Psychobehavioral predictors of somatoform disorders in patients with suspected allergies

Impact of Patient-Reported Allergies on Early Postoperative Opioid Use and Outcomes Following Ambulatory Hand Surgery

Background: Patient-reported allergies (PRAs) are associated with suboptimal orthopaedic surgery outcomes and may serve as a proxy for mental health. While mental health disorders are known risk factors for increased opioid use, less is known about how PRAs impact opioid use after orthopedic surgery. The purpose of this study was to investigate the association between PRAs and postoperative opioid use, pain, and satisfaction following hand surgery. Methods: Patients who underwent ambulatory hand surgery at a single institution from May 2017 to March 2019 were retrospectively reviewed. Various scores, including the Mindfulness Attention Awareness Scale (MAAS), were collected preoperatively. Postoperatively, patients completed a 2-week pain diary, satisfaction, and visual analog scale (VAS) pain scores. Opioid consumption was converted to oral morphine equivalents (OMEs) using standard conversions. Results: A total of 137 patients were divided into 2 groups based on presence (≥1) (n = 73) or absence (0) (n = 64) of PRAs. At baseline, the ≥ 1 PRA group had significantly higher female composition (P < .001) and pain (P < .001) and lower PROMIS mental health scores (P = .044). Postoperative OME consumption averaged 42.5 (range 0-416) in the entire cohort, with no differences between groups. Among patients with ≥ 1 PRA, increasing number of allergies significantly correlated with increasing OME consumption across all time points (week 1, P = .016; week 2, P = .001; total, P = .005). Conclusions: The presence of PRAs did not impact postoperative narcotic usage, pain, or satisfaction. Increasing numbers of PRAs did, however, significantly correlate with higher narcotic use. These results may have implications for postoperative pain management in this population.

The predictive value of self-reported allergies for reoperation after index hip arthroscopy

The purpose of this study is to compare the rate of reoperation after index hip arthroscopy for symptomatic femoroacetabular impingement in patients with, and without, at least one self-reported allergy. Data were collected prospectively in 1468 patients whose records were retrospectively reviewed. After the application of inclusion and exclusion criteria, two cohorts were formed: (i) a study cohort (n = 261) composed of patients with a self-reported allergy and (ii) a control cohort. (n = 666). The allergy cohort had a significantly larger [P < 0.001] reoperation rate (24.1% [63/261]) compared to the control cohort (9.6% [64/66]). Univariate analysis (UVA) and multivariate analysis (MVA) were then performed to better understand the implications of allergy status on the arthroscopic outcome. On UVA the presence of an allergy increased the odds of reoperation after index hip arthroscopy by 2.99 [OR (95% CI): 2.99 (2.04, 4.39); P < 0.001] and for each additional allergy a patient reported, their odds of subsequent surgery increased by 1.27 per allergy [OR (95% CI): 1.27 (1.15, 1.39); P < 0.001]. However, on the MVA, allergy status was not an independent risk factor for reoperation. These findings suggest that allergy status is associated with a higher reoperation rate, however, allergy status alone cannot prognosticate the risk of subsequent surgery. Therefore, allergy status and its association with future surgery after hip arthroscopy should be considered in the context of multiple patient-specific factors that influence the surgical outcome. An understanding of this association enables patient-centered care and will strengthen the physician–patient relationship.

Patient-reported drug and latex allergies negatively affect outcomes after total and reverse shoulder arthroplasty

BACKGROUND

Patient-reported allergies (PRAs) have been identified as a risk factor for worse outcomes and less satisfaction in patients undergoing knee and hip arthroplasty. Similar associations have not been elucidated in shoulder arthroplasty patients; however, previous research is sparse. The purpose of this study was to assess the outcomes following shoulder arthroplasty surgery with respect to patient-reported drug allergies. It was hypothesized that a higher number of allergies would be associated with worse patient-reported outcomes (PROs) following shoulder arthroplasty surgery.

METHODS

Consecutive patients aged 18-89 years at the time of surgery who underwent primary shoulder arthroplasty between October 2005 and March 2018 performed by a single surgeon and had a minimum follow-up period of 1 year were reviewed. PRO scores, including the American Shoulder and Elbow Surgeons score, Single Assessment Numerical Evaluation score, QuickDASH (short version of Disabilities of the Arm, Shoulder and Hand questionnaire) score, and 12-Item Short Form Health Survey Physical Component Summary and Mental Component Summary scores, as well as patient satisfaction, were collected preoperatively and postoperatively. Early clinical failures were reported. Subjects were categorized into a 3-level factor based on the number of PRAs (0, 1, or ≥2), and bivariate comparisons of mean postoperative PRO scores were performed using Kruskal-Wallis analyses. Additionally, multivariate regression was performed to assess the effect of PRAs on PROs while controlling for age, sex, arthroplasty type, baseline PRO scores, and Charlson Comorbidity Index.

RESULTS

Overall, 411 shoulders were included in the final study population (367 patients, 44 of whom were treated bilaterally). The population was predominately male patients (n = 265, 64.5%), and the median age at the time of surgery was 66.5 years (first quartile-third quartile, 61.3-71.4 years). Of the patients, 253 (61.6%) underwent total shoulder arthroplasty (TSA) whereas 158 (38.4%) underwent reverse TSA. Five patients (2 TSA and 3 reverse TSA patients) experienced early clinical failure and required revision surgery. Minimum 1-year PROs were obtained for 345 of 406 patients (85.0%) with a mean follow-up period of 1.9 ± 1.2 years. Nearly all postoperative PROs reflected a trend of worse outcomes with more preoperative PRAs; however, the QuickDASH score was the only score showing a significant difference between allergy groups (P = .004). Pair-wise comparison using Nemenyi post hoc testing showed that the QuickDASH score was significantly higher (worse outcomes) for the group with ≥2 allergies compared with the group with 0 allergies. PRA was found to be a statistically significant predictor of higher postoperative QuickDASH scores (P = .043) and was more influential than the Charlson Comorbidity Index and sex. Additionally, PRA was the only statistically significant predictor of patient satisfaction (P = .016).

CONCLUSION

An increasing number of preoperative PRAs is associated with worse PROs and patient satisfaction following shoulder arthroplasty. The number of PRAs was the most influential predictor of patient satisfaction.

Self-reported allergies correlate with a worse patient-reported outcome after hip arthroscopy: a matched control study

Patient-reported outcome measures (PROMs) in patients with and without at least one self-reported allergy undergoing hip arthroscopy were compared. Data on 1434 cases were retrospectively reviewed, and 267 patients were identified with at least one self-reported allergy and randomly matched to a control group on a 1:2 ratio. Four PROMs [Modified Harris Hip Score (mHHS), Hip Outcome Score-Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sports (HOS-Sport) and 33-item International Hip Outcome Tool (iHOT-33)] were collected preoperatively, and at 5–11, 12–23 and 24–35 months postoperatively. Significant PROM differences were found 5–11 months postoperative on mHHS (P < 0.001), HOS-ADL (P = 0.002), HOS-Sport (P < 0.001) and iHOT-33 (P < 0.001). At 12–23 months postoperative, the allergy cohort had significantly worse scores on mHHS (P = 0.002), HOS-ADL (P = 0.001), HOS-Sport (P < 0.001) and iHOT-33 (P < 0.001). They also had significantly worse measures 24–35 months postoperative on mHHS (P = 0.019), HOS-Sport (P = 0.006) and iHOT-33 (P < 0.001). Multivariable logistic regression showed that each additional allergy reported significantly increased the risk of failing to meet the minimal clinically important difference 5–11 months after surgery on mHHS by 1.15 [OR (95% CI): 1.15 (1.03, 1.30), P = 0.014], on HOS-ADL by 1.16 [OR (95% CI): 1.16 (1.02, 1.31), P = 0.021] and on iHOT-33 by 1.20 [OR (95% CI): 1.20 (1.07, 1.36), P = 0.002]. Results suggest self-reported allergies increase the likelihood of a patient-perceived worse outcome after hip arthroscopy. An understanding of this association by the physician is essential during presurgical planning and in the management of postoperative care.

Patient-Reported Allergies Do Not Predict Poorer PROMIS Function, Pain, and Depression Scores Following Foot and Ankle Surgery

BACKGROUND

Identifying preoperative risk factors that may portend poorer operative outcomes remains a topic of current interest. In hip and knee arthroplasty patients, the presence of patient-reported allergies (PRAs) has been associated with worse pain and function after joint replacement. However, these results have not been replicated across studies, including in shoulder arthroplasty cases. The impact of PRAs on foot and ankle outcomes has yet to be studied. The purpose of our study was to evaluate whether PRAs influence patient-reported outcome in foot and ankle surgery.

METHODS

To determine if PRAs are linked to poorer operative outcomes, we retrospectively identified 159 patients who underwent elective foot and ankle surgery. PRA data were obtained via chart review, and patient-reported outcomes were assessed preoperatively and postoperatively via multiple domains, including Patient Reported Outcome Measurement Information System (PROMIS) physical function, pain interference, and depression measures. Consistent with prior methodology, we compared outcome measures (preoperative, postoperative, and the change in outcome scores) between patients without self-reported allergies to patients with at least 1 PRA.

RESULTS

There were 159 patients studied; 79 patients had no allergies listed, and 80 patients had at least 1 PRA. Of the 80 patients with at least 1 PRA, there were a total of 170 possible allergies. There were no differences in preoperative, postoperative, or the change in outcome scores for all PROMIS measures (physical function, pain interference, and depression; P > .05) between patients with at least 1 PRA and those patients without any listed PRAs.

CONCLUSIONS

We were unable to prove our hypothesis that PRAs were linked to poorer patient-reported outcomes following foot and ankle surgery. Closer review of the published reports linking PRAs to worse total joint arthroplasty outcomes revealed data that, while statistically significant, are likely not clinically relevant. Our negative findings, then, may in fact parallel prior studies on hip, knee, and shoulder arthroplasty patients. The presence of PRAs does not appear to be a risk factor for suboptimal outcomes in foot and ankle surgery.

LEVEL OF EVIDENCE

Level III, comparative series.

Screening for DSM-5 Somatic Symptom Disorder: Diagnostic Accuracy of Self-Report Measures Within a Population Sample

OBJECTIVE

The new DSM-5 somatic symptom disorder was introduced to improve the diagnosis of persons experiencing what used to be called somatoform disorders. So far, it is unclear whether existing self-report measures are useful to detect the new somatic symptom disorder. This study investigates the diagnostic accuracy of three self-report questionnaires that measure somatic complaints (15 item Patient Health Questionnaire [PHQ-15]) and psychological features (7-item Whiteley Index [WI-7]; Scale for Assessing Illness Behavior [SAIB]), in detecting somatic symptom disorder.

METHODS

A nationally representative general population survey was performed resulting in 250 participants (minimum age = 14 years. 12.8% participation rate). Assessment took place at baseline and 12-month follow-up. Individual and combined diagnostic accuracy of the PHQ-15, WI-7, and SAIB in detecting somatic symptom disorder was evaluated using the area under the curve (AUC) of a receiver operating characteristic.

RESULTS

Diagnostic accuracy was adequate to good for each individual questionnaire (PHQ-15: AUC = 0.79, p < .001, 95% confidence interval [CI] = 0.73-0.85; WI-7: AUC = 0.76, p < .001, 95% CI = 0.69-0.83; SAIB: AUC = 0.77, p < .001, 95% CI = 0.71-0.83). Combining the PHQ-15 and the WI-7 slightly improved diagnostic accuracy (AUC = 0.82, p < .001, 95% CI = 0.77-0.88), as did the combination of all three questionnaires (AUC = 0.85, p < .001, 95% CI = 0.79-0.90).

CONCLUSIONS

The PHQ-15, WI-7, and SAIB are useful screening instruments to detect persons at risk for somatic symptom disorder, and a combination of these three instruments slightly improves diagnostic accuracy. Their use in routine care will lead to improved detection rates.

Patient-Reported Allergies Are Associated With Poorer Patient Satisfaction and Outcomes After Lower Extremity Arthroplasty: A Retrospective Cohort Study

Anecdotal evidence suggests that patient-reported allergies (PRAs) may exhibit prognostic value for patient-reported outcomes after lower extremity arthroplasty. This study's purpose was to investigate associations between PRAs, patient satisfaction and outcomes after total hip arthroplasty (THA) and total knee arthroplasty (TKA). PRAs in 274 patients undergoing primary THA and 257 patients receiving primary TKA were reviewed retrospectively. Satisfaction scores, baseline Western Ontario and McMaster Universities Arthritis Index (WOMAC), 2-year postoperative WOMAC and length-of-stay (LOS) were analyzed with PRAs. Increasing number of PRAs was significantly associated with worse satisfaction scores and worse WOMAC scores for TKA and THA, and it was significantly associated with increased LOS for TKA. These results may have implications for patient counseling and risk-adjusted outcome models.

Psychological and interactional characteristics of patients with somatoform disorders: Validation of the Somatic Symptoms Experiences Questionnaire (SSEQ) in a clinical psychosomatic population

OBJECTIVE

The new DSM-5 Somatic Symptom Disorder (SSD) emphasizes the importance of psychological processes related to somatic symptoms in patients with somatoform disorders. To address this, the Somatic Symptoms Experiences Questionnaire (SSEQ), the first self-report scale that assesses a broad range of psychological and interactional characteristics relevant to patients with a somatoform disorder or SSD, was developed. This prospective study was conducted to validate the SSEQ.

METHODS

The 15-item SSEQ was administered along with a battery of self-report questionnaires to psychosomatic inpatients. Patients were assessed with the Structured Clinical Interview for DSM-IV to confirm a somatoform, depressive, or anxiety disorder. Confirmatory factor analyses, tests of internal consistency and tests of validity were performed.

RESULTS

Patients (n=262) with a mean age of 43.4 years, 60.3% women, were included in the analyses. The previously observed four-factor model was replicated and internal consistency was good (Cronbach's α=.90). Patients with a somatoform disorder had significantly higher scores on the SSEQ (t=4.24, p<.001) than patients with a depressive/anxiety disorder. Construct validity was shown by high correlations with other instruments measuring related constructs. Hierarchical multiple regression analyses showed that the questionnaire predicted health-related quality of life. Sensitivity to change was shown by significantly higher effect sizes of the SSEQ change scores for improved patients than for patients without improvement.

CONCLUSION

The SSEQ appears to be a reliable, valid, and efficient instrument to assess a broad range of psychological and interactional features related to the experience of somatic symptoms.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Assessment of psychological aspects of somatoform disorders: a study on the German version of the Health Attitude Survey (HAS)

OBJECTIVE

Given the prevalence and costs of somatoform disorders, it is important to identify and adequately treat these patients as early as possible. Instruments assessing experiences, perceptions, and behaviors of somatoform disorders are rare. In this study we evaluated the structure and validity of the German version of the Health Attitude Survey (HAS), a multidimensional self-report questionnaire for somatoform disorders.

METHODS

This cross-sectional study involved 1452 participants. The sample was randomly split for independent exploratory (EFA) and confirmatory factor analyses (CFA). Each of the two samples (n1=726; n2=726) included patients with organic vertigo and current mental disorders (somatoform and other mental disorders). Somatic symptom burden was assessed using the Patient Health Questionnaire (PHQ-15).

RESULTS

The CFA did not confirm the original HAS factor structure. The EFA revealed six factors. To enhance the fit of the model, we deleted two factors with the poorest reliability and items with low factor loadings. A modified and shortened version achieved good fit indices (CFI=0.92; RMSEA=0.068). It consists of 14 instead of 27 items and four scales ("dissatisfaction with care," "frustration with ill health," "high utilization of care," "excessive health worry"). HAS subscales discriminated among somatoform patients and physically ill and/or patients with a mental but not somatoform disorder, controlled for age, sex and number of (comorbid) mental diagnoses, confirming its construct validity.

CONCLUSION

A modified shortened version of the HAS appears to be a reliable, valid, and economical instrument for assessing facets of somatoform disorders or of the recently published DSM-5 Somatic Symptom Disorder.

Validation of the Scale for the Assessment of Illness Behavior (SAIB) in a community sample of elderly people

The aim of this study was to evaluate the construct validity of the SAIB in a community sample of elderly people. The SAIB was administered to a large community sample representative of the German population aged 60-85 years (n=1593). The original model was assessed and then refined through confirmatory and exploratory factor analyses. Criterion validity was evaluated by comparing SAIB scores with external criteria in 3 categories: subjective health, chronic illness and health care utilization. The originally suggested five factor structure of the SAIB yielded a comparative fit index (CFI) of 0.70 and the weighted root mean square residual (WRMR) was 3.68. A shortened questionnaire with 13 items and four factors resulted in better model fit (CFI 0.97 and WRMR 1.3). Correlations between subjective health and the new scales ranged from 0.06 to 0.33. Effect sizes (Cohens d) of mean differences in factor scores between those with and without healthcare system contact varied by healthcare type, ranging from 0.05 to 0.94; effect sizes were largest in relation to contact with psychotherapy and alternative medicine practitioners. We propose a shortened version of the SAIB with a different scale structure, which resulted in better model fit with our data. Neither the original nor revised SAIB appeared to discriminate well in terms of health care use, suggesting that the illness behavior as currently conceptualized may not fully explain the increased use of healthcare in the elderly.

Evaluating new proposals for the psychiatric classification of patients with multiple somatic symptoms

OBJECTIVES

The current DSM-IV classification of somatoform disorders has been criticized, and several new proposals for classification have been suggested (e.g., DSM-V work group: complex somatic symptom disorder [CSSD]). Our aim was to empirically validate and compare new proposals for the classification of people with multiple somatic complaints.

METHODS

Three hundred twenty-one participants were selected from a general population sample of more than 2500; half were selected from a subgroup with increased somatization scores (Patient Health Questionnaire 15-item somatic symptom subscale). Clinical and psychological variables and health care use were assessed with interviews and self-ratings to validate the new proposals. In addition, a high-risk group was defined to check whether new classification proposals could identify people in this a priori defined group; criteria for this high-risk group were disabling medically unexplained somatic symptoms and increased health care use. To analyze the stability of the syndromes, participants were recontacted 1 year later (completion rate, 76%).

RESULTS

The DSM-V proposal for CSSD shows good validity in the identification of people with disability and people requiring medical treatment. It is still restrictive but to a much lesser degree than the current somatization disorder: 29% of our a priori high-risk group was identified, whereas none of the participants fulfilled criteria for somatization disorder. For most proposals, the temporal stability is satisfactory yet substantially lower than expected for clinical samples. Classification criteria that include psychological features are advantageous in identifying people with health care needs.

CONCLUSIONS

Whereas some validation criteria for the new proposals (including CSSD) are satisfactory, most of the new proposals are still restrictive.

Perceived food hypersensitivity: a review of 10 years of interdisciplinary research at a reference center

Perceived food hypersensitivity is a prevalent, but poorly understood condition. In this review article, we summarize narratively recent literature including results of our 10 years' interdisciplinary research program dealing with such patients. The patients (more than 400) included in our studies were all adults referred to a university hospital because of gastrointestinal complaints self-attributed to food hypersensitivity. Despite extensive examinations, food allergy was seldom diagnosed. The majority of the patients fulfilled the diagnostic criteria for irritable bowel syndrome. In addition, most suffered from several extra-intestinal health complaints and had considerably impaired quality of life. However, psychological factors could explain only approximately 10% of the variance in the patients' symptom severity and 90% of the variance thus remained unexplained. Intolerance to low-digestible carbohydrates was a common problem and abdominal symptoms were replicated by carbohydrate ingestion. A considerable number of patients showed evidence of immune activation by analyses of B-cell activating factor, dendritic cells and "IgE-armed" mast cells. Multiple factors such as immune activation, disturbed intestinal fermentation, enteric dysmotility, post-infectious changes and "local" allergy in the gut as well as psychological disturbances may play a role in the pathophysiology of perceived food hypersensitivity. Hence, our results support the view that management of these patients should be interdisciplinary.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Approach to psychosomatic illness in adolescents

PURPOSE OF REVIEW

Due to the increased prevalence of psychosomatic presentations and the difficulty of managing such patients, this article summarizes the latest findings for identifying individual and family risk factors, and new trends in the evaluation and management of pediatric patients with psychosomatic illness.

RECENT FINDINGS

Up to 50% of patients in pediatric care will complain of medically unexplained symptoms with significant functional and emotional impairment. Such patients place heavy burdens on the healthcare system (frequent utilization of health resources and hospitalizations, specialist consultations, unnecessary investigations, and treatments). Somatoform disorders in pediatric care are associated with risks for psychiatric co-morbidity (anxiety and depressive disorders), family conflict, parent-perceived ill health, and school problems/absenteeism.

SUMMARY

Gaining expertise in addressing pediatric psychosomatic illness can make a great difference in patients' life and in physicians' professional satisfaction. Effective treatment approaches involve a multidisciplinary approach to consolidate care and facilitate communication, target the patient/family's understanding of the mind-body relationship and their acceptance of the bio-psycho-social formulation and treatment, and utilize functional rehabilitation and cognitive behavioral therapy for the individual and family and management guidance for schools.

Course and prediction of somatoform disorder and medically unexplained symptoms in primary care

THEORY/OBJECTIVE: Somatoform disorder (SFD) is associated with considerable psychosocial impairment. However, only a few studies have dealt with the course of this clinical subgroup. Therefore, the objective was to identify predictors for the various courses of SFD and medically unexplained symptoms (MUS).

METHOD

We screened 620 consecutive patients in primary care using the Patient Health Questionnaire (PHQ-15). Afterwards, 308 patients were studied in more detail using a diagnostic interview and a set of questionnaires. One year later, we were able to interview 277 participants a second time.

RESULT

After 1 year, 48.8% of the respondents had a remitted SFD. The following variables proved to be significant predictors of MUS: current depressive episode, negative life events, number of MUS at baseline, attributional style, autonomic sensations and catastrophizing cognitions. The course of SFD could be predicted through current depressive or anxiety disorder, negative life events, functional disability and attributional style.

CONCLUSION

Somatoform disorder has a favorable course. The predictors of the courses of SFD and MUS we found can be integrated into previous explanatory models. The coping with MUS or SFD can be seen as a mediating factor.

Somatoform disorders and causal attributions in patients with suspected allergies: Do somatic causal attributions matter?

OBJECTIVE

Somatic causal illness attributions are being considered as potential positive criteria for somatoform disorders (SFDs) in DSM-V. The aim of this study was to investigate whether patients diagnosed with SFDs tend towards a predominantly somatic attribution style.

METHODS

We compared the causal illness attributions of 48 SFD and 149 non-somatoform disorder patients, in a sample of patients presenting for an allergy diagnostic work-up, and those of 47 controls hospitalised for allergen-specific venom immunotherapy. The SFD diagnosis was established by means of the Structured Clinical Interview for DSM-IV. Both spontaneous and prompted causal illness attributions were recorded through interview and by means of the causal dimension of the Revised Illness Perception Questionnaire (IPQ-R), respectively. Patients' spontaneous and prompted responses were assigned to a psychosocial, somatic, or mixed attribution style.

RESULTS

Both in the free-response task and in their responses to the IPQ-R, SFD patients were no more likely than their nonsomatoform counterparts to focus on somatic explanations for their symptoms. They were just as likely to make psychosocial or mixed causal attributions. However, patients with SFDs were significantly more likely to find fault with medical care in the past.

CONCLUSION

Our data do not support the use of somatic causal illness attributions as positive criteria for SFDs. They confirm the dynamic and multidimensional nature of causal illness attributions. Clinical implications of these findings are discussed.

Magical thinking in somatoform disorders: an exploratory study among patients with suspected allergies

BACKGROUND

In order to reconceptualize somatoform disorders (SFDs), the psychological characteristics of SFD patients are increasingly investigated. The cognitive style of magical thinking (MT) has not been studied so far in patients with SFDs.

SAMPLING AND METHODS

In a cross-sectional study, 201 allergy workup patients were interviewed using the Structured Clinical Interview for DSM-IV; they answered a set of self-report questionnaires including the Schizotypal Personality Questionnaire subscale for MT and the Patient Health Questionnaire (PHQ). The expression of MT was explored in 61 patients with SFDs compared to 140 patients without SFDs.

RESULTS

Patients with SFDs reached higher scores of MT, also when controlled for gender, depression, and anxiety. In particular, they stated more frequently that they were believers in telepathy (64 vs. 44%) and clairvoyance (43 vs. 16%). MT correlated only weakly with somatization/somatic symptom severity, depression, and anxiety.

CONCLUSIONS

Among allergy workup patients with SFDs we found considerable MT. This indicates that SFD patients may tend to mistake correlation for causality in a more general way, and not just in an illness-related context. The relation to indicators of illness severity (somatic symptom severity/somatization, depression, and anxiety) was relatively weak. Possible implications for research, diagnostics, and therapy are discussed.

Characteristics of oligosymptomatic versus polysymptomatic presentations of somatoform disorders in patients with suspected allergies

OBJECTIVE

Psychobehavioral characteristics of patients with somatoform disorders (SFDs), are increasingly discussed as possible positive criteria for this diagnostic group. However, little is known about psychobehavioral differences, or similarities, between the different SFD presentations, i.e., polysymptomatic [multisomatoform/somatization disorders (MSD)] versus mono- or oligosymptomatic courses [pain disorder (PD), undifferentiated somatoform disorder (USD)].

METHODS

This is a cross-sectional study including 268 consecutive allergology inpatients. After an Structured Clinical Interview for DSM-IV, patients completed several self-rating questionnaires. Results were compared within the different SFD presentations as well as between patients with versus without SFDs.

RESULTS

We identified 72 patients with an SFD. There were fewer and smaller psychobehavioral differences within patients with the different SFD presentations (MSD, USDs, PDs) than between patients with undifferentiated versus no SFD. Patients with one of the three different SFD subdiagnoses scored similarly on many measures referring to psychosocial distress (e.g., psychological distress, mental health-related quality of life, dissatisfaction with care). The number of reported symptoms, somatic symptom severity, a self-concept of bodily weakness, the degree of disease conviction, and physical health-related quality of life discriminated the different SFD presentations not only from patients without SFDs but also from each other.

CONCLUSIONS

Patients diagnosed with one of the different SFD subtypes share many psychobehavioral characteristics, mostly regarding the reporting of psychosocial distress. Perceived somatic symptom severity and physical impairment as indicators of bodily distress could either further define categorical subdivisions of SFD or dimensionally graduate one general SFD category defined by bothering bodily symptoms and disproportionate psychosocial distress.

Do psychological factors predict symptom severity in patients with subjective food hypersensitivity?

OBJECTIVE

We examined whether psychological factors such as general and gastrointestinal symptom-specific anxiety and depression could predict symptom severity in patients with unexplained, self-reported (subjective) food hypersensitivity. For the purpose, we translated and validated the Visceral Sensitivity Index (VSI).

MATERIAL AND METHODS

Seventy consecutive patients completed questionnaires for Hospital Anxiety and Depression Scale, VSI, Irritable Bowel Syndrome Symptom Questionnaire, and Subjective Health Complaints Inventory. Relationship between scores on psychological factors and scores on somatic symptoms were studied by multiple regression analyses.

RESULTS

Most patients reported non-gastrointestinal symptoms in addition to their irritable bowel syndrome complaints, but general and symptom-specific anxiety, and depression could not explain a significant amount of the variance in somatic complaints. Gastrointestinal symptom-specific anxiety was a significant predictor of gastrointestinal complaints (p = 0.02), and age was the sole significant predictor of non-gastrointestinal complaints (p = 0.01). Approximately 90% of the total variance in symptom severity remained unexplained by the psychological factors. The Norwegian version of the VSI had satisfactory validity (Cronbach alfa = 0.93). Symptom-specific and general anxiety were significantly correlated (r = 0.48, p < or = 0.0001).

CONCLUSIONS

Psychological factors were not major predictors of symptom severity in patients with subjective food hypersensitivity. The Norwegian version of VSI had satisfactory validity.