Abnormal illness behaviour: physiological, psychological and social dimensions of coping with distress

A theoretical and clinical perspective of an embodied view in psychotherapy of somatic symptoms disorders

In this paper, we offer some ideas for the treatment of somatoform patients and related pathologies based on the concept of embodiment. Embodiment refers to the interplay between body and mind in behavior. The word refers to giving a body to something, "incarnate". Spinoza wrote extensively about the topic in the 17th century. In the 20th century, picking up on Spinoza's work, Damasio presented extensive and important neuro-scientific evidence that feelings can be direct perceptions of internal body states, substantiating the growing understanding of emotions and feelings as a core component of the embodied experience. Here, we summarize the evidence for the intersection of emotion and cognition in the body, which impinges on the effectiveness of using the body and movement in psychotherapy and the management of somatic symptoms and related disorders. We present evidence indicating that movement would be a way to reach unconscious processes dealing with body-mind interaction and body awareness.

Education on medically unexplained symptoms: a systematic review with a focus on cultural diversity and migrants

BACKGROUND

Health care providers often struggle with the management of patients with medically unexplained symptoms (MUS), especially in case of a different ethnicity and/or cultural background. These challenges are insufficiently addressed in their training.

OBJECTIVES

A systematic review on education in the field of MUS in a diverse context to improve MUS healthcare provider-patient interaction focused on intercultural communication.

METHODS

Screening of PubMed, Web of Science, Cinahl and Cochrane Library on the keywords 'Medical unexplained (physical) symptoms (MUS)', 'Somatoform disorder', 'Functional syndrome', 'Diversity', 'Migrants', 'Ethnicity', 'Care models', 'Medical education', 'Communication skills', 'Health literacy'.

RESULTS

MUS patients, especially with a different ethnic background, often feel not understood or neglected. Health care providers experience feelings of helplessness, which may provoke medical shopping and resource consumption. Attitudes and perceptions from undergraduate trainees to senior physicians tend to be negative, impacting on the quality of the patient/health care provider relationship and subsequently on health outcomes, patient satisfaction and therapeutic adherence. Current undergraduate, graduate and postgraduate education and training does not prepare health care providers for diagnosing and managing MUS patients in a diverse context. A continuum of training is necessary to achieve a long term and lasting change in attitudes towards these patients and trainers play a key role in this process. Hence, education should pay attention to MUS, requiring a specific competency profile and training, taken into account the variety in patients' cultural backgrounds.

CONCLUSIONS

This systematic review identified significant gaps and shortcomings in education on MUS in a diverse context. These need to be addressed to improve outcomes.

Epidemiology and organisation of care in medically unexplained symptoms: A systematic review with a focus on cultural diversity and migrants

BACKGROUND

Since the pathophysiology of medically unexplained symptoms (MUS) remains unclear, healthcare providers often struggle with these patients, especially with a different ethnic and/or cultural background. These challenges are insufficiently addressed in their training and in the organisation of care.

AIM

To improve healthcare provider-patient interaction focused on MUS patients in general and in ethnic minorities and refugees in particular through a systematic review of syndromal definitions and epidemiology and organisation of care of MUS patients.

METHODS

Screening of PubMed, Web of Science, Cinahl and Cochrane Library on the keywords 'Medical unexplained (physical) symptoms (MUPS)', 'Somatoform disorder', 'Functional syndrome', 'Diversity', 'Migrants', 'Ethnicity', 'Care models', 'Medical education', 'Communication skills', 'Health literacy'.

RESULTS

Different case definitions result in markedly different epidemiological estimates for MUS patients. Nevertheless, they are prevalent in a wide range of healthcare settings. Literature offers evidence of the effectiveness of structural frameworks in approaching MUS patients. Organisation of MUS care needs to transcend different levels of care: specialist tertiary and secondary care and primary care involving different qualifications of caregivers need to be aligned.

CONCLUSION

The systematic review identified significant gaps and shortcomings in organisation of care. These need to be addressed in order to improve outcomes.

Infertility as seen by the infertile couples from a collectivistic culture

Infertility in collectivistic cultures is usually regarded as a matter of social stigmatization instead of a biomedical problem. It has adverse sociocultural consequences, especially for the female spouse. The current study, by involving 20 infertile couples, was a qualitative research focusing on the sociocultural experiences of the infertile couples about the nature, causes, and consequences of infertility. The findings of the current study clearly depicted the sociocultural factors involved in interpreting infertility as a matter of shame and bad reputation for the couple and its family. The study has filled a significant knowledge gap and will be useful in identifying and addressing the cultural barriers in the treatment of infertility.

Contribution of individual psychological and psychosocial factors to symptom severity and time-to-recovery after naturally-occurring acute infective illness: The Dubbo Infection Outcomes Study (DIOS)

BACKGROUND

Substantial heterogeneity exists in both the severity of symptoms experienced as part of the sickness response to naturally-occurring infections, and the time taken for individuals to recover from these symptoms. Although contributing immunological and genetic factors have been previously been explored, less is known about the role of individual psychological and psychosocial factors, which may modulate the host immune response, or contribute independently, to symptom severity and duration.

METHODS

Longitudinally-collected data from 484 Caucasian participants (mean age: 33.5 years; 51% women) experiencing a naturally-occurring acute infective illness enrolled in the prospective Dubbo Infection Outcome Study (DIOS) were analysed. At intake and subsequent follow-up assessments, self-report questionnaires were used to ascertain individual psychological and psychosocial characteristics and symptom information. Principal component analysis was applied to symptom data to derive endophenotype severity scores representing discrete symptom domains (fatigue, mood, pain, neurocognitive difficulties) and an overall index of severity. The contribution of individual psychological (trait neuroticism, locus of control, and illness behaviours) and psychosocial factors (relative socioeconomic advantage) to endophenotype severity at baseline were examined using multivariable linear regression models; interval-censored flexible parametric proportional hazards survival models were used to explore time to recovery (defined using within-sample negative threshold values).

RESULTS

After controlling for time since symptom onset, greater levels of trait neuroticism consistently predicted greater symptom severity across all symptom domains (all p's < 0.015). Similarly, greater relative socioeconomic disadvantage was significantly associated with greater severity across all endophenotypes (p's < 0.025) except neurocognitive disturbance. Locus of control and illness behaviours contributed differentially across endophenotypes. Reduced likelihood of recovery was significantly predicted by greater initial symptom severity for all endophenotypes (all p's < 0.001), as well as higher levels of trait neuroticism.

CONCLUSIONS

Individual psychological and psychosocial factors contribute to the initial severity and to the prolonged course of symptoms after naturally-occurring infective illnesses. These factors may play an independent role, represent a bias in symptom reporting, or reflect increased stress responsivity and a heightened inflammatory response. Objective metrics for severity and recovery are required to further elucidate their roles.

Clinical and economic outcomes of remotely delivered cognitive behaviour therapy versus treatment as usual for repeat unscheduled care users with severe health anxiety: a multicentre randomised controlled trial

BACKGROUND

It is challenging to engage repeat users of unscheduled healthcare with severe health anxiety in psychological help and high service costs are incurred. We investigated whether clinical and economic outcomes were improved by offering remote cognitive behaviour therapy (RCBT) using videoconferencing or telephone compared to treatment as usual (TAU).

METHODS

A single-blind, parallel group, multicentre randomised controlled trial was undertaken in primary and general hospital care. Participants were aged ≥18 years with ≥2 unscheduled healthcare contacts within 12 months and scored >18 on the Health Anxiety Inventory. Randomisation to RCBT or TAU was stratified by site, with allocation conveyed to a trial administrator, research assessors masked to outcome. Data were collected at baseline, 3, 6, 9 and 12 months. The primary outcome was change in HAI score from baseline to six months on an intention-to-treat basis. Secondary outcomes were generalised anxiety, depression, physical symptoms, function and overall health. Health economics analysis was conducted from a health service and societal perspective.

RESULTS

Of the 524 patients who were referred and assessed for trial eligibility, 470 were eligible and 156 (33%) were recruited; 78 were randomised to TAU and 78 to RCBT. Compared to TAU, RCBT significantly reduced health anxiety at six months, maintained to 9 and 12 months (mean change difference HAI -2.81; 95% CI -5.11 to -0.50; P = 0.017). Generalised anxiety, depression and overall health was significantly improved at 12 months, but there was no significant change in physical symptoms or function. RCBT was strictly dominant with a net monetary benefit of £3,164 per participant at a willingness to pay threshold of £30,000. No treatment-related adverse events were reported in either group.

CONCLUSIONS

RCBT may reduce health anxiety, general anxiety and depression and improve overall health, with considerable reductions in health and informal care costs in repeat users of unscheduled care with severe health anxiety who have previously been difficult to engage in psychological treatment. RCBT may be an easy-to-implement intervention to improve clinical outcome and save costs in one group of repeat users of unscheduled care.

TRIAL REGISTRATION

The trial was registered at ClinicalTrials.gov on 19 Nov 2014 with reference number NCT02298036.

"A body in transformation"-An empirical phenomenological study about fear-avoidance beliefs towards physical activity among persons experiencing moderate-to-severe rheumatic pain

Aims and objectives

To gain a better understanding of fear‐avoidance beliefs towards physical activity and body awareness in people experiencing moderate‐to‐severe rheumatic pain.

Background

Rheumatoid arthritis and psoriatic arthritis are long‐term conditions with pain as the prominent symptom. Health‐promoting physical activity is recommended and can have an analgesic effect. High self‐rated pain has previously been reported to be associated with increased fear‐avoidance behaviour in relation to physical activity. Body awareness, which includes attentional focus and awareness of internal body sensations, could be valuable in the nursing care of long‐term diseases.

Design

Empirical phenomenological.

Methods

An empirical phenomenological psychological method was applied. The interviews took place between autumn 2016–spring 2017 with 11 informants (eight women and three men, age range 44–71 years) who were diagnosed with rheumatoid arthritis (n = 7) or psoriatic arthritis (n = 4), with a disease duration ranging from 3–35 years. The mean visual analogue scale score in the study sample was 60 mm.

Results

Three typologies were identified: “My relatively fragile physical status”, “I am an active creator” and “Part of something bigger than myself.”

Conclusions

The current findings indicated that pain anticipation and fear‐avoidance beliefs towards physical activity sometimes affected the behaviour of individuals with long‐term rheumatic pain syndromes. People experiencing moderate‐to‐severe rheumatic pain tended to focus on their fragile physical and emotional state. By adopting a more favourable attitude towards the self, the body could be restored to a state of calm and balance.

Relevance to clinical practice

The current findings are relevant for healthcare professionals engaged in health‐promotion clinical practice.

Psychological Symptom Amplification: Are Psychological Symptoms Subject to "Somatization"-Like Processes?

Many patients demonstrate amplified somatic symptom experiences that are felt by providers to cause excessive distress and functional impairment, and that can be diagnostically misleading. Terms attached to these presentations include somatization, medically unexplained symptoms, and, most recently, somatic symptom disorder. The analogous amplification of psychological symptoms has not been considered. Accordingly, this column makes a case for discussion and investigation of psychological symptom amplification (PSA), a process made possible by the medical legitimization of certain types of human suffering. As various forms of psychological suffering gain greater medical legitimacy, PSA becomes increasingly relevant. Circumstantial evidence suggests that unrecognized PSA may distort research findings and clinical efficacy in psychiatry. The largely symptom-based nature of psychiatric diagnosis makes PSA a challenging, but necessary, object of further scientific and clinical scrutiny.

Searching for existential security: a prospective qualitative study on the influence of mindfulness therapy on experienced stress and coping strategies among patients with somatoform disorders

OBJECTIVE

The aim was to explore how mindfulness group therapy for somatoform disorders influenced the patients' stress experiences, coping strategies and contextual psychosocial processes.

METHODS

A longitudinal pre- and post-treatment design, using 22 semi-structured individual pre- and post-treatment interviews. Data-analysis was based on a thematic methodology.

RESULTS

Pre-treatment patients were struggling in an existential crisis, feeling existentially insecure about their social identity, the causes, consequences and management of their illness; experiencing difficulties identifying and expressing stress-related cognitions, emotions and feelings, and low bodily and emotional self-contact; often leading to avoidant coping, making these individuals highly stress-vulnerable. Post-treatment, the overall change was conceptualized as increased existential security, defined by patients being more self-confident; more clarified with their social identity, the nature, management and future prospects of their illness; generally using more flexible coping strategies to reduce their daily stress experiences. Four related subthemes were identified contributing to increased existential security: 1) more secure illness perceptions - feeling existentially recognized as "really" ill, 2) enhanced relaxation ability - using mindfulness techniques, 3) increased awareness - connecting differently to mind and body 4) improved ability to identify and express needs and feelings of distress - more active communicating. Patients suggested that mindfulness therapy could be expanded with more time for group-discussions followed by additional individual therapy.

CONCLUSION

Generally, treatment positively influenced the patients' illness perceptions, stress-experiences, body- and self-awareness, coping strategies, self-image, social identity and social functioning. However, patients identified potentials for treatment improvements, and they needed further treatment to fully recover.

Trauma-related psychiatric comorbidity of somatization disorder among women in eastern Turkey

OBJECTIVE

This study sought to determine the trauma-related psychiatric comorbidity of somatization disorder among women who applied to an outpatient psychiatric unit of a general hospital in eastern Turkey.

METHODS

Forty women with somatization disorder and 40 non-clinical controls recruited from the same geographic region participated in the study. Somatization disorder and posttraumatic stress disorder (PTSD) sections of the Structured Clinical Interview for DSM-IV (including its criterion A traumatic events checklist), Dissociative Disorders Interview Schedule, Dissociative Experiences Scale (Taxon), Hamilton Depression Rating Scale, and Childhood Abuse and Neglect Questionnaire were administered to all participants.

RESULTS

A significant proportion of the women with somatization disorder had the concurrent diagnoses of major depression, PTSD, dissociative disorder, and borderline personality disorder. Women with somatization disorder reported traumatic experiences of childhood and/or adulthood more frequently than the comparison group. A significant proportion of these patients reported possession and/or paranormal experiences. Binary logistic regression analysis demonstrated that current major depression, being married, total number of traumatic events in adulthood, and reports of possession and/or paranormal experiences were independent risk factors for somatization disorder diagnosis.

CONCLUSIONS

Among women with endemically high exposition to traumatic stress, multiple somatic complaints were in a significant relationship with major depressive disorder and lifelong cumulative traumatization. While accompanying experiences of possession and paranormal phenomena may lead to seeking help by paramedical healers, the challenge of differential diagnosis may also limit effective service to this group of somatizing women with traumatic antecedents and related psychiatric comorbidities.

Body awareness in persons diagnosed with rheumatoid arthritis

Living with rheumatoid arthritis (RA) poses physiological and psychological demands on a person. RA is a autoimmune disease that can cause pain, disability, and suffering. The ability to notice bodily inner sensations and stimuli (body awareness, BA) is described in the literature in ways that could have either a positive or a negative impact on a person's health. The concept of BA is complex and a thorough understanding is needed about what BA means from the patient's perspective. This study was therefore conducted to acquire greater insight into this phenomenon. The study is grounded in a phenomenological life-world perspective. Eighteen narrative interviews were conducted in patients (age range 23-78 years) with RA. The interviews were analyzed using the Empirical Phenomenological Psychological method. General characteristics were found running through all 18 interviews, indicating that the disease resulted in a higher degree of negatively toned BA. BA was either a reactive process of searching or controlling after disease-related symptoms or a reactive process triggered by emotions. BA was an active process of taking an inventory of abilities. All participants had the ability to shift focus from BA to the outside world. Four typologies were identified: "A reactive process on symptoms," "A reactive process on emotional triggers," "An active process of taking an inventory of abilities," and "A shifting from BA to the outside world." In conclusion, because BA can be both positively and negatively toned, health care professionals must have a good understanding of when BA is positive and when it is negative in relation to the patient. RA had caused a higher degree of negatively toned BA. Thus, the ability to shift attention from BA to activity in the outside world could sometimes be beneficial for the patient's general health.

The relevance of the philosophical 'mind-body problem' for the status of psychosomatic medicine: a conceptual analysis of the biopsychosocial model

Psychosomatic medicine, with its prevailing biopsychosocial model, aims to integrate human and exact sciences with their divergent conceptual models. Therefore, its own conceptual foundations, which often remain implicit and unknown, may be critically relevant. We defend the thesis that choosing between different metaphysical views on the 'mind-body problem' may have important implications for the conceptual foundations of psychosomatic medicine, and therefore potentially also for its methods, scientific status and relationship with the scientific disciplines it aims to integrate: biomedical sciences (including neuroscience), psychology and social sciences. To make this point, we introduce three key positions in the philosophical 'mind-body' debate (emergentism, reductionism, and supervenience physicalism) and investigate their consequences for the conceptual basis of the biopsychosocial model in general and its 'psycho-biological' part ('mental causation') in particular. Despite the clinical merits of the biopsychosocial model, we submit that it is conceptually underdeveloped or even flawed, which may hamper its use as a proper scientific model.

Understanding psychopathology in migrants: a mixed categorical-dimensional approach

BACKGROUND

Literature on mental disorders in migrants is constantly increasing. Only a few studies describe psychopathological dimensions in migrants over their nosographic diagnoses; however, there is a growing literature about the greater utility of a categorical-dimensional approach, rather than a solely categorical approach, in the understanding of mental disorders. The aim of this paper is to describe the phenomenology of mental disorders in migrants referred to the Transcultural Psychiatric Team of Bologna (BoTPT), by analysing the psychopathological dimensions that underlie their clinical diagnoses.

METHODS

We recruited all migrants who attended the BoTPT between May 1999 and July 2009. The psychopathological assessment was conducted with the Association for Methodology and Documentation in Psychiatry (AMDP) and clinical diagnoses were formulated according to ICD-10. We proceeded through a two-step analysis: (1) comparing the prevalence rates of psychopathological symptoms across diagnoses; then (2) conducting a factor analysis to assess how those symptoms configure psychopathological dimensions and how these dimensions underlie clinical diagnoses.

RESULTS

As expected, we found significant associations between diagnoses and the prevalence of their core psychopathological symptoms. Factor analysis revealed a strong polymorphism of the psychopathological presentation of mental disorders and unexpectedly showed that in each diagnostic cluster, the first extracted factor was not composed of core symptoms.

CONCLUSIONS

A mixed categorical-dimensional approach seems to improve the description of the psychopathology among migrants, as it adds relevant information regarding psychopathological dimensions useful to the understanding of the peculiar clinical expressivity of our patients.

Social cognition and levels of personality organization in patients with somatoform disorders: a case-control study

Social cognition and its association with level of personality organization (PO) were examined in 163 patients with severe somatoform disorders (SFDs) and 151 psychiatric (PSA) control patients. Social cognition was measured with the Social Cognition and Object Relations Scale, which assessed both affective and cognitive facets of social cognition. Levels of PO were assessed using theory-driven profiles of the Dutch Short Form of the Minnesota Multiphasic Personality Inventory (MMPI). The SFD patients exhibited impairments in the cognitive facets of social cognition but not more so than the PSA controls. The results for the affective aspects indicated that the SFD patients exhibited lower levels of emotional investment yet higher affect tone in interactions than the PSA controls. In contrast to the control group, level of PO was not associated with social cognition in SFD. Together, the results indicated that impairments in complexity of mental representations are not specific to SFD patients, yet impairments in emotional investment may be specific to SFD.

Longing for existential recognition: a qualitative study of everyday concerns for people with somatoform disorders

OBJECTIVE

Patients with somatoform disorders could be vulnerable to stressors and have difficulties coping with stress. The aim was to explore what the patients experience as stressful and how they resolve stress in everyday life.

METHODS

A cross-sectional retrospective design using 24 semi-structured individual life history interviews. Data-analysis was based on grounded theory.

RESULTS

A major concern in patients was a longing for existential recognition. This influenced the patients' self-confidence, stress appraisals, symptom perceptions, and coping attitudes. Generally, patients had difficulties with self-confidence and self-recognition of bodily sensations, feelings, vulnerability, and needs, which negatively framed their attempts to obtain recognition in social interactions. Experiences of recognition appeared in three different modalities: 1) "existential misrecognition" covered the experience of being met with distrust and disrespect, 2) "uncertain existential recognition" covered experiences of unclear communication and a perception of not being totally recognized, and 3) "successful existential recognition" covered experiences of total respect and understanding. "Misrecognition" and "uncertain recognition" related to decreased self-confidence, avoidant coping behaviours, increased stress, and symptom appraisal; whereas "successful recognition" related to higher self-confidence, active coping behaviours, decreased stress, and symptom appraisal.

CONCLUSION

Different modalities of existential recognition influenced self-identity and social identity affecting patients' daily stress and symptom appraisals, self-confidence, self-recognition, and coping attitudes. Clinically it seems crucial to improve the patients' ability to communicate concerns, feelings, and needs in social interactions. Better communicative skills and more active coping could reduce the harm the patients experienced by not being recognized and increase the healing potential of successful recognition.

Construct validity and temporal stability of the abridged 31-item Illness Behaviour Questionnaire

OBJECTIVE

Key psychometric information was sought for three newly derived dimensions from an abridged Illness Behaviour Questionnaire (IBQ-31): Affirmation of Illness (AI), Concern for Health (CH) and General Affective State (GAS). The construct validity of these scales was examined along with their test-retest reliability and long-term stability.

DESIGN

A longitudinal, observational study was conducted with 675 participants (general community members and those with either asthma, diabetes and chronic pain or chronic fatigue syndrome) providing self-report questionnaire data at baseline, with additional information sought at three (n = 483; 71.6%) and 12 months (n = 517, 76.6%).

MAIN OUTCOME MEASURES

Construct validity of the IBQ-31 was explored using well-validated psychological measures of Symptom Attributions and Symptom Experience, Cognitive Distortion of Somatic Information and Illness Likelihood.

RESULTS

In general, AI, CH and GAS shared predictable empirical overlap with related psychological indices across the five samples. Adequate three-month test-retest reliability was evident, with greater score variability over 12 months.

CONCLUSION

The IBQ-31 comprises three theoretically relevant dimensions which demonstrate relative short- and long-term stability for individuals with diverse illness experiences. Future investigations should explore the predictive validity of AI, CH and GAS, along with the potential value of 'cut-off' scores for clinical use.

Exploring the relevance of autonomy and relatedness for mental health in healthy and depressed women from two different cultures: when does culture matter?

BACKGROUND

It is well known that the absence of both autonomy and social support (relatedness) are two important etiologic pathways to major depressive disorder (MDD). However, cross-cultural researchers state that the implications of autonomy and relatedness for mental health vary across cultures.

AIM

To test these assumptions, the current study investigated the relevance of autonomy and relatedness for mental health in healthy and depressed women from two different cultures (Germans and Turkish immigrants in Germany).

METHODS

One hundred and eight (108) women were evaluated for their levels of autonomy/relatedness satisfaction, for overall psychopathological complaints including depression, for affectivity and for perceived loneliness through self-report measures.

RESULTS

Among healthy groups, relatedness satisfaction predicted better mental health in Turkish women, whereas in German women, autonomy satisfaction was the better mental health predictor. Within depressed groups however, cultural differences in mental health outcomes regarding autonomy were no longer evident. Autonomy was associated with higher levels of mental health in Turkish as well as in German patients.

CONCLUSIONS

Our findings indicate that the relationship between autonomy and mental health is culture-specific in healthy women, but disappears in depressed women. These findings are discussed with consideration of clinical implications and an outlook regarding further research.

Measuring illness behavior in patients with systemic sclerosis

OBJECTIVE

Illness behaviors (cognitive, affective, and behavioral reactions) among individuals with systemic sclerosis (SSc; scleroderma) are of clinical concern due to relationships between these behaviors and physical and mental quality of life, such as pain and symptoms of depression. Self-report measures with good psychometric properties can aid in the accurate assessment of illness behavior. The Illness Behavior Questionnaire (IBQ) was designed to measure abnormal illness behaviors; however, despite its longstanding use, there is disagreement regarding its subscales. The goal of the present study was to evaluate the validity of the IBQ in a cohort of patients with SSc.

METHODS

Patients with SSc (n = 278) completed the IBQ at enrollment into the Genetics Versus Environment in Scleroderma Outcome Study. Structural validity of previously derived factor solutions was investigated using confirmatory factor analysis. Exploratory factor analysis was utilized to derive SSc-specific subscales.

RESULTS

None of the previously derived structural models were supported for SSc patients. Exploratory factor analysis supported an SSc-specific factor structure with 5 subscales. Validity analyses suggested that the subscales were generally independent of disease severity, but were correlated with other health outcomes (i.e., fatigue, pain, disability, social support, and mental health).

CONCLUSION

The proposed subscales are recommended for use in SSc, and can be utilized to capture illness behavior that may be of clinical concern.

Frequency shifts in the anterior default mode network and the salience network in chronic pain disorder

BACKGROUND

Recent functional imaging studies on chronic pain of various organic etiologies have shown significant alterations in both the spatial and the temporal dimensions of the functional connectivity of the human brain in its resting state. However, it remains unclear whether similar changes in intrinsic connectivity networks (ICNs) also occur in patients with chronic pain disorder, defined as persistent, medically unexplained pain.

METHODS

We compared 21 patients who suffered from chronic pain disorder with 19 age- and gender-matched controls using 3T-fMRI. All neuroimaging data were analyzed using both independent component analysis (ICA) and power spectra analysis.

RESULTS

In patients suffering from chronic pain disorder, the fronto-insular 'salience' network (FIN) and the anterior default mode network (aDMN) predominantly oscillated at higher frequencies (0.20 - 0.24 Hz), whereas no significant differences were observed in the posterior DMN (pDMN) and the sensorimotor network (SMN).

CONCLUSIONS

Our results indicate that chronic pain disorder may be a self-sustaining and endogenous mental process that affects temporal organization in terms of a frequency shift in the rhythmical dynamics of cortical networks associated with emotional homeostasis and introspection.

Somatic symptom disorders and illness behaviour: current perspectives

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

Somatization and somatic symptom presentation in cancer: a neglected area

Abstract The recognition of somatization process in cancer patients is a challenging and neglected area, for the extreme difficulty in differentiating and assessing the psycho(patho)logical components from those biologically determined and related to cancer and cancer treatment, as well as for the scarce usefulness of rigid categorical DSM criteria. However, several dimensions of somatization (and the interconnected concept of abnormal illness behaviour) have been shown to be diagnosable in cancer patients and to negatively influence coping and quality of life outcomes. An integration of the formal DSM-ICD nosology with a system specifically taking into account the patients' emotional responses to cancer and cancer treatment, such as the Diagnostic Criteria for Psychosomatic Research (DCPR), is suggested. More data on some specific symptom dimensions, including pain, fatigue and sexual disorders, are needed to examine their possible psychological components. More research is also needed regarding the association of somatization with personality traits (e.g. type D distressed personality, alexithymia), developmental dimensions (e.g. attachment), and cultural issues (e.g. culturally mediated attributional styles to somatic symptoms). Also, the impact and effectiveness of specific therapeutic intervention in 'somatizing' cancer patients is necessary.

The influence of stigma on depression, overall psychological distress, and somatization among female Turkish migrants

BACKGROUND

Even though some studies suggest that in Mediterranean and non-western cultures more somatic and less psychological symptoms are reported, this so-called 'somatization' hypothesis has been challenged. Reviews show that somatic symptoms are a core component of depressive episodes regardless of cultural background. The expression of symptoms might be related to the psychosocial, social and cultural context surrounding the patient rather than 'ethnicity' or related constructs. Also, stigma associated with mental disorders can affect patients'symptom presentation.

METHODS

The interrelationships of perceived stigmatization (Explanatory Model Interview Catalogue - Stigma Scale), depression (Beck Depression Index II), overall psychological distress (Symptom Checklist-90-R), and somatic symptoms (The screening for SOMATOFORM SYMPTOMS II) was assessed in a sample of female patients with Turkish descent with a diagnosis of depression (N=63).

RESULTS

Depression, overall psychological distress, and somatic symptoms were positively and significantly related. Stigma was positively related to depression and overall psychological distress. There was no significant relationship between stigma and somatic symptoms, neither among the severely depressed group (N=39), nor among the less depressed group (N=24).

CONCLUSION

The positive relationships between stigma, depression, and overall psychological distress indicate that patients who are more depressed and who have higher levels of overall psychological distress experience their condition as more stigmatizing. Since somatic symptoms and stigma were not related (neither positively, nor negatively), it appears that depressive symptoms and other symptoms of psychological distress affect concerns about stigmatizing attitudes in a way that somatic symptoms do not. This result challenges common assumption of the 'somatization'hypothesis, i.e. that depression is 'somatized'because of concern about stigmatizing attitudes.

Medically unexplained illness and the diagnosis of hysterical conversion reaction (HCR) in women's medicine wards of Bangladeshi hospitals: a record review and qualitative study

BACKGROUND

Frequent reporting of cases of hysterical conversion reaction (HCR) among hospitalized female medical patients in Bangladesh's public hospital system led us to explore the prevalence of "HCR" diagnoses within hospitals and the manner in which physicians identify, manage, and perceive patients whom they diagnose with HCR.

METHODS

We reviewed admission records from women's general medicine wards in two public hospitals to determine how often and at what point during hospitalization patients received diagnoses of HCR. We also interviewed 13 physicians about their practices and perceptions related to HCR.

RESULTS

Of 2520 women admitted to the selected wards in 2008, 6% received diagnoses of HCR. HCR patients had wide-ranging symptoms including respiratory distress, headaches, chest pain, convulsions, and abdominal complaints. Most doctors diagnosed HCR in patients who had any medically-unexplained physical symptom. According to physician reports, women admitted to medical wards for HCR received brief diagnostic evaluations and initial treatment with short-acting tranquilizers or placebo agents. Some were referred to outpatient psychiatric treatment. Physicians reported that repeated admissions for HCR were common. Physicians noted various social factors associated with HCR, and they described failures of the current system to meet psychosocial needs of HCR patients.

CONCLUSIONS

In these hospital settings, physicians assign HCR diagnoses frequently and based on vague criteria. We recommend providing education to increase general physicians' awareness, skill, and comfort level when encountering somatization and other common psychiatric issues. Given limited diagnostic capacity for all patients, we raise concern that when HCR is used as a "wastebasket" diagnosis for unexplained symptoms, patients with treatable medical conditions may go unrecognized. We also advocate introducing non-physician hospital personnel to address psychosocial needs of HCR patients, assist with triage in a system where both medical inpatient beds and psychiatric services are scarce commodities, and help ensure appropriate follow up.

Catastrophising and normalising in patient's accounts of their seizure experiences

PURPOSE

To extend our previous research demonstrating that linguistic/interactional features in patients' talk can assist the challenging differential diagnosis of epilepsy and psychogenic nonepileptic seizures (PNES) by exploring the differential diagnostic potential of references to non co-present persons (third parties).

METHOD

Initial encounters were recorded between 20 seizure patients (13 with PNES, seven with epilepsy) who were subsequently diagnosed by the recording of typical seizures with video-EEG. An analyst blinded to the medical diagnoses coded and analysed transcripts.

RESULTS

There were no significant differences between the two diagnostic groups in terms of the total number of third party references or references made spontaneously by patients without prompting from the doctor. However, patients with PNES made significantly more prompted references to third parties (p=0.022). 'Castrophising' third party references were made in 12/13 (92.3%) of encounters with PNES patients and 1/7 (14.3%) of encounters with epilepsy patients (p=0.001, OR 72, 95% CI=3.8-1361.9). Normalising references were identified in 2/13 (15.4%) of encounters in the PNES and 6/7 (85.7%) of encounters in the epilepsy groups (p=0.004, OR 33, 95% CI=2.5-443.6).

CONCLUSION

There are significant differences in how patients with epilepsy or patients with PNES refer to third parties. Patients with PNES are more likely to be prompted to tell doctors what others have told them about their seizures. Patients using third party references to catastrophise their seizure experiences are more likely to have PNES, whilst patients who use third party references to normalise their life with seizures are more likely to have epilepsy.

[Etiopathogenetic aspects of somatoform disorders]

The etiopathology of somatoform disorders can only be understood against the background of an integrated biopsychosocial model. Cultural and historical influences must be taken into account as well as contemporary settings of scientific or medical priorities. In this context the emphasis on neurobiological findings can be interpreted as the non-accidental struggle for legitimacy of both patients and physicians. Altogether the available data on factors influencing the formation and maintenance of somatoform symptoms has to be described as both diverse and unspecific and thus points to a challenging research program in the coming years.

Patient anxiety and concern as predictors for the perceived quality of treatment and patient reported outcome (PRO) in orthopaedic surgery

BACKGROUND

Previous studies have shown that patients' anxiety and dissatisfaction are predictors for increased postoperative pain and reduced efficacy of pain treatment. However, it remains to be shown whether patient anxiety and concern are predictors for the perceived quality of treatment and patient reported outcome (PRO).The aim of this study is to investigate whether there is a correlation between preoperative anxiety and concern, and the perceived quality of postoperative treatment and outcome. The hypothesis is that anxious and concerned patients are less satisfied with treatment and have a poorer outcome.

METHODS/DESIGN

This study is designed as a prospective follow-up study and has the aim of investigating the correlation between patient anxiety and concern, patients' perceived quality of treatment and outcome. This correlation will be detected using five questionnaires: CMD-SQ (Common Mental Disorders Screening Questionnaire), EuroQol 5 Dimensions (EQ-5D), Short form 12 (SF-12), "What is your evaluation of the patient progress in the Department of Orthopaedic Surgery?" (HVOK), Questionnaire for patients who have had hip surgery (RCS) and Oxford Hip Score (OHS) or Oxford Shoulder Score (OSS). The patients will complete the above mentioned questionnaires preoperatively in the outpatient department, and postoperatively just before discharge from the inpatient department, and 12 and 52 weeks after the operation. The study includes a reliability test of CMD-SQ regarding this specific population and tested by means of a Kappa. A total of 500 hip- and shoulder-patients will be included from October 2010 till October 2011.

DISCUSSION

If a correlation between patient anxiety and concern, patients' perceived quality of treatment and patient reported outcome is found, it will be recommended to screen all hip- and shoulder-patients for anxiety and concern preoperatively. Besides, it would be relevant to carry out investigations of possible interventions towards anxious and concerned patients.

TRIAL REGISTRATION

Current Controlled Trials: NCT01205295.

Abuse history, depression, and somatization are associated with gastric sensitivity and gastric emptying in functional dyspepsia

OBJECTIVE

Gastric sensitivity testing relies on subjective reporting and may therefore be influenced by psychosocial factors and somatization. Furthermore, psychological processes may affect gastric motor function (accommodation to a meal emptying) through efferent brain-gut pathways. This study sought to determine the association of abuse history, psychiatric comorbidity, and somatization with gastric sensorimotor function.

METHODS

In 201 patients with functional dyspepsia, gastric sensitivity and accommodation were studied with a barostat. Gastric emptying of solids was studied using a breath test. Sexual and physical abuse history, psychiatric comorbidity (depression and panic disorder), and somatization were assessed using validated questionnaires. Multiple linear regression models were used to identify patient characteristics independently associated with gastric sensitivity and emptying.

RESULTS

Age (p = .02), sexual abuse history (p < .001), physical abuse history (p = .004), and somatization (p < .001) were independently associated with gastric discomfort threshold (R(2) = 0.30); a significant depression-by-sexual abuse interaction effect was also found (p = .003). None of the factors studied were associated with gastric accommodation to a meal. Physical abuse history (p = .003) and somatization (p = .048) were independently associated with gastric emptying (R(2) = 0.19).

CONCLUSIONS

These results demonstrate the complex relationship among abuse history, psychiatric comorbidity, somatization, and gastric sensorimotor (dys)function. Although the psychobiological mechanisms underlying these relationships remain to be determined, the autonomic nervous, stress hormone, and immune systems may be involved.

Pain and disability related to osteoarthrosis of the trapeziometacarpal joint

We investigated the relationship between trapeziometacarpal arthrosis, pain, and upper extremity specific disability by surveying patients from a prior prevalence study. The 456 adult (age 18 or greater) patients from a prior prevalence study were mailed a questionnaire consisting of the full DASH outcome measure as well as additional questions to identify sources of pain other than the thumb, pain in the thumb and whether the patient has received treatment for thumb arthritis. A response rate of 27% was achieved (122 responses). Thumb pain correlated with pain elsewhere in the arm (r = 0.354, p < 0.001), but not with higher grades of arthrosis. The average DASH score was 9.9 [range 0-60.0]. Higher grades of arthrosis (p = 0.013), pain in the thumb (r = 0.602, p < 0.001) and pain elsewhere in the arm (r = 0.665, p < 0.001) were found to be predictors of a higher DASH score. Arthrosis grade explained only 3% of the variation of DASH scores in linear regression modeling, but was included in the best multivariable model-along with thumb pain and pain elsewhere in the arm-which explained 52% of the variation in DASH scores. Higher grades of trapeziometacarpal arthrosis do not correlate with complaints of thumb pain and have a significant, but very limited affect on arm-specific disability, compared to pain elsewhere in the arm.

The role of temperament in somatic complaints among young female adults

We examined a temperament-driven construct in relation to broad patterns of somatic behavior among young females (N = 215, 18-23 years). A multidimensional construct, socio-affective vigilance (SAV), encompassing affective, behavioral, and cognitive traits, along with sensitivity to sensory stimuli (low threshold), were used as predictors. SAV positively predicted somatic behavior and a low sensory threshold was associated with somatic complaints over and above SAV effects. A multidimensional construct, coupled with a low threshold, could underlie a vulnerability to somatization. These findings create a more comprehensive view of the temperament-somatization link by predicting a pattern of somatic behavior rather than individual symptom complaints.

Towards positive diagnostic criteria: a systematic review of somatoform disorder diagnoses and suggestions for future classification

OBJECTIVES

The classification of somatoform disorders is currently being revised in order to improve its validity for the DSM-V and ICD-11. In this article, we compare the validity and clinical utility of current and several new diagnostic proposals of those somatoform disorders that focus on medically unexplained somatic symptoms.

METHODS

We searched the Medline, PsycInfo, and Cochrane databases, as well as relevant reference lists. We included review papers and original articles on the subject of somatoform classification in general, subtypes of validity of the diagnoses, or single diagnostic criteria.

RESULTS

Of all diagnostic proposals, only complex somatic symptom disorder and the Conceptual Issues in Somatoform and Similar Disorders (CISSD) example criteria reflect all dimensions of current biopsychosocial models of somatization (construct validity) and go beyond somatic symptom counts by including psychological and behavioral symptoms that are specific to somatization (descriptive validity). Predictive validity of most of the diagnostic proposals has not yet been investigated. However, the number of somatic symptoms has been found to be a strong predictor of disability. Some evidence indicates that psychological symptoms can predict disease course and treatment outcome (e.g., therapeutic modification of catastrophizing is associated with positive outcome). Lengthy symptom lists, the requirement of lifetime symptom report (as in abridged somatization), complicated symptom patterns (as in current somatization disorder), and imprecise definitions of diagnostic procedures (e.g., missing symptom threshold in complex somatic symptom disorder) reduce clinical utility.

CONCLUSION

Results from the reviewed studies suggest that, of all current and new diagnostic suggestions, complex somatic symptom disorder and the CISSD definition appear to have advantages regarding validity and clinical utility. The integration of psychological and behavioral criteria could enhance construct and descriptive validity, and confers prospectively relevant treatment implications. The incorporation of a dimensional approach that reflects both somatic and psychological symptom severity also has the potential to improve predictive validity and clinical utility.

Body image and self-esteem in somatizing patients

AIM

The aim of the present study was to determine dissatisfaction with body appearance and bodily functions and to assess self-esteem in somatizing patients.

METHODS

Body image and self-esteem were investigated in 128 women; 34 of those had diagnosed somatoform disorders, 50 were breast cancer patients with total mastectomy surgery alone, and 44 were healthy subjects. Body image and self-esteem were assessed using the Body Cathexis Scale and Rosenberg Self-Esteem Scale.

RESULTS

The two clinical groups did not differ from one another (z = -1.832, P = 0.067), but differed from healthy controls in terms of body image (somatizing patients vs healthy controls, z = -3.628, P < 0.001; total mastectomy patients vs healthy controls, z = -3.172, P = 0.002). They also did not differ significantly in terms of self-esteem (z = -0.936, P = 0.349) when depressive symptoms were controlled. No statistically significant difference was observed between total mastectomy patients and healthy controls in terms of self-esteem (z = -1.727, P = 0.084). The lower levels of self-esteem in somatizing patients were largely mediated by depressive symptoms. Depressed and non-depressed somatizing patients differed significantly from healthy controls with respect to their self-esteem and body image.

CONCLUSIONS

Somatizing patients who were dissatisfied with their bodily functions and appearance had lower levels of self-esteem and high comorbidity of depression. In clinical practice it is suggested that clinicians should take into account psychiatric comorbidity, self-esteem, and body image in somatizing patients when planning treatment approaches.

Body awareness: construct and self-report measures

Objectives

Heightened body awareness can be adaptive and maladaptive. Improving body awareness has been suggested as an approach for treating patients with conditions such as chronic pain, obesity and post-traumatic stress disorder. We assessed the psychometric quality of selected self-report measures and examined their items for underlying definitions of the construct.

Data sources

PubMed, PsychINFO, HaPI, Embase, Digital Dissertations Database.

Review methods

Abstracts were screened; potentially relevant instruments were obtained and systematically reviewed. Instruments were excluded if they exclusively measured anxiety, covered emotions without related physical sensations, used observer ratings only, or were unobtainable. We restricted our study to the proprioceptive and interoceptive channels of body awareness. The psychometric properties of each scale were rated using a structured evaluation according to the method of McDowell. Following a working definition of the multi-dimensional construct, an inter-disciplinary team systematically examined the items of existing body awareness instruments, identified the dimensions queried and used an iterative qualitative process to refine the dimensions of the construct.

Results

From 1,825 abstracts, 39 instruments were screened. 12 were included for psychometric evaluation. Only two were rated as high standard for reliability, four for validity. Four domains of body awareness with 11 sub-domains emerged. Neither a single nor a compilation of several instruments covered all dimensions. Key domains that might potentially differentiate adaptive and maladaptive aspects of body awareness were missing in the reviewed instruments.

Conclusion

Existing self-report instruments do not address important domains of the construct of body awareness, are unable to discern between adaptive and maladaptive aspects of body awareness, or exhibit other psychometric limitations. Restricting the construct to its proprio- and interoceptive channels, we explore the current understanding of the multi-dimensional construct and suggest next steps for further research.

The relationship of pain catastrophizing to heightened feelings of distress

This study examined pain catastrophizing in individuals experiencing chronic pain conditions. Total score on the Pain Catastrophizing Scale (PCS) was examined, along with its relationship to several clinical scales of the Minnesota Multiphasic Inventory-Second Edition to answer the question of which scale would have the strongest relationship with total score on the PCS. These three scales have been most commonly implicated in chronic pain conditions. Overall results supported the importance of pain catastrophizing in helping to create heightened feelings of distress. Individuals higher in catastrophizing tend to experience increased pain, distress, anxiety, and depression with lower levels of functioning. A quick measure of catastrophizing is supported that will allow the professional more knowledge of the role of pain in the individual's condition and how pain-related thoughts may modify their quality of life.

The measurement of abnormal illness behavior: toward a new research agenda for the Illness Behavior Questionnaire

Abnormal illness behavior (AIB) refers to a maladaptive manner of experiencing, evaluating, or acting in response to health and illness that is disproportionate to evident pathology. The construct was originally informed by the sociological notions of the sick role and illness behavior. The present article provides a comprehensive review of the conceptual and empirical development of AIB with a detailed insight into the variety of illness contexts to which it has been applied using the Illness Behavior Questionnaire (IBQ). While the relevance of AIB continues to be demonstrated within the prescribed contexts of the chronic pain and psychiatric literatures, criticisms of AIB and its measurement have arisen when researchers have attempted to move beyond these contexts. In recognition of these criticisms, this article presents a new research agenda to address key limitations that currently impede the broader development and application of AIB. Most importantly, it is proposed that greater consideration needs to be given to the definition of AIB according to type of illness and for general community members without a current illness. The article concludes with comment on the potential practical implications of any future reconceptualization of AIB, including the need to reconsider the manner in which IBQ scores are derived and interpreted, and the need for caution when applying the label "abnormal" in specific illness contexts.

Impact of physical symptoms on perceived health in the community

OBJECTIVE

Physical symptoms, such as musculoskeletal pain, dizziness, or headache, are common. People with more symptoms are reported to use more healthcare and have higher sickness absenteeism. We studied the impact of the number of symptoms on perceived health in a community sample.

METHODS

Between June 2005 and March 2006, a random sample of 4741 adults was selected from the records of five general practices in The Netherlands. They were sent a questionnaire regarding the frequency and impact of physical symptoms, and other factors that may influence health (potential confounders or modifiers), including lifestyle factors, childhood illness experiences, and psychological factors. We studied the association between increasing number of physical symptoms and perceived health using the SF-36 as the outcome measure.

RESULTS

Response rate was 53.5% (n=2447). Fatigue was the most commonly reported symptom with a prevalence of 57%, followed by headache (40%) and back pain (39%). More than half of responders reported three symptoms or more. Responders with multiple symptoms were more often female, had lower educational level, less often paid work, higher body mass index, more negative childhood health experiences, and higher scores for anxiety and depression. Multiple symptoms were strongly associated with perceived health, especially among responders with negative illness perceptions, more anxiety, or those reporting family members with a chronic illness during childhood.

CONCLUSION

Physical symptoms are common and often seem to be mild. However, increasing number of symptoms is strongly associated with poorer physical, emotional, and social functioning. Different somatization processes may explain our findings.

Cultural models and somatic syndromes

OBJECTIVES

To review the relevance of cultural models in the generation and amplification of somatic symptoms and syndromes.

METHODS

Based on a selective review of literature, we examine evidence that cultural and personal explanatory models can contribute to the pathogenesis, symptomatology, and chronicity of medically unexplained symptoms and functional somatic syndromes.

RESULTS

In the contemporary world, culture involves flows of information, roles, and institutions that offer individuals multiple models for understanding illness. Cultural models include 1) explanatory models, which make causal attributions and impute specific mechanisms or processes of pathophysiology; 2) prototypes, which are salient images or exemplars drawn from personal experience, family, friends, mass media, and popular culture that are used to reason analogically about one's own condition; and 3) implicit models and procedural knowledge that may be difficult to articulate because they are embedded in body practices and ways of experiencing distress. Symptom attributions and explanations can participate in vicious circles of symptom amplification that give rise to culture-specific varieties of panic disorder, hypochondriacal worry, and medically unexplained symptoms.

CONCLUSIONS

Clinical research using the methods of experimental cognitive and social psychology as well as community-based ethnographic and ecological research are needed to advance our understanding of the impact of personal and cultural models on somatic distress. Nevertheless, the current state of knowledge on social and cultural dimensions of somatic syndromes suggests a typology of forms of psychosomatic and sociosomatic looping that has implications for the nosology of somatoform disorders.

With an attack I associate it more with going into hospital: understandings of asthma and psychosocial stressors; are they related to use of services?

Asthma is still a major cause of morbidity and mortality. Patients who use hospital services frequently tend to have more severe asthma and lack formal support. Attitudes to self-management also tend to differ and qualitative studies of frequent attenders have identified differing views of the appropriateness of service use between patients and their physicians. We undertook a qualitative study of patients with severe asthma admitted and not admitted to hospital in a 12-month period in the UK. The aim of the study was to investigate the relationship between perception of life events, psychosocial factors, coping and asthma admission in these two groups of patients. We interviewed 50 patients (aged 16 and over) admitted to two large teaching hospitals in London with asthma exacerbations, 25 patients with similar levels of asthma severity (step 3 or higher of the British Thoracic Society guidelines) sampled in General Practice and 19 general practitioners (GPs). Data were analysed using an adapted framework analysis. Patients admitted to hospital reported high levels of psychosocial problems and life events but tended to make few connections between these and their asthma attacks or their ability to manage their asthma. Patients reporting frequent hospital use tended to value professionals working in hospitals while reporting poor relationships with GPs; views that appeared related to delays in seeking help from primary care. Among GPs, knowledge of patients having attended hospital was generally poor, although they appeared more aware of those who were high users of General Practice (whether they were high attenders at hospital or not). GPs perceived stressful life events in patients with asthma to compound existing dispositions and be related to poor control and poor adherence. These findings suggest that vulnerable patient groups often face poor material circumstances and chaotic lives, impacting on their capacity to manage their illness and on their ability to derive benefit from primary care. Policy interventions aimed at reducing 'unnecessary' admissions will need to be tailored to the psychosocial circumstances and health beliefs of vulnerable patient groups.

Conflict, collusion or collaboration in consultations about medically unexplained symptoms: the need for a curriculum of medical explanation

OBJECTIVE

To identify the basis of the communication problems that characterise consultations about medically unexplained symptoms (MUS) and to identify implications for clinical education.

METHOD

Recent research into the details of clinical communication about MUS was reviewed narratively and critically, and broader research literature was scrutinised from the perspective of a practitioner who wishes to provide patients with explanations for such symptoms.

RESULTS

Consultations about MUS often involve contest between patients' authority, resting on their knowledge of their symptoms, and practitioners' authority, based on the normal findings of tests and investigations. The outcome of consultations can therefore depend on the strategies that each party uses to press their authority, rather than on clinical need.

CONCLUSION

Contest is a product of patients and practitioners occupying separate conceptual 'ground'. Avoiding contest requires the practitioner to find common conceptual ground within which each party can understand and discuss the symptoms. Finding common ground by collusion with explanations that patients suggest can damage clinical relationships. Instead the practitioner needs to fashion explanation that is acceptable to both parties from available medical and lay material.

PRACTICE IMPLICATIONS

Although practitioners commonly fashion such explanations, this aspect of their professional role seems not to be greatly valued amongst practitioners or in medical curricula. Clinical education programmes could include curricula in symptom explanation, drawing from research in medicine, psychology and anthropology.

The relationship between chronic fatigue and somatization syndrome: a general population survey

OBJECTIVE

The objective of this study was to assess the prevalence of chronic fatigue (CF) and its association with somatization syndrome [Somatization Syndrome Index (SSI) 4/6: >/=4 somatoform symptoms in men, 6 in women] in the general population.

METHODS

A representative sample of the German population (N=2412) completed a fatigue questionnaire and a screening instrument for current somatoform symptoms (Screening for Somatoform Symptoms 7).

RESULTS

The prevalence rate of CF was 6.1% (n=147). Females were affected significantly more often as compared with males (7% vs. 5.1%). The mean number of somatoform symptoms was higher in CF cases than in control subjects without CF (11 vs. 2; P<.001). Seventy-two percent of the subjects with CF fulfilled the SSI4/6 criterion for somatization syndrome. Quality of life (EUROHIS-QOL and 8-item Short-Form Health Survey) and well-being (5-item WHO Well-Being Index) were markedly decreased in CF and SSI4/6. The results of regression analyses suggest that fatigue and somatization severity had a similar impact on quality of life.

CONCLUSIONS

The results suggest that CF is relevant in the general population. Its substantial overlap with somatization syndrome supports the hypothesis that the two syndromes are only partially different manifestations of the same underlying processes.

Dysfunctional cognitions in idiopathic environmental intolerances (IEI)—An integrative psychiatric perspective

Idiopathic environmental intolerances (IEI) - formerly multiple chemical sensitivities (MCS) - are characterized by diffuse symptoms reported after exposure to low doses of everyday chemicals. Previous theories about the origin of IEI have emphasized either biological or psychological factors, neglecting a probable interplay. Many have suggested classifying IEI as a somatoform or an anxiety disorder, irrespective of some incongruities. By focusing on dysfunctional cognitions we discuss obvious parallels of IEI with somatoform disorders, and also indicate overlaps with anxiety and delusional disorders. To propose a hypothetical psycho-neurobiological basis of IEI, recent evidence about cortically represented symptoms in the absence of peripheral stimuli is briefly summarized. We conclude that IEI can serve as an illustrative example for the impact of cognitive, representational processes in symptom generation.