Somatoform disorders in consultation-liaison psychiatry: a comparison with other mental disorders

Studying ICD-11 Primary Health Care bodily stress syndrome in Brazil: do many functional disorders represent just one syndrome?

Objective:

Disorders characterized by “distressing unexplained somatic symptoms” are challenging. In the ICD-11 Primary Health Care (PHC) Guidelines for Diagnosis and Management of Mental Disorders (ICD-11 PHC), a new category, bodily stress syndrome (BSS), was included to diagnose patients presenting unexplained somatic symptoms. The present study investigated the association of BSS with anxiety, depression, and four subgroups of physical symptoms in a Brazilian primary health care (PHC) sample.

Methodology:

As part of the international ICD-11 PHC study, 338 patients were evaluated by their primary care physicians, followed by testing with Clinical Interview Schedule (CIS-R) and World Health Organization Disability Assessment Schedule, Version 2.0 (WHODAS 2.0). BSS was diagnosed in the presence of at least three somatic symptoms associated with incapacity. The association between anxiety, depression, and four subgroups of physical symptoms with being a BSS case was analyzed.

Results:

The number of somatic symptoms was high in the overall sample of 338 patients (mean = 8.4), but even higher in the 131 BSS patients (10.2; p < 0.001). Most BSS patients (57.3%) had at least three symptoms from two, three, or four subgroups, and these were associated with anxiety and depression in 80.9% of these patients. The symptom subgroup most strongly associated with “being a BSS” case was the non-specific group (OR = 6.51; 95%CI 1.65-24.34), followed by musculoskeletal (OR = 2,31; 95%CI 1.19-4.72).

Conclusion:

Somatic symptoms were frequent in a sample of PHC patients in Brazil. In the present sample, one third were BSS cases and met the criteria for at least two symptom subgroups, supporting the hypothesis that different functional symptoms are related to each other.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Somatoform, factitious, and related diagnoses in the national hospital discharge survey: addressing the proposed DSM-5 revision

BACKGROUND

The DSM-5 working group on the somatoform (SFD) and factitious (FD) disorders has recommended substantial revisions of these categories. The recommendations are based, in part, on anecdotal evidence that the diagnoses are infrequently used.

OBJECTIVE

To assess the assignment rates for SFD, FD, and related diagnoses among general medical inpatients.

METHOD

The National Hospital Discharge Survey was queried for instances of SFD and FD, along with related diagnoses identifying medical cases in which psychological factors play a role. Diagnoses of major depression and generalized anxiety disorder were queried for comparison purposes.

RESULTS

The target diagnoses were assigned far less frequently than published prevalence and recognition rates suggest. Nearly half of the assigned target diagnoses were generic diagnoses (esp. physiological malfunction due to psychological factors) other than SFD or FD. However, the apparent degree of underassignment of the target diagnoses was not dramatically greater than the underassignment observed for major depression and generalized anxiety disorder.

CONCLUSION

The results provide empirical support for the impression that physicians do not assign SFD and FD diagnoses in recognized cases, but do not strongly support the assertion that these diagnoses are uniquely problematic.

Hysteria and its metamorphoses

OBJECTIVE: To investigate the historical evolution of hysteria and its possible psychopathological ramifications in today’s diagnostic classifications. Method: Clinical and historical problematization contrasting classical and contemporary references on the subject. Conclusion: Higher incidence of certain conditions and decline in the use of the construct of hysteria should be seen as different moments in a continuum.

Health care utilization and poor reassurance: potential predictors of somatoform disorders

OBJECTIVE

Somatoform disorders are common conditions, but the current diagnostic criteria are considered to be unreliable, based largely on medically unexplained symptoms. DSM-5 is considering other possible characteristics of somatizers including high utilization, dissatisfaction with care, and poor response to reassurance. This paper reviews the available literature for evidence to support these criteria, and evaluates if distinctive aspects of these characteristics exist in somatizers.

METHODS

The Pubmed database was searched combining terms such as “somatoform disorder” with “reassurance,” “satisfaction,” and “utilization.” Articles were individually inspected.

RESULTS

Many studies report a deficit in long-term response to reassurance in somatizers; there was some evidence that patients respond initially to reassurance, followed by return of anxiety, leading to further reassurance seeking. There was insufficient evidence to support poor satisfaction with care as a characteristic of somatizers. While there is no standard criterion for high utilization, regardless of definition, evidence was found to support over-utilization, particularly in outpatient visits. However, no unique pattern of utilization was found that could identify somatizers within a broader group of high utilizers.

CONCLUSIONS

This review revealed evidence of over-utilization in many areas of healthcare, as well as poor long term response to reassurance in somatizers. Dissatisfaction with care, though, was not a consistent finding. It is difficult to study alternative diagnostic criteria for somatoform patients when the current criteria rest on so many problematic assumptions. Future research should attempt to validate criteria empirically in patient groups, with selection not based on medically unexplained symptoms.

Validity of current somatoform disorder diagnoses: perspectives for classification in DSM-V and ICD-11

BACKGROUND

The impending revisions of DSM-IV and ICD-10 provide an excellent opportunity to improve the diagnostic accuracy of the current somatoform disorder classification. To prepare for these revisions, this study systematically investigates the validity of the current classification of somatoform disorders.

METHODS

We searched Medline, Psycinfo and reference lists to investigate convergent, divergent, criterion and predictive validity of the current somatoform disorder classification.

RESULTS

Substantial associations of somatoform disorders with functional impairment and elevated health care costs give evidence for the clinical and societal importance of somatoform disorders and for the convergent validity of the current operationalization. The specificity of the current somatoform disorder classification, i.e. their divergent validity, is demonstrated by the fact that functional somatic syndromes and their consequences are only partially explained by association with anxiety and depression. However, the imprecision of the diagnostic criteria, which are not based on positive criteria but on the exclusion of organic disease, largely limits the criterion validity of the current classification systems. Finally, studies investigating the predictive potential of somatoform disorders are lacking, and to date predictive validity has to be considered as low.

CONCLUSIONS

The insufficient criterion and predictive validity of the present somatoform classification underlines the need to revise the diagnostic criteria. However, an abolishment of the whole category of somatoform disorders would ignore the substantial convergent and divergent validity of the current classification and would exclude patients with somatoform symptoms from the current health care system. A careful revision of the current somatoform disorder diagnoses, based on positive criteria of psychological, biological and social features, has the potential to substantially improve the reproducibility and clinical utility of the existing classification system.

Clinical characteristics and outcome of patients diagnosed with psychogenic nonepileptic seizures: a 5-year review

OBJECTIVE

The goal of this article was to describe the clinical characteristics and outcomes of patients diagnosed with psychogenic nonepileptic seizures (PNES).

METHODS

We conducted a retrospective review of patients diagnosed with PNES in a 5-year period.

RESULTS

Fifty patients with PNES were identified, giving an estimated incidence of 0.91/100,000 per annum. Thirty-eight were included for review, 15 of whom were male (39%). Eighteen patients had been diagnosed with epilepsy as well as PNES (47%). We demonstrated a gender difference in our patients, with males having higher seizure frequencies, more antiepileptic drug use, and a longer interval before diagnosis of PNES. Females were diagnosed with other conversion disorders more often than males. Impaired social function was observed in PNES, as was resistance to psychological interventions with a subsequent poor response to treatments.

CONCLUSIONS

PNES remains a difficult condition to treat, and may affect males in proportions higher than those described in previous studies.

Psychogenic dyspnea and therapeutic chest radiograph

Conversion disorders, the physical expression of unresolved psychological pain, can be associated with mourning. This case report is third in a series of articles by the authors on childhood mourning reflecting the effects of multiple losses (K. R. Kaufman & N. D. Kaufman, 2005; K. R. Kaufman & N. D. Kaufman, 2006). In this case report, perception of potential death (self or parent) after a motor vehicle accident precipitated psychogenic dyspnea. A "therapeutic" chest radiograph was an effective initial treatment. Rapid intervention with explanation of the functional nature of the conversion symptom, why this symptom developed, and how to address the underlying stresses in the future led to an excellent outcome. Psychosocial intervention should be included in the multidisciplinary approach toward the child with conversion disorder, be it in an ambulatory, ER, or inpatient setting. The clinician must remember that medically unexplained symptoms in childhood may represent a child's expression of mourning.

Conversion disorder with convulsion and motor deficit mimicking the adverse effects of high-dose Ara-C treatment in a posttransplant acute myeloid leukemia patient: a case report and review of the literature

In this communication, we report an acute leukemia patient who developed conversion disorder mimicking the adverse effects of high-dose cytosine arabinoside (Ara-C) treatment after the patient received high-dose Ara-C treatment. A 21-year-old woman, with acute recurrent leukemia after bone marrow transplantation, received high-dose Ara-C treatment and 10 days later was referred for psychiatric consultation because of an abrupt onset of convulsion. On neurologic examination, she showed convulsion of all the limbs without loss of consciousness. All limbs looked paretic; however, tendon reflexes in all limbs were normal and pathological reflex was not recognized. When her hand was dropped onto her own face, it fell next to her face but not on her face. Laboratory data were unremarkable. She had no history of psychiatric illness or drug or alcohol abuse. The patient explained that she knew about the recurrence of her own leukemia and the news of the death of a close friend due to leukemia at the same time, which was a shocking event for her, focusing her attention on her own fears of dying from the same disease. Conversion disorder in cancer patients is not common; however, appropriate diagnosis is very important to avoid inappropriate examinations and treatments. In leukemia patients receiving chemotherapy, various kinds of signs and symptoms may develop due to the adverse effects of chemotherapy and/or infection. Therefore, conversion disorder might be overlooked and inappropriate treatment and examinations might be performed. Clinicians should consider conversion disorder in the differential diagnosis when patients develop unexplained neurological symptoms.

Somatoform disorders: the role of consultation liaison psychiatry

The somatoform disorders are encountered commonly in both primary and secondary care. Despite their high incidence, few hospitals have teams with the expertise to manage this group of conditions. The lack of appropriate carers leads to inappropriate care, including increased numbers of admissions and investigations, to the detriment of the patients. The absence of appropriate care also increases the cost to the health services. Multidisciplinary Consultation Liaison (C-L) Psychiatry teams operate within non-psychiatric settings and are dedicated to the mental health care of patients presenting in these areas. Their unique skills and approaches offer support and education to these non-psychiatric teams and care to this group of patients. They are thus ideally placed to assess, diagnose and manage individuals presenting with somatoform disorders. Unfortunately, these teams are not widely available, largely because the current climate within psychiatry leads services to concentrate on what is defined as serious mental illness, a term usually used synonymously with psychotic disorders, despite the large number of people suffering from somatoform disorders and the cost of their care. The dislike that some colleagues have for this group of conditions may further hamper the creation of these services. In order to provide efficient assessment of and treatment for individuals with somatoform disorders, C-L Psychiatry teams must be created to lead clinical development, research and training in this discipline. These teams will also lead on the further research required.

Insomnia in somatoform pain disorder: sleep laboratory studies on differences to controls and acute effects of trazodone, evaluated by the Somnolyzer 24 x 7 and the Siesta database

Patients with chronic pain often suffer from sleep disturbances, specifically decreased deep sleep, and thus may get into a vicious circle which maintains their pain condition. Utilizing polysomnography and psychometry, objective and subjective sleep and awakening quality was investigated in 11 patients with nonorganic insomnia (F51.0) related to somatoform pain disorder (SPD; F45.4) as compared with age- and sex-matched healthy controls of the Siesta normative database. Patients demonstrated a markedly deteriorated Pittsburgh Sleep Quality Index, a decreased Quality of Life Index, slightly increased self-reported anxiety (Zung SAS) and depression scores (Zung SDS), as well as an increased Epworth Sleepiness Scale and International Restless Legs Syndrome Scale score. Subjective sleep and awakening quality was markedly reduced, while somatic complaints were increased. Polysomnographic evaluation by a recently developed automatic sleep classifier (Somnolyzer 24 x 7) based on the rules of Rechtschaffen and Kales demonstrated reduced slow-wave sleep (SWS), the target variable in the present study, a decreased stage shift index, increased SWS latency and stage 4 sleep (S4) latency and an increased frequency of shifts from S2 to wakefulness (W) in patients as compared with controls. Minimal oxygen saturation was found decreased, periodic leg movements (PLMs) were increased. In the morning, patients showed deteriorated well-being, drive, mood and wakefulness. There were no significant noopsychic or psychophysiological differences between patients and controls (except for a reduced numerical memory and a slightly increased morning diastolic blood pressure in patients). Subsequent evaluation of the acute effects of 100 mg of a controlled-release formulation of trazodone (Trittico retard) in the patients demonstrated an increase in the target variable SWS, accompanied by a reduction in the number of awakenings and stage shifts. It normalized the frequency of shifts from S2 to W and reduced the frequency of shifts from W to S1, from S1 to S2, as well as from any stage to S1 and S2. Trazodone, however, also significantly reduced the total sleep period and S2 and increased the latency to S1. Moreover, the drug increased the reduced minimal O(2 )saturation, reduced the arousal index and the PLMs-in-wake index and normalized the increased morning diastolic blood pressure. In conclusion, our study demonstrated that SPD induced significant changes in subjective and objective sleep and awakening quality, which were partially mitigated by trazodone therapy. The data on the target variable SWS support our hypothesis of a key-lock principle in the diagnosis and drug treatment of sleep disorders. Our study provided the first evidence on the usefulness of the Somnolyzer 24 x 7 and the Siesta database in clinical practice.

What influences self-perception of health in the elderly? The role of objective health condition, subjective well-being and sense of coherence

The study examines in what way objective health-related variables interfere with psychic health and personality factors in explaining self-perception of health in the elderly. Two hundred and sixty-one patients aged 60 and older of an internal medicine hospital previously examined between 1994 and 1997 were once more contacted five years later. One hundred and sixty-four patients could not be included in the present investigation because of death, dementia, or severe physical illness. Of the 97 patients eligible for this second investigation, 74 agreed to participate. They were investigated extensively by means of psychometric scales and diagnostic interviews. A positive selection effect could be found for the sample of the present investigation with regard to age and health-related variables. Subjective evaluation of health correlated highly with the self-evaluation scales that recorded subjective well-being (life satisfaction, anxiety, and depression), and with the sense of coherence, but not substantially with objective health-related variables. A backward regression resulted in an adjusted R2 = 0.33 for the three retained variables "subjective physical complaints", "sense of coherence" and "self-evaluated depression" which rendered the same variance clarification of subjective health as did the model including all variables. Since the elderly represent the majority of patients treated in general hospitals and as subjective health and subjective physical complaints influence frequency of medical consultations and health care utilization, this is an important issue for consultation-liaison-psychiatry and health policy.

Somatization disorder: a practical review

OBJECTIVE

This paper reviews the present state of knowledge on the etiology, prevalence, diagnosis, and treatment of somatization disorder (SD).

METHOD

A comprehensive review of the literature on SD is described under the above headings.

RESULTS

SD is a common condition that is not well managed by many physicians. Patients with SD get caught between the cracks of the health care system, with expensive consequences. SD is a psychiatric disorder, but patients are reluctant to see and be treated by psychiatrists. They frequently are managed by nonpsychiatric physicians who have limited understanding of the condition. Cognitive-behavioural therapy (CBT) is the most efficacious treatment in SD, although antidepressants and supportive psychotherapy also have a role for some patients.

CONCLUSIONS

A cadre of clinicians with training in the theory and practice of CBT for SD is required. They need to be based both in the community and in tertiary health care centres, where most patients with this condition are located.