform disorders and anxiety/depression and 24% of patients with anxiety or depressive disorders (χ2=269.2, df=3, P<.0001). In a multiple regression model, a 'physical illness only' perception predicted lower health expenditures [β = -0.31, 95% confidence interval (-0.55; -0.07), P=.013].

CONCLUSIONS

The prevalent assumption that physical symptom attributions are a central aspect in somatoform disorders is not supported by the current study.

Are illness perceptions related to future healthcare expenditure in patients with somatoform disorders?

BACKGROUND

Somatoform disorders are costly for society in terms of increased healthcare expenditure. Patients' illness perceptions have been found to play a role in somatoform disorders. However, it is unclear whether illness perceptions predict higher health costs in these patients.

METHOD

A total of 1785 primary care patients presenting a new health complaint completed a questionnaire on their illness perceptions and emotional distress before the consultation. The physicians completed a questionnaire for each patient on diagnostics after the consultation. In a stratified subsample, physician interviewers established diagnoses of DSM-IV somatization and undifferentiated somatoform disorders (n = 144) using the Schedules for Clinical Assessment in Neuropsychiatry. Healthcare expenditure was obtained from Danish health registers for a 2-year follow-up period.

RESULTS

Patients had more negative perceptions of their well-defined physical health problems when they had a co-morbid somatoform disorder. A strong illness identity [β = 0.120, 95% confidence interval (CI) 0.029-0.212, p = 0.012], perceived negative consequences (β = 0.010, 95% CI 0.001-0.019, p = 0.024), a long timeline perspective (β = 0.013, 95% CI 0.005-0.021, p = 0.001), low personal control (β = - 0.009, 95% CI -0.015 to -0.002, p = 0.011) and negative emotional representations (β = 0.009, 95% CI 0.002-0.017, p = 0.020) predicted healthcare expenditure in somatoform disorders.

CONCLUSIONS

The results suggest that illness perceptions play a role in the perpetuation of symptoms in somatoform disorders and predict higher future healthcare expenditure among a subgroup of these patients.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Predictive validity and clinical utility of DSM-5 Somatic Symptom Disorder: prospective 1-year follow-up study

OBJECTIVE

To compare the predictive validity and clinical utility of DSM-IV somatoform disorders and DSM-5 Somatic Symptom Disorder (SSD) at 12-month follow-up.

METHODS

In a sample of psychosomatic inpatients (n=322, mean age=45.6 years (SD 10.0), 60.6% females) we prospectively investigated DSM-IV somatoform disorders and the DSM-5 diagnosis of SSD plus a variety of psychological characteristics, somatic symptom severity, and health-related quality of life at admission, discharge, and follow-up.

RESULTS

DSM-IV diagnoses and DSM-5 SSD similarly predicted physical functioning at follow-up; SSD also predicted mental functioning at follow-up. Bodily weakness, intolerance of bodily complaints, health habits, and somatic attribution at admission were significant predictors of physical functioning at follow-up. The change in physical functioning during inpatient therapy was a significant predictor for the course of physical functioning until follow-up.

CONCLUSIONS

Psychological symptoms appear to be predictively valid diagnostic criteria for the 12-month functional outcome in patients with SSD. Mental functioning can be better predicted by the DSM-5 diagnosis than by DSM-IV diagnoses. Not the change in single psychological features but in physical functioning during the treatment interval predicted the change in physical functioning until follow-up.

Somatic symptom disorders and illness behaviour: current perspectives

The behavioural aspects of somatic symptom disorders have received minimal research attention to date. The first section of this paper identifies key theoretical perspectives relevant to behavioural responses to illness. Specifically, the sociological concept of illness behaviour is offered as a general framework in which to consider the range of psychosocial factors associated with responses to perceived illness. Further, the potential relevance of the construct of abnormal illness behaviour and the cognitive behavioural conceptualization of health anxiety is explored. The second part of the paper describes various approaches to the operationalization of illness behaviour, with particular emphasis on the Illness Behaviour Questionnaire, an instrument with a rich history of application. Additional insight is provided into two contemporary instruments which aim to measure overt behavioural aspects of illness more specifically. The third and final section of the paper makes recommendations for how future research may advance the understanding of state- versus trait-based characteristics of illness behaviour. Suggestions are made for how adaptive forms of behaviour (e.g. self-management, appropriate coping) may reduce the risk of developing a somatic symptom disorder or alternatively, minimizing the potentially negative psychosocial implications of such a presentation.

Predictive validity and clinical utility of DSM-5 Somatic Symptom Disorder--comparison with DSM-IV somatoform disorders and additional criteria for consideration

OBJECTIVE

Major changes to the diagnostic category of somatoform disorders are being proposed for DSM-5. The effect of e.g. the inclusion of psychological criteria (criterion B) on prevalence, predictive validity, and clinical utility of "Somatic Symptom Disorder" (SSD) remains unclear. A prospective study was conducted to compare current and new diagnostic approaches.

METHODS

In a sample of N=456 psychosomatic inpatients (61% female, mean age=44.8±10.4 years) diagnosed with somatoform, depressive and anxiety disorders, we investigated the current DSM-5 proposal (SSD) plus potential psychological criteria, somatic symptom severity, and health-related quality of life at admission and discharge.

RESULTS

N=259 patients were diagnosed with DSM-IV somatoform disorder (56.8%). With a threshold of 6 on the Whiteley Index to assess psychological criteria, the diagnosis of SSD was similarly frequent (51.8%, N=230). However, SSD was a more frequent diagnosis when we employed the recommended threshold of one subcriterion of criterion B. Patients diagnosed with only SSD but not with DSM-IV somatoform disorder showed greater psychological impairment. Both diagnoses similarly predicted physical functioning at discharge. Bodily weakness and somatic and psychological attributions at admission were among significant predictors of physical functioning at discharge. Reduction of health anxiety, bodily weakness, and body scanning significantly predicted an improvement of physical functioning.

CONCLUSIONS

Psychological symptoms enhance predictive validity and clinical utility of DSM-5 Somatic Symptom Disorder compared to DSM-IV somatoform disorders. The SSD diagnosis identifies more psychologically impaired patients than its DSM-IV precursor. The currently suggested diagnostic threshold for criterion B might increase the disorder's prevalence.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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