Irritable bowel, chronic widespread pain, chronic fatigue and related syndromes are prevalent and highly overlapping in the general population: DanFunD

Comorbidity and sex differences in functional disorders and internalizing disorders

OBJECTIVE

In the current exploratory study we estimate comorbidity rates between FDs [fibromyalgia (FM), myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), and irritable bowel syndrome (IBS)]-and IDs-[major depressive disorder (MDD) and generalized anxiety disorder (GAD)] by using self-reported diagnostic criteria.

METHOD

We analyzed data from 107,849 participants (mean age = 49.3 (SD = 13.0), 58.6% women) of the Lifelines Cohort Study. Lifelines is a prospective population-based cohort study in the northeast of the Netherlands. Current IDs were assessed using the Mini-International Neuropsychiatric Interview. Current FM, ME/CFS, and IBS were assessed according to the 2010 American College of Rheumatology criteria, the 1994 Centers for Disease Control and Prevention criteria and the ROME IV criteria, respectively. We estimated tetrachoric correlations between diagnoses and tested for sex differences. Additionally, we estimated the ratio of observed-to-expected frequency for combinations of diagnoses.

RESULTS

FDs and IDs are highly comorbid (odds ratios: 3.2-12.6) with associations stronger among men. Participants with at least three disorders/diagnoses were more prevalent than expected by chance.

CONCLUSION

Studies that aim to explain sex differences and the comorbidity of specific combinations of IDs and FDs will be an important contribution to understanding the etiology of these conditions.

Multiple physical symptoms and coping strategies over the last decade - Knowledge from two Danish population-based cross-sectional studies in 2012 and 2022

OBJECTIVE

To compare the prevalence of multiple physical symptoms, coping scores, and associations between multiple physical symptoms and coping in two population-based surveys within a 10-year interval.

METHODS

A nationwide study on symptoms and healthcare-seeking, the Danish Symptom Cohort, was carried out in 2012 and repeated in 2022. For each survey, 100,000 randomly selected individuals were invited, and individuals aged 20-64 years were eligible for inclusion. Multiple physical symptoms were identified using the 25-item Bodily Distress Syndrome checklist, and coping was assessed with the Brief Approach/Avoidance Coping Questionnaire. Statistical analyses included multinomial and logistic regressions.

RESULTS

A total of 35,877 were included in 2012 and 18,330 in 2022. Overall, 35.1% reported multiple physical symptoms in 2022 compared with 23.8% in 2012. The mean sum score for approach was lower in 2022 than in 2012 with a statistically significant mean difference of -1.27 (Cohen's d = -0.34), while diversion and resignation scores were significantly higher in 2022 with mean differences of 0.34 (Cohen's d = 0.11) and 0.52 (Cohen's d = 0.17), respectively. Regression analyses showed that lower approach scores and higher diversion and resignation scores were associated with an increased probability of having multiple physical symptoms in 2022, thereby confirming the results from 2012.

CONCLUSION

Over the decade, symptom reporting may have increased while coping strategies may have changed towards a slightly higher use of avoidance and lower use of approach. It seems relevant to identify modifiable contributing factors in society to prevent an acceleration of symptom reporting and avoidant behavior.

The Latest Data Concerning the Etiology and Pathogenesis of Irritable Bowel Syndrome

Globally, irritable bowel syndrome (IBS) is present in approximately 10% of the population. While this condition does not pose a risk of complications, it has a substantial impact on the patient's quality of life. Moreover, this disease has a significant financial impact on healthcare systems. This includes the direct costs associated with the diagnosis and treatment of these patients, as well as the indirect costs that arise from work absenteeism and reduced productivity. In light of these data, recent research has focused on elucidating the pathophysiological basis of this condition in order to improve the quality of life for affected individuals. Despite extensive research to date, we still do not fully understand the precise mechanisms underlying IBS. Numerous studies have demonstrated the involvement of the gut-brain axis, visceral hypersensitivity, gastrointestinal dysmotility, gut microbiota dysbiosis, food allergies and intolerances, low-grade mucosal inflammation, genetic factors, and psychosocial factors. The acquisition of new data is crucial for the advancement of optimal therapeutic approaches aimed at enhancing the general health of these patients while simultaneously reducing the financial burden associated with this ailment.

Insecure Attachment, Oxytocinergic System and C-Tactile Fibers: An Integrative and Translational Pathophysiological Model of Fibromyalgia and Central Sensitivity Syndromes

Although the pathophysiology of fibromyalgia syndrome has been better understood in recent decades, a unified model of its pathogenesis and an effective therapeutic approach are still far from being realized. The main aim of this article will be to delve into the fundamental mechanisms of the pathophysiology of fibromyalgia conceptualized as stress intolerance syndrome. Using the biopsychosocial model of chronic pain syndromes, we will describe the potential role of the attachment system, C-tactile fibers, and oxytocinergic system dysfunction in the pathophysiology of fibromyalgia syndrome and other central sensitivity syndromes. At the end of the article, the therapeutic implications of this new global and translational pathophysiological model will be briefly discussed.

Addressing GI Health Through the Bidirectional Modulation of the Gut-Brain Axis With Herbal Extracts: A Narrative Review

Functional gastrointestinal disorders (FGIDs) refer to a group of disorders with chronic symptoms, such as abdominal pain, dysphagia, dyspepsia, diarrhea, constipation, and bloating. Among these, functional constipation significantly impacts the quality of life and is linked with comorbidities, such as anxiety and depression. The exact pathophysiology remains unclear despite the widespread occurrence. Research suggests that the gut-brain axis plays a role in FGIDs. Disruptions in the bidirectional communication between the brain and gastrointestinal (GI) tract contribute to GI symptoms and mood disturbances. The incomplete understanding of FGID pathophysiology has led to limited treatment options. Traditional treatments often focus on single symptoms and come with side effects, prompting the need for alternative approaches that address both GI and psychological components. Alternative approaches including herbal supplements offer a natural alternative to conventional medicine by promoting regularity and gut health. Abelmoschus esculentus L. or okra has a history of use in traditional medicine. Bioactive compounds such as polysaccharides and fibers found in okra offer gastroprotective benefits. Withania somnifera is a plant commonly referred to as ashwagandha. The plant root has been used for its health-promoting effects. Research supports the use of W. somnifera to help with stress and sleep. Digexin is a herbal supplement combining W. somnifera (ashwagandha) and A. esculentus (okra). It has shown promise in improving both GI regularity and mood by modulating the gut-brain axis. Clinical studies support the potential of a novel herbal supplement that aids in the management of FGIDs. This narrative review looks at FGIDs, etiologies, current treatment, and possible therapeutic supplements to aid in symptom management.

How to understand the overlap of long COVID, chronic fatigue syndrome/myalgic encephalomyelitis, fibromyalgia and irritable bowel syndromes

Long COVID should be limited to patients with multiple, persistent symptoms not related to well-defined organ damage. Once redefined, a focused review of long COVID demonstrates striking similarity to chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME), fibromyalgia (FM) and irritable bowel syndrome (IBS). Research in long COVID has revealed similar findings to those noted in CFS/ME and FM, characterized by central nervous system organ dysfunction. Long COVID, like CFS/ME, FM and IBS, is best understood as a bidirectional mind-body, neuroimmune illness.

Multivariate, Multi-omic Analysis in 799,429 Individuals Identifies 134 Loci Associated with Somatoform Traits

Somatoform traits, which manifest as persistent physical symptoms without a clear medical cause, are prevalent and pose challenges to clinical practice. Understanding the genetic basis of these disorders could improve diagnostic and therapeutic approaches. With publicly available summary statistics, we conducted a multivariate genome-wide association study (GWAS) and multi-omic analysis of four somatoform traits-fatigue, irritable bowel syndrome, pain intensity, and health satisfaction-in 799,429 individuals genetically similar to Europeans. Using genomic structural equation modeling, GWAS identified 134 loci significantly associated with a somatoform common factor, including 44 loci not significant in the input GWAS and 8 novel loci for somatoform traits. Gene-property analyses highlighted an enrichment of genes involved in synaptic transmission and enriched gene expression in 12 brain tissues. Six genes, including members of the CD300 family, had putatively causal effects mediated by protein abundance. There was substantial polygenic overlap (76-83%) between the somatoform and externalizing, internalizing, and general psychopathology factors. Somatoform polygenic scores were associated most strongly with obesity, Type 2 diabetes, tobacco use disorder, and mood/anxiety disorders in independent biobanks. Drug repurposing analyses suggested potential therapeutic targets, including MEK inhibitors. Mendelian randomization indicated potentially protective effects of gut microbiota, including Ruminococcus bromii. These biological insights provide promising avenues for treatment development.

Can internal medicine specialists diagnose functional somatic disorders (FSDs)? Training and comparison with FSD specialists

BACKGROUND

Functional somatic disorders (FSD) are a common problem across medical settings and remain challenging to diagnose and treat. Many patients with FSD undergo sequential and unnecessary extensive diagnostic work-up, which is costly for society and stressful for patients. Previous studies have shown that the empirically based FSD diagnostic entities are interrater reliable and stable over time.

OBJECTIVE

The aim of this study was to investigate whether internists who have received adequate training and with sufficient time per patient could diagnose FSD.

DESIGN

This was a prospective diagnostic accuracy study. The study was conducted from May 2020 to April 2022.

PARTICIPANTS

The study included 27 consecutive patients referred by their general practitioner to a non-psychiatric diagnostic clinic for assessment of physical symptoms on suspicion of FSD.

INTERVENTIONS

The internists received a 30-hour training course in the use of a tailored version of the SCAN interview.

MAIN MEASURES

The main outcome measure was the agreement between the diagnoses of the internists and the reference diagnoses made by specialists in FSD on the basis of the full SCAN interview.

KEY RESULTS

The interrater agreement between the internists and the FSD experts was substantial for any FSD (kappa = 0.63) as well as multi-organ vs. single-organ FSD (kappa = 0.73), indicating good diagnostic agreement.

CONCLUSIONS

Internists with proper training and sufficient time (3-4 hours) per patient can proficiently diagnose FSD employing a tailored version of the SCAN interview for use in a non-psychiatric diagnostic setting.

The role of the gut microbiome in disorders of gut-brain interaction

Disorders of Gut-Brain Interaction (DGBI) are widely prevalent and commonly encountered in gastroenterology practice. While several peripheral and central mechanisms have been implicated in the pathogenesis of DGBI, a recent body of work suggests an important role for the gut microbiome. In this review, we highlight how gut microbiota and their metabolites affect physiologic changes underlying symptoms in DGBI, with a particular focus on their mechanistic influence on GI transit, visceral sensitivity, intestinal barrier function and secretion, and CNS processing. This review emphasizes the complexity of local and distant effects of microbial metabolites on physiological function, influenced by factors such as metabolite concentration, duration of metabolite exposure, receptor location, host genetics, and underlying disease state. Large-scale in vitro work has elucidated interactions between host receptors and the microbial metabolome but there is a need for future research to integrate such preclinical findings with clinical studies. The development of novel, targeted therapeutic strategies for DGBI hinges on a deeper understanding of these metabolite-host interactions, offering exciting possibilities for the future of treatment of DGBI.

Prevalence of functional disorders across Europe: a systematic review and meta-analysis

Functional Disorders (FD) refer to persistent somatic symptoms caused by changes in the functioning of bodily processes. Previous findings suggest that FD are highly prevalent, but overall prevalence rates for FD in European countries are scarce. Therefore, the aim of the present work was to estimate the point prevalence of FD in adult general populations. PubMed and Web of Science were searched from inception to June 2022. A generalized linear mixed-effects model for statistical aggregation was used for statistical analyses. A standardized quality assessment was performed, and PRISMA guidelines were followed. A total of 136 studies were included and systematically synthesized resulting in 8 FD diagnoses. The large majority of studies was conducted in the Northern Europe, Spain, and Italy. The overall point prevalence for FD was 8.78% (95% CI from 7.61 to 10.10%) across Europe, with the highest overall point prevalence in Norway (17.68%, 95% CI from 9.56 to 30.38%) and the lowest in Denmark (3.68%, 95% CI from 2.08 to 6.43%). Overall point prevalence rates for specific FD diagnoses resulted in 20.27% (95% CI from 16.51 to 24.63%) for chronic pain, 9.08% (95% CI from 7.31 to 11.22%) for irritable bowel syndrome, and 8.45% (95% CI from 5.40 to 12.97%) for chronic widespread pain. FD are highly prevalent across Europe, which is in line with data worldwide. Rates implicate the need to set priorities to ensure adequate diagnosis and care paths to FD patients by care givers and policy makers.

Validity and diagnostic overlap of functional somatic syndrome diagnoses

OBJECTIVE

We present the first study that investigates the validity and the diagnostic overlap of the three main functional somatic syndrome (FSS) diagnoses, i.e. chronic fatigue syndrome (CFS), fibromyalgia (FM), and irritable bowel syndrome (IBS), irrespective of help-seeking behaviour or diagnostic habits, and irrespective of differences in diagnostic thresholds for chronicity or symptom interference.

METHODS

This cross-sectional analysis was performed in 89,781 participants of the general-population cohort Lifelines. Diagnostic criteria for CFS (Centers for Disease Control and Prevention), FM (American College of Rheumatology) and IBS (Rome IV) were assessed by questionnaire. Additional items were added to enable studying the effects of differences in thresholds for minimum symptom chronicity (varying from three for FM to six months for CFS and IBS), and symptom interference (required for CFS but not for FM and IBS).

RESULTS

The diagnostic criteria were met by 3.1% for CFS, 6.6% for FM, and 5.5% for IBS participants. The number of participants that met criteria for all three diagnoses was 45 times higher than what would have been expected based on chance. After alignment of the chronicity and symptom interference criteria to circumvent differences in diagnostic thresholds, the overlap between diagnoses increased to 152 times. Furthermore, there was a similar pattern of symptom occurrence, particularly for those fulfilling diagnostic criteria for CFS and FM.

CONCLUSION

The diagnostic overlap of different FSS was much higher than would be expected by chance, and substantially increased when FSS were more chronic and serious in nature.

Factors associated with having previously received a diagnosis of fibromyalgia, chronic fatigue syndrome and irritable bowel syndrome: A cross sectional DanFunD study

OBJECTIVES

Fibromyalgia, chronic fatigue syndrome, and irritable bowel syndrome are highly prevalent conditions and part of the functional somatic syndromes (FSS) diagnosis, that are classified under the unifying umbrella term functional somatic disorder (FSD). Multiple factors are associated with FSD symptom development; However, few studies have explored these associations in relation to the diagnosis status. This study aims to examine associations with a previously received FSS diagnosis from a physician in participants fulfilling the FSD diagnostic criteria in a population-based sample.

METHODS

This research employs a comprehensive observational approach using a cross sectional design with data from the DanFunD part two cohort. Information about received FSS diagnoses was obtained from self-reported questionnaires. Participants fulfilling the FSD diagnostic criteria were identified with both self-reported questionnaires and diagnostic interviews. Validated questionnaires were used to assess the examined factors.

RESULTS

1704 cases fulfilled the diagnostic criteria for an FSD according to questionnaires or interviews in the DanFunD study. In participants fulfilling the diagnostic criteria, having previously received an FSS diagnosis by a physician was strongly associated with female sex, negative illness perceptions and poor health-related quality of life for questionnaire and interview-based diagnoses. Less consistent associations were observed for lower socioeconomic status, anxiety, and adverse life events.

CONCLUSION

Previously received FSS diagnoses showed associations with multiple factors with a particular strong association with female sex and poor health related quality of life.

Efficacy of patient education and duloxetine, alone and in combination, for patients with multisystem functional somatic disorder: Study protocol for the EDULOX trial

BACKGROUND

Multisystem functional somatic disorder is characterized by specific patterns of persistent physical symptoms with a complex biopsychosocial etiology. The disorder can lead to disability and personal suffering. Current treatment options require specialized settings, therefore patients often wait a long time to receive specific treatment. Patient education is considered important in most treatment programs, but has only been investigated sparsely as a stand-alone treatment. Pharmacological treatment is limited to tricyclic antidepressants in low doses with no antidepressant properties. Duloxetine has been found effective in single organ functional disorders. As a treatment for multisystem functional somatic disorder, duloxetine could reduce symptoms and treat comorbid anxiety and depression. It may furthermore enhance the effect of patient education through a hypothesized effect on cognitive functioning. The purpose of the EDULOX trial is to study psycho-EDUcation and duLOXetine alone and in combination.

METHODS

This is a nested study design. The parent trial "EDULOX1" (n = 424) will compare a patient education program with enhanced usual care in an open-labelled, randomized controlled trial. In addition to this, eligible participants will furthermore receive either duloxetine or active placebo in the nested, double-blinded, randomized controlled trial, "EDULOX2" (n = 212). Patient and clinician reported outcomes will be collected through questionnaires.

CONCLUSION

The EDULOX trial may establish evidence for treatments applicable for the majority of patients with multisystem functional somatic disorder. If effective, duloxetine would be a more tolerable pharmacological treatment option that can target comorbid depression and anxiety, and potentially boost the effect of patient education. Trial registration number The study is registered at www.

CLINICALTRIALS

gov (NCT06232473) and the internal list of research projects at the Region of Central Denmark (Case number 1-16-02-305-23). Approval from the Danish Medical Research Ethics Committees (Case number: 2212291) and the Danish Medicines Agency was obtained under EudraCT Number: 2022-002780-30 and Sponsor's Protocol Code Number: 9515.

Is reduced heart rate variability associated with functional somatic disorders? A cross-sectional population-based study; DanFunD

OBJECTIVES

It has been hypothesised that functional somatic disorders (FSD) could be initiated by sympathetic predominance in the autonomic nervous system as measured by low heart rate variability (HRV). Earlier studies on the association between HRV and FSD are small case-control studies hampered by selection bias and do not consider the great overlap between the various FSDs. The aim of the present study is to assess any associations between HRV and various FSDs and whether chronic stress confounds such an association.

DESIGN

A cross-sectional general population-based study.

SETTING

The Danish Study of Functional Somatic Disorders conducted 2013-2015 in 10 municipalities in the western part of Greater Copenhagen, Denmark.

PARTICIPANTS

A total of 6891 men and women aged 18-72 years were included in the analyses after exclusion of 602 persons with missing HRV data. Various delimitations of FSD (chronic fatigue, chronic widespread pain, irritable bowel and bodily distress syndrome) were identified by validated questionnaires and diagnostic interviews. HRV parameters in time and frequency domains were calculated from successive beat-to-beat heart rate (HR) data using the 'E-motion' HR monitor device during 7 min of supine rest. Chronic stress was assessed by Cohen's self-perceived stress scale.

OUTCOME MEASURES

Logistic regression analyses were used to calculate possible associations between the various delimitations of FSD and HRV adjusting for chronic stress.

RESULTS

Persons with FSD had a slightly higher mean HR and lower HRV as measured by time domain parameters, whereas associations with frequency domain parameters were not consistent. Adjusting for chronic stress attenuated associations slightly.

CONCLUSION

The study supports a sympathetic predominance in persons with FSD, which could not be entirely explained by chronic stress. However, it is not possible to conclude whether the association is a causal factor to or a consequence of FSD.

Exploratory assessment of parental physical disease categories as predictors of documented physical child abuse

Improved prediction of physical child abuse could aid in developing preventive measures. Parental physical disease has been tested previously as a predictor of documented physical child abuse but in broad categories and with differing results. No prior studies have tested clinically recognizable categories of parental disease in a high-powered dataset. Using Danish registries, data on children and their parents from the years 1997-2018 were used to explore several parental physical disease categories' associations with documented physical child abuse. For each disease category, survival analysis using pseudovalues was applied. When a parent of a child was diagnosed or received medication that qualified for a category, this family and five comparison families not in this disease category were included, creating separate cohorts for each category of disease. Multiple analyses used samples drawn from 2,705,770 children. Estimates were produced for 32 categories of physical diseases. Using Bonferroni-corrected confidence intervals (CIc), ischemic heart disease showed a relative risk (RR) of 1.44 (CIc 1.13-1.84); peripheral artery occlusive disease, RR 1.39 (CIc 1.01-1.90); stroke, RR 1.19 (1.01-1.41); chronic pulmonary disease, RR 1.33 (CIc 1.18-1.51); ulcer/chronic gastritis, RR 1.27 (CIc 1.08-1.49); painful condition, 1.17 (CIc 1.00-1.37); epilepsy, RR 1.24 (CIc 1.00-1.52); and unspecific somatic symptoms, RR 1.37 (CIc 1.21-1.55). Unspecific somatic symptoms were present in 71.87% of families at some point during the study period.

CONCLUSION

Most parental physical disease categories did not show statistically significant associations, but some showed predictive ability. Further research is needed to explore preventive potential.

WHAT IS KNOWN

• Few and broad categories of parental physical disease have been examined as risk factors for severe physical child abuse; no prior study has used several categories as predictors.

WHAT IS NEW

• Unspecific symptoms, ischemic heart disease, peripheral artery occlusive disease, stroke, chronic pulmonary disease, stomach ulcer/chronic gastritis, painful condition, and epilepsy all showed to be potential predictors, with unspecific symptoms being the most prevalent.

Lipid metabolism and functional somatic disorders in the general population. The DanFunD study

OBJECTIVES

Earlier studies on the association between plasma lipid profiles and functional somatic disorders (FSD) are mainly small case control studies hampered by selection bias and do not consider the great overlap between the various FSDs. The aim of the present study was to investigate the associations between various FSDs and plasma lipid profiles (total cholesterol, HDL cholesterol, non-HDL cholesterol and triglycerides) in a large, unselected population.

DESIGN

A cross-sectional general population-based study.

SETTING

The Danish Study of Functional Somatic Disorders (DanFunD) conducted in 2011-2015 in 10 municipalities in the western part of greater Copenhagen, Denmark.

PARTICIPANTS

A total of 8,608 men and women aged 18-76 years were included in the analyses. Various delimitations of FSD such as chronic fatigue, chronic widespread pain, irritable bowel, and bodily distress syndrome were measured using validated self-administrated questionnaires. Lipid parameters were measured from fasting plasma samples using colorimetric slide methods with Vitros 4600/5600 Ortho Clinical Diagnostics.

OUTCOME MEASURES

Logistic regression analyses were used to calculate possible associations between plasma lipids and the various delimitations of FSD. Associations are presented by OR (95% CI) and shown in boxplots.

RESULTS

We found a positive association between bodily distress syndrome and triglycerides and non-HDL cholesterol and a negative association with HDL-cholesterol, but no consistent association with total cholesterol. A similar pattern was observed for persons with chronic fatigue, and to some degree for persons with chronic widespread pain, whereas persons with irritable bowel did not show a clear association with the lipid profiles.

CONCLUSION

This is the first major study on plasma lipid profiles and FSD indicating an association between some delimitations of FSD and an unfavorable lipid profile. Due to the cross-sectional design, it cannot be determined whether the findings are consequences or determinants of FSD. Further studies-preferable prospective studies-are needed.

Sociodemographic and hospital characteristics for patients with severe functional disorder receiving specialized treatment at hospital. A regional register-based cross-sectional study from Denmark

OBJECTIVE

10% of all adult Danish citizen has a functional disorder (FD). This study aimed to describe how patients referred to specialized treatment (CFD; Clinic for Functional Disorders) differentiate from those not referred to specialized treatment in terms of sex, comorbidty, different types of hospital contacts and affiliation to labour market 12 and 60 months prior discharged from the hospital with a FD-diagnosis between 2019 and 2021.

METHODS

The study was a register-based cross-sectional study of patients discharged with a FD in North Denmark Region between 2019 and 2021 (study period). Patients between 18 and 65 years of age with FD were identified in the regional patient administrative system.

RESULTS

A total of 6831 patients were discharged from the hospital with a FD, of which 160 were referred to CFD. Patients with FD were more likely to be referred to CFD, if they were female, had reduced or no affiliation to the labour market or most hospital contacts were as outpatient. Moreover, an increase in hospital contacts as outpatient and a reduction in affiliation to labour market over time increased the chance of being treated at CFD.

CONCLUSION

Patients referred to CFD differed from patients not referred to CFD. Patients referred to CFD were to a lesser extent affiliated to the labour market but had more often hospital contacts as outpatient prior to being discharged with FD. In addition, patients referred to CFD increased their contacts to the hospital as outpatient more than those not referred during the preceding 5 years from discharge with FD.

Not a general, symptom-unspecific, transdiagnostic marker for functional symptoms: sensorimotor processing of head control is intact in chronic pain

Introduction

Functional disorders are prevalent in all medical fields and pose a tremendous public health problem, with pain being one of the most common functional symptoms. Understanding the underlying, potentially unifying mechanism in functional (pain) disorders is instrumental in facilitating timely diagnosis, stigma reduction, and adequate treatment options. Neuroscientific models of perception suggest that functional symptoms arise due to dysregulated sensorimotor processing in the central nervous system, with brain-based predictions dominating the eventual percept. Experimental evidence for this transdiagnostic mechanism has been established in various functional symptoms. The goal of the current study was to investigate whether erroneous sensorimotor processing is an underlying transdiagnostic mechanism in chronic (functional) pain.

Method

A total of 13 patients with chronic (functional) pain [three patients with chronic (functional) pain disorder, F45.40, ICD-10; 10 patients with chronic pain disorder with somatic and psychological factors, F45.41, ICD-10]; and 15 healthy controls performed large combined eye-head gaze shifts toward visual targets, naturally and with increased head moment of inertia. We simultaneously measured participants' eye and head movements to assess head oscillations at the end of the gaze shift, which are an established indicator of (transdiagnostic) sensorimotor processing deficits of head control.

Results

Using a Bayesian analysis protocol, we found that patients with chronic (functional) pain and control participants stabilized their heads equally well (Bayes Factor 01 = 3.7, Bayes Factor exclusion = 5.23; corresponding to substantial evidence) during all sessions of the experiment.

Conclusion

Our results suggest that patients with chronic (functional) pain do not show measurable symptom-unspecific sensorimotor processing deficits. We discuss outcome parameter choice, organ system specificity, and selection of patient diagnoses as possible reasons for this result and recommend future avenues for research.

Chronic fatigue syndromes: real illnesses that people can recover from

The 'Oslo Chronic Fatigue Consortium' consists of researchers and clinicians who question the current narrative that chronic fatigue syndromes, including post-covid conditions, are incurable diseases. Instead, we propose an alternative view, based on research, which offers more hope to patients. Whilst we regard the symptoms of these conditions as real, we propose that they are more likely to reflect the brain's response to a range of biological, psychological, and social factors, rather than a specific disease process. Possible causes include persistent activation of the neurobiological stress response, accompanied by associated changes in immunological, hormonal, cognitive and behavioural domains. We further propose that the symptoms are more likely to persist if they are perceived as threatening, and all activities that are perceived to worsen them are avoided. We also question the idea that the best way to cope with the illness is by prolonged rest, social isolation, and sensory deprivation.Instead, we propose that recovery is often possible if patients are helped to adopt a less threatening understanding of their symptoms and are supported in a gradual return to normal activities. Finally, we call for a much more open and constructive dialogue about these conditions. This dialogue should include a wider range of views, including those of patients who have recovered from them.

The distribution of somatic symptom disorder and bodily distress syndrome in general hospital outpatients in China: A multicenter cross-sectional study

OBJECTIVE

To investigate the distribution of somatic symptom disorder (SSD) and bodily distress syndrome (BDS) and analyze the differences in psychosocial characteristics of patients with the two diagnoses.

METHODS

A total of 694 general hospital outpatients completed the diagnostic interviews for SSD and BDS, and a set of questionnaires evaluating their psychosocial characteristics. A secondary analysis of these data is done.

RESULTS

SSD and BDS had a moderate overlap (kappa value = 0.43). Patients who fulfilled both SSD and BDS diagnosis showed significantly higher levels of symptom-related psychological distress (SSD-12), somatic symptom severity (PHQ-15), depression (PHQ-9), and general anxiety (GAD-7), as well as lower mental and physical quality of life (SF-12) compared to patients with neither diagnosis and patients with only one diagnosis. Patients with either diagnosis were associated with significantly higher psychosocial impairments as compared to those with neither diagnosis. Patients who only met SSD had higher SSD-12 scores, whereas those with only BDS had higher PHQ-15 scores (p<0.001).

CONCLUSIONS

SSD and BDS appear to represent somewhat different psychopathologies, with SSD more associated with psychological distress and BDS associated with greater experience of somatic symptoms. Patients fulfilling both diagnosis show higher symptom severity in various psychosocial aspects.

Emotional Awareness and Expression Interview: Examining Interview Content and Patient Experiences in Two Medical Samples

A single session of Emotional Awareness and Expression Therapy (EAET)-the EAET Interview-was previously shown to lead to clinical benefits for patients with centralized somatic conditions in primary care (Ziadni et al. in Health Psychol 37(3):282-290, 2018) and tertiary care (Carty et al. in Pain Med 20(7):1321-1329, 2019) settings. There has yet to be an examination of patients' experiences of and reactions to the EAET Interview, which is crucial in evaluating possible clinical implementation of the interview. We conducted secondary analyses on 88 patients (M age = 41.32, 90.9% women) from the two prior trials (primary care N = 51; tertiary care N = 37). Analyses examined interview processes (stress disclosure themes, working alliance, and emotional processing) and patients' reactions to the interview (interview credibility and perceived value of the interview), comparing the two samples and examining correlations among these variables. All patients disclosed at least one stressful life experience, commonly interpersonal problems (89.2%) and childhood adversity (51.5%). Patients had moderately high levels of working alliance and emotional processing during the interview and reported high interview credibility and perceived value of the interview. More extensive emotional processing of stressors was associated with more positive patient reactions to the interview, including higher interview credibility (r = .23) and perceived value (r = .32). We conclude that the single-session EAET Interview was valued by most patients, and patients' emotional processing is particularly beneficial. Addressing the trauma and emotional conflicts of patients with centralized somatic conditions is both feasible and valuable in front-line medical settings.

Clinical Impact of Systematic Assessment and Psychoeducation in Specialized Treatment of Adolescents with Severe Functional Somatic Disorders: Results from the AHEAD Study

Functional somatic disorders (FSD), characterized by persistent and disabling physical symptoms, are common in adolescents. Diagnostic uncertainty and insufficient illness explanations are proposed perpetuating factors that may constitute barriers for treatment engagement. This study describes the impact of manualized assessment and psychoeducation on diagnostic certainty and various clinical outcomes in adolescents with multi-system FSD. Ninety-one adolescents (15-19 years) received systematic assessment (4 h) and a subsequent psychiatric consultation (1.5 h). Clinical characteristics included self-reported physical health, symptom severity, illness perception, illness-related behavior, and psychological flexibility assessed before and approximately two months after assessment, prior to specialized treatment. Data were analyzed using t-tests. Immediately following assessment, 71 (80.7%) adolescents out of 88 reported a higher diagnostic certainty and 74 (84.1%) reported that attending assessment gave them positive expectations for future treatment. A clinically relevant improvement of physical health was not observed at two months but considerable reductions were seen in symptom severity, illness worry, negative illness perceptions, illness-related limiting behavior, and psychological inflexibility. The results emphasize that systematic assessment and psychoeducation are important in their own right in the specialized treatment of adolescents with severe FSD.

Early identification of persistent somatic symptoms in primary care: data-driven and theory-driven predictive modelling based on electronic medical records of Dutch general practices

OBJECTIVE

The present study aimed to early identify patients with persistent somatic symptoms (PSS) in primary care by exploring routine care data-based approaches.

DESIGN/SETTING

A cohort study based on routine primary care data from 76 general practices in the Netherlands was executed for predictive modelling.

PARTICIPANTS

Inclusion of 94 440 adult patients was based on: at least 7-year general practice enrolment, having more than one symptom/disease registration and >10 consultations.

METHODS

Cases were selected based on the first PSS registration in 2017-2018. Candidate predictors were selected 2-5 years prior to PSS and categorised into data-driven approaches: symptoms/diseases, medications, referrals, sequential patterns and changing lab results; and theory-driven approaches: constructed factors based on literature and terminology in free text. Of these, 12 candidate predictor categories were formed and used to develop prediction models by cross-validated least absolute shrinkage and selection operator regression on 80% of the dataset. Derived models were internally validated on the remaining 20% of the dataset.

RESULTS

All models had comparable predictive values (area under the receiver operating characteristic curves=0.70 to 0.72). Predictors are related to genital complaints, specific symptoms (eg, digestive, fatigue and mood), healthcare utilisation, and number of complaints. Most fruitful predictor categories are literature-based and medications. Predictors often had overlapping constructs, such as digestive symptoms (symptom/disease codes) and drugs for anti-constipation (medication codes), indicating that registration is inconsistent between general practitioners (GPs).

CONCLUSIONS

The findings indicate low to moderate diagnostic accuracy for early identification of PSS based on routine primary care data. Nonetheless, simple clinical decision rules based on structured symptom/disease or medication codes could possibly be an efficient way to support GPs in identifying patients at risk of PSS. A full data-based prediction currently appears to be hampered by inconsistent and missing registrations. Future research on predictive modelling of PSS using routine care data should focus on data enrichment or free-text mining to overcome inconsistent registrations and improve predictive accuracy.

Functional Somatic Disorders, Their Subtypes, and Their Association With Self-Rated Health in the German General Population

OBJECTIVE

The heterogeneous conceptualizations and classifications of persistent and troublesome physical symptoms impede their adequate clinical management. Functional somatic disorder (FSD) is a recently suggested interface concept that is etiologically neutral and allows for dysfunctional psychobehavioral characteristics as well as somatic comorbidity. However, its prevalence and impact are not yet known.

METHODS

We analyzed 2379 participants (mean age = 48.3 years, 52.5% female) from a representative German community survey using operationalized FSD criteria. These criteria defined FSD types based on somatic symptom count, type, and severity assessed by the Bodily Distress Syndrome Checklist. In addition, the associations of those types with health concerns, comorbidity, psychological distress, and self-rated health were determined.

RESULTS

There were four clearly demarcated groups with no relevant bothering symptoms, with one or with few bothering symptoms from one organ system, and with multiple bothering symptoms from at least two organ systems. Psychological distress, health concerns, and comorbidity steadily increased, and self-rated health decreased according to the number and severity of symptoms. Somatic symptom burden, health concerns, and comorbidity independently predicted self-rated health, with no interaction effect between the latter two.

CONCLUSIONS

Our data support an FSD concept with two severity grades according to persistent and troublesome symptoms in one versus more organ systems. The delimitation of subtypes with psychobehavioral characteristics and/or with somatic comorbidity seems useful, while still allowing the demarcation of a group of participants with high symptom burden but without those additional characteristics.

Alexithymia and intolerance of uncertainty predict somatic symptoms in autistic and non-autistic adults

LAY ABSTRACT

Autistic people have more physical health problems than non-autistic people. We were interested in whether autistic people experience more discomfort in their bodies than non-autistic people and whether certain psychological traits contribute to that. A survey was completed online by older adolescents and adults, 51 of whom were autistic, 32 of whom thought they might be autistic but were not diagnosed and 119 who were not autistic. They completed measures of somatic symptoms (daily experience of pain, discomfort, dizziness), alexithymia (difficulty identifying and expressing feelings), interoception (how much people are aware of their bodies) and intolerance of uncertainty (how people handle doubt or uncertainty), and reported any physical or mental health conditions. We found that the autistic participants had more physical and mental health conditions than the non-autistic participants, but even when we took account of this, they experienced higher levels of somatic symptoms. We looked at which psychological factors influenced levels of somatic symptoms across the whole sample, and found that alexithymia, intolerance of uncertainty, having physical health problems, being female and the number of mental health conditions predicted somatic symptoms, while interoception and autism diagnosis did not. The findings suggest that people may be more likely to experience physical discomfort if they are female, and have difficulty identifying and expressing feeling and difficulty tolerating doubt. As these psychological factors are more prominent in autism, we think this is important for physical and mental health providers to know about, so that these psychological factors can be considered when assessing and treating autistic people.

Social economic factors and the risk of multiple chemical sensitivity in a Danish population-based cross-sectional study: Danish Study of Functional Disorders (DanFunD)

OBJECTIVES

Multiple chemical sensitivity (MCS) is a rare multisystem and poly-symptomatic disease characterised by a report of various somatic symptoms attributed to inhalation of volatile chemicals in usually harmless doses. The aim was to explore four selected social factors and the risk of MCS in the general Danish population.

DESIGN

A cross-sectional general population-based study.

SETTING

The Danish Study of Functional Disorders was conducted from 2011 to 2015 which included 9656 participants.

PARTICIPANTS

A total of 8800 participants were included in analyses after observations with missing data on exposure and/or outcome were excluded. A total of 164 cases fulfilled the questionnaire criteria for MCS. Of the 164 MCS cases, 101 reported no comorbid functional somatic disorder (FSD) and were included in a subgroup analysis. A total of 63 MCS cases fulfilled the criteria for at least one additional FSD, this subgroup was not included in further analysis. The remaining study population without MCS or any FSD were regarded as controls.

OUTCOME MEASURES

We used adjusted logistic regression to calculate OR and 95% CIs of MCS and MCS without FSD comorbidities for each social variable separately including education, employment, cohabitation and subjective social status.

RESULTS

We found an increased risk of MCS among the unemployed (OR: 2.95, 95% CI: 1.75 to 4.97), and a twofold increased risk of MCS among individuals with low subjective social status (OR: 2.00, 95% CI: 1.08 to 3.70). At the same time, 4 years or more of vocational training were protective of MCS. No significant associations were observed among MCS cases with no comorbid FSD.

CONCLUSION

Lower socioeconomic status was found to be associated with a higher risk of having MCS but not with MCS without FSD comorbidities. Due to the cross-sectional design of the study, we cannot determine whether social status is a determinant or a consequence of MCS.

High Perceived Stress and Low Self-Efficacy are Associated with Functional Somatic Disorders: The DanFunD Study

Objective

Several psychological factors have been proposed to be associated with functional somatic disorders (FSD) including functional somatic syndromes, such as irritable bowel, chronic widespread pain, and chronic fatigue. However, large randomly selected population-based studies of this association are sparse. This study aimed to investigate the association between FSD and perceived stress and self-efficacy, respectively, and to investigate if FSD differed from severe physical diseases on these aspects.

Methods

This cross-sectional study included a random sample of the adult Danish population (n = 9656). FSD were established using self-reported questionnaires and diagnostic interviews. Perceived stress was measured with Cohen's Perceived Stress Scale and self-efficacy with the General Self-Efficacy Scale. Data were analysed with generalized linear models and linear regression models.

Results

FSD were associated with higher perceived stress and lower self-efficacy, especially for the multi-organ and the general symptoms/fatigue FSD types and for chronic fatigue. However, controlling for the personality trait neuroticism altered the associations with self-efficacy so it became insignificant. The analysis did not support an important interaction between perceived stress and self-efficacy on the likelihood of having FSD. Individuals with FSD presented levels of perceived stress that were not equal, ie higher, to those in individuals with severe physical diseases.

Conclusion

FSD were positively associated with perceived stress and negatively associated with self-efficacy. Our study may point to stress being part of the symptomatology of FSD. This underlines the severity of having FSD and stresses the relevance of the resilience theory in the understanding of the condition.

The role of psychological factors in functional gastrointestinal disorders: a systematic review and meta-analysis

PURPOSE

To systematically reevaluate the role of psychological factors in functional gastrointestinal disorders (FGIDs) and thus provide a scientific basis for the psychological treatment of FGIDs.

METHODS

A literature search was conducted using the PubMed, Embase, Web of Science, and Cochrane Library databases from January 2018 to August 2022 for researches on psychological factors affecting patients with functional gastrointestinal disorders. Meta-analysis was carried out with Stata17.0 after the screening, extraction, and evaluation of article quality.

RESULTS

The search included 22 articles with 2430 patients in the FGIDs group and 12,397 patients in the healthy controls. Meta-analysis showed anxiety [(pooled SMD = 0.74, 95%CI: 0.62 ~ 0.86, p < 0.000) (pooled OR = 3.14, 95%CI: 2.47 ~ 4.00, p < 0.000)], depression [(pooled SMD = 0.79, 95%CI: 0.63 ~ 0.95, p < 0.000) (pooled OR = 3.09, 95%CI: 2.12 ~ 4.52, p < 0.000)], mental disorders (pooled MD =  -5.53, 95%CI: -7.12 ~  -3.95, p < 0.05), somatization (pooled SMD = 0.92, 95%CI: 0.61 ~ 1.23, p < 0.000), and sleep disorders (pooled SMD = 0.69, 95%CI: 0.04 ~ 1.34, p < 0.05) are risk factors for functional gastrointestinal disorders.

CONCLUSION

There is a significant association between psychological factors and FGIDs. Interventions such as anti-anxiety drugs, antidepressants, and behavioral therapy are of great clinical significance in reducing FGIDs risk and improving prognosis.

Social position and functional somatic disorders: The DanFunD study

BACKGROUND AND AIM

It is generally accepted that functional somatic disorders (FSDs) are a product of biological, psychological, and social factors. Social position might be part of this complex, but the literature on this issue is currently heterogeneous and inconsistent. The aim of the present study was - in a population-based cohort - to test the hypothesis that lower social position would be associated with higher a risk of FSD.

METHOD

The association between social position and FSD was examined in a cross-sectional study with various measures of social position (education as measured by vocational training; employment; cohabitation; subjective social status) and delimitations of FSD (irritable bowel syndrome, chronic fatigue syndrome, fibromyalgia, bodily distress syndrome, and symptom profiles). The associations were analyzed using logistic regressions to calculate odds ratios and 95% confidence intervals. Each social measure was analyzed independently and was adjusted for age and sex.

RESULTS

Lower levels of vocational training, being unemployed, and living alone were associated with higher risk of FSD, regardless of the FSD delimitation. There was also a significant negative association between subjective evaluated social status and FSD. The associations remained after multiple adjustments, and seemed to be strongest for the more severe FSD-types.

CONCLUSIONS

Lower social position is associated with higher risk of FSD, especially the more severe FSD delimitations, which might constitute an especially vulnerable group. However, the mechanisms behind the relations remain unknown.

Predictors of Persistent Somatic Symptoms in the General Population: A Systematic Review of Cohort Studies

OBJECTIVE

Up to 10% of the general population experiences persistent somatic symptoms (PSS). Numerous studies in a variety of health domains are dedicated to identifying factors that are associated with PSS onset. The present study aimed to provide an overview of predictors for PSS onset in the general population and the related health domains.

METHODS

A systematic search was performed identifying longitudinal cohort studies that examined factors associated with PSS onset in the general population. Included studies measured potential predictors before PSS onset and were categorized according to the dynamic biopsychosocial model. Four levels of evidence were discerned for predictors, based on the number of studies and percentage of consistent findings.

RESULTS

In the 154 articles eligible for analysis, 27 PSS subtypes were studied, with primary focus on fibromyalgia (25.0%) and irritable bowel syndrome (23.3%). Of the >250 predictors of PSS onset, 46 were investigated more than once and showed consistent results. Strong evidence identifies biological (e.g., infections, body weight-related metrics), psychological (e.g., sleep problems, psychopathology), interpersonal (life events, childhood/interpersonal stress), contextual (employment), and health behavioral (health care utilization) predictors.

CONCLUSIONS

The results provide strong evidence for factors from all dynamic biopsychosocial domains, although interpersonal and health behavioral factors are relatively under investigated. Thus, evidence suggests that reduction of predictors of PSS onset to a specific factor/domain may be too restrictive. There is no evidence that this differs per PSS subtype. Exploring all domains and measuring common factors across subtypes are essential to improve the clinical course of PSS.

Autism Spectrum Disorder May Be Highly Prevalent in People with Functional Neurological Disorders

Recent observations suggest that autism spectrum disorder (ASD) co-occurs in people with a functional neurological disorder (FND), but little systematic data are available on the relationship between FND and autism. The study aimed to assess the self-reported autistic traits via a standardized questionnaire and the prevalence of previously diagnosed ASD among people with FND and their 1st-degree relatives. We performed a survey of members of the patient organization FNDHope, using a self-completed questionnaire for screening for autistic traits and ASD: the adult autism subthreshold spectrum (AdAS spectrum). There were 344 respondents diagnosed with FND with a mean age of 39.8 ± 11.6 years (female sex 90%). Eight per cent of respondents volunteered a previous diagnosis of ASD, and 24% reported a 1st-degree relative with a formal diagnosis of ASD, mostly their children. We found that 69% of respondents had scores in the AdAS spectrum indicating a clinically significant ASD and 21% indicating autistic traits. Further studies are needed to provide more evidence regarding the prevalence of ASD in people with FND and how this may influence the aetiology, treatment selection and prognosis.

A multicenter study of bodily distress syndrome in Chinese outpatient hospital care: prevalence and associations with psychosocial variables

BACKGROUND

Bodily distress syndrome (BDS) is a new, empirical-based diagnosis of functional somatic symptoms. This study aimed to explore the prevalence of BDS and its association with psychosocial variables in a Chinese clinical population.

METHODS

A multicentre cross-sectional study of 1269 patients was conducted in 9 different Chinese tertiary outpatient hospitals. The BDS was identified by trained interviewers face-to face, based on a brief version of the Schedules for Assessment in Neuropsychiatry (RIFD) and the BDS Checklist-25. Sociodemographic data and further information were characterised from psychometric questionnaires (The Patient Health Questionnaire-15, the Patient Health Questionnaire-9, the General Anxiety Disorder-7, the Whiteley scale-8) .

RESULTS

Complete data were available for 697 patients. The prevalence of BDS was 26.8% (95% confidence interval (CI): 23.5-30.1). Among the participants, 5.8% (95% CI: 4.1-7.6) fulfilled the criteria for single-organ BDS, while 20.9% (95%CI: 17.9-24.0) had multi-organ BDS. Comparison of the PHQ-15, PHQ-9, GAD-7, and WI-8 scores revealed higher scores on all dimensions for patients with BDS. In a binary logistic regression analysis, BDS was significantly associated with increased health-related anxiety (WI-8) and depression (PHQ-9). The explained variance was Nagelkerke's R² = 0.42.

CONCLUSIONS

In China, the BDS is a common clinical condition in tertiary outpatient hospital settings with high prevalence, and is associated with health anxiety and depressive symptoms. In this clinical population, the severe multi-organ subtype of BDS was the most frequent.

Neuroticism and adverse life events are important determinants in functional somatic disorders: the DanFunD study

Several psychological factors have been proposed to be associated with functional somatic disorders (FSD). However, large population-based studies investigating the importance of both personality and adverse life events (ALE) are sparse. This study aimed to investigate the association between FSD and neuroticism and the accumulated number of ALE, respectively. This cross-sectional study included a random sample of the adult Danish population (N = 7493). FSD were established by means of self-reported questionnaires and diagnostic interviews. Neuroticism was measured with the Danish version of the short-form NEO Personality Inventory. ALE were measured with the Danish version of the Cumulative Lifetime Adversity Measure. Strong positive associations were found between neuroticism and FSD, and ALE and questionnaire-based FSD. For interview-based FSD, strong positive associations were found for FSD, multi-organ type, and for the subtype of the general symptoms. The level of self-efficacy did not modify these associations, and no moderating effect of neuroticism and ALE in combination on the probability of having FSD was found. FSD were strongly associated with both neuroticism and the accumulated number of ALE, and these associations were not modified by self-efficacy. In combination, neuroticism and ALE did not have a moderating effect on the probability of having FSD.

Association between infections and functional somatic disorders: a cross-sectional population-based cohort study

OBJECTIVES

It has been suggested that infections can trigger functional somatic disorders (FSD). However, current evidence is limited by inconsistent findings in smaller studies conducted in clinical settings within selected populations and short follow-up times. We aimed to test the hypothesis that former infections are associated with FSD using data from nationwide registries and a large population-based cohort study, the Danish Study of Functional Disorders study.

DESIGN

FSD cases were identified in a cross-sectional population-based cohort and linked retrospectively to former hospital contacts with infections identified in the Danish National Patient Registry. The associations between FSD and former infections within 17 years were analysed using logistic regressions to calculate ORs and 95% CIs adjusted for age, sex and subjective social status.

SETTING

A population-based cohort in Denmark examined between 2011 and 2015.

PARTICIPANTS

A total of 9656 men and women aged 18-76 years.

MAIN OUTCOME MEASURES

FSD measured by various delimitations, including bodily distress syndrome (BDS), irritable bowel (IB), chronic fatigue (CF), chronic widespread pain (CWP), and multiple chemical sensitivity (MCS).

RESULTS

Overall, infections were associated with increased risk of all delimitations of FSD. The associations were more pronounced for multisystemic FSD. The number of prior infections increased the risk in a dose-response manner (p<0.0001). Bacterial but not viral infections were significantly associated with BDS (OR 1.69 (95% CI 1.46 to 1.96)), IB (OR 1.41 (95% CI 1.06 to 1.88)), CWP (OR 1.47 (95% CI 1.13 to 1.90)) and CF (OR 1.62 (95% CI 1.34 to 1.96)), but not MCS.

CONCLUSION

Former infections leading to hospital contacts were associated with a higher risk of having FSD. These associations were more pronounced for bacterial than viral infections, and more infections increased the risk in a dose-response manner. These results tend to support the idea that severe infections could play a role in FSD.

Examine the public health impacts of functional somatic disorders using the DanFunD study

Background: Persistent physical symptoms (e.g. pain, fatigue) are prevalent in the population and some persons may develop a functional somatic disorder (FSD). We still need to explore the limits between general bodily sensations and FSD, and great controversies exist as regard delimitation, occurrence, risk factors, prognosis, and costs of FSD in the general population. This is mainly due to the lack of focused, sufficient powered, population-based epidemiological studies. Material and Methods: The DanFunD study is the largest focused population-based study on FSD and has the potential to answer these crucial questions regarding the FSD disorders. DanFunD has its origin in the Copenhagen area of Denmark and was initiated in 2009 by an interdisciplinary team of researchers including basic scientists, clinical researchers, epidemiologists, and public health researchers. A population-based cohort of nearly 10,000 people have filled in detailed questionnaires, gone through a thorough health examination, and a biobank is established. The cohort was re-examined after five years. Results:The prevalence of FSD in the Danish population is about 10-15% and is twice as common in women as in men. Persons with FSD report impaired daily activities and low self-perceived health, which qualifies FSD as a major public health problem. The research plan to unravel the risk factors for FSD employs a bio-psycho-social approach according to a detailed plan. Preliminary results are presented, and work is in progress. Likewise, plans for assessing prognosis and health care costs are provided. Conclusion: We invite researchers in the field to collaborate on this unique data material.

Stability and predictors of somatic symptoms in men and women over 10 years: A real-world perspective from the prospective MONICA/KORA study

OBJECTIVE

To assess the stability of somatic symptoms in community-dwelling participants.

METHODS

The study included 2472 participants (1190 men, 1282 women; mean age 44.3 ± 10.9) from the prospective population-based MONICA-S3 cohort (1994/95) and the 10-year follow-up KORA-F3 cohort. Somatic symptoms were assessed by an adapted version of the Somatic Symptom Scale-8 (SSS-8a) with scores ranging from 0 to 24. Somatic symptom stability was assessed by weighted kappa values (κ). Generalized Estimating Equation models assessing symptom stability were adjusted for sociodemographic, lifestyle, clinical and psychosocial risk factors, as well as pre-existing medical conditions.

RESULTS

The mean (±SD) SSS-8a was lower in men (S3: 6.88 ± 3.87, F3: 6.60 ± 3.86) than women (S3: 8.43 ± 4.0, F3: 8.31 ± 4.2) at both time points. However, somatic symptoms remained moderately stable in both genders over 10 years (κ =0.42 in men and κ = 0.48 in women), with the largest stability observed in trouble sleeping for men (κ =0.41) and pain in the joints for women (κ =0.41). Pre-existing somatic symptoms were significantly associated with increasing symptoms at follow-up [men: β = 0.82 (SE 0.12), women: β = 0.85 (SE 0.12)], followed by age and psychosocial factors, whereas higher education and recent health care utilization were inversely associated with increasing symptoms. Although hypertension and obesity were associated with increasing somatic symptoms in men, pre-existing medical conditions were not associated with increasing somatic symptoms in men nor women.

CONCLUSIONS

The current findings indicate that somatic symptoms remain moderately stable in the general population during 10 years of follow-up, mainly driven by sociodemographic and psychosocial factors.

Generalized Worry in Patients With Chronic Fatigue Syndrome Following Cognitive Behavioral Therapy: A Prospective Cohort Study in Secondary Care

Research has shown that generalized anxiety disorder is commonly associated with Chronic Fatigue Syndrome (CFS). This prospective cohort study aimed to investigate the prevalence of generalized worry in CFS patients and its relationship with fatigue, anxiety and social functioning, before and after Cognitive Behavioral Therapy (CBT). Our cohort consisted of 470 patients diagnosed with CFS who received CBT at a secondary care, specialist clinic. Patients completed self-report measures investigating levels of generalized worry, fatigue, work and social adjustment, anxiety and depression at baseline (pretreatment), discharge from treatment, 3-month and 6-month follow up (posttreatment). Analysis indicated a high prevalence of generalized worry (72.4%) at assessment. A significant reduction in worry following CBT (M = -3.42, p < .001, 95% CIs: 2.26, 4.57) was observed at discharge, which remained stable at follow-up. Severe baseline worriers had greater overall fatigue score (M = 3.74, p = .026, 95% CIs: .33, 7.15) and worse overall work and social adjustment than mild worriers across time-points (M = 5.42, p = .035 95% CIs: .27, 10.58). Avoidance behavior mediated the association between generalized worry and work and social adjustment (95% bootstrap CIs: 013, .080). The majority of patients with CFS had comorbid generalized worry and severe worriers reported greater fatigue, anxiety, and worse work and social adjustment. This suggests that CFS patients may benefit from targeting generalized worry during CBT.

Physiological Health and Physical Performance in Multiple Chemical Sensitivity-Described in the General Population

Multiple chemical sensitivity (MCS) is a multifactorial somatic disorder characterized by physical reactions triggered by even extremely low levels of different airborne chemicals. In most individuals with MCS, these reactions have substantial negative impact on social, occupational, and everyday life often including limited or no engagement in physical activities. The aim of this study was to explore associations between MCS and objective measurements of anthropometry, cardiorespiratory health, and physical performance. From the Danish population-based cohort DanFunD counting 9656 participants aged 18–76 years, 1.95% (n = 188) were categorized as MCS individuals (MCS All). Of those 188, 109 participants were subcategorized as having MCS without functional somatic disorders (FSD) (MCS with no comorbid FSD). The remaining study population without any FSD were regarded controls. We used adjusted multiple linear regression analyses to evaluate associations between MCS and anthropometry, cardiorespiratory fitness, and physical performance. Compared with the general population, MCS All had less optimal body composition, increased risk of obesity, impaired cardiorespiratory fitness, and physical performance which was not seen in MCS with no comorbid FSD. MCS individuals may be inhibited to maintain an active lifestyle which can increase risk of obesity and consequently have negatively impact on general health, which may not be the case among MCS with no comorbid FSD.

The underlying sex differences in neuroendocrine adaptations relevant to Myalgic Encephalomyelitis Chronic Fatigue Syndrome

INTRODUCTION

Myalgic Encephalomyelitis/ Chronic Fatigue Syndrome (ME/CFS) is a complex multisystem disease characterised by severe and disabling new-onset symptoms of post-exertional malaise (PEM), fatigue, brain fog, and sleep dysfunction that lasts for at least six months. Accumulating evidence suggests that sex and endocrine events have a significant influence on symptom onset and moderation of ME/CFS, with female sex being one of the most consistent and credible predictive risk factors associated with diagnosis. Such sex differences suggest sex chromosomes and sex steroids may play a part in the development of the condition or moderation of symptoms, although this has yet to be explored in detail.

METHODS/AIMS

This narrative review outlines sex differences in ME/CFS in terms of vulnerability factors and clinical phenotype and explores the known sex differences in neuroendocrine systems affected in ME/CFS and how this may relate to disease risk, onset, pathophysiology, and potential treatment avenues.

CONCLUSIONS

There is clear evidence of a sex dimorphism with regards to prevalence (3:1 female preponderance), clinical phenotypes, and aetiological triggers prior to symptom onset of ME/CFS. Endocrinological events, particularly those throughout the female lifespan, are associated with ME/CFS and include reproductive menstrual cycle fluctuations, pregnancy, post-partum and perimenopause. Further, there is evidence for gonadal sex, adrenal stress and renal neuroendocrine systems as implicated in ME/CFS, including changes in estrogen, progesterone compounds, aldosterone, and cortisol levels, of which there are established sex differences. The broad effects of steroid hormones on the physiological systems may also speak to the diversity of ME/CFS symptomatology observed in patients. Further attention must be paid to sex, age, and steroid biology in ME/CFS.

[Functional somatic symptoms: Clinical varieties, diagnostic challenges, therapeutic principles]

Functional somatic symptoms are common and multiform. They occur in all genders and age groups, with and without somatic or mental comorbidity. Dysfunctional illness behaviour on the patients' (e. g., excessive attention or anxiety) and also on the caregivers' side (e. g., nocebo messages, redundant investigations or risky treatments) can promote chronification. Empathy, well balanced diagnostics, comprehensible information within individual multifactorial explanatory models, refocussing, activation, and - in more severe forms - additional measures such as psychotherapy are recommended.

Four clinical profiles of adult outpatients with somatic Symptom Disorders and Related Disorders (SSRD). A latent class analysis

OBJECTIVE

To obtain more insight into the patterns of co-occurring symptoms, biomarkers and predictors in Somatic Symptom Disorders and Related Disorders (SSRD) and to identify subgroups with profiles that might allow for personalised treatment.

METHODS

Cross-sectional study design with Latent class analysis (LCA) to determine different subgroups in a cohort of 239 outpatients with SSRD in 3 steps: 1) building a latent class model; 2) assigning subjects to the latent classes that suited them best based on their posterior probability; 3) investigating the associations between these classes and personal characteristics such as age, gender, somatic comorbidity and general health perception.

RESULTS

Four classes with clinically relevant profiles were found. One with trauma plus elevated inflammation biomarkers, high somatic symptom levels, pain and comorbid depression and anxiety. One with pain plus elevated biomarkers, depression and anxiety. One with low IL-6 and hsCRP, mostly linked to Illness Anxiety. And one with high pain and high elevated biomarkers, but less probability of other factors, that occurred mostly in men. General health perception was lower in classes with elevated inflammation biomarkers.

CONCLUSIONS

The findings of this first study exploring latent classes in an SSRD sample corroborate the current DSM-5 SSD subclassification for pain and Illness Anxiety Disorder. There is scope to extend the current DSM-5 classification with a subclassification of SSD with trauma, and a subclassification with elevated IL6 or hsCRP, as relevant for developing new personalised treatments addressing trauma or SLI in SSRD. Further research is needed to explore this.

Are study populations in trials of antidepressants and psychotherapy comparable? A retrospective case study of two parallel running trials for multi- organ functional somatic disorder

This study retrospectively compares two previous parallel running, randomized, controlled trials of pharmacotherapy (imipramine) and psychotherapy (acceptance and commitment therapy) for multi-organ functional somatic disorder (FSD). Differences in demographics, psychiatric comorbidity, illness severity, and illness duration associated with eligibility for the two trials and patients' willingness to participate are explored using linear or binary regression models. 418 patients with multi-organ FSD was included. We found that 377 (95%) were eligible for psychotherapy and 257 patients (61%) for pharmacotherapy. Patients eligible for pharmacotherapy were less severely impaired, less often received disability pension, reported shorter illness duration and experienced less psychological distress than patients eligible for psychotherapy. Whilst exclusion criteria for both trials differed markedly, it was not possible to clearly identify patient or illness characteristics associated with patients' willingness to participate. The study showed that trial-specific exclusion criteria led to the selection of less complex and less severely impaired patients in the pharmacological trial in this sample of multi-organ FSD. Our findings have important implications for the interpretation and comparability of RCT results of different treatments in multi-organ FSD and may point to some common flaws in study design and interpretation of pharmacological vs. psychotherapeutic intervention trials in psychiatry.

Scoping review and interpretation of myofascial pain/fibromyalgia syndrome: An attempt to assemble a medical puzzle

BACKGROUND

Myofascial Pain Syndrome (MPS) is a common, overlooked, and underdiagnosed condition and has significant burden. MPS is often dismissed by clinicians while patients remain in pain for years. MPS can evolve into fibromyalgia, however, effective treatments for both are lacking due to absence of a clear mechanism. Many studies focus on central sensitization. Therefore, the purpose of this scoping review is to systematically search cross-disciplinary empirical studies of MPS, focusing on mechanical aspects, and suggest an organic mechanism explaining how it might evolve into fibromyalgia. Hopefully, it will advance our understanding of this disease.

METHODS

Systematically searched multiple phrases in MEDLINE, EMBASE, COCHRANE, PEDro, and medRxiv, majority with no time limit. Inclusion/exclusion based on title and abstract, then full text inspection. Additional literature added on relevant side topics. Review follows PRISMA-ScR guidelines. PROSPERO yet to adapt registration for scoping reviews.

FINDINGS

799 records included. Fascia can adapt to various states by reversibly changing biomechanical and physical properties. Trigger points, tension, and pain are a hallmark of MPS. Myofibroblasts play a role in sustained myofascial tension. Tension can propagate in fascia, possibly supporting a tensegrity framework. Movement and mechanical interventions treat and prevent MPS, while living sedentarily predisposes to MPS and recurrence.

CONCLUSIONS

MPS can be seen as a pathological state of imbalance in a natural process; manifesting from the inherent properties of the fascia, triggered by a disrupted biomechanical interplay. MPS might evolve into fibromyalgia through deranged myofibroblasts in connective tissue ("fascial armoring"). Movement is an underemployed requisite in modern lifestyle. Lifestyle is linked to pain and suffering. The mechanism of needling is suggested to be more mechanical than currently thought. A "global percutaneous needle fasciotomy" that respects tensegrity principles may treat MPS/fibromyalgia more effectively. "Functional-somatic syndromes" can be seen as one entity (myofibroblast-generated-tensegrity-tension), sharing a common rheuma-psycho-neurological mechanism.

Association among Disorders of Gut-Brain Interaction (DGBI) and Fibromyalgia: A Prospective Study

The disorders of gut-brain interaction (DGBI) have been associated with Fibromyalgia (FM). However, there are no data about the relationship between FM and DGBI using Rome IV criteria. This study aimed to evaluate the prevalence of FM in patients with Irritable Bowel Syndrome (IBS) and/or Functional Dyspepsia (FD) and the prevalence of IBS and FD in FM patients using Rome IV criteria. DGBI patients and FM patients were recruited from two outpatient clinics devoted to DGBI and FM. All patients underwent a standardized gastrointestinal (GI) symptoms questionnaire. FM symptoms in DGBI patients were assessed through Fibromyalgia Rapid Screening Tool (FiRST) and Fibromyalgia Impact Questionnaire. Thereafter, the rheumatologists evaluated them. 49.0% of FM patients fulfilled the diagnostic criteria for IBS, 81.6% for FD with an overlap for both IBS/FD in 44.9%. IBS-C was the most prevalent IBS-subtype in DGBI patients, whereas IBS-M was the most prevalent in FM patients (p = 0.01). 45.3% of DGBI patients reported pathological FiRST scores. DGBI patients with FM showed the highest score at the standardized GI questionnaire followed by FM patients with DGBI and DGBI without FM. In conclusion DGBI are common in FM patients and vice versa. The presence of FD is extremely frequent in FM patients. A multidisciplinary approach should be routinely used for the management of these patients.

Multiple Chemical Sensitivity

Multiple Chemical Sensitivity (MCS), a condition also known as Chemical Sensitivity (CS), Chemical Intolerance (CI), Idiopathic Environmental Illness (IEI) and Toxicant Induced Loss of Tolerance (TILT), is an acquired multifactorial syndrome characterized by a recurrent set of debilitating symptoms. The symptoms of this controversial disorder are reported to be induced by environmental chemicals at doses far below those usually harmful to most persons. They involve a large spectrum of organ systems and typically disappear when the environmental chemicals are removed. However, no clear link has emerged among self-reported MCS symptoms and widely accepted objective measures of physiological dysfunction, and no clear dose-response relationship between exposure and symptom reactions has been observed. In addition, the underlying etiology and pathogenic processes of the disorder remain unknown and disputed, although biologic and psychologic hypotheses abound. It is currently debated whether MCS should be considered a clinical entity at all. Nevertheless, in the last few decades MCS has received considerable scientific and governmental attention in light of the many persons reporting this illness. In this review, we provide a general overview of the history, definition, demographics, prevalence, and etiologic challenges in defining and understanding MCS.

A Coached Digital Cognitive Behavioral Intervention Reduces Anxiety and Depression in Adults With Functional Gastrointestinal Disorders

INTRODUCTION

Traditional cognitive behavioral interventions (CBIs) improve mood and gastrointestinal symptom severity in patients with functional gastrointestinal disorders (FGIDs) but face substantial barriers to implementation. Integrating behavioral health technology into medical clinic workflows could overcome these barriers. We evaluated the feasibility and impact of a coached digital CBI (dCBI) as a first-line intervention in a prospective cohort of emotionally distressed patients with FGID.

METHODS

Patients with anxiety and/or depressive symptoms were offered a dCBI (an app called RxWell) during routine clinic visits. RxWell provides cognitive behavioral techniques enhanced by within-app text messaging with a health coach. Both gastroenterology and behavioral health-care providers electronically prescribed RxWell. We tracked patient interactions with RxWell, and patients completed anxiety (General Anxiety Disorder-7) and depression (Personal Health Questionniare Depression Scale) measures through the app. Our primary study outcome was the change in General Anxiety Disorder-7 and Personal Health Questionniare Depression Scale scores.

RESULTS

Of 364 patients with FGID (mean age 43 years [SD 16 years]; 73.1% women) prescribed the dCBI, 48.4% enrolled (median use, 3 techniques [interquartile range 1-14]). About half of RxWell enrollees communicated with health coaches. The mean baseline anxiety score was 11.4 (SD 5.5), and the depression score was 11.5 (SD 6.1). RxWell users experienced improvements in anxiety (mean change 2.71 [t = 3.7, df = 58; P < 0.001]) and depression (mean change 2.9 [t = 4.2, df = 45; P < 0.001]) at 4 months.

DISCUSSION

Patients with FGIDs and moderately severe anxiety and depressive symptoms are willing to use dCBI tools recommended by their providers. Our pilot data demonstrate that dCBI usage is associated with clinically and statistically significant mood symptom reductions.

Group-based Acceptance and Commitment Therapy (AHEAD) for adolescents with multiple functional somatic syndromes: A randomised trial

Background

Evidence for treatment of adolescents with multiple functional somatic syndromes (FSS) is sparse. This study examined the efficacy of 'Acceptance and Commitment Therapy for Health in Adolescents' (AHEAD), a generic group-based treatment for adolescents with co-occurrence of multiple FSS.

Methods

A randomized trial was conducted at a specialized university hospital clinic. Adolescents (15-19 years) with multiple FSS of at least 1 year's duration were randomly assigned to AHEAD or enhanced usual care (EUC). AHEAD consisted of nine modules (i.e., 27 h) and one follow-up meeting. Primary outcome was physical health (SF-36). Various secondary outcomes and treatment targets were included (e.g., symptom severity, symptom impact, and illness perception). A linear mixed-effects model was used for analysis. Trial-registration: ClinicalTrials.gov NCT02346071.

Results

Ninety-one patients were included. At 12 months, no significant difference in physical health was identified between groups (mean adjusted difference 1.2 [95% CI -1.6 to 4.0], p = .404). However, different developments over time were seen with an interaction effect between intervention arm and time (χ2(5) = 14.1, p = .0148). AHEAD patients (n = 44) reported a clinically relevant improvement at end of treatment and at 8 and 12 months, while EUC patients (n = 47) displayed a clinically relevant improvement at 12 months. Furthermore, AHEAD patients showed a faster improvement on symptom severity, symptom impact and illness perception. EUC patients received more psychological treatment outside the trial (p ≤ .001) than AHEAD patients. Treatment satisfaction with AHEAD was high in contrast to EUC.

Conclusions

Compared with EUC, AHEAD had no additional advantage on the improvement of physical health at the primary endpoint of 12 months. However, a faster improvement of physical health was seen in AHEAD and considerably more psychological treatment was received outside the trial in EUC with clinically meaningful improvements in both groups. The results underpin the importance of an organised and systematic treatment offer for the most severely affected youth.

Insulin Resistance Is Associated with Multiple Chemical Sensitivity in a Danish Population-Based Study-DanFunD

Multiple chemical sensitivity (MCS) is a multisystem syndrome, and limited knowledge of its pathophysiology exists. Based on the population-based Danish cohort DanFunD, this study investigated metabolic health in people with MCS compared to individuals who did not have MCS. From 9656 cohort participants aged 18–76 years old, 1.95% were categorized as MCS individuals with comorbid functional somatic disorders (MCS +FSD, n = 188), and 1.13% were categorized as MCS without functional somatic disorders (MCS ÷FSD, n = 109). MCS was characterized based on three criteria: the experience of symptoms upon exposure to common odors and airborne chemicals, symptoms related the central nervous systems and others organ symptoms, and significant impact on every day, social, and occupational life. The remaining study population without MCS or any other functional somatic disorders were regarded as controls. We used adjusted multiple linear regression with link-function to evaluate the associations between lipid and glucose metabolism markers and MCS. We also tested the odds ratio of metabolic syndrome in MCS. Results did not point to statistically significant associations between lipid biomarkers or metabolic syndrome and both MCS groups compared to the controls. We found that MCS individuals may be more insulin resistant and that MCS ÷ FSD may have an impaired glucose metabolism when compared to controls.